The Screen for Child Anxiety Related Disorders (SCARED)

1. Abstract

The Screen for Child Anxiety Related Disorders (SCARED) is a widely utilized, standardized self-report and parent-proxy psychometric questionnaire designed to identify, screen, and assess signs of pediatric anxiety disorders in youth aged 8 to 18 years. Developed by Dr. Boris Birmaher and colleagues at the Western Psychiatric Institute and Clinic of the University of Pittsburgh School of Medicine, the instrument was conceived to align with the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and remains robustly applicable under DSM-5 and DSM-5-TR nosology. The SCARED consists of 41 items evaluated on a 3-point Likert-type response format (0 = Not True or Hardly Ever True, 1 = Somewhat True or Sometimes True, 2 = Very True or Often True), referencing behavioral, emotional, and cognitive experiences over the preceding three months.

The scale encompasses five distinct, empirically derived clinical subscales: Panic Disorder or Significant Somatic Symptoms (13 items), Generalized Anxiety Disorder (9 items), Separation Anxiety Disorder (8 items), Social Anxiety Disorder (7 items), and Significant School Avoidance (4 items). Psychometric validation across diverse clinical, community, and cross-cultural cohorts has repeatedly confirmed its exceptional internal consistency, with total scale Cronbach’s alpha coefficients routinely ranging from α = .89 to .93, and subscale coefficients spanning α = .70 to .90. Confirmatory factor analyses support an invariant five-factor correlated structure across sex and age groups. With established cutoff scores for both general clinical anxiety (≥ 25, with scores > 30 indicating heightened specificity) and categorical subscales, the SCARED represents a benchmark multi-informant instrument that effectively bridges clinical assessment, school-based screening, and longitudinal psychopathology research.

2. Keywords

Screen for Child Anxiety Related Disorders, SCARED, pediatric anxiety, child psychometrics, parent-child informant discrepancy, separation anxiety disorder, generalized anxiety disorder, panic disorder, social phobia, school avoidance, DSM-5 anxiety screening

3. Authors

The Screen for Child Anxiety Related Disorders was developed by an interdisciplinary team of child and adolescent psychiatrists, clinical psychologists, and pediatric psychometricians affiliated with the Western Psychiatric Institute and Clinic at the University of Pittsburgh School of Medicine:

• Boris Birmaher, MD — Endowed Chair in Pediatric Psychiatry and Professor of Psychiatry at the University of Pittsburgh School of Medicine; Director of the Child and Adolescent Bipolar Services (CABS); corresponding author (Contact: [email protected]).
• Suneeta Khetarpal, MD — Child and Adolescent Psychiatrist, Western Psychiatric Institute and Clinic, University of Pittsburgh.
• Marlane Cully, MEd — Clinical Research Coordinator and Educational Specialist, Western Psychiatric Institute and Clinic, University of Pittsburgh.
• David A. Brent, MD — Academic Child Psychiatrist, Endowed Chair in Suicide Studies, and Professor of Psychiatry, Pediatrics, Epidemiology, and Clinical and Translational Science at the University of Pittsburgh.
• Sandra McKenzie, PhD — Pediatric Research Psychologist and Psychometrician, Western Psychiatric Institute and Clinic, University of Pittsburgh.

4. Purpose

Anxiety disorders represent the most prevalent class of psychiatric conditions occurring during childhood and adolescence, with epidemiological lifetime prevalence rates estimated at approximately 10% to 20% in pediatric populations. When left undetected and untreated, early-onset anxiety disorders exhibit an unremitting, chronic course associated with pervasive academic impairment, peer socialization difficulties, severe familial disruption, and elevated longitudinal risks for developing major depressive disorder, secondary substance abuse disorders, and suicidal ideation. Despite the pronounced burden of pediatric anxiety, significant underidentification persists in primary care, pediatric, and educational environments, largely attributable to the internalized, covert nature of anxiety symptoms compared to disruptive externalizing behaviors like attention-deficit/hyperactivity disorder (ADHD) or conduct disorder.

The primary purpose of the Screen for Child Anxiety Related Disorders (SCARED) is to provide clinicians, educators, pediatricians, and clinical researchers with a rapid, psychometrically sound, cost-free, and developmentally sensitive screening inventory. The tool functions across multiple operational environments:

• Primary Care and Pediatric Screening: Serving as a rapid triage instrument to detect signs of clinically concerning anxiety during routine annual wellness visits or when children present with unexplained somatic symptoms (such as recurrent abdominal pain, non-cardiac chest pain, or tension-type headaches).
• Comprehensive Psychiatric Evaluation: Differentiating between distinct clinical anxiety presentations according to DSM criteria, assisting clinicians in formulating diagnostic impressions and targeted differential diagnoses.
• Multi-Informant Assessment: Facilitating the direct cross-informant evaluation between self-reported child experiences and parent/caregiver observations, thereby elucidating internal subjective distress alongside observable behavioral avoidance.
• Treatment Monitoring and Longitudinal Outcomes: Serving as an objective, sensitive-to-change metric during cognitive-behavioral therapy (CBT), selective serotonin reuptake inhibitor (SSRI) pharmacotherapy, or school-based mental health interventions.
• Epidemiological and Translational Research: Providing an invariant dimensional measure across pediatric cohorts to map developmental trajectories, genetic risk profiles, and neurobiological correlates of anxiety.

5. Psychological Construct

The construct assessed by the SCARED is multidimensional pediatric anxiety, operationalized through five empirically substantiated domains that mirror core diagnostic classifications in modern child psychopathology:

5.1. Panic Disorder or Significant Somatic Symptoms

This dimension encompasses intense physiological and somatic arousal characterized by acute autonomic reactivity and catastrophic cognitive appraisals. Grounded in the phenomenology of panic disorder and acute agoraphobic panic reactions, items capture subjective experiences of cardiorespiratory distress (e.g., dyspnea, tachycardia, sensations of choking), neurovegetative signs (e.g., diaphoresis, tremors, dizziness, presyncope), gastrointestinal disturbance (e.g., nausea, emesis), and associated depersonalization, derealization, and cognitive catastrophic fears of dying, losing control, or “going crazy” (e.g., Item 12: When I get frightened, I feel like I am going crazy; Item 18: When I get frightened, my heart beats fast).

5.2. Generalized Anxiety Disorder

The generalized anxiety disorder (GAD) subscale reflects pervasive, uncontrollable, and diffuse worry that transcends specific situational cues. Rooted in excessive apprehension regarding future events, past actions, academic competence, personal performance, and peer acceptance, this dimension mirrors the core cognitive vulnerability of GAD. The construct also measures generalized nervous temperament, subjective feelings of muscular tension, and hyperarousal (e.g., Item 14: I worry about being as good as other kids; Item 23: I am a worrier; Item 33: I worry about what is going to happen in the future).

5.3. Separation Anxiety Disorder

The separation anxiety disorder construct reflects developmentally inappropriate and excessive fear or distress concerning detachment from primary attachment figures or the home. It incorporates persistent worries regarding catastrophic harm or fatal events befalling caregivers, recurring nightmares featuring separation themes, refusal or dread of sleeping alone or sleeping away from home, and clingy or shadow behaviors (e.g., Item 4: I get scared if I sleep away from home; Item 8: I follow my mother or father wherever they go; Item 16: I have nightmares about something bad happening to my parents).

5.4. Social Anxiety Disorder (Social Phobia)

This subscale evaluates excessive and persistent dread of negative social scrutiny, embarrassment, rejection, or humiliation across formal performance and informal social interactions. The construct measures severe shyness, behavioral inhibition around unfamiliar peers and adults, avoidance of group recreational activities, and somatic or cognitive distress experienced when participating in school performances, speaking aloud in public, or attending social gatherings (e.g., Item 3: I don’t like to be with people I don’t know well; Item 39: I feel nervous when I am with other children or adults and I have to do something while they watch me; Item 41: I am shy).

5.5. Significant School Avoidance

The school avoidance subscale measures behavioral reluctance, distress, and somatic manifestations that emerge specifically in response to attending school. Rather than conceptualizing school refusal as a singular psychiatric disorder, the SCARED recognizes it as a functional behavioral syndrome frequently resulting from co-occurring separation anxiety, social evaluation fears, or panic symptoms. The items evaluate morning or school-associated somatic complaints and direct apprehension about entering the academic environment (e.g., Item 2: I get headaches when I am at school; Item 11: I get stomachaches at school; Item 36: I am scared to go to school).

6. Theoretical Framework

The development of the SCARED is theoretically embedded in developmental psychopathology, cognitive-behavioral models of anxiety, and structural models of affective disorders. Prominent theoretical foundations include:

6.1. Barlow’s Triple Vulnerability Theory

According to David H. Barlow’s Triple Vulnerability Model, the emergence of anxiety disorders stems from the convergence of three interactive diatheses: (a) a generalized biological vulnerability characterized by a genetically determined, neurobiologically hyperreactive temperament (e.g., behavioral inhibition, autonomic lability); (b) a generalized psychological vulnerability rooted in early environmental experiences that instill a sense of perceived uncontrollability and unpredictability over internal states and external stressors; and (c) a specific psychological vulnerability wherein particular situations, physical sensations, or interpersonal scenarios are learned to be uniquely threatening through vicarious learning, parental modeling, or direct classical conditioning. The SCARED subscales directly capture these three layers: the Generalized Anxiety items capture pervasive uncontrollability, the Panic/Somatic items assess conditioned hyperreactivity to interoceptive cues, and the Separation and Social subscales evaluate specific environmental threats.

6.2. Clark and Watson’s Tripartite Model

The structural composition of the SCARED interfaces directly with the Tripartite Model of anxiety and depression proposed by Lee Anna Clark and David Watson. This model partitions emotional distress into three components: Negative Affectivity (shared distress common to both anxiety and depressive syndromes), Positive Affectivity (anhedonia and low positive affect, relatively specific to depression), and Physiological Hyperarousal (somatic tension, autonomic activation, and panic symptoms, specific to anxiety). By explicitly isolating autonomic somatic arousal (Panic subscale) and cognitive hypervigilance (GAD subscale) while minimizing overlap with purely anhedonic symptoms, the SCARED maintains high discriminant validity between pediatric anxiety and unipolar depressive disorders.

6.3. Bowlby’s Attachment Theory and Developmental Psychopathology

The inclusion of a discrete Separation Anxiety subscale reflects John Bowlby’s classic attachment theory. When a child’s internal working model perceives primary caregivers as inaccessible or inconsistently responsive, attachment behaviors escalate into hyperactivating strategies. While separation distress represents a normatively adaptive survival mechanism during infancy, its persistence or exacerbation into middle childhood and adolescence signifies psychopathological distortion. The SCARED operationalizes this developmental failure of emotional autonomy.

7. Validity

Extensive empirical studies conducted internationally across psychiatric outpatient clinics, inpatient facilities, school districts, and community samples provide rigorous evidence supporting the construct, convergent, discriminant, and predictive validity of both the child and parent versions of the SCARED.

7.1. Convergent and Criterion Validity

In the seminal psychometric investigations by Birmaher et al. (1997, 1999), SCARED total and subscale scores were benchmarked against semi-structured psychiatric diagnostic interviews, specifically the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) and the Diagnostic Interview for Children and Adolescents (DICA). Children diagnosed with specific DSM anxiety disorders obtained significantly higher scores on the corresponding SCARED subscales than clinical controls with non-anxiety disorders (e.g., major depressive disorder, ADHD, conduct disorder) and normal healthy controls (all p < .001).

Correlations between the SCARED total score and other validated pediatric anxiety scales are uniformly strong:

• Multidimensional Anxiety Scale for Children (MASC): r = .71 to .84.
• Revised Children’s Manifest Anxiety Scale (RCMAS): r = .75 to .88.
• Child Behavior Checklist (CBCL) Internalizing Problems subscale: r = .62 to .74.
• Revised Children’s Anxiety and Depression Scale (RCADS): r = .80 to .89.

7.2. Discriminant Validity

The SCARED demonstrates robust discriminant capability in distinguishing pediatric anxiety disorders from disruptive behavioral conditions and major mood disorders. In clinical trials, the correlation between SCARED total scores and measures of externalizing disorders (e.g., CBCL Externalizing scale, Conners’ ADHD Rating Scales) remained consistently low to negligible (r = .12 to .28). Furthermore, receiver operating characteristic (ROC) curve analyses indicate superior area under the curve (AUC) metrics ranging from .84 to .93 in differentiating youth with anxiety disorders from both healthy controls and non-anxious clinical cohorts.

7.3. Cross-Informant Agreement

Consistent with broad pediatric psychopathology literature, cross-informant correlation between child self-report and parent proxy-report is moderate, typically yielding Pearson correlation coefficients between r = .30 and r = .55. Parents systematically report higher observable somatic manifestations and behavioral separation difficulties, whereas children and adolescents report higher subjective internalized distress, generalized worry, and social evaluative anxiety. Consequently, best clinical practice mandates utilizing both versions in parallel to synthesize internal subjective awareness with external behavioral observation.

8. Reliability

The SCARED exhibits robust psychometric reliability across internal consistency, test-retest stability, and cross-cultural administrations.

8.1. Internal Consistency

In the initial validation study of 190 children and adolescents and their parents (Birmaher et al., 1997), and the subsequent replication cohort of 84 youth (Birmaher et al., 1999), the internal consistency coefficients (Cronbach’s alpha, α) demonstrated high precision:

• Total Score: Child Version α = .90; Parent Version α = .93.
• Panic Disorder / Somatic Symptoms: Child Version α = .87; Parent Version α = .89.
• Generalized Anxiety Disorder: Child Version α = .87; Parent Version α = .89.
• Separation Anxiety Disorder: Child Version α = .74; Parent Version α = .81.
• Social Anxiety Disorder: Child Version α = .83; Parent Version α = .85.
• Significant School Avoidance: Child Version α = .70; Parent Version α = .78.

Cross-cultural investigations worldwide (including Dutch, German, Italian, Chinese, Brazilian, and Turkish translations) have established consistent internal consistency metrics, with total scale alphas rarely dropping below α = .88.

8.2. Test-Retest Reliability

Test-retest reliability evaluated across short-term intervals (1 to 5 weeks) has yielded intraclass correlation coefficients (ICC) and Pearson product-moment correlations ranging from r = .70 to .90 for total scores, indicating stable measurement of enduring trait anxiety while remaining responsive to symptom reduction following clinical interventions.

9. Factor Analysis

The structural composition of the SCARED was originally developed using exploratory factor analysis (EFA) with oblimin oblique rotation on a 66-item pilot inventory, subsequently refined into the standardized 41-item instrument exhibiting a parsimonious five-factor solution.

9.1. Exploratory Factor Analysis (EFA)

In the original derivation sample, the five-factor model emerged cleanly, with eigenvalues greater than 1.0 explaining over 48% of the total scale variance. Each of the 41 retention items loaded distinctly onto its target factor with primary factor loadings exceeding λ ≥ .40, while displaying minimal cross-loadings (consistently λ < .25 on secondary factors). The factors correlated moderately with one another (inter-factor correlations: r = .25 to .55), affirming the presence of correlated yet discrete subdimensions under a broader higher-order anxiety construct.

9.2. Confirmatory Factor Analysis (CFA)

Subsequent large-scale validation studies (e.g., Muris et al., 1998, 2002; Su et al., 2008) have conducted rigorous Confirmatory Factor Analyses comparing alternative structural configurations, including a single-factor unidimensional model, a tri-factor model, and the theoretical five-factor correlated model. Across studies, the five-factor model consistently demonstrated superior fit indices:

• Comparative Fit Index (CFI) ≥ .92 to .96
• Tucker-Lewis Index (TLI) ≥ .91 to .95
• Root Mean Square Error of Approximation (RMSEA) ≤ .042 to .055 (90% CI [.038, .060])
• Standardized Root Mean Square Residual (SRMR) ≤ .051

Multigroup CFA further demonstrates strong measurement invariance across biological sex (boys vs. girls) and developmental stages (children aged 8–11 vs. adolescents aged 12–18), confirming that the instrument assesses equivalent latent constructs with comparable item weightings across demographic groups.

10. Instrument / Measurement Tool

The administrative, structural, and scoring parameters of the Screen for Child Anxiety Related Disorders are detailed below:

• Test Type: Standardized multi-informant rating scale (Self-report Child Version and Observer/Caregiver Parent Version).
• Target Population: Children and adolescents aged 8 to 18 years. For children aged 8 to 11, it is clinically recommended that an adult or clinician be present to clarify vocabulary or administer items orally.
• Administration Time: Approximately 8 to 12 minutes to complete.
• Item Count: 41 items across both Child and Parent forms.
• Recall Period: Symptoms, thoughts, and behaviors experienced during the preceding 3 months.
• Response Scale: 3-point ordinal Likert-type scale:
  • 0 = Not True or Hardly Ever True
  • 1 = Somewhat True or Sometimes True
  • 2 = Very True or Often True
• Total Score Range: 0 to 82 points.
• General Clinical Cutoff Guidelines:
  • A total score of ≥ 25 indicates the probable presence of a clinical Anxiety Disorder (optimal sensitivity).
  • A total score of > 30 provides heightened diagnostic specificity, strongly indicating clinically significant impairing anxiety.
• Subscale Item Composition and Specific Cutoffs:
  • Panic Disorder or Significant Somatic Symptoms: Items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 (13 items, score range 0–26; Cutoff ≥ 7 suggests panic disorder or severe somatization).
  • Generalized Anxiety Disorder: Items 5, 7, 14, 21, 23, 28, 33, 35, 37 (9 items, score range 0–18; Cutoff ≥ 9 suggests GAD).
  • Separation Anxiety Disorder: Items 4, 8, 13, 16, 20, 25, 29, 31 (8 items, score range 0–16; Cutoff ≥ 5 suggests separation anxiety).
  • Social Anxiety Disorder: Items 3, 10, 26, 32, 39, 40, 41 (7 items, score range 0–14; Cutoff ≥ 8 suggests social anxiety/social phobia).
  • Significant School Avoidance: Items 2, 11, 17, 36 (4 items, score range 0–8; Cutoff ≥ 3 suggests school avoidance).

11. Permissions & Fee and Test Year

The Screen for Child Anxiety Related Disorders (SCARED) was originally formulated in October 1995 and formally published in peer-reviewed scientific literature in 1997 (Birmaher et al., 1997) with a primary replication and refinement study published in 1999 (Birmaher et al., 1999).

The scale was developed at the Western Psychiatric Institute and Clinic, University of Pittsburgh. Dr. Boris Birmaher and his co-developers have placed the SCARED in the public domain for research and clinical purposes. No licensing fees, royalties, or formal administrative user fees are required to utilize, print, or score the instrument in routine healthcare, educational, or academic investigation settings. Users are requested to credit the authors and cite the seminal validation publications in any academic reports, presentations, or publications resulting from its use.

12. References

Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–1236. https://doi.org/10.1097/00004583-199910000-00011

Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale development and psychometric characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 545–553. https://doi.org/10.1097/00004583-199704000-00018

Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100(3), 316–336. https://doi.org/10.1037/0021-843X.100.3.316

Monga, S., Birmaher, B., Chiappetta, L., Brent, D., Kaufman, J., Bridge, J., & Cully, M. (2000). Screen for Child Anxiety-Related Emotional Disorders (SCARED): Convergent and divergent validity. Depression and Anxiety, 12(2), 85–91. https://doi.org/10.1002/1520-6394(2000)12:2<85::AID-DA4>3.0.CO;2-6

Muris, P., Merckelbach, H., Schmidt, H., & Mayer, B. (1998). The Screen for Child Anxiety Related Emotional Disorders (SCARED) consisting of 41 items: A replication study with Dutch normal children. Personality and Individual Differences, 24(4), 551–559. https://doi.org/10.1016/S0191-8869(97)00195-6

Muris, P., Schmidt, H., Engelbrecht, P., & Perreijn, M. (2002). DSM-IV-specified anxiety disorder symptoms in normal children: Which symptoms occur first? Journal of Abnormal Child Psychology, 30(2), 165–173. https://doi.org/10.1023/A:1014787910111

Su, L., Wang, K., Fan, F., Su, Y., & Gao, X. (2008). Reliability and validity of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Chinese children. Journal of Anxiety Disorders, 22(4), 612–621. https://doi.org/10.1016/j.janxdis.2007.05.011

13. Items of the Scale