# Evidence-based assessment/Generalized anxiety disorder (assessment portfolio)/extended version

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
Does this page feel like too much information? Click here for the condensed version.

## Preparation phase
### Diagnostic criteria for generalized anxiety disorder

   ICD-11 Diagnostic Criteria
   * Generalised anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free-floating anxiety’) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.
   Changes in DSM-5
   * The diagnostic criteria for generalized anxiety disorder changed slightly from DSM-IV-TR to DSM-5. Summaries are available here.

### Base rates of GAD in different clinical settings

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of GAD that they are likely to see in their clinical practice.
* To see prevalence rates across multiple disorders, click here.
| Demography | Setting | Base Rate | Diagnostic Method |
| Adults and adolescences in all of U.S.A. | US National Comorbidity Survey Replication (NCS-R; age > = 13) (2012) | 0.9% (age 13-17) 2.9% (age 18-64) 1.2% (age >= 65) 2.0% (age >=13) | Fully-structured CIDI Version 3.0 |
| Psychiatric outpatients | Individuals seeking treatment in a Psychiatric Outpatient Clinic (age range not reported) (2014) | 21% | Structured Clinical Interview for DSM-IV (SCID) |
| Caucasian youth | Children seeking treatment in a Child & Adolescent Anxiety Diagnostic Clinic (age 7 – 18 years old) (2011) | 0.39% (parent report) 0.38% (child report) | ADIS-C for DSM-IV Spence Children's Anxiety Scale (SCAS) |
| Caucasian, African American, Asian American, and Hispanic population | Collaborative Psychiatric Epidemiology Studies (CPES; age >= 18, data merged from three representative national database) (2011) | 4.1% (female) 2.1% (male) | World Mental Health Survey Initiative Version of the World Health Organization Composite International Interview (WMH-CIDI) |
| Pennsylvania | Metropolitan Community Sample, all individuals with eating disorders (ages 13 – 65) (2014) | 10% | Structured Clinical Interview for DSM-IV (SCID) |
| Adolescents in all of U.S.A. | National Comorbidity Survey Replication Adolescent Supplement (NCS-A; ages 3–18 in the continental U.S) (2011) | 2.2% | World Health Organization Composite International Diagnostic Interview (WHO-CIDI) |
| Adolescents in all of U.S.A | National Comorbidity Survey Replication Adolescent Supplement (NCS-A; ages 3–18 in the continental U.S) | 5.4% | Composite International Diagnostic Interview (CIDI) |
| North Carolina | Rural community sample African American and White youth (ages 13-16) (2002) | 1.4% | The Child and Adolescent Psychiatric Assessment (CAPA) |
| Texas | Metropolitan Community Sample (ages 11-17) (2007) | 0.4% | Diagnostic Interview Schedule for Children, Version IV (DISC-IV) |
| Midwestern Urban | Incarcerated adolescents (ages 10-18) (2002) | 1% | Diagnostic Interview Schedule for Children, Version IV (DISC-IV) |
| The southern Appalachian mountain region of North Carolina | Great Smoky Mountain (ages 9-12) (1996) | 1.67% | DSM-III-R, DSM-IV and CAPA |
| New Jersey | Non-referred Adolescent Population (ages 9-17) (1990) | 3.7% | DSM-III & Beck Depression Inventory (BDI) |
| Non-institutionalized general US population | LGBTQ sample (ages 20-65) (2013) | Women: 14.8% same-sex 22.5% bisexual Men: 16.9% same-sex 11.5% bisexual | The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV) |
| Non-institutionalized general US population | Cross-ethnic American population (ages 18+) (2018) | White 8.6% African Americans 4.9% Hispanic Americans 5.8% Asian Americans 2.4% | World Mental Health Survey Initiative Version of the World Health Organization Composite International Interview (WMH-CIDI) |
| Outpatient clinics worldwide | Samples across multiple studies worldwide (all ages) | 5% | Clinical evaluations |
| Outpatient clinic worldwide | Samples across multiple studies worldwide (all ages) | 10% | Standardized Diagnostic Interviews (SDIs) |
Search terms: [General Anxiety Disorder] AND [youth OR adolescents OR pediatric] AND [prevalence OR incidence] in GoogleScholar and PsycINFO

## Prediction phase
### Psychometric properties of screening instruments for GAD

The following section contains a list of screening and diagnostic instruments for generalized anxiety disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
Screening measures for GAD :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | PDF |
| Penn State Worry Questionnaire (PSWQ) | Questionnaire (Adult Version, Child Version) | 18+ (Adult Version), 6-18 (Child Version) | 4 minutes | NA | G | G | G | PSWQ homepage Assessment Center Online Adult Version PDFs of the PSWQ Penn State Worry Questionnaire PSWQ-C PSWC-C Korean PSWQ-C Danish Scoring of the PSWQ-C |
| Screen for Child Anxiety Related Emotional Disorder (SCARED) | Questionnaire (Child, Parent) | 8-19 | 9 or 16 minutes | NA | G | G | G | SCARED homepage Assessment Center Online Youth Version Assessment Center Online Parent Version PDFs of SCARED SCARED English + Translations & Automatic Scoring |
| State/Trait Anxiety Inventory for Children (STAIC) | Questionnaire (Child, Parent) | 6-18 | 5 or 10 minutes | NA | G | G | G | *not free* STAIC Website |
| Revised Children’s Anxiety and Depression Scale (RCADS) | Questionnaire (Child) | 6-18 | 12 minutes | G | G | G | | RCADS homepage Assessment Center Online Parent Version Assessment Center Youth Version PDFs for RCADS RCADS Child Self-reported (8-18 years) RCADS Parent-reported Child Scoring Aid Parent Scoring Aid Subscales Generalized Anxiety Child Self-reported Generalized Anxiety Parent-reported Panic Self-Report Panic Parent-Report Translations User Guide |
| Spence Children’s Anxiety Scale (SCAS) | Questionnaire (Child, Parent) | 7-19 | 11 minutes | NA | A | E | E | SCAS homepage Child Version PDF Parent Version PDF |
| GAD-7 Scale | Self report | 18+ | 5 minutes | G | Intraclass correlation 0.83 | G | G | GAD-7 homepage PDF (english) PDF (spanish) Assessment Center Online Version |
| Kessler Psychological Stress Scale (K10 and K6 Scales) | Self or interview administered | | | | | | | Available in many languages |
| Worry and Anxiety Questionnaire (WAQ) | Self report | | 10 minutes | NA | A | A | G | WAQ homepage PDF |
| Brown Assessment of Beliefs Scale (BABS) | | | | G | A | G | G | BABS Adult BABS Original Publication |
| Back Anxiety Inventory (BAI) | Self-report | 17-80 | 5-10 minutes | G | | G | G | BAI homepage PDF |
| The Clinically Useful Anxiety Outcome Scale (CUXOS) | Self-report | 18-85 | Less than 2 minutes | E | | E | G | CUXOS homepage PDF |
| Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR) | CBCL: Parent report, TRF: Teacher report, YSR: Child report | 6-18 (CBCL & TRF), 11-18 (YSR) | 10 - 15 minutes | A | E | E | G | ASEBA homepage PDF |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening instruments for GAD

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure (Primary Reference) | Format (Reporter) | Area Under Curve (AUC) | LR+ (Score) | LR- (Score) | Citation | Clinical Generalizability |
| Penn State Worry Questionnaire (PSWQ) | Questionnaire (Child) | 0.74 (N=164) | 1.8 (65+) | 0.5 (< 65) | Fresco, D.M., Mennin, D.S., Heimberg, R.G., Turk, C.L. (2003) | Generalized Anxiety Disorder vs. social anxiety disorder, adults presenting to specialty anxiety clinic |
| Screen for Child Anxiety Related Disorders (SCARED) | Questionnaire (Child, Parent) | .70 (N=243) | 5.0 (+32) | .04 | (Birmaher et al., 1997) | High: Pure anxiety disorder versus non-anxiety psychiatric disorder, excluding children with disruptive disorder and depression |
| Screen for Child Anxiety Related Disorders (SCARED) | Questionnaire (Child, Parent) | 0.911 (First screen) (N= 923) | 2.81 (4+; FS) | 0.15 (4-; FS) | Hale III, et al., 2014 | High: Pure anxiety disorder versus non-anxiety psychiatric disorder, excluding children with disruptive disorder and depression |
| STAIC | Questionnaire (Child, Parent) | -- (N=70) | 2 (+69) | .79 | DLR: (Hodges, 1990) | STAIC does well in discriminating between children and adolescents with anxiety disorders and youth without a disorder and moderately well in measuring treatment response and discriminating youth with anxiety disorders from those with externalizing disorders |
| RCADS | Questionnaire (Child) | -- (N=513) | 9.8 | 0.24 | DLR: (Chorpita, Moffitt & Gray, 2005) | High: Several studies demonstrate support for the RCADS in non-referred samples of youth |
| SCAS | Questionnaire (Child, Parent) | 0.83 (N=654) | -- | -- | (Nauta et al., under review) | |
| Generalized Anxiety Disorder Scale (GADS) | Questionnaire | 0.88 (N = 438) | 6.3 (5+) | .41 (5-) | Wild et al., 2014 | Elderly persons (ages 58–82) from general population in German |
| Generalized Anxiety Disorder Screener (GAD-7) | Questionnaire | 0.906 (N = 2149) | 5.17 (8+) | .20 (8-) | Plummer et al., 2016 | Adults aged 16 years and older in any setting (meta-analysis) |
| CBCL Anxious/Depressed Scale T-score | Questionnaire | .75 (N = 1445) | 1.49 (9+) | .67(9-) | Eimecke et al., (2011) | Inpatient and outpatient children and adolescents |
Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.
Search terms: [General Anxiety Disorder] AND [children OR adolescents OR pediatric] AND [sensitivity OR specificity] in GoogleScholar and PsycINFO

### Interpreting GAD screening measure scores

* For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

* For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Recommended diagnostic instruments for GAD

Diagnostic instruments for GAD :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Free and Accessible Measures |
| Anxiety Disorders Interview Schedule for Children (ADIS-C) | Child | 6-16 | Varies | E | E | G to E | N/A | Purchase |
| Anxiety Disorders Interview Schedule for Children (ADIS-P) | Parent | 6-16 | Varies | E | E | E | N/A | Purchase |
| Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) *not free | Adult | 16+ | Varies | A | NA | A | A | |
| Structured Clinical Interview for DSM-IV-TR for Axis I Disorders (SCID-I/P) *not free | | | Varies | A | NA | A | A | Website and purchase |
| Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) *not free | | | Varies | E | NA | U | U | Website and purchase |
| Structured Clinical Interview for DSM-IV (SCID-IV) *not free | | | Varies | A | A | E | E | Website and purchase |
| Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) | Structured Interview (Adult) | 16+ | Varies | | | | | Purchase |
| Structured Clinical Interview for DSM-5 Clinician Version (SCID-5- CV) | Structured Interview (Adult) | 16+ | Varies | E | A | | | Purchase |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Severity interviews for GAD

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Children's Depression Rating Scale - Revised (CDRS-R) | Structured Interview | 6-12 | 15-20 minutes | G | A | G | G | X | Link to purchase PDF (excerpt) |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a list of process and outcome measures for generalized anxiety disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

### Outcome and severity measures

* This table includes clinically significant benchmarks for generalized anxiety disorder specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for GAD :
| Measure | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms |||||||
| | A | B | C | 95% | 90% | SE$_{difference}$ |
| GAD-7 | -1 | 1.3 | 0.5 | 0.6 | 0.5 | 0.3 |
| PSWQ | 51 | 73 | 59 | 9 | 8 | 4.8 |
| SCARED | 9.9 | 18.1 | 15.3 | 8.9 | 7.5 | 4.5 |
| STAIC | 0.9 | 30.1 | 18.2 | 18.9 | 15.9 | 9.6 |
| RCADS | -1.1 | 12.7 | 6.6 | 7.3 | 6.1 | 3.7 |
| SCAS | -0.7 | 15.1 | 5.4 | 6.2 | 5.2 | 3.2 |
Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.
Search terms: [General Anxiety Disorder] AND [children OR adolescents OR pediatric] AND [clinical significance OR outcomes] in GoogleScholar and PsycINFO

### Treatment

* Please refer to the page on generalized anxiety disorder for more information on available treatment or go to Effective Child Therapy for a curated resource on effective treatments for GAD.
* For information on conducting Exposure Therapy for anxiety disordered youth, see www.BravePracticeForKids.com

## External Resources

* ICD-10 diagnostic criteria
* Find-a-Therapist
** This is a curated list of find-a-therapist websites where you can find a provider
* NIMH entry about anxiety disorders
* OMIM (Online Mendelian Inheritance in Man)
** 607834
* eMedicine entry about anxiety disorders
* Society of Clinical Child and Adolescent Psychology
* Effective Child Therapy information on Fear, Worry, & Anxiety
** Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
* Links to SCARED Child, Parent, and Adult + Translations