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The Multidimensional Anxiety Scale for Children: A Further Validation With

Australian Adolescents With and Without ADHD

Article  in  Journal of Attention Disorders · March 2012

DOI: 10.1177/1087054712439100 · Source: PubMed

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 The Multidimensional Anxiety Scale for Children (MASC): A further validation with

Australian adolescents with and without Attention-Deficit/Hyperactivity Disorder

Stephen Houghton
Graduate School of Education,
The University of Western Australia

Simon C. Hunter
School of Psychological Sciences and Health,
University of Strathclyde

Toby Trewin
Graduate School of Education,
The University of Western Australia

&
Annemaree Carroll
School of Education,
The University of Queensland

Cite as: Houghton, S., Hunter, S.C., Trewin, T., & Carroll, A. (2014). The

Multidimensional Anxiety Scale for Children (MASC): A further validation with

Australian adolescents with and without Attention-Deficit/Hyperactivity Disorder.

Journal of Attention Disorders, 18(5), 402-411. DOI: 10.1177/1087054712439100

Find online: http://jad.sagepub.com/content/18/5/402

Correspondence: Professor Stephen Houghton.
Graduate School of Education
The University of Western Australia,
Crawley 6009, WA
Email: [email protected].
 Abstract

Objective: To examine the factor structure of the Multidimensional Anxiety Scale for

Children (MASC) with Australian adolescents with and without Attention–

Deficit/Hyperactivity Disorder (ADHD). Method: The MASC was administered to

210 high school aged adolescents (109 males, 101 females), 115 of who were clinically

diagnosed as ADHD (86 males, 29 females). The remaining 95 were non ADHD

Community Comparisons. Results: Analyses supported a three-factor model, with a

reduced item pool, which combined the Harm Avoidance and Separation Anxiety

scales together. This model was invariant across younger and older participants, and

across boys and girls. The model was largely invariant across ADHD and non-ADHD

groups. The ADHD group had significantly higher Physical Symptom factor scores

than the non-ADHD group. Conclusion: The MASC is useful for assessing anxiety in

adolescents with and without ADHD but items reflecting the Harm Avoidance and

Separation Anxiety scales may need revising.

2
Attention-Deficit/Hyperactivity Disorder (ADHD) is characterised by

developmentally inappropriate symptoms of inattention, hyperactivity, and

impulsivity (American Psychiatric Association, APA: 2000), which can affect many

aspects of children’s and adolescents’ functioning and development (Bell, 2011). It is

the most pervasive psychological disorder in children in their schooling years (Woo

& Keatinge, 2008) affecting 3-7% of school-aged children (APA, 2000). Studies have

reported prevalence rates for children and adolescents with ADHD in the United

States as ranging from 3-11% (Barkley & Biederman, 1997), 4.2-6.3% (Mash &

Barkely, 2003), 5.9% (Rohde, 2008) and up to 16.1% (see Lecendreux, Konofal, &

Faraone, 2011). In Australia prevalence has been reported to range from 3% to 9%

(Graetz, Sawyer, Hazel, Arney, & Baghurst 2001; Mental Health Division of Western

Australia, 2000; National Institute of Health, 2000) to as high as 14% (Sawyer,

Arney, Baghurst, Clark, Graetz, Kosky et al., 2000).

Of those with ADHD, 20-60% will continue to experience it during late

adolescence and adulthood as an incomplete or full syndrome (see Barkley, 1996;

Spencer, Biederman, Wilens, & Faraone, 2002). Hence, ADHD is a major clinical and

public health concern (Perwien, Kratochvil, Faries, Vaughan et al., 2008) that affects

health care costs significantly (Chan, Zhan, & Homer, 2002; Leibson, Katusic,

Barbaresi, Ranson, & O’Brien, 2001).

ADHD is also highly comorbid with a range of psychiatric disorders (Baldwin &

Dadds, 2008; Jarrett & Ollendick, 2008) and one of the most consistent findings in

ADHD research over the past 25 years has been the high prevalence rates of comorbid

anxiety (see Sorenson, Plessen, Nicholas, & Lundervold, 2011). Studies (Alqahtani,

2010; Jensen, Martin, & Cantwell, 1997; Pliszka, 1998; Tannock, 2000; Vloet,

Konrad, Herpertz-Dahlmann, Polier, & Gunther, 2010) have reported 25% to 50% of

children with ADHD as exhibiting an anxiety disorder and/or meeting the Diagnostic

3
and Statistical Manual of Mental Disorders-Version IV-Text Revision (DSM-IV-TR;

American Psychiatric Association, 2000) criteria for an anxiety diagnosis. This

relationship between ADHD and anxiety, which exists across international populations

(Souza, Pinheiro, Denardin, Mattos, & Rohde, 2004), is in excess of the 10-21% and 5-

15% reported in normative samples of school-aged children (Thaler, Kazemi, & Wood,

2010; Pliszka, Carlson, & Swanson, 1999). If left untreated pediatric anxiety disorders

predict adult anxiety disorders and depression (Kendall, Compton, Walkup, Birmaher

et al., 2010).

Stimulants are effective medications for treating the core symptoms of ADHD

(American Academy of Pediatrics Committee on Quality Improvement, Subcommittee

on Attention-Deficit/Hyperactivity Disorder, 2001) however, ADHD and anxiety

disorders have different treatment needs and pharmacological interventions

(Hammerness, Geller, Petty, Lamb, Bristol, & Biederman, 2010). Furthermore,

children with comorbid anxiety respond differently to treatments (Baldwin & Dadds,

2008), and when stimulant medication is employed the response of the individual with

ADHD is often less robust (Ter-Stepanian, Grizenko, Zappitelli, & Joober, 2010).

Developing a better understanding of the association between ADHD and anxiety

is therefore critical both from a clinical and scientific perspective. To achieve this

there is a need for a reliable instrument to measure levels of anxiety symptoms (and to

monitor progress of treatment). Perceiving the internal world of their children is often

difficult for parents however, and likewise confessing anxiety problems to parents

may be uncomfortable for children (Baldwin & Dads, 2007). Children are consistent

within themselves across measures of anxiety (Barbosa, Tannock, & Manassis, 2002)

and therefore, self-report measures may be advantageous for facilitating a young

person’s reporting of symptoms of anxiety.

4
 One of the most commonly used, empirically driven, self-report measures for

anxiety is the Multidimensional Anxiety Scale for Children (MASC: March, 1998).

The MASC was developed as a state measure of anxiety because of the need for such a

measure that was appropriate for use with children and adolescents and which had

specific or pure anxiety items or subscale scores (Osman, Williams, Espenschade,

Guiterrez, Bailey, & Chowdhry, 2010). Suitable for assessing broad dimensions of

anxiety in 8 to 19 year olds, the MASC was developed using a “bottom up” approach

whereby the 39 items (comprising the MASC) were adopted from a 104 item pool, (see

March, 1998). Exploratory and confirmatory factor analyses (March, Parker, Sullivan,

Stallings, & Connors, 1997; March, Sullivan, & Parker, 1999) identified four correlated

factors during instrument development: Physical Symptoms (12 items), Social Anxiety

(9 items), Harm Avoidance (9 items), and Separation Anxiety/Panic (9 items) with

internal consistencies ranging from .74 to .90. Each of the items on these domains is

rated on a four-point scale ranging from “never true about me” (score 0) to “often true

about me” (score 3).

The MASC factor structure has been cross validated with community and clinical

samples of children and adolescents in the United States (see Grills-Tacquechel,

Ollendick, & Fisak, 2008; March, Sullivan, & Parker, 1999; Rynn, Barber, Khalid-

Khan, Siqueland et al, 2006), Iceland (Olason, Sighvatsson, & Smari 2004), Sweden

(Ivarsson, 2006), Australia (Baldwin & Dadds, 2007), Taiwan (Yen, Yang, Wu, Hsu,

& Cheng, 2010) and South Africa (Fincham, Schickerling, Temane, De Roover, &

Seedat, 2008) and has been shown to be invariant across gender. Acceptable levels of

convergent and divergent validity and test-retest reliability have also been reported for

the MASC (see Baldwin & Dadds, 2007). Additional research conducted with

adolescent psychiatric in-patient samples (Osman et al., 2009) also supports the four-

factor structure. However, Osman et al. (2009) suggested that some MASC items from

5
the Harm Avoidance and Separation Anxiety subscales may need to be revised.

Kingery, Ginsburg and Burstein (2009) also identified problems with the Harm

Avoidance and Separation Anxiety subscales, with none of the items from these

loading on to any of the factors. Overall, the four-factor model provided a poor fit with

a community sample of 118 African American adolescents and a three-factor solution

was supported.

Although evaluations of the psychometric properties of the MASC have been

positive, a validation of its factor structure with adolescents diagnosed with ADHD

appears missing from the literature. March, Connors, Arnold, Epstein et al. (1999)

conducted a confirmatory factor analysis of data provided by 579 pre-adolescent

children (ages 7 to 9 years) “with DSM IV ADHD Combined Type” (p. 86) and found

an excellent fit of the four factor model. Additional information on the structure of the

MASC among adolescents presenting with ADHD would be valuable, particularly

given Baldwin and Dadds’ (2007, p. 253) conclusion that it is “most clinically useful

self-report anxiety measure for children available”.

Despite the excellent psychometrics of the MASC there is limited research with

adolescents diagnosed with ADHD. The primary aim of this study therefore was to

examine the factor structure of the MASC with adolescents with and without ADHD.

A secondary aim was to compare fit across younger and older adolescents, and across

male and female participants.

Method

Participants and Settings

The sample consisted of 210 high school aged adolescents (109 males, 101

females) recruited from Grades 8 to 12 (ages 13 to 17.7 years). Of these, 115 were

clinically diagnosed by pediatricians as meeting DSM-IV-TR (American Psychiatric

Association, 2000) criteria for ADHD (86 males, 29 females) and 95 were non ADHD

6
Community Comparisons (23 males and 72 females) who had no known diagnosed

neurological deficits. The distribution according to school grade levels was: Grade 8

(13 years of age; N = 52, Males 30, Females 22), Grade 9 (14 years; N = 49, Males 16,

Females 33), Grade 10 (15 years; N = 30, Males 18, Females 12), Grade 11 (16 years;

N = 43, Males 22, Females 21), and Grade 12 (17-18 years; N = 36, Males 23, Females

13).

The ADHD sample was recruited in one of two ways: (i) from the database of

families with children diagnosed with ADHD stored at a University based clinic for

psychological assessment (N = 89 adolescents); and (ii) from four ADHD support

groups in Western Australia (N = 26 adolescents). The non ADHD community

comparisons were recruited by requesting the parents of adolescents with ADHD to

each invite a parent who had an adolescent (in the same school grade level) without

ADHD or any other known diagnosed neurological disorder to participate. The non

ADHD comparisons attended nine separate high schools located in low to middle (N =

6) and high (N = 3) socio-economic status areas (as determined by an index defined at

the postcode level from the Australian Bureau of Statistics, 2003) in the metropolitan

area of Perth, Western Australia.

The Multidimensional Anxiety Scale for Children (MASC: March, 1998) was

completed by all participants (ADHD/Non ADHD) in their home setting. The

researchers requested that for all test administrations rooms should be quiet, free from

extraneous distracters and that testing be conducted in the morning, to control for

diminished persistence noted in children with ADHD (see Houghton, Douglas, West,

Whiting, et al., 1998; Lawrence, Houghton, Tannock, Douglas, et al., 2002). Verbal

checks with parents affirmed that these requests had been adhered to.

Instrumentation

7
 The Multidimensional Anxiety Scale for Children (MASC: March, 1998) is a self-

report instrument developed to assess the major dimensions of anxiety in children and

adolescents aged 8 to 19 years. A standardised child version (used in this study) and a

research based parent version are available, the items being fundamentally identical.

Respondents rate each of the 39 items separately using a four-point scale anchored with

the response options: “never true about me” (score 0), “rarely true about me” (= 1),

“sometimes true about me” (= 2) and “often true about me” (=3). Completion of the

MASC takes approximately 15 minutes.

Procedure

Permission to conduct the research was initially obtained from the Human

Research Ethics Committee of the administering institution. Following this, the parents

of potential participants with ADHD held on the university based clinic database (n =

160) and in the ADHD support groups (n = 40) were all sent personalised letters of

introduction, information sheets describing the research, consent to participate forms

and reply paid envelopes. Parents who agreed to allow their son(s)/daughter(s) to

participate subsequently received a package via the mail containing two copies of the

MASC, written instructions describing how the instrument should be completed (to

ensure standardisation of procedures), and a reply paid envelope. Overall, the 115

completed MASCs represent a positive response of 57.5% for the ADHD group.

The non ADHD community comparisons (n = 95) were recruited by requesting the

parents of adolescents with ADHD to each invite a parent who had an adolescent (in

the same school grade level) without ADHD or any other known neurological disorder

to participate. If a parent of an adolescent without ADHD agreed to participate then the

second copy of all information along with the MASC was provided. Overall, the 95

completed MASCs represent a positive response of 82.6% for the non ADHD

community comparisons.

8
Results

Many item responses were skewed, therefore bootstrapping with maximum

likelihood estimation was employed (Byrne, 2010). In order to enable bootstrapping

using AMOS 19.0 it was necessary to work with a complete data set. Listwise deletion

of cases with missing data on MASC items reduced the sample size from 210 to 199

(5.3% deletion). There were no differences in whether cases did or did not have

missing data when comparing the ADHD and non ADHD groups, χ2 (df = 1) = 1.51, p

= .219.

Goodness of fit in all models was assessed using the Comparative Fit Index (CFI:

above .95 indicates good fit, above .90 indicates adequate fit), the root mean-square

error or approximation (RMSEA: .05 or less indicates good fit, .08 or less indicates

adequate fit), the CMIN/DF (lower than 2-3 indicates good fit: Carmines & McIver,

1981), Standardized Root Mean Square Residual (SRMR: less than .08 reflects good

fit: Hu & Bentler, 1999) and chi-square (non-significant values represent good fit).

This was to confirm the hypothesized relationships between item indicators and latent

variables. The number of bootstrap samples was set at 2000.

A confirmatory factor analysis of a first-order model using AMOS 19.0 (Arbuckle,

2010) was conducted. This model viewed the four latent variables as independent but

correlated. This revealed a model which had mixed results from the goodness of fit

indicators: χ2 (df = 696) = 1254.02, p < .001, CMIN/DF ratio = 1.80, CFI = .76,

RMSEA = .06 (90% confidence interval [CI]: .06, .07), SRMR = .08. In order to

improve the fit of the model, we refined the model by iteratively deleting those items

with the lowest loadings, until we reached the point where no items loaded under .4.

This meant we deleted 10 items in the following order: Item 21 (“I try to do things

other people will like”, factor loading = .20); item 11 (“I try hard to obey my parents

and teachers”, factor loading = .19); item 5 (“I keep my eyes open for danger”, factor

9
loading = .24); item 26 (“I sleep next to someone from my family”, factor loading =

.25); item 33 (“I get nervous if I have to perform in public”, factor loading = .30); item

2 (“I usually ask permission”, factor loading = .33); item 13 (“I check things out first”,

factor loading = .31); item 32 (“If I get upset or scared, I let someone know right

away”, factor loading = .37); item 36 (“I check to make sure things are safe”, factor

loading = .36); and item 28 (“I try to do everything exactly right”, factor loading = .38).

This final adjustment resulted in a not positive definite covariance matrix. In this

instance, the correlation between Harm Avoidance and Separation Anxiety latent

variables was 1.067, which signals a multicollinearity problem (Byrne, 2010).

Following Byrne (2010) these two factors were therefore combined into a single factor.

This resolved the multicollinearity issue, and the fit of the model was better than the

original model, but still remained unsatisfactory: χ2 (df = 374) = 620.36, p < .001,

CMIN/DF ratio = 1.66, CFI = .87, RMSEA = .06 (90% confidence interval [CI]: .05,

.07), SRMR = .07.

Next, we examined the MASC items to identify similarities in order to amend the

model by correlating the errors associated with those items. We therefore correlated the

following error terms: Items 4 (“I get scared when my parents go away”) and 9 (“I try

to stay near my mom or dad”); items 1 (“I feel tense or uptight”) and 27 (“I feel restless

and on edge”); items 8 (“I get shaky or jittery”) and 35 (“My hands shake”); and items

18 (“I have pains in my chest”) and 24 (“My heart races or skips a beat”). These

refinements led to acceptable model fit: χ2 (df = 370) = 550.76, p < .001, CMIN/DF

ratio = 1.49, CFI = .90, RMSEA = .06 (90% confidence interval [CI]: .04, .06), SRMR

= .07. The final items, the scales they belong to, and the factor loadings are shown in

Table 1. As shown in Table 1, all three scales had good internal reliability (all

Cronbach’s alphas ≥ .78).

Table 1 about here.

10
 Invariance of the measurement model across group (ADHD/Non ADHD),

school-stage, and gender

Invariance across ADHD and non ADHD groups. Our baseline model was one in

which the factor loadings, correlations between latent factor scores, and variance in

factor scores were allowed to vary across groups. A second model, which additionally

constrained all factor loadings to be equal across groups, was then compared to the

baseline model. Change in chi-square between the two models was non-significant, ∆χ2

(df = 26) = 20.78, p = .753, indicating that factor loadings were invariant across groups.

Our third model, compared to the second model, added the constraint that correlations

between latent factor scores also had to be equal across groups. Again, the two models

did not differ significantly, ∆χ2 (df = 3) = 1.07, p = .785. Finally, a fourth model was

compared against the third model, and the fourth model added the constraint that factor

variances also be equal. These two models did differ significantly, ∆χ2 (df = 3) = 13.77,

p = .003. Using the critical ratios of differences, this showed that there was a difference

for the Physical symptoms factor (z = -2.25) but not the Social Anxiety (z = -1.25) or

Separation Anxiety Harm Avoidance (z = -1.01) factors. For the Physical Symptoms

factor there was greater variation in factor scores among the ADHD group (.17, SE =

.054) than among the non ADHD group (.10, SE = .033).

Invariance across gender. The same incremental procedure as above was used to

assess invariance across gender. The model was invariant with respect to factor

loadings, ∆χ2 (df = 26) = 26.79, p = .420, correlations between factors, ∆χ2 (df = 3) =

1.77, p = .621, and the variances of the factors, ∆χ2 (df = 3) = 1.53, p = .675. Thus,

there were no gender differences in the fit of the model.

Invariance across school-stage. We created roughly equal sized groups of students

by splitting the sample into Grades 8 to 9 (N=94) and Grades 10 to 12 (N=105). This

allowed us to conduct the multi-groups analysis in AMOS19.0. However, as was the

11
case for gender, there were no differences across these two groups: factor loadings

were equal, ∆ χ2 (df = 26) = 34.47, p = .124, factor correlations were equal, ∆χ2 (df = 3)

= 4.89, p = .181, and factor variances were equal, ∆χ2 (df = 3) = 2.27, p = .519.

Effects of gender, age, and status as ADHD/Non ADHD on factor scores

We computed factor scores for each of the factors using the factor score

weightings calculated by AMOS 19.0 using the formula W = BS-1, where B is the

matrix of covariances between the unobserved and observed variables, and S is the

matrix of covariances among the observed variables. To use these, each participant’s

score on each item is multiplied by the factor score weight for that item, and this is then

added to a similar score for the following item, and so on (see Table 1 for factor score

weights). Three separate three-way independent groups ANOVAs were conducted, one

for each factor score. Each ANOVA had Group (ADHD vs non ADHD), Grades

(Grades 8 to 9 vs Grades 10 to 12) and Gender as between-groups variables (see Table

2 for means and standard deviations). These revealed only one significant effect, which

was large in magnitude, revealing that the ADHD group had significantly higher scores

on the Physical Symptoms factor (Mean = 0.59, S.D. = 0.37) than the non ADHD

group (M = 0.33, SD = 0.28), F (1,191) = 24.70, p < .001, ηp2 = .12.

Table 2 about here

In summary, our analyses suggest that the MASC is better conceptualized as a

three-factor rather than a four-factor measure when applied to adolescent participants.

The measure was equivalent across younger and older participants and across male and

female participants with respect to factor loadings, correlations between factors and

factor variances. Factor loadings and correlations between factors also were invariant

across the ADHD and non ADHD groups, though there was greater variation in

Physical Symptoms factor scores among the ADHD group than the non ADHD group.

In terms of mean scores on the three factors, there were no differences according to

12
school-stage or gender, and the only difference between the ADHD group and the non

ADHD group was on the Physical Symptoms factor where the latter group displayed

lower scores.

Discussion

The aim of this research was to address the limited research examining the

psychometric properties of the Multidimensional Anxiety Scale for Children in

adolescents with ADHD. As pointed out by Tannock (2003) “comorbidity is the rule

rather than the exception in ADHD” (p. 759) and there is converging literature

documenting the considerable overlap between anxiety and ADHD in both referred

and community samples (see Hammerness et al., 2010; Kollins, 2007; Mayes,

Calhoun, & Crowell, 2000; Schatz & Rostain, 2006). To date, many studies

examining anxiety in children and adolescents with ADHD have tended to report

“internalizing disorders” or “global anxiety”, rather than examining its

multidimensional nature. Given that young people with ADHD and comorbid anxiety

experience greater cognitive impairment (Hammerness et al., 2010; Schatz & Rostain,

2006), and respond differently (Baldwin & Dadds, 2008) or experience less robust

effects of treatment (Ter-Stepanian, Grizenko, Zappitelli, & Joober, 2010), it is

important to identify reliable instrumentation for use in clinical and educational

contexts.

The present study did not confirm the four factor model (i.e., Physical

Symptoms, Social Anxiety, Separation Anxiety, and Harm Avoidance) reported in

the research conducted with children with DSM IV ADHD Combined Type (see

March et al., 1999), or with the majority of studies using community and clinical

samples (e.g., Grills,Tacquechel, Ollendick, & Fisak, 2008; Olason, Sighvatsson, &

Smari 2004; Rynn, Barber, Khalid-Khan, Siqueland, Dembiski, McCarthy, & Gallop,

2006; Yen, Yang, Wu, Hsu, & Cheng, 2010). Rather, a three-factor model with

13
satisfactory reliabilities comprising Physical Symptoms (α = .84), Social Anxiety (α

= .88), and a combined Separation Anxiety/ Harm Avoidance (α = .78) scale

produced the best-fit. Kingery et al. (2009) also reported a similar three-factor model

in their adolescent sample whereby none of the Separation Anxiety items loaded on

to any factor. The reason put forward by the authors for this was that the Separation

Anxiety items did not appear relevant to the African American adolescents in their

study and therefore may not have accurately captured how anxiety is manifested in

this population. The suggestion made was that a broader range of items may be

needed on the MASC to adequately assess the various types of anxiety with African

Americans.

Other researchers have also suggested the need to revise some of the items from

the Harm Avoidance and Separation Anxiety subscales of the MASC. Osman et al.

(2009) suggested that in their study this might have been due to the nature of the

anxiety disorder symptoms seen in adolescent psychiatric inpatients referred for high

rates of internalizing disorders. Rynn et al. (2006) also highlighted issues relating to

the Harm Avoidance subscale, particularly its poor correlation with self-report

anxiety measures. Specifically, the features of Harm Avoidance (e.g., to avoid or

reduce conflict, a desire to please others, and to do everything exactly right) may be

related more to generalized anxiety (see March et al., 1997) especially in those

reporting feelings of apprehension and the need for constant reassurance (see Masi,

Millepiedi, Mucci, Poli et al., 2004). Baldwin and Dadds (2007) further argued that

the Harm Avoidance subscale may capture young people who are perfectionist and

those who seek to present themselves in a favorable light (e.g., “I usually ask

permission”, “I try hard to obey my parents and teachers”). By way of clarification,

Baldwin and Dadds (2007) hypothesized that their findings regarding the weakness

of the Harm Avoidance scale may have been the result of social desirability

14
characteristics specific to community samples. In the present study, both clinical and

community samples were recruited and weaknesses were still evident, which led to

the Harm Avoidance and Separation Anxiety factors being combined into a single

factor.

The only significant difference evident between the adolescents with ADHD and

without ADHD was for Physical Symptoms, with the former recording higher scores

than the latter. Although this concurs with Baldwin and Dadds’ (2008) findings, it

appears that the children and adolescents in their study had not been diagnosed with

ADHD, rather “ADHD symptoms” were measured in a community sample. Our

findings pertaining to Physical Symptoms is supportive of the research documenting

that children and adolescents with ADHD worry about their performance and

behaviour, their susceptibility to embarrassment and future events (Strauss et al.,

1988), and as a result manifest overt signs and symptoms of anxiety (see Jensen,

Hinshaw, Swanson, Greenhill, et al., 2001; Molina, Hinshaw, Swanson, Arnold, et al.,

2009).

It is well documented that 30-40% of those with ADHD referred to clinics meet

the diagnostic criteria for more than one form of comorbid anxiety (see Tannock,

2000). That there were no differences between adolescents with ADHD and those

without ADHD on Social Anxiety and the combined Separation Anxiety/Harm

Avoidance scale appears contrary to these data and other research (see Last, Perrin,

Hersen, & Kazdin, 1992; Spencer, Biederman, & Wilens, 1998). The relative lack of

differences in anxiety must also be considered in terms of pharmacological

intervention. The adolescents with ADHD in the present study had received a formal

diagnosis from a primary care physician and it is therefore highly likely that at the time

of the study they were receiving pharmacological intervention. This may have masked

the true extent of any anxiety.

15
 No age (Grades 8 and 9 vs Grades 10 to 12) and/or gender differences were found

in the present study. With reference to no gender differences, this is somewhat

surprising given the evidence to date (see Gershon, 2002; Rucklidge, 2010, for a

comprehensive review). Cross sectional and prospective studies show adolescent girls

with ADHD display higher levels of internalizing behavior problems, more multiple

anxiety disorders, and more specific anxiety disorders than boys (e.g., Gershon, 2002;

Hammerness, Geller, Petty, Lamb, Bristol, & Biederman, 2010; Levy, Hay, Bennett,

& McStephen, 2005; Rucklidge, 2010). Many previous studies have used teacher

and/or parent ratings of ADHD and anxiety, which according to Schatz and Rostain

(2006) may be less reliable in gauging anxiety accurately. Thus, self-report

instruments, such as the MASC, may be a more effective means of obtaining an

accurate insight into the subjective dispositions that can be difficult to obtain from third

parties.

Generally, this present study supports the utility of the MASC as a measure of

anxiety in adolescents with ADHD. However, the present study also indicates that

items in the Separation and Harm Avoidance subscales may need to be re-examined

and perhaps revised and as such a degree of caution may be warranted when

interpreting these subscales. For example, some of these items (e.g., “I try hard to

obey my parents and teachers”, “I usually ask permission”, and “I try to do

everything exactly right”) may not resonate with today’s young people, irrespective

of whether they have ADHD or not. Nevertheless, the identification of Physical

Symptoms as particularly problematic for adolescents with ADHD provides direction

for future research and treatment focus in the ADHD population.

As with most research there are some limitations associated with the present

research and these need to be acknowledged. For example, the sample size was

relatively small and replication with a much larger sample of adolescents is

16
warranted. Self-report was the single source of data collection for anxiety and

therefore other methods such as semi-structured interviews for validating responses on

the MASC should be considered in future. Furthermore, multiple informants such as

parents and teachers may be beneficial. Although the adolescents in the ADHD group

had received a formal diagnosis, their ADHD subtypes were unknown. Given that

research has shown anxiety is more likely to occur with ADHD (Inattentive Type) the

absence of sub typing information limits the findings to some extent. Finally, it was

not known whether the adolescents with ADHD were receiving medication at the time

of administration of the MASC, which may have had the effect of masking the true

extent of their anxiety.

In conclusion, Souza, Pinheiro, Denardin, Mattos, and Rohde (2004), and

Hammerness et al. (2010) affirm that the relationship between ADHD and anxiety

appears to be robust, existing in international populations of children and adolescents

seen by primary care paediatricians. Therefore, there is a need for reliable

instrumentation with which to measure anxiety. This present study has led to an

increased understanding of the psychometric properties of the MASC, an instrument

currently used extensively by clinicians worldwide, dealing with adolescents who

present with ADHD.

17
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25
Table 1.
Factor structure, item loadings (factor score weightings), and Cronbach’s alphas.
Factor loadings
Item Physical Social Separation/Harm
(α = .84) (α = .88) (α = .78)
1. I feel tense or uptight .52 (.039)
8. I get shaky or jittery .59 (.056)
12. I get dizzy or faint feelings .51 (.051)
15. I’m jumpy .54 (.053)
18. I have pains in my chest .49 (.038)
20. I feel strange, weird, or unreal .71 (.119)
24. My heart races or skips beats .62 (.067)
27. I feel restless and on edge .62 (.063)
31. I feel sick to my stomach .61 (.085)
35. My hands shake .53 (.037)
38. My hands feel sweaty or cold .48 (.045)
3. I worry about other people laughing at me .69 (.095)
10. I’m afraid that other kids will make fun of me .82 (.178)
14. I worry about getting called on in class .59 (.061)
16. I’m afraid other people will think I’m stupid .69 (.091)
22. I worry about what other people think of me .76 (.116)
29. I worry about doing something stupid or embarrassing .77 (.112)
37. I have trouble asking other kids to play with .62 (.068)
39. I feel shy .57 (.055)
4. I get scared when my parents go away .57 (.057)
7. The idea of going away to camp scares me .55 (.091)
17. I keep the light on at night .49 (.083)
19. I avoid going to places without my family .59 (.105)
23. I avoid watching scary movies and TV shows .45 (.043)
30. I get scared riding in the car or on the bus .43 (.097)
34. Bad weather, the dark, heights, animals, or bugs scare me .46 (.052)
6. I have trouble getting my breath .56 (.083)
9. I try to stay near my mom or dad .58 (.068)
25. I stay away from things that upset me .48 (.060)
26
Table 2.

Means (standard deviations) for factor scores by Grade, Gender and Group.

Factor

Grade Gender Group Physical Separation/Harm Social

8&9 Male ADHD (N=28) 0.60 (0.33) 0.56 (0.43) 1.06 (0.50)

Non-ADHD (N=16) 0.24 (0.20) 0.37 (0.23) 0.81 (0.64)

Female ADHD (N=11) 0.66 (0.44) 0.58 (0.43) 0.90 (0.64)

Non-ADHD (N=39) 0.34 (0.33) 0.56 (0.36) 0.98 (0.61)

10, 11, 12 Male ADHD (N=54) 0.57 (0.32) 0.38 (0.29) 0.99 (0.63)

Non-ADHD (N=7) 0.38 (0.23) 0.44 (0.23) 0.99 (0.23)

Female ADHD (N=14) 0.65 (0.53) 0.46 (0.39) 1.02 (0.65)

Non-ADHD (N=30) 0.36 (0.28) 0.46 (0.29) 0.88 (0.39)

Total (N=199) 0.47 (0.36) 0.47 (0.34) 0.96 (0.57)

27
 Biographies

Professor Stephen Houghton is a Registered Psychologist and Director of the

Centre for Child and Adolescent Related Disorders at the University of Western

Australia. His research activities focus on childhood and adolescent psychopathology

particularly in relation to ADHD and executive functions, conduct disorder,

developmental trajectories to delinquency and the affective and interpersonal traits

constituting juvenile psychopathy.

Simon C. Hunter, PhD, is a Chartered Psychologist and Senior Lecturer in the

School of Psychological Sciences and Health at the University of Strathclyde. His

research focuses primarily on the ways in which children and young people respond,

and adjust, to peer-victimization experiences.

Mr Toby Trewin is a postgraduate student in the Graduate School of Education,

at the University of Western Australia. He is a senior teacher in Information and

Communication Technology.

Annemaree Carroll, PhD, is Associate Professor in the School of Education at

The University of Queensland, Brisbane, Australia. Her research focuses on the

establishment of a new theoretical perspective and social-cognitive model for

predicting at-risk and delinquent behaviours that incorporates two major motivational

determinants for involvement in risky behaviour – goal and reputational orientations.

28

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