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Clinical Reference Points for the Screen for Child Anxiety–related Disorders in 2 Investigations of Youth With Chronic Pain

Cunningham, Natoshia R., PhD*,†; Jagpal, Anjana, BA*; Nelson, Sarah, PhD*; Jastrowski Mano, Kristen E., PhD; Tran, Susan T., PhD§; Lynch-Jordan, Anne M., PhD*,†,∥; Hainsworth, Keri, PhD; Peugh, James, PhD*,†; Mara, Constance A., PhD*,†; Kashikar-Zuck, Susmita, PhD*,†

doi: 10.1097/AJP.0000000000000667
Original Articles

Objective: Anxiety is common in pediatric chronic pain and is related to a higher risk for poor outcomes; thus, there is a need for effective clinical screening methods to identify youth with chronic pain and co-occurring anxiety. The Screen for Child Anxiety–related Disorders (SCARED) is a validated measure that defines clinically significant anxiety using the traditional clinical cut-off, but in pain populations, may fail to screen in youth with subclinical anxiety that may also be at increased risk. Two studies aimed to devise a clinically meaningful approach to capture anxiety severity in pediatric chronic pain.

Materials and Methods: Study 1 (n=959) and Study 2 (n=207) were completed at 2 separate pediatric pain clinics, where the SCARED was administered along with measures of disability, activity limitations, pain intensity, quality of life, and pain catastrophizing. Groups with different levels of anxiety were compared on clinical outcomes via multivariate analyses of variance or independent samples t tests.

Results: A tertile solution suggested the following anxiety groupings based on the SCARED: minimal (0 to 12), subclinical (13 to 24), and clinical (≥25). Across both studies, the tertile solution was generally superior in classifying different levels of pain-related outcomes.

Discussion: Future directions include testing the utility of this anxiety classification system to identify youth with subclinical levels of anxiety for early intervention focused on both pain and anxiety management.

*Division of Behavioral Medicine and Clinical Psychology

Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center

University of Cincinnati College of Medicine

Department of Psychology, University of Cincinnati, Cincinnati, OH

§Department of Psychology, DePaul University, Chicago, IL

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI

Supported in part by NIH grants #K23 AT009458-01A1, a training grant awarded to the first author (N.R.C.), and # K24 AR056687, a midcareer mentorship award to the last author (S.K.-Z.). The authors declare no conflict of interest.

Reprints: Natoshia R. Cunningham, PhD, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026 (e-mail:

Received January 18, 2018

Received in revised form September 30, 2018

Accepted October 9, 2018

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