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International Journal of Methods in Psychiatric Research logoLink to International Journal of Methods in Psychiatric Research
. 2023 Mar 15;32(4):e1965. doi: 10.1002/mpr.1965

The German version of the Revised Children's Anxiety and Depression Scale—Psychometric properties and normative data for German 8‐ to 17‐year‐olds

Susanne Grothus 1,2,✉, Ariane Sommer 1,2, Benedikt B Claus 1, Lorin Stahlschmidt 1,2, Bruce F Chorpita 3, Julia Wager 1,2,4
PMCID: PMC10698823  PMID: 36920869

Abstract

Objectives

Anxiety and depression are internalizing mental disorders often commencing in childhood and manifesting in adolescence. The Revised Anxiety and Depression Scale (RCADS) is an internationally widely used standardized diagnostic tool, but the German version has only been validated in a pediatric chronic pain sample; normative data are not available. The aim of this study is to test its reliability (internal consistency) and validity (factorial, convergent, known‐groups) in a representative German school sample and to provide norm data.

Methods

Data were collected from N = 1562 German schoolchildren (M age = 12.2; SD age = 2.33; range 8–17 years; 52.4% girls).

Results

Cronbach's α ranged from 0.73 to 0.96 for the total and the six subscales (five anxiety and one depression). Confirmatory factor analysis showed the 6‐factor model had acceptable to good model fit with CFI = 0.93, TLI = 0.93, RMSEA = 0.05, SRMR = 0.05, which was better than 1‐ and 2‐factor models. The (sub)scales correlated moderate to high negatively with health‐related quality of life (−0.31 ≤ τ ≤ −0.51; p < 0.001) and positively with functional impairment (0.31 ≤ τ ≤ 0.48; p < 0.001). Mean scores of anxiety and depression scales were significantly higher in girls and partly in adolescents.

Conclusion

Findings provide support for the good psychometric properties of the German RCADS in a community sample.

Keywords: anxiety, depression, psychometric properties, RCADS, youth

1. INTRODUCTION

Anxiety and depression are internalizing mental disorders often commencing in childhood and manifesting in adolescence (Beesdo et al., 2009; Kessler & Bromet, 2013). They are among the most commonly diagnosed disorders in youths (Beesdo et al., 2009; Kessler & Bromet, 2013). Nationally representative data on child and adolescent health show a high prevalence of depression and anxiety. For U.S. children up to the age of 17, prevalence rates for anxiety range between 7.1% (Ghandour et al., 2019) and 20.0% (Kessler et al., 2012) and for depression between 3.2% (Ghandour et al., 2019) and 11.3% (Avenevoli et al., 2015; Mojtabai et al., 2016). In Germany, prevalence rates are even higher, with 16.1% of children and adolescent self‐reporting clinically significant symptoms of depression and 15.1% reporting clinically significant symptoms of anxiety (Klasen et al., 2016). Both disorders are among the top 20 conditions of personal health care spending for children and adolescents in the US; in 2013, costs added up to $ 5.0 billion for depression and $ 3.4 billion for anxiety (Bui et al., 2017).

Anxiety and depression are highly comorbid in youth (Bitsko et al., 2018; Cummings et al., 2014; Garber et al., 2016). The prevalences of both conditions increase with age (Bitsko et al., 2022; Ghandour et al., 2019), and girls are two to three times more likely than boys to be affected (Beesdo et al., 2009; Cummings et al., 2014). Anxiety disorders and depression that are not detected and treated timely are more likely to progress into adulthood (Fichter et al., 2009; Johnson et al., 2018; Pine et al., 1998).

Therefore, a standardized diagnostic tool is needed to identify symptoms of both anxiety and depression early, through self‐assessment based on age‐ and sex‐specific norms. Early detection is essential for timely diagnosis and treatment and helps to prevent the negative long‐term impacts of these disorders. One of the most widely used measuring instruments for anxiety and depression in children and youth is the Revised Children's Anxiety and Depression Scale (RCADS; Chorpita et al., 2000). This diagnostic instrument efficiently assesses the six DSM‐based dimensions of generalized anxiety disorder, obsessive‐compulsive disorder, panic disorder, separation anxiety disorder, social phobia, and major depressive disorder in children and adolescents aged eight to 18 years (for more details see 2.3.2). The questionnaire is recommended for standardized assessment by the International Consortium for Health Outcomes Measurement (ICHOM; Krause et al. (2021)). Its international and intercultural comparability has been widely supported (Stevanovic et al., 2017). Currently, freely accessible versions of the RCADS are available in numerous languages (see https://www.childfirst.ucla.edu/resources/). A German version of the RCADS is already available (Stahlschmidt et al., 2019), and its good psychometric properties (e.g. reliability, item properties, construct validity) have been proven in a pediatric chronic pain sample. The RCADS shows strong correlations with other measures of anxiety and depression as well as sex differences (Stahlschmidt et al., 2019). The German RCADS, however, has not yet been validated in a community sample. Representative German normative data are not yet available, but are important for comparing results with the general population and identifying those with elevated anxiety and/or depression scores.

The aim of the present study, therefore, is (a) to test the reliability and construct validity of the RCADS in a large representative community sample of German schoolchildren, and (b) to provide representative normative data. Psychometric properties as well as German age‐ and sex‐specific T‐scores for the (sub‐) scales of anxiety and depression are provided to make interpretation comparable with other countries and to detect elevated values.

It is hypothesized that the German version of the RCADS is a reliable and valid measurement tool for children and adolescents aged eight to 17 years. Construct validity is tested using the following criteria: (a) factorial validity, that is, fitting data from the German RCADS to the factor structure of the original English version; (b) convergent validity, that is, higher depression or anxiety scores should be associated with lower health‐related quality of life (HRQoL) and higher functional impairment; (c) known‐groups validity, where mean scores of anxiety and depression scales should be highest in adolescents and girls.

2. METHOD

2.1. Study procedure

Data were collected at all six public schools (three secondary and three elementary) in a town of 30,000 inhabitants in the northern Ruhr region of North Rhine‐Westphalia, Germany, during October/November 2019 (secondary schools) and September 2021 (elementary schools). The three secondary schools were representative regarding all possible school qualification types in Germany. Data assessment in the elementary schools was originally planned to be conducted in 2020, but was postponed due to the COVID‐19‐related school closings.

For recruitment, study coordinators first presented the project to headmasters and teachers in a personal meeting, then to parents at parent class meetings. Students were informed about the study in class, during normal school lessons. Study information, including consent forms for both parents and students, were distributed to all children and adolescents. All students between eight and 17 years of age who spoke sufficient German were eligible to participate in the study if written informed consent was obtained from parents and the child. Class teachers were requested to preselect which students understood German sufficiently to participate.

Data collection took place at the schools during one (secondary schools) or two (primary schools) lessons. Participants completed the RCADS as part of a larger battery of questionnaires on tablet computers during normal school lessons. To prevent missing data, responses were mandatory. Participants could only proceed to the next question if the previous one had been completed.

The questionnaire battery was part of the MeMaps project (“Chronische Schmerzen bei Kindern und Jugendlichen—multidimensionales Ergebnisqualitätsmaß und praxistaugliche Stratifizierungsstrategie”), which was approved by the Ethics Committee of the University of Witten/Herdecke, Germany (approval code 75/2019).

2.2. Participants

A total of N = 446 children from elementary schools and N = 2209 adolescents from secondary schools were potentially eligible to participate in the study. Of these, N = 1586 parents and children provided written informed consent (59.7% of the total eligible population). N = 19 children and adolescents missed data collection and five participants had to be excluded because n = 4 youths did not fulfill the age criterion, and n = 1 questionnaire was canceled before completion. Thus, N = 1562 complete data sets were available for statistical analysis, which corresponds to a participation rate among all originally registered students of 98.5%. The sample's sex ratio was balanced (n = 818 girls, 52.4%) with M age  = 12.2 (SD = 2.33; range 8–17 years). Nearly all participants (94.5%) were born in Germany.

2.3. Measures

All scales and variables included in this study were obtained by self‐report. Participants answered questions regarding demographic characteristics, anxiety, depression, HRQoL, and functional impairment. Further variables were recorded as part of the MeMaps project but were not relevant for the present work and are therefore not described in more detail.

2.3.1. Demographic variables

Participants reported age (8–17 years), sex (boy, girl), grade level (3–11), and country of birth.

2.3.2. Revised Children's Anxiety and Depression Scale

The RCADS (Chorpita et al., 2000) is a self‐report anxiety and depression questionnaire for children and adolescents aged eight to 18 years. A total of 47 items assess the six relevant DSM‐IV dimensions: general anxiety disorder (GAD; six items; e.g. “I worry about what is going to happen”), obsessive‐compulsive disorder (OCD; six items; e.g. “I get bothered by bad or silly thoughts or pictures in my mind”), panic disorder (PD; nine items; e.g. “All of a sudden I feel really scared for no reason at all”), separation anxiety disorder (SAD; seven items; e.g. “I worry about being away from my parents”), social phobia (SP; nine items; e.g. “I worry about making mistakes”), and MDD (10 items; e.g. “I feel worthless”). The five anxiety‐related subscales comprise a 37‐item Total Anxiety Scale, which is aggregated with the Depression scale into a Total Internalizing Score. The questionnaire is based on a four‐point Likert scale ranging from 0 (never) to 3 (always). Higher scores are associated with greater emotional impairment (Chorpita et al., 2000). The original English version has demonstrated good reliability with Cronbach's α ranging from 0.71 to 0.88, and good validity by means of good model fit for the factor structure and high correlations with other depression and anxiety scales (Chorpita et al., 2000). In this study, the German version translated by Stahlschmidt et al. (2019) used a forward‐backward translation process, which also showed good reliability and validity in assessing anxiety and depression in German pediatric chronic pain patients (Stahlschmidt et al., 2019).

2.3.3. Health‐related quality of life

HRQoL was assessed using the validated German short version of the KIDSCREEN (KIDSCREEN‐10 Index; Ravens‐Sieberer et al., 2010). The questionnaire was developed for children and adolescents aged eight to 18 years to measure HRQoL in the past week. Ten questions (e.g. “Have you felt fit and well?”) are self‐reported on a five‐point Likert scale from 1 (never/not at all) to 5 (always/extremely). Items are summed into a total score, with higher scores representing better HRQoL. T‐values by age and sex are available. In the present sample, internal consistency was good (Cronbach's α = 0.85).

2.3.4. Functional impairment

Functional impairment was assessed with the Functional Disability Inventory (FDI, Walker & Greene, 1991), a self‐report questionnaire assessing functional impairment in 15 daily activities (e.g. “Being at school all day”) in the last 4 weeks in children and adolescents aged eight to 18 years. It is answered on a five‐point Likert scale ranging from 0 (no trouble) to 4 (impossible). A total score is calculated by summing all items; higher scores indicate higher functional disability (Walker & Greene, 1991). The German version used in this study was translated by Offenbächer et al. (2016) and has been validated for children and adolescents with juvenile fibromyalgia syndrome (Offenbächer et al., 2016) and for pediatric chronic pain patients (Stahlschmidt et al., 2018). In the present study, the instrument showed good internal consistency (Cronbach's α = 0.90).

2.4. Data analysis and statistical methods

Statistical data analysis was calculated using the IBM Statistical Package for Social Sciences version 28 for Windows. Confirmatory factor analyses were conducted using R version 4.1.2 (R Core Team, 2022) and RStudio (RStudio Team, 2020) with the lavaan package (Rosseel, 2012). The significance level was set at α < 0.05. To avoid α‐error accumulation due to multiple testing, a Bonferroni correction was applied according to the number of tests performed and the local significance level was adjusted (Curtin & Schulz, 1998). Cohen's d effect sizes are reported (Cohen, 1992, 2013).

2.4.1. Item properties

Item means, standard deviations, and ranges as well as corrected item‐total correlations are reported. For reliability analyses, Cronbach's α was calculated to examine the internal consistency of the RCADS for the six subscales, the Total Anxiety Scale, and Total Internalizing Score. In addition to the total sample, age‐ and sex‐specific subgroup analyses were conducted, as the normative values formed subsequently are stratified by age and sex.

2.4.2. Construct validity

Factorial validity. Confirmatory factor analyses was used to examine the factor structure, model fit, and factor loadings. Based on previous research (Brown et al., 2013; Chorpita et al., 2005; Donnelly et al., 2019; Fontana et al., 2019; Stahlschmidt et al., 2019; Trent et al., 2013), three different models were tested against each other: a 1‐factor model (one overall internalizing factor), a 2‐factor model (separate anxiety and depression scales), and a 6‐factor model (MDD, GAD, OCD, PD, SAD and SP). For confirmatory factor analyses, the Diagonally Weighted Least Squares method was chosen for categorical data. Two recommendations were applied to compare model fit: (1) the one of Beaujean (2014) where better model fit is indicated by a Comparative Fit Index (CFI) and Tucker–Lewis Index (TLI) closer to 1.0, and a Root Mean Square Error of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR) closer to 0.0, and (2) the more conservative one by Schermelleh‐Engel et al. (2003) with CFI and TLI: ≥0.95 = acceptable, ≥0.97 = good; RMSEA: ≤0.08 = acceptable, ≤0.05 = good; and SRMR: ≤0.10 = acceptable, ≤0.05 = good. Δχ 2‐tests compared the three factor models.

Convergent validity. As the convergent validity of the German RCADS with other measures of anxiety and depression has already been demonstrated by Stahlschmidt et al. (2019), this study analyzed convergent validity by Kendall's tau‐b (τ) correlations between the RCADS (sub)scales and HRQoL or functional impairment. τ‐correlations are used because variables were not normally distributed, and associations were interpreted as small (|τ| = 0.1), moderate (|τ| = 0.3), or large (|τ| = 0.5) (Cohen, 2013).

Known‐groups validity. Because of the age and sex effects on depression and anxiety reported above, sex differences were examined using independent t‐tests, which are robust to violations of the normal distribution assumption. Degrees of freedom were adjusted because Levene's test indicated unequal variances for all RCADS scales. To test if RCADS (sub)scales are affected by age, τ‐correlations were performed separately for boys and girls. The local significance level for both tests is reported for significant results after Bonferroni correction.

2.4.3. Generation of normative data

Normative data including means and standard deviations were stratified by age and sex, or by age only for non‐specific data. Five age groups were differentiated (8–9, 10–11, 12–13, 14–15, and 16–17 years). A scoring program with spreadsheets is provided for automatic calculation of the T‐scores.

3. RESULTS

3.1. Item properties

Item means ranged from M = 0.24 (SD = 0.57; “feels scared to stay away from home overnight”, SAD) to M = 1.37 (SD = 1.01; “worries something awful will happen to family”, GAD). The properties of all items are shown in Table A1 of the Appendix. The right‐skewed distribution shows items were frequently answered with never (0). Despite the low item means, the full range of the scale responses (from 0 to 3) were used for all items. The average item means of the subscales ranged from 0.36 to 1.01 (0.36 (SAD), 0.44 (GAD), 0.52 (PD), 0.66 (OCD), 0.67 (MDD), 1.01 (SP)). The Total Anxiety Scale as well as the Total Internalizing Score both have an average of M = 0.69. The corrected item‐total correlations for all subscales were within acceptable ranges (MDD: 0.48–0.65; GAD: 0.48–0.69; OCD: 0.43–0.61; PD: 0.52–0.70; SAD: 0.37–0.52; SO: 0.58–0.74, see Appendix Table A1).

The internal consistency for the Total Internalizing Score of the German version of RCADS was excellent, with Cronbach's α = 0.96. For the subscales, Cronbach's α ranged from 0.73 (OCD) to 0.89 (SP). Internal consistencies within the subgroups were comparable, with slightly lower Cronbach's α for younger children and boys. Internal consistencies of all scales and subgroups are shown in Table 1.

TABLE 1.

Cronbach's α of RCADS scales for the total sample and stratified by sex and age.

Group N Total Internalizing Score Total Anxiety Scale MDD GAD OCD PD SAD SP
Total sample 1562 0.96 0.95 0.87 0.82 0.76 0.85 0.73 0.89
Girls 818 0.96 0.95 0.89 0.83 0.80 0.89 0.74 0.89
Boys 744 0.94 0.93 0.81 0.79 0.68 0.80 0.69 0.87
8–9 years 214 0.94 0.93 0.76 0.78 0.64 0.80 0.69 0.82
10–11 years 420 0.96 0.95 0.87 0.83 0.78 0.87 0.73 0.90
12–13 years 404 0.96 0.96 0.88 0.86 0.78 0.89 0.75 0.90
14–15 years 392 0.96 0.95 0.88 0.82 0.78 0.88 0.74 0.90
16–17 years 132 0.96 0.95 0.89 0.82 0.76 0.88 0.75 0.90
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Abbreviations: GAD, Generalized anxiety disorder; MDD, Major depressive disorder; N, sample size; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; RCADS, Revised Children's Anxiety and Depression Scale; SAD, Separation anxiety disorder; SP, Social phobia.

3.2. Construct validity

3.2.1. Factorial validity

According to recommendations by Schermelleh‐Engel et al. (2003), fit indices for the 6‐factor model were acceptable to good. Compared with the 1‐ and 2‐factor models, model fit for the 6‐factor model was best with CFI = 0.93 and TLI = 0.93 closest to 1.0, and RMSEA = 0.05 and SRMR = 0.05 closest to 0.0 (Beaujean, 2014). The 6‐factor model was tested against the 1‐ and 2‐factor models showing significantly better model fit (Δχ 2(15) = 3694.42, p < 0.001 (1 factor against 6 factor); Δχ 2(14) = 2824.86, p < 0.001 (2 factor against 6 factor)), with only RMSEA and SRMR showing acceptable fit. Fit statistics of all models tested are shown in Table 2.

TABLE 2.

Model fit of all models tested in the confirmatory factor analysis.

χ 2 df p CFI TLI RMSEA SRMR
1‐Factor model 9189.42 1034 <0.001 0.87 0.87 0.07 0.07
2‐Factor‐model 8319.86 1033 <0.001 0.89 0.88 0.07 0.06
6‐Factor model 5495.00 1019 <0.001 0.93 0.93 0.05 0.05
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Abbreviations: CFI, Comparative Fit Index; RMSEA, Root Mean Square Error of Approximation; SRMR, Standardized Root Mean Square Residual; TLI, Tucker‐Lewis Index.

Because of the best model fit, only the factor loadings for the 6‐factor model are reported, all of which were within an acceptable range: 0.53–0.80 for the SAD subscale, 0.62–0.87 for SP, 0.53–0.84 for OCD, 0.67–0.83 for GAD, 0.70–0.86 for PD, and 0.59–0.80 for MDD. The factor loadings are presented in Table A1 of the Appendix.

3.2.2. Convergent validity

With significant negative τ‐correlations ranging from −0.51 ≤ τ ≤ −0.31, p < 0.001, the RCADS subscales MDD, GAD, OCD, PD, SAD, and SP as well as both the Total Anxiety Scale and the Total Internalizing Score demonstrated moderate to large associations with the KIDSCREEN‐10, indicating that higher scores on these subscales are associated with lower HRQoL. All eight (sub)scales also had significant positive correlations with the FDI (0.31 ≤ τ ≤ 0.48, p < 0.001), indicating those with higher anxiety or depression scores are more likely to experience more functional limitations. Table 3 displays all τ‐correlation coefficients.

TABLE 3.

τ‐Correlations of the RCADS with functional impairment and HRQoL.

MDD GAD OCD PD SAD SP Total Anxiety Scale Total Internalizing Score
HRQoL −0.51* −0.32* −0.34* −0.38* −0.31* −0.39* −0.41* −0.47*
Functional Impairment a 0.48* 0.32* 0.36* 0.42* 0.31* 0.36* 0.41* 0.45*
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Abbreviations: GAD, Generalized anxiety disorder; HRQoL, Health‐Related Quality of Life, measured with KIDSCREEN‐10; MDD, Major depressive disorder; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; SAD, Separation anxiety disorder; SP, Social phobia.

a

Measured with FDI, Functional Disability Inventory.

* Significant at p ≤ 0.006 after Bonferroni correction.

3.2.3. Know‐groups validity

Girls reported significantly higher means than boys on all RCADS subscales as well as the Total Anxiety Scale and the Total Internalizing Score (−0.65 ≤ Cohens's d ≤ −0.39). Means and standard deviations for all RCADS scales for girls and boys are shown in Table 4.

TABLE 4.

Means and standard deviations for all RCADS scales of the total sample and stratified by sex.

Total sample N = 1562 Girls n = 818 Boys n = 744 t [95% CI] p* Cohen's d
M SD M SD M SD
MDD 6.73 5.42 8.05 5.98 5.27 4.28 −10.65 [−3.30; −2.27] <0.001 −0.53
GAD 5.44 3.74 6.21 3.91 4.59 3.35 −8.79 [−1.98; −1.25] <0.001 −0.44
OCD 3.93 3.45 4.57 3.78 3.23 2.88 −7.88 [−1.67; −1.00] <0.001 −0.39
PD 4.64 4.79 5.91 5.41 3.24 3.50 −11.67 [−3.12; −2.22] <0.001 −0.58
SAD 2.48 2.84 3.11 3.13 1.80 2.29 −9.51 [−1.58; −1.04] <0.001 −0.48
SP 9.06 6.02 10.83 6.28 7.11 5.05 −12.93 [−4.28; −3.15] <0.001 −0.65
Total Anxiety Scale 25.55 17.79 30.62 19.17 19.98 14.19 −12.54 [−12.31; −8.98] <0.001 −0.63
Total Internalizing Score 32.28 22.30 38.67 24.18 25.25 17.52 −12.64 [−15.51; −11.34] <0.001 −0.63
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Abbreviations: CI, Confidence Interval; GAD, Generalized anxiety disorder; M, mean; MDD, Major depressive disorder; N, sample size; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; RCADS, Revised Children's Anxiety and Depression Scale; SAD, Separation anxiety disorder; SD, standard deviation; SP, Social phobia.

* Significant at p ≤ 0.006 after Bonferroni correction.

τ‐correlation analyses showed weak associations between age and RCADS (sub)scales for girls and for boys (see Table 5).

TABLE 5.

τ‐Correlations of the RCADS and age stratified by sex.

MDD GAD OCD PD SAD SP Total Anxiety Scale Total Internalizing Score
Age girls (n = 818) 0.14* 0.05 0.03 0.12* −0.07* 0.14* 0.09* 0.10*
Age boys (n = 744) −0.09* −0.10* −0.12* −0.09* −0.21* 0.02 −0.09* −0.10*
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Abbreviations: GAD, Generalized anxiety disorder; MDD, Major depressive disorder; n, sample size; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; RCADS, Revised Children's Anxiety and Depression Scale; SAD, Separation anxiety disorder; SP, Social phobia.

* Significant at p ≤ 0.006 after Bonferroni correction.

3.3. Generation of normative data

Based on the sample of N = 1562 schoolchildren, means and standard deviations were generated by age and sex (see Table 6). For non‐specific T‐Scores, means and standard deviations are provided separately by age in the Appendix (see Table A2). In the present sample, 16.5% of children and adolescents had striking anxiety levels and 14.3% had striking depression levels. A program and syntax to calculate and score German T‐values are provided (see https://www.childfirst.ucla.edu/resources/).

TABLE 6.

Ranges, means and standard deviations for the RCADS subscales/total scale in combined samples.

Sex Age Scale N Minimum Maximum M SD
Girls 8–9 years MDD 111 0 22 7.37 4.60
GAD 111 0 16 6.27 3.60
OCD 111 0 13 4.42 3.07
PD 111 0 23 4.82 4.38
SAD 111 0 15 4.08 3.36
SP 111 0 26 9.05 5.01
Total Anxiety 111 0 73 28.64 16.48
Total Internalizing 111 0 95 36.29 20.44
10–11 years MDD 185 0 27 6.32 5.85
GAD 185 0 18 5.71 4.00
OCD 185 0 18 4.32 4.05
PD 185 0 27 5.17 5.52
SAD 185 0 16 2.94 3.11
SP 185 0 27 9.72 6.55
Total Anxiety 185 0 101 27.88 20.31
Total Internalizing 185 0 127 34.20 25.33
12–13 years MDD 227 0 30 7.80 6.12
GAD 227 0 18 6.19 4.21
OCD 227 0 18 4.48 3.89
PD 227 0 27 5.99 5.71
SAD 227 0 17 3.04 3.15
SP 227 0 27 10.83 6.27
Total Anxiety 227 1 100 30.53 20.05
Total Internalizing 227 1 128 38.33 25.34
14–15 years MDD 225 0 29 9.40 5.97
GAD 225 0 18 6.57 3.64
OCD 225 0 18 4.87 3.74
PD 225 0 24 6.58 5.34
SAD 225 0 15 2.8 2.9
SP 225 0 27 11.85 6.29
Total Anxiety 225 2 93 32.68 18.17
Total Internalizing 225 2 122 42.08 22.94
16–17 years MDD 70 1 29 10.06 6.34
GAD 70 0 17 6.24 3.89
OCD 70 1 27 4.73 6.16
PD 70 0 21 7.11 5.41
SAD 70 0 13 3.17 3.25
SP 70 1 27 13.09 6.16
Total Anxiety 70 3 85 34.34 19.30
Total Internalizing 70 4 114 44.40 25.50
Boys 8–9 years MDD 103 0 16 7.29 3.83
GAD 103 0 13 5.41 3.20
OCD 103 0 13 4.12 3.00
PD 103 0 18 4.04 3.65
SAD 103 0 11 3.21 2.68
SP 103 0 18 6.50 4.32
Total Anxiety 103 0 55 23.28 13.47
Total Internalizing 103 0 70 30.57 16.41
10–11 years MDD 235 0 23 5.06 4.32
GAD 235 0 16 4.90 3.47
OCD 235 0 14 3.58 2.99
PD 235 0 20 3.49 3.68
SAD 235 0 13 2.01 2.40
SP 235 0 26 7.54 4.99
Total Anxiety 235 0 74 21.52 14.91
Total Internalizing 235 0 90 26.58 18.30
12–13 years MDD 177 0 19 4.47 3.94
GAD 177 0 13 4.25 3.27
OCD 177 0 12 2.80 2.67
PD 177 0 14 2.84 3.05
SAD 177 0 9 1.47 1.95
SP 177 0 25 6.62 5.17
Total Anxiety 177 0 63 17.97 13.42
Total Internalizing 177 0 80 22.45 16.43
14–15 years MDD 167 0 20 5.10 4.19
GAD 167 0 16 4.25 3.37
OCD 167 0 18 2.84 2.87
PD 167 0 23 2.93 3.52
SAD 167 0 12 1.14 1.85
SP 167 0 27 7.07 5.29
Total Anxiety 167 0 96 18.24 14.21
Total Internalizing 167 0 116 23.34 17.44
16–17 years MDD 62 0 21 5.40 5.03
GAD 62 0 11 3.97 2.95
OCD 62 0 11 2.74 2.41
PD 62 0 12 2.98 3.51
SAD 62 0 13 1.31 2.06
SP 62 0 23 8.05 5.25
Total Anxiety 62 2 56 19.05 13.39
Total Internalizing 62 2 69 24.45 17.53
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Abbreviations: GAD, Generalized anxiety disorder; M, mean; MDD, Major depressive disorder; N, sample size; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; RCADS, Revised Children's Anxiety and Depression Scale; SAD, Separation anxiety disorder; SD, standard deviation; SP, Social phobia.

4. DISCUSSION

The RCADS is an internationally‐validated measurement tool to assess anxiety and depression in children and adolescents of both clinical and community samples. The aim of the current study was to evaluate the reliability and validity of the German version of the RCADS in a large representative sample of German schoolchildren and to provide sex‐ and age‐specific normative data. Results indicate that the German version of the RCADS is a reliable and valid measurement instrument for German children and adolescents aged eight to 17 years. The internal consistency of the German RCADS was good to excellent. Construct validity was supported by good model fit in confirmatory factor analysis for the 6‐factor model and by the hypothesized significant negative correlations with HRQoL as well as the positive correlations with functional impairment. In addition, known‐groups validity showed expected differences in relation to sex and age, with girls reporting higher scores that increased slightly with age, particularly for scales measuring internalizing syndromes whose rates are known to increase across development in girls, such as depression and PD.

4.1. Item properties

The good internal consistency of the RCADS (sub)scales is consistent with the review of Piqueras et al. (2017), who reported good RCADS reliability across different settings and countries. Item and scale means were rather low compared to the original US study by Chorpita et al. (2000), except for the PD subscale. But, these low‐mean, right‐skewed score distributions are reported in other validation studies in healthy samples of the general population, including Denmark, Brazil, the Netherlands and Australia (Brown et al., 2013; Esbjørn et al., 2012; Fontana et al., 2019; Kösters, Chinapaw, Zwaanswijk, van der Wal, & Koot, 2015; Ross et al., 2002). Unexpectedly, the mean score for the Total Anxiety Scale (M = 25.6; SD = 17.8, N = 1562) and the subscales were significantly higher than the scale mean found by Stahlschmidt et al. (2019) in a German pediatric chronic pain sample (M = 22.7, SD = 16.5, N = 300); t(1860) = 2.967, p = 0.003, d = 0.19). Further German studies need to be conducted with other clinical samples to explain this unexpected finding.

For the depression subscale, the mean score of M MDD = 6.7 in the present sample was found to be within range of the reference school samples (from M MDD = 4.8 (Esbjørn et al., 2012) to M MDD = 7.81 (Chorpita et al., 2000)). Compared with the German pediatric pain sample (M MDD = 9.3), the mean of the depression scale was lower in the present sample. This is to be expected, given that a clinical pain sample will exhibit more associated depressive symptoms than a healthy comparison sample.

4.2. Construct validity

4.2.1. Factorial validity

The model fit for the 6‐factor model, which was better than the 1‐ and 2‐factor models, is in line with other school‐based validation studies in the United States (Brown et al., 2013) and Europe (Donnelly et al., 2019; Esbjørn et al., 2012; Giannopoulou et al., 2022; Lisøy et al., 2022; Skoczeń et al., 2019), as well as with clinical samples (Chorpita et al., 2005; Gormez et al., 2017). Moreover, all items were strongly correlated with the factors, indicated by high factor loadings ranging from 0.53 to 0.83. Overall, the good fit indices confirm the factor structure. This indicates that the six factors reasonably reflect the six DSM‐based dimensions of anxiety and depression.

4.2.2. Convergent validity

Numerous studies have reported good convergent validity with other anxiety and depression scales in school samples (e.g. Chorpita et al., 2000; Fard et al., 2021; Fontana et al., 2019; Giannopoulou et al., 2022; Gormez et al., 2017; Lu et al., 2021; Muris et al., 2002). This was also supported in a German study with children and adolescents with chronic pain (Stahlschmidt et al., 2019). In the present study, convergent validity analyses were expanded to the related constructs of HRQoL and functional impairment. Significant negative τ‐correlations between RCADS (sub)scales and HRQoL (τ = −0.51 to −0.31) showed that as expected, HRQoL decreased as anxiety and depression symptoms increased. Previous studies have demonstrated this relationship using different questionnaires for depression (Center of Epidemiological Studies Depression Scale for Children; CES‐DC), anxiety (Screen for Child Anxiety Related Disorders; SCARED), and HRQoL (KIDSCREEN‐52, Pediatric Quality of Life Inventory; PedsQL) (Bettge, Wille, Barkmann, Schulte‐Markwort, & Ravens‐Sieberer, 2008; Stevanovic, 2013). The significant positive τ‐correlations between RCADS (sub)scales and functional impairment showed that depression or anxiety symptoms increased with greater functional impairment. This relationship is also reported in large adolescent population samples for both anxiety (Raknes et al., 2017) and depression (Nagar et al., 2010). Furthermore, Stahlschmidt et al. (2019) found weak, but significant, positive correlations between FDI and these constructs (r general anxiety and r depression = 0.20) for German pediatric chronic pain patients. Therefore, the results in the present study are in line with expectations and provide support for the convergent validity of the German version of the RCADS.

The correlations of MDD symptoms with both HRQoL and functional impairment were higher than correlations between anxiety symptoms with those same two impairment criteria, indicating that depression might be more burdensome in daily life for children and adolescents than are anxiety disorders. These findings are supported by a large Dutch study that also found a higher individual burden of disease from depression than from anxiety (Klaufus et al., 2022). In contrast, Stevanovic (2013) found that anxiety in children and adolescents was more strongly correlated with Quality of Life than depression (zero‐order correlations = −0.49 and −0.54, respectively). Further studies examining the relationship between anxiety, depression and HRQoL in German schoolchildren are needed to investigate these different outcomes.

4.2.3. Known‐groups validity

As reported in previous studies (Chorpita et al., 2000; Donnelly et al., 2019; Esbjørn et al., 2012; Fard et al., 2021; Fontana et al., 2019; Giannopoulou et al., 2022; Kösters et al., 2015; Lu et al., 2021; Muris et al., 2002; Ross et al., 2002), there were sex differences among all subscales of the RCADS as well as the Total Anxiety Scale and Total Internalizing Score. For all, girls scored significantly higher than boys.

The hypothesis that anxiety and depression symptoms increase with age was weakly supported in girls, with small significant τ‐correlations among MDD, PD, SP, the Total Anxiety Scale and the Total Internalizing Score. In contrast, weak negative correlations between age and all subscales, except for SP, showed symptoms decreased with age for boys, which is in contrast to our hypothesis. Ross et al.’s (2002) explanation for this finding is that girls are more willing to admit symptoms of anxiety and depression, whereas boys—especially during puberty—are more likely to model the "strong man" and feel constrained to underreport feelings of anxiety or depression. This seems possible in this context, although we did not have any measure of gender identity or acculturation in this sample to test this “underreporting” hypothesis. Nevertheless, Kösters et al. (2015), Muris et al. (2002) and Ross et al. (2002) found older children had lower RCADS scores in both Australian and European samples. Further studies specifically examining this relationship are needed to explain the unexpected negative relationship between RCADS scores and age in boys. These studies would be aided by the inclusion of measures of gender identity and perceptions of gender roles in the local cultural context.

4.3. Generation of normative data

This study is the first to produce T‐values and normative data for RCADS (sub)scales for German schoolchildren. Because children in German grades are heterogeneous, we decided to use age levels. In the present sample, 16.5% of the schoolchildren had striking levels for an anxiety disorder. This corresponds well with the 15.1% prevalence of anxiety symptoms in German children reported by Klasen et al. (2016), who conducted a large nationwide study (N = 3256) on mental health problems in children and adolescents. In the present study, 14.3% had striking levels for depression. These align with the 16.1% prevalence of depressive symptoms in German children (Klasen et al., 2016). Nevertheless, these are self‐reported symptoms and not clinical diagnoses. A future German study using the RCADS should examine the extent to which self‐reported anxiety and depression symptoms correspond to clinical diagnoses.

The different mean values of the RCADS subscales in this German school sample compared with those of Chorpita et al. (2000) clearly show that German normative data are necessary and informative. Thus, normative data from different countries can be meaningfully compared in research settings. Due to the τ‐correlations of age or sex and RCADS subscales, a separate calculation of the T‐values according to age and sex is generally warranted. Due to the increasing diversity of genders, non‐specific T‐values were also provided in this work, allowing for a gender‐independent evaluation. However, since clear and significant sex differences were found in the analyses, which in turn will produce different T‐scores with different implications, practitioners should consider whether it is appropriate to use sex‐based norms or non‐specific norms based on how the gender of the individual respondent is reported.

5. LIMITATIONS

Although valuable findings have been obtained from this German RCADS study, there are some limitations. First, it must be considered that the primary schoolchildren data were obtained in 2021, during the Coronavirus pandemic. Globally, both anxiety and depression scores increased in children and adolescents during this period (Racine et al., 2021). After the acute phase of the pandemic has ended, the mean scores of the RCADS (sub)scales should be re‐examined in a smaller sample of children aged eight to 10 years. Second, despite the high participation rate of all eligible students (59.7%), those suffering from depression or anxiety symptomatology may have been underrepresented, as studies show that depression and anxiety are associated with increased school absenteeism. Thus, it would be possible in a school‐based study that these children were absent due to their anxiety and depressive disorder and therefore did not participate (Askeland et al., 2020; Finning et al., 2019). Third, the group size of 16‐ and 17‐year‐olds is smaller than those of the younger age groups. Nevertheless, the sample size seems sufficient to obtain reliable mean values for generating normative data. Fourth, for the nonclinical school sample, symptoms of depression and anxiety could not be matched with a clinical diagnosis. A clinical study is needed to examine whether anxious and depressive disorder symptomatology assessed with the German RCADS corresponds to clinical diagnoses. Fifth, such a clinical study is required to generate clinically relevant depression and anxiety disorder cutoff points for the German version of the RCADS. Cutoff points help to assess, for example, whether patients need therapy or not. Beyond the benefit of cut‐off points for individual patients, they are essential for clinical trials that enable evidence‐based treatment. Sixth, in this context, the sensitivity to change of the RCADS must be examined, because an instrument used in clinical trials needs to be sensitive to changes produced by an intervention. Finally, no German short version of the RCADS has been developed, unlike those available in other languages (e.g., Ebesutani et al., 2012; Klaufus et al., 2020; Radez et al., 2021; Skoczeń et al., 2019; Young et al., 2021). A shorter, pragmatic instrument would simplify screening for anxiety and depression in children and adolescents in the general population. In clinical settings, patient impairment could be monitored more easily over time using a shorter instrument, if a valid brief measure was available.

6. CONCLUSION

The German version of the RCADS is a reliable and valid measurement tool to assess DSM‐based symptoms of anxiety and depression in German students. The sound psychometric properties reported in previous studies were supported in this large German school sample, and t‐scores were calculated. Further validation studies in large clinical samples are needed to improve the diagnostic utility of the German RCADS by establishing cutoff points.

AUTHOR CONTRIBUTIONS

Susanne Grothus: Data curation; Formal analysis; Investigation; Methodology; Project administration; Validation; Writing – original draft. Ariane Sommer: Data curation; Investigation; Methodology; Project administration; Writing – review & editing. Benedikt Claus: Formal analysis; Writing – review & editing. Lorin Stahlschmidt: Conceptualization; Writing – review & editing. Bruce Chorpita: Methodology; Writing – review & editing. Julia Wager: Conceptualization; Methodology; Project administration; Writing – review & editing.

CONFLICT OF INTEREST STATEMENT

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ACKNOWLEDGMENTS

The data set used for validation was retrieved from a study supported by the Joint Federal Committee Innovation Fund (identification number: 01VSF18020). No other funding was received. The funding source had no role in study design; in the collection, analysis or interpretation of data; in writing the report; or in the decision to submit the article for publication. We would like to thank the schools contributing to the study for their support during recruitment and data collection. We are very grateful to all the children and adolescents for their study participation. Finally, we would like to acknowledge Alexandra van der Valk for proofreading this article.

Open Access funding enabled and organized by Projekt DEAL.

TABLE A1.

Cronbach's α, itemmean, mean inter‐item correlation, and item properties for the 6‐factor model.

Subscale (Cronbach's α) Itemmean (MIC) Item and abbreviation M SD Skewness Item‐total‐correlations ʎ 6‐Factor model (N = 1562)
MDD (0.87) 0.67 (0.41) 2 feels sad or empty 0.77 0.80 0.88 0.65 0.80
6 feels nothing is much fun anymore 0.41 0.70 1.78 0.60 0.72
11 has trouble sleeping 0.82 0.89 0.92 0.55 0.64
15 has problems with appetite 0.57 0.78 1.33 0.48 0.59
19 has no energy 0.62 0.73 1.11 0.65 0.72
21 feels tired a lot 0.98 0.90 0.66 0.58 0.63
25 cannot think clearly 0.70 0.70 0.82 0.60 0.73
29 feels worthless 0.50 0.80 1.57 0.63 0.86
40 feels like doesn't want to move 0.63 0.83 1.22 0.59 0.73
47 feels restless 0.73 0.81 0.98 0.58 0.72
GAD (0.82) 0.91 (0.44) 1 worries about things 1.00 0.80 0.64 0.48 0.71
13 worries something awful will happen to family 1.37 1.01 0.31 0.58 0.70
22 worries bad things will happen 0.74 0.82 1.00 0.67 0.82
27 worries something bad will happen 0.73 0.80 1.00 0.69 0.83
35 worries about what is going to happen 0.71 0.80 1.02 0.64 0.83
37 thinks about death 0.89 0.90 0.78 0.51 0.67
OCD (0.76) 0.66 (0.37) 10 bothered by bad or silly thoughts 0.91 0.93 0.77 0.54 0.78
16 keeps checking if things done right 0.80 0.93 0.99 0.43 0.56
23 can't get bad or silly thoughts out of head 0.87 0.93 0.85 0.61 0.84
31 has to think special thoughts to stop bad events 0.25 0.60 2.64 0.49 0.74
42 has to do things over and over again 0.68 0.94 1.22 0.44 0.53
44 has to do things the right way to stop bad events 0.43 0.71 1.73 0.60 0.79
PD (0.87) 0.52 (0.45) 3 when has a problem, gets funny feeling in stomach 0.98 0.93 0.67 0.52 0.68
14 suddenly can't breathe for no reason 0.35 0.69 2.06 0.62 0.75
24 when has a problem, heart beats fast 0.87 0.90 0.84 0.60 0.72
26 suddenly starts shaking for no reason 0.48 0.77 1.57 0.60 0.70
28 when has a problem, feels shaky 0.48 0.77 1.62 0.64 0.79
34 suddenly feels scared for no reason 0.30 0.62 2.22 0.63 0.82
36 suddenly becomes dizzy for no reason 0.49 0.75 1.46 0.63 0.75
39 heart suddenly beats too quickly for no reason 0.38 0.70 1.95 0.70 0.81
41 worries of suddenly getting scared for no reason 0.30 0.62 2.35 0.64 0.86
SAD (0.73) 0.36 (0.28) 5 feels afraid of being alone at home 0.39 0.73 2.02 0.47 0.56
9 worries being away from parents 0.56 0.71 1.29 0.46 0.60
17 feels scared to sleep alone 0.30 0.62 2.42 0.47 0.54
18 trouble going to school 0.29 0.60 2.30 0.42 0.77
33 afraid of being in crowded places 0.30 0.63 2.37 0.37 0.70
45 worries to go to bed at night 0.41 0.71 1.81 0.52 0.80
46 feels scared to stay away from home overnight 0.24 0.57 2.70 0.41 0.53
SP (0.89) 1.01 (0.49) 4 worries when done poorly at something 1.36 0.91 0.30 0.63 0.77
7 scared to take a test 1.10 0.96 0.62 0.58 0.62
8 worries when someone gets angry 1.12 0.93 0.55 0.63 0.72
12 worries will do badly at school work 1.13 0.95 0.48 0.63 0.71
20 worries might look foolish 0.78 0.85 0.91 0.70 0.82
30 worries about making mistakes 0.96 0.86 0.67 0.74 0.87
32 worries what others think of them 0.90 0.92 0.80 0.69 0.80
38 afraid of talking in front of class 0.81 0.93 0.99 0.59 0.70
43 afraid of looking foolish 0.90 0.88 0.79 0.72 0.83
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Abbreviations: GAD, Generalized anxiety disorder; M, mean; MDD, Major depressive disorder; MIC, Mean inter‐item correlation; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; SAD, Separation anxiety disorder; SD, standard deviation; SP, Social phobia.

TABLE A2.

Ranges, means and standard deviations for the RCADS subscales/total scale for non‐specific gender.

Gender Age Scale N Minimum Maximum M SD
Non‐specific 8–9 years MDD 214 0 22 7.37 4.26
GAD 214 0 16 5.87 3.43
OCD 214 0 13 4.29 3.03
PD 214 0 23 4.47 4.06
SAD 214 0 15 3.67 3.07
SP 214 0 26 7.87 4.90
Total Anxiety 214 0 73 26.17 15.36
Total Internalizing 214 0 95 33.54 18.79
10–11 years MDD 420 0 27 5.62 5.08
GAD 420 0 18 5.26 3.73
OCD 420 0 18 3.91 3.51
PD 420 0 27 4.23 4.65
SAD 420 0 16 2.42 2.77
SP 420 0 27 8.50 5.83
Total Anxiety 420 0 101 24.32 17.75
Total Internalizing 420 0 127 29.94 21.98
Non‐specific 12–13 years MDD 404 0 30 6.34 5.52
GAD 404 0 18 5.34 3.94
OCD 404 0 18 3.74 3.51
PD 404 0 27 4.61 4.98
SAD 404 0 17 2.35 2.80
SP 404 0 27 8.99 6.17
Total Anxiety 404 0 100 25.03 18.52
Total Internalizing 404 0 128 31.37 23.24
14–15 years MDD 392 0 29 7.57 5.69
GAD 392 0 18 5.58 3.71
OCD 392 0 18 4.01 3.54
PD 392 0 24 5.03 4.98
SAD 392 0 15 2.10 2.64
SP 392 0 27 9.82 6.33
Total Anxiety 392 0 96 26.53 18.05
Total Internalizing 392 0 122 34.10 22.73
16–17 years MDD 132 0 29 7.87 6.20
GAD 132 0 17 5.17 3.65
OCD 132 0 16 3.80 3.42
PD 132 0 21 5.17 5.05
SAD 132 0 13 2.30 2.90
SP 132 0 27 10.72 6.26
Total Anxiety 132 2 85 27.16 18.39
Total Internalizing 132 2 114 35.03 23.65
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Abbreviations: GAD, Generalized anxiety disorder; M, mean; MDD, Major depressive disorder; N, sample size; OCD, Obsessive‐compulsive disorder; PD, Panic disorder; RCADS, Revised Children's Anxiety and Depression Scale; SAD, Separation anxiety disorder; SD, standard deviation; SP, Social phobia.

Grothus, S. , Sommer, A. , Claus, B. B. , Stahlschmidt, L. , Chorpita, B. F. , & Wager, J. (2023). The German version of the Revised Children's Anxiety and Depression Scale—Psychometric properties and normative data for German 8‐ to 17‐year‐olds. International Journal of Methods in Psychiatric Research, 32(4), e1965. 10.1002/mpr.1965

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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