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Racial differences in anxiety symptoms among school age youth

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Title:
Racial differences in anxiety symptoms among school age youth
Creator:
Davis, Elizabeth
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Doctor of psychology
Degree Grantor:
University of Colorado Denver
Degree Divisions:
School of Education and Human Development, CU Denver
Degree Disciplines:
School psychology
Committee Chair:
Harris, Bryn
Committee Members:
Crepeau-Hobson, Franci
Stein, Rachel

Notes

Abstract:
Data was collected in 2014 and 2015 by principle investigator Dr. Lorraine Kubicek, Ph.D. as part of the Project to Learn about Youth-Mental Health (PLAY-MH). The study was funded by the Disability Research and Dissemination Center, University of South Carolina School of Medicine and the Center for Disease Control. Parents of 250 students completed the phone interview that included the demographic questionnaire (Kubicek et. al., 2016) and the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC-IV) (Shaffer, et al., 2000). It was hypothesized that students who identified as non-white would have lower symptom counts of both agoraphobia and generalized anxiety disorder. Two one-way analysis of variance (ANOVA) tests were conducted on mean symptom counts of agoraphobia and generalized anxiety disorder, identified on the DISC-IV, by race, identified on the demographic questionnaire. Significance was found for symptom counts of agoraphobia by race and symptom counts of generalized anxiety disorder by race. The agoraphobia hypothesis was not supported, African American students had the highest mean symptom count of agoraphobia. The generalized anxiety disorder hypothesis was partially supported because white students had the highest mean symptom count, however those results were only statistically significant when compared to Hispanic students.

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University of Colorado Denver
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Auraria Library
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Copyright Elizabeth Davis. Permission granted to University of Colorado Denver to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Full Text
RACIAL DIFFERENCES IN ANXIETY SYMPTOMS AMONG SCHOOL AGE
YOUTH
By
ELIZABETH DAVIS
B.A., University of Colorado, Denver, 2014
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Psychology School Psychology Program
2019


This thesis for the Doctor of Psychology degree by Elizabeth Davis has been approved for the School Psychology Program by
Bryn Harris, Chair Franci Crepeau-Hobson Rachel Stein
Date: May 18, 2019
11


Davis, Elizabeth (Psy.D, School Psychology)
Racial Differences in Anxiety Symptoms Among School Aged Youth Thesis directed by Associate Professor Bryn Harris
ABSTRACT
Data was collected in 2014 and 2015 by principle investigator Dr. Lorraine Kubicek, Ph.D. as part of the Project to Learn about Youth-Mental Health (PLAY-MH). The study was funded by the Disability Research and Dissemination Center, University of South Carolina School of Medicine and the Center for Disease Control. Parents of 250 students completed the phone interview that included the demographic questionnaire (Kubicek et. al., 2016) and the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC-IV) (Shaffer, et al., 2000). It was hypothesized that students who identified as non-white would have lower symptom counts of both agoraphobia and generalized anxiety disorder. Two one-way analysis of variance (ANOVA) tests were conducted on mean symptom counts of agoraphobia and generalized anxiety disorder, identified on the DISC-IV, by race, identified on the demographic questionnaire. Significance was found for symptom counts of agoraphobia by race and symptom counts of generalized anxiety disorder by race. The agoraphobia hypothesis was not supported, African American students had the highest mean symptom count of agoraphobia. The generalized anxiety disorder hypothesis was partially supported because white students had the highest mean symptom count, however those results were only statistically significant when compared to Hispanic students.
Approved: Bryn Harris


DEDICATION
This project is dedicated to my close friends and family, without whom I wouldn’t have been able to complete this capstone project or graduate program.
IV


ACKNOWLEDGEMENTS
I would like to acknowledge Dr. Lorraine Kubichek, Dr. Nuri Reyes, Kristina Hightshoe and JFK Partners for their support in this research project.
v


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION.............................................1
Problem and Significance...........................1
Research Questions and Hypothesis..................3
II. LITERATURE REIYEW........................................5
History of Anxiety.................................5
Symptoms of Anxiety and Diagnosis..................6
Anxiety in Young Children..........................7
Differences Among Racial Groups....................7
Mental Health Treatment of Minorities..............9
III. METHODS..................................................10
Data Collection and Measures.......................10
NIMH Diagnostic Interview Schedule for Children IV.. 10
Demographic Questionnaire....................13
Participants.......................................13
Data Analysis......................................14
ANOVA........................................14
III. RESULTS..................................................15
Agoraphobia........................................15
Generalized Anxiety Disorder.......................17
V. DISCUSSION AND FUTURE DIRECTIONS.........................19
Discussion.........................................19
Limitations and Future Directions..................20
Implications for School Psychologists..............21
REFERENCES............................................................22
APPENDIX..............................................................26
vi


CHAPTERI
INTRODUCTION Problem and Significance
Over the last several decades, the prevalence of anxiety disorders has been steadily increasing and is now the seventh most common condition diagnosed worldwide (Rose & Devine, 2014). According to the National Institute of Mental Health, in the United States an estimated 31.9% of adolescents aged 13-18 have a diagnosable anxiety disorder; this includes panic disorder, generalized anxiety disorder, agoraphobia, specific phobia, social anxiety disorder, post-traumatic stress disorder, obsessive compulsive disorder, and separation anxiety disorder (NIMH, 2004). While some of the anxiety experienced by these individuals is mild to moderate, 8.3% were severely impaired by their anxiety (NIMH, 2004).
Research using the National Comorbidity Survey Replication found that the median age of onset of anxiety is 11 years old (Kessler, et al. 2005). Anxiety disorders are one of the most untreated conditions of childhood (Towe-Goodman et. al., 2015; Mazzone et. al., 2007). Only 72% of children aged three to 18 receive any treatment for their anxiety (Towe-Goodman et. al., 2015). Psychiatric conditions like anxiety, depression, and Obsessive-Compulsive Disorder (OCD), lead to greater disability than chronic illness, costing the United States about $300 billion each year (Coleman et. al., 2016).
Struggling with anxiety can lead to school refusal in younger children and an increased risk of drop out for adolescents (Berg, 1992; Kessler, Foster, Saunders, & Stang, 1995), both with severe socioeconomic, educational, and social consequences. Mazzone et al. (2007) found that students with higher anxiety ratings on a self-report anxiety measure were more likely to


have lower grades in school. Ialongo et. al. (1995) explain that lower grades and poor school performance could be do to concentration problems and overall avoidance of new tasks in children with anxiety. When a child avoids new and challenging school work because they are afraid to fail, they may fall further behind their peers as time progresses because they lack prerequisite knowledge or skills (Ialongo et. al., 1995). Anxiety, specifically social anxiety, in school-age children can also hinder the development of important social skills (Weeks, Coplan,
& Kingsbury, 2009). This can lead to more negative reactions to social situations, low selfesteem and more difficulty making and sustaining friendships (Weeks, Coplan, & Kingsbury, 2009).
Anxiety during childhood or adolescence can also lead to anxiety, depression, suicidality, substance abuse disorders and poor psychosocial functioning in adulthood (Latzman, et al., 2011; Bittner, 2007). Its symptoms can cause major stress and have a negative impact on the individual and their family (Towe-Goodman et. al., 2015). In the United States suicide is the 10th leading cause of death for people of any age (NIMH). However, it is the third leading cause of death for youth aged 10 to 14 and the second leading cause of death for youth aged 15-24 (NIMH). Research has also shown that a school-aged child with any psychiatric condition has a negative impact on family functioning, including: increased worrying about the child, additional expenses, strain on family relationships, restricted activities, and a decrease in parental adjustment (Towe-Goodman et. al., 2015).
Anxiety at any age can lead to changes in the brain itself. Cognitive impairments in the prefrontal cortex have been reported in children and adults with anxiety (Park, & Moghaddam,


2016;2017). Children and adults who suffer from anxiety can experience difficulty with flexibility and decision making (Park, & Moghaddam, 2016;2017). They may also be more distracted by irrelevant stimuli than peers who do not have anxiety (Park, & Moghaddam, 2016;2017). Children who experience anxiety also report many somatic symptoms like headaches, stomach aces, and panic attacks, all having a negative impact on the child’s quality of life (Weeks, Coplan, & Kingsbury, 2009).
Research suggests that children of color in the United States are less likely to experience psychiatric disorders than other school-aged children. Several studies have shown that Hispanics, Asians and African Americans were at a lower risk of experiencing generalized anxiety disorder than whites (Breslau et. al., 2006; Grant, et al., 2005). Studies like these suggest that people of color have some protective factors that develop early in life that reduce their risk for developing anxiety disorders (Breslau, et. al., 2006). However, some speculate that this difference is instead due to assessments and diagnostic practices being less likely to diagnose people of color. More research in this area needs to be done to ensure that cultural differences in conditions like anxiety are being identified, diagnosed and treated at the same rate as whites. Changing the rate of identification and diagnosis could have a lasting positive impact on many factors of the individual’s life.
Research Questions and Hypotheses
The goal of the present study is to examine differences in the number of parent reported symptoms of Generalized Anxiety Disorder and Agoraphobia as measured by the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC-IV; Shaffer, et al., 2000)


experienced by individuals of different racial backgrounds as measured by a demographic questionnaire (Kubicek et. al., 2015). The NIMH DISC-IV consists of questions regarding symptoms and diagnostic criteria for each disorder. For generalized anxiety disorder, parents could endorse up to 12 symptoms. For agoraphobia, parents could endorse up to four symptoms. It is hypothesized that individuals who identify as non-white will have lower counts of diagnostic symptoms of agoraphobia and generalized anxiety disorder than their white peers.


CHAPTER II
LITERATURE REVIEW
History of Anxiety
Anxiety is an evolutionary advantage, it was necessary for survival and told a person to stay away from dangerous situations (Crocq, 2015). However, when this anxiety interferes with everyday life and without adequate stimuli it becomes an extremely troubling condition (Rose & Devine, 2014). In the fourth and fifth centuries BCE philosophers and physicians began documenting normal and pathological forms of fear and anxiety (Horwitz, 2013). In the 17th century Robert Burton wrote about anxiety in his book The Anatomy of Melancholy, which encapsulated the negative effects of internalizing symptoms (Crocq, 2015; Bandelow & Michaelis, 2015). Melancholia today could be broken down and separated into a number of diagnoses including anxiety. In the 18th century, panic attacks were classified as a symptom of melancholia instead of as a separate disorder (Crocq, 2015).
All anxiety disorders were termed phobias in the DSM-I and this diagnosis was not specific to children (Huberty, 2012). It wasn’t until the DSM-II that “overanxious reaction” had a specific category that could be diagnosed in childhood (Huberty, 2012). This inclusion was the beginning of the movement to diagnose and treat anxiety disorders in children (Huberty, 2012). The DSM-III was the first to identify anxiety as a sperate condition and included many sub categories of anxiety (Crocq, 2015). The DSM-III also included three child-specific anxiety disorders: avoidant disorder of childhood and adolescence, overanxious disorder, and separation anxiety disorder (Huberty, 2012). The DSM-V utilized neurobiological, genetic, and


psychological features to separate and diagnose subcategories of anxiety and was the first to use brain function as a part of the diagnosis (Crocq, 2015).
Symptoms of Anxiety and Diagnosis
Today, the DSM-V identifies four main subtypes of anxiety disorders including generalized anxiety disorder, phobic disorders, panic disorders, and post-traumatic stress disorder (Rose & Devine, 2014). Each anxiety disorder can only be diagnosed when the cause of the anxiety is not due to a substance or another mental disorder (American Psychiatric Association [APA], 2013). There are differences between each anxiety disorder relating to the objects or types of situations that cause the anxiety (American Psychiatric Association [APA], 2013). Currently the majority of studies focus on racial differences in symptoms of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder and Conduct Disorder. Few studies have focused on racial differences in symptoms of Generalized Anxiety Disorder and Agoraphobia in school aged youth. Therefore, this study will focus on the symptoms of these disorders specifically.
Generalized Anxiety Disorder is a “persistent and excessive anxiety and worry” about several domains including school and work performance that the individual finds difficult to control (American Psychiatric Association [APA], 2013). Individuals experiencing Generalized Anxiety Disorder will have some physical symptoms as well. Some of these physical symptoms include sleep disturbance, feeling restless, muscle tension, being easily fatigued and difficulty concentrating (American Psychiatric Association [APA], 2013).


Agoraphobia is classified by an individual feeling anxious or fearful about at least two of the following situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside the home alone (American Psychiatric Association, 2013). This fear is due to the person believing that escape or assistance might be difficult if panic occurs, making the person likely to avoid all situations that could cause the anxiety (American Psychiatric Association [APA], 2013).
Anxiety in Young Children
It is rare that children aged zero to four are identified with an anxiety disorder (Huberty, 2012). However, symptoms of separation anxiety are often seen when young children are exposed to new situations, but symptoms usually stop after a few days (Huberty, 2012). According to Lavigne et. al. (2009), less than 1% of preschool students showed symptoms of generalized anxiety disorder. However, according to Huberty (2012), generalized anxiety disorder onset can occur at any age, and affects 3% of children. Shamir-Essakow, Ungerer, & Rapee (2005), found that anxiety symptoms were most common in young children who have anxious mothers, were behaviorally inhibited, and insecurely attached. Lavigne et. al. (2009) found no significant differences in rates if anxiety between races.
Differences Among Racial Groups
As the United States population grows, so does its diversity (Wu & Wyman, 2016). According to the United States Census, there are over 300 million people in the United states. The majority of the population (65.8%) are white, 2.1% African American, 0.9% American


Indian or Alaska Native, 0.3% Asian, 4.6% two or more races, and 26.2% identify as another race (U.S. Census, 2016). The U.S. Census Bureau also predicts that the United States will become more diverse as time goes on.
Many studies suggest that racial differences exist between symptoms of diagnosable psychiatric conditions including mood disorders, schizophrenia, obsessive compulsive disorder (OCD), depression, anxiety, eating disorders and aggression (Latzman et al., 2011; Wu, & Wyman, 2016; McLaughlin, et. al., 2007; Romero-Acosta, et al., 2014; Neighbors et. al., 2003). Coleman et. al., (2016) found that African Americans were almost twice as likely to be diagnosed with schizophrenia than whites. Chen, Killeya-Jones, & Vega (2005) found that the adolescent Latino population had significantly higher rates of any anxiety disorder when compared to European American youths. It was also reported that Mexican American youth had higher rates of anxiety disorders than African American or European American youth (Chen, Killeya-Jones, & Vega; 2005). Asnaani, et. al., (2010) found that Hispanic and Asian Americans were less likely to meet diagnostic criteria for many anxiety disorders when compared to white Americans. African Americans were less likely to be identified with generalized anxiety disorder, and social anxiety disorder, but more likely to be diagnosed with Post Traumatic Stress Disorder when compared to white, Hispanic and Asian Americans (Asnaani, et. al., 2010). Compton, Nelson, & March (2000), reported that African American students were more likely to report symptoms of separation anxiety than whites. Differences in rates of specific anxiety disorders by race have not been published.


Coleman et. al. (2016) found that all people of color (African American, Asian, and Latino/a), with the exception of Native Americans, had lower rates of diagnosed psychiatric conditions than whites. There are many theories that try to describe the reason for the discrepancy. Some believe that there are true differences in rates of the mental illnesses, others theorize that the instruments used to diagnose disorders and the use of clinical judgment are less likely to identify people of color (Lancaster et al., 2015; Neighbors et. al., 2003). Another theory is that there is a view of white people as less ill and clinicians see psychiatric symptoms in minorities as more serious than in whites (Strakowski et. al., 1996). Others say that at least part of the difference is due to a difference in presentation of symptoms between racial groups and the lack of culturally specific presentations of mental illness being listed in the diagnostic manual (Strakowski et. al., 1996; Lancaster et al., 2015). Breslau et. al. (2006), stated that this is due to reduced lifetime risk for psychiatric disorders in people of color. Regardless of the reason, having such differences among diagnosis can have a negative impact on the treatment and outcome of patients of color because there are fewer people of color being referred for and receiving treatment that could impact their mental health outcomes (Neighbors et. al., 2003).
Mental Health Treatment of Minorities
It has been reported that people of color are less likely to seek help for their mental health needs, receive a lower quality of care and have less access to services than white Americans (Eack & Newhill, 2012). Lack of medical insurance and limited health literacy are more common among people of color and can also subtract from their likelihood to seek treatment. It was also found that primary care physicians are less likely to identify the mental health problems


of African Americans and Hispanics when compared to whites (Borowsky et. al., 2000). This could have a significant impact on the rates at which they are referred for and receive treatment for their mental illnesses.
When treatment is given, Eack & Newhill (2012) reported that African Americans showed less improvement in their symptoms than their white peers with a similar severe diagnosis. Furthermore, significantly fewer numbers of the African Americans in this study were able to return to work after being discharged from treatment (Eack & Newhill, 2012). These findings point out the intense need to improve the diagnosis and treatment disparities between people of color and whites in the United States. It is important that this disparity be addressed to ensure that all people needing treatment will have better care and better long-term
outcomes.


CHAPTER III
METHODS
Data Collection and Measures
Data was collected in 2014 and 2015 by principle investigator Dr. Lorraine Kubicek, Ph.D. as part of the Project to Learn about Youth-Mental Health (PLAY-MH). The study was funded by the Disability Research and Dissemination Center, University of South Carolina School of Medicine and the Center for Disease Control. The grant given to the principle investigator was titled “Prevalence, Treated Prevalence, and Co-Occurrence of Internalizing, Externalizing, and Tic Disorders in [State omitted] School-Aged Youth”.
Data was collected using a two-stage design. In the first stage, 858 teachers completed the Behavior Assessment System for Children, Behavioral and Emotional Screening system (BASC-2 BESS) (Kamphaus & Reynolds, 2007) to screen 4,183 students from a stratified random sample in one public school district in the mountain west region if the United States. The BASC-2 BESS is a brief screening form that consists of 25-30 questions and can be filled out by parents, students or teachers (Kettler et al., 2017). It assesses a broad range of students’ strengths and weaknesses within internalizing, externalizing, school problems, and adaptive skills (Kettler et al., 2017). Reliability for all forms ranges from 0.90 to 0.97 (Kettler et al., 2017).
Using the scores from the BASC-2 BESS teacher form, all students were placed into one of two groups: the students with the highest scores were placed in the high risk group and students with the lowest scores were placed in the low risk group. In step two, randomly


selected parents of 600 students from each group where invited to participate in a phone interview that was focused on the mental health of their child. These interviews were conducted in either English or Spanish. Spanish interviews were conducted by clinicians fluent in both English and Spanish. Of the parents who were invited to participate, 250 completed the phone interview. Demographic data for these participants is presented in the “Participants” section of this paper.
NIMH Diagnostic Interview Schedule for Children IV
During the interview the parents completed the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC-IV) (Shaffer, et al., 2000) and a demographic questionnaire that was developed for this study (Kubicek et. al., 2016). The NIMH DISC-IV is a structured interview for parents of children aged six to 17, available in both English and Spanish. The DISC-IV consists of over 2, 000 “yes” or “no” questions, however only questions relevant to the family are asked. It covers most internalizing, externalizing and tic disorders using criteria from the Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) and International Classification of Diseases- Tenth Edition (ICD-10). The DISC-IV explores possible symptoms of 34 diagnoses in 26 diagnostic sections (Fisher, Lucas, L., Lucas, C., Sarsfield, and Shaffer, 2006). These sections are arranged into modules A through F. Included in Module A are Anxiety Disorders: Social Phobia, Separation Anxiety Disorder, Specific Phobia, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Selective Mutism, Obsessive-Compulsive Disorder, and Post-Traumatic Stress Disorder (Fisher, Lucas, L., Lucas, C., Sarsfield, and Shaffer, 2006). Modules B through F include Mood disorders, Schizophrenia,


Disruptive Behavior Disorders, Alcohol and Substance Abuse Disorders and Miscellaneous Disorders (Fisher, Lucas, L., Lucas, C., Sarsfield, and Shaffer, 2006).
The DISC-IV assesses the prevalence of symptoms in three time formats: over the last 12 months, over the last four weeks and over the last 2 weeks (Fisher, Lucas, L., Lucas, C.,
Sarsfield, and Shaffer, 2006). The 12-month time period may be less reliable because of how distant some of the symptoms may be, however it does allow the researcher to examine symptoms over the course of an entire school year (Fisher, Lucas, L., Lucas, C., Sarsfield, and Shaffer, 2006). For this reason, only the 12-month time period will be used for this study.
According to Shaffer, Fisher, Lucas, C., Dulcan, & Schwab-Stone, (2000). The DISC-IV is an acceptable and convenient way to assess and identify many different mental health diagnoses. Retests given by clinicians showed that the DISC-IV had moderate to good diagnostic reliability (Shaffer, Fisher, Lucas, C., Dulcan, & Schwab-Stone, 2000). Fair to Moderate agreement (K=0.4 to <0.8) was observed for parent reports for generalized anxiety (K=.65) (Bravo, et. al., 2001). When comparing the DISC-IV to previous versions, the DISC-IV compares favorably. When given to Chinese adolescents in Hong Kong, the DISC-IV was also seen as reliable, identifying internalizing and externalizing disorders at a rate similar to previous studies using other measures (Leung et. al., 2008).
The Spanish version of the DISC-IV was developed by Glorisa Canino, Ph.D. at the University of Puerto Rico (Bravo, et. al., 2001). An international Spanish Advisory group also consulted on the creation of the Spanish DISC-IV (Shaffer, Fisher, Lucas, C., Dulcan, & Schwab-Stone, 2000). According to one study, the Spanish version of the parent and self-report


interviews were reliable across time frames for most disorders evaluated in the DISC-IV (Bravo, et. al., 2001). However, no studies currently exist on its reliability on the American population. On both the Spanish and English version of the DISC-IV parents were more reliable reporters of younger children than of older children (Bravo, et. al., 2001).
Demographic Questionnaire
The demographic questionnaire (Appendix A) was a short survey consisting of questions about the child’s race, the parent’s education level, marital status, number of children in their home, primary language spoken at home, income, relationship to the child and health or behavioral problems that could limit the child’s activities. All data was collected from parent or caregiver report as part of the phone interview that also included the DISC-IV.
Participants
The data was collected from one public school district in the mountain west region of the United States, consisting of more than 30,000 students between kindergarten and 12th grade. Of the 250 participants who completed the phone interview in 2014 and 2015, 1.2% was American Indian or Alaska Native, 16.5% was Black or African American, 1.6% was Asian, 49.8% was Hispanic or Latino/a, 12% was white, 2.4% was other, and 16.5% identified more than one race. This sample is generally congruent with the US population with a slight overrepresentation of Hispanic students and an underrepresentation of Asian and white students (U.S. Census Bureau, 2016). The sample was also representative of the district, however there is a large


overrepresentation of students who identify as more than one race in this study. The American Community Survey, conducted by the United States Census, gathers detailed information from the general population about their household. The survey indicated that approximately 30% of the students in this district do not speak any English at home; of those 30%, 66% spoke Spanish (Kubicek et. al., 2016). For the purposes of this study, only families that speak either English or Spanish were chosen to take part in the phone interview (stage 2).
Data Analysis
ANOVA
To answer the research questions “Is there a significant difference between race and symptom counts of agoraphobia,” and “Is there a significant difference between race and symptom counts of generalized anxiety disorder,” two one-way analysis of variance tests were conducted. Parent reported races included were American Indian, Black or African American, Asian, Hispanic, White, Other, or Multi-racial. Total number of symptoms reported by parents were reported as symptom counts


CHAPTER IV
RESULTS
Agoraphobia
Assumptions were tested, and the Test of Independence was met. The test of normality was violated however, ANOVA is robust to this due to the large sample size in this study. The test of Homogeneity of Variance was also violated therefore a Games-Howell post-hoc test was conducted to analyze specific differences between racial groups. A main effect was found for agoraphobia symptom counts by race, F (6, 236) = 3.16, p< 01, eta=.07 (Table 1). The effect size (eta = .07) is considered medium.
Table 1.
Agoraphobia and Race ANOVA
Sum of Squares df Mean Square F p value
Between Groups 3.18 6 .53 3.16 .005
Within Groups 39.56 236 .17
Total 42.74 242
Post-hoc tests were conducted to explore difference between groups using Games-Howell. At a 95% confidence level, difference was seen between American Indian and African American students, p=.02 with African American student having higher symptom counts, between American Indian and Hispanic students, p<01 with Hispanic students having higher symptom counts, between African American and students who were identified as another race, p=.02, with African American students having higher symptom counts, between Asian and Hispanic students, p< 01, with Hispanic students having higher symptom counts, and between Hispanic students and students who identified as another race, p<01 with Hispanic students


having higher symptom counts. Results that include Asian, American Indian, and students who were identified as “other” should be interpreted with caution due to the small sample size of those races. These differences can be seen in the means plot (Figure 1) and the Discriptives table below (Table 2).
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Figure 1. Agoraphobia Means Plot Table 2.
Agoraphobia Descriptive Statistics
n Mean Std. Deviation Std. Error
American Indian 3 .00 .000 .000
African American 37 .41 .686 .113
Asian 4 .00 .000 .000
Hispanic 122 .16 .386 .035
White 30 .10 .305 .056
Other 6 .00 .000 .000
Multi-Racial 41 .05 .218 .034


Total
243
.16
.420
.027
Generalized Anxiety Disorder
Assumptions were tested, and the Test of Independence and the test of Homogeneity of Variance were met. The test of normality was violated however, ANOVA is robust to this due to the large sample size in this study. A main effect was found for generalized anxiety disorder symptom count by race, F (6, 236) = 2.83, p=.01, eta=.07 (Table 3). The effect size (eta = .07) is considered medium.
Table 3.
Generalized Anxiety Disorder ANOVA
Sum of Squares df Mean Square F p Value
Between Groups 90.13 6 15.02 2.83 .01
Within Groups 1253.94 236 5.31
Total 1344.07 242
Post-hoc tests were conducted to explore difference between groups using Tukey’s HSD. At a 95% confidence level, a difference was seen between white and Hispanic students, p=.05, with white students having higher symptom counts. These differences can be seen in the means plot (Figure 2) and the descriptives table (Table 4) below.


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American African Asian Hispanic White Other Multi-Racial
Indian American
Race
Figure 2. Generalized Anxiety Disorder Means Plot
Table 4.
Generalized Anxiety Disorder Discriptives
N Mean Std. Deviation Std. Error
American Indian 3 1.67 1.528 .882
African American 37 2.92 2.361 .388
Asian 4 .75 1.500 .750
Hispanic 122 1.89 2.357 .213
White 30 3.30 2.452 .448
Other 6 .83 1.602 .654
Multi-Racial 41 2.49 2.135 .333
Total 243 2.27 2.357 .151




CHAPTER V
DISCUSSION AND FUTURE DIRECTIONS Discussion
Over the last several decades, the prevalence of anxiety disorders has been steadily increasing and is now the seventh most common condition diagnosed worldwide (Rose & Devine, 2014). Anxiety is one of the most untreated mental illnesses in the United States and can have severe social, emotional and socioeconomic consequences (Towe-Goodman et. al., 2015; Mazzone et. al., 2007; Berg, 1992; Kessler, Foster, Saunders, & Stang, 1995). Many studies suggest that racial differences exist between symptoms of diagnosable psychiatric conditions including anxiety (Latzman et al., 2011; Wu, & Wyman, 2016; McLaughlin, et. al., 2007; Romero-Acosta, et al., 2014; Neighbors et. al., 2003). However, few studies exist that examine the differences between race and reported symptoms of diagnosable anxiety disorders like generalized anxiety disorder and agoraphobia.
The purpose of the current study was to examine differences in symptom counts of generalized anxiety disorder and agoraphobia by race. It was hypothesized that individuals who identify as non-white will have lower counts of diagnostic symptoms of agoraphobia and generalized anxiety disorder than their white peers. The hypothesis was not supported for agoraphobia; parents of African American students reported the highest mean symptom counts and Hispanic students had the second highest mean symptom counts. This contradicts previous research that stated that people of color would report fewer symptoms of mental health disorders. The hypothesis was partially supported for generalized anxiety disorder because parents of white


students reported the highest mean symptom count, however those results were only statistically significant when compared to Hispanic students.
Limitations & Future Directions
This study included 250 parent participants, however a limited number of participants identified American Indian, Pacific Islander, and Asian as the student’s race. This means that results regarding those samples should be interpreted with caution. Previous studies have stated that parents are more reliable reporters of symptoms of anxiety and depression (Bravo, et. al., 2001). However, those same studies also state that parents are more reliable when reporting symptoms of younger children than adolescents (Bravo et. al., 2001). The current study included participants in kindergarten through 12th grade, therefore results of older children may be less reliable. Different forms of measurement, like self-report or multiple informants, should be used to increase the overall validity in this study.
While the Spanish version of the DISC-IV has been studied extensivly in Puerto Rico its validity has not been studied in the United States. While it is seen as a valid measure in Puerto Rico, without having data about its validity in the United States means that the results of the interviews conducted in Spanish should also be interpreted with caution. More research needs to be done using Spanish speaking individuals within the United States before the DISC-IV Spanish version can be considered valid and reliable.
Future studies should include larger populations of all races to examine possible differences not seen in this study. It may also be beneficial to add more variables to discover


more differences; socioeconomic status, age, and gender in connection with symptoms should be considered. Future studies could also examine differences between individuals with clinically significant symptoms. Learning more about who is most likely and least likely to present with clinically significant symptoms could show who is being diagnosed and who is being missed. This research could have a lasting impact on the diagnostic prosses.
Implications for School Psychologists
The prevalence and impact anxiety disorders have on school aged children in ever present in our society today. When children experience symptoms of anxiety it is important that school psychologists have the ability and resources to provide interventions and supports for students. These interventions will provide students the opportunities and skills to lessen the impact anxiety could have on their lives. While budgets for mental health continue to shrink, it will be important for school professionals to continue to advocate for the mental health needs of all students to ensure that these services will continue to be available.
It will be important for school psychologists to continue to educate themselves about the racial differences in symptoms of mental illnesses to ensure that all students are identified and receive interventions that benefit them. School psychologists have to look at their students through a multicultural lense to ensure that students of color receive an identification when appropriate and misidentification doesn’t occur. School Psychologists need to continue to monitor patterns and social changes that could influence rates of identification of students in their schools. Being able to identifying and provide supports for all students who need it will have a large positive effect on the lives of the students of all school psychologists.




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Kubicek L.F., Hightshoe, K. D., Moody E. J., Reyes N. M., Davidson S. L., Rosenberg S. A., (2016) Prevalence and Treatment of Mental Health Disorders and Developmental Disabilities: A Comparison of High and Low Risk Colorado School-Aged Youth.
Lancaster, S. L., Melka, S. E., Klein, K. P., & Rodriguez, B. F. (2015). Ethnicity and anxiety: A psychometric evaluation of the STICSA. Measurement and Evaluation in Counseling and Development, 48(3), 163-176. doi: 10.1177/0748175615578757
Latzman, R. D., Naifeh, J. A., Watson, D., Vaidya, J. G., Heiden, L. J., Damon, J. D., . . . Young, J. (2011). Racial differences in symptoms of anxiety and depression among three cohorts of students in the southern united states. Psychiatry, 74(4), 332-348. doi:10.1521/psyc.2011.74.4.332
Lavigne J. V., LeBailly S. A., Hopkins J., Gouze K. R. & Binns H. B., (2009) The Prevalence of ADHD, ODD, Depression, and Anxiety in a Community Sample of 4-Year-Olds, Journal of Clinical Child & Adolescent Psychology, 38:3, 315-328, DOI: 10.1080/15374410902851382
Leung, P. W. L., Hung, S., Ho, T., Lee, C., Liu, W., Tang, C., & Kwong, S. (2008). Prevalence of DSM-IV disorders in Chinese adolescents and the effects of an impairment criterion: A pilot community study in hong kong. European Child & Adolescent Psychiatry, 17(7), 452-461. doi: 10.1007/s00787-008-0687-7
Mazzone, L., Ducci, F., Scoto, M. C., Passaniti, E., D'Arrigo, V. G., & Vitiello, B.
(2007). The role of anxiety symptoms in school performance in a community sample of children and adolescents. BMC Public Health, 7(1), 347-347. doi:10.1186/1471-2458-7-347
McLaughlin, K. A., Hilt, L. M., & Nolen-Hoeksema, S. (2007). Racial/Ethnic differences in internalizing and externalizing symptoms in adolescents. Journal of Abnormal Child Psychology, 35(5), 801-816. doi:10.1007/sl0802-007-9128-l
Merikangas, K. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity survey replication-adolescent supplement (NCS-A). J Am Academic Child Adolescent Psychiatry, 49(10), 980-989. doi:10.1016/j.jaac.2010.05.017


National Alliance on Mental Illness (NAMI). (n.d.). Retrieved from http s ://www. nami. org/Learn-More/Mental -Health-By-the-Numb er s
National Institute of Mental Health (NIMH). Any Anxiety Disorder, (n.d.). Retrieved March 14, 2018, from https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml
Neighbors, H., Trierweiler, S., Ford, B., & Muroff, J. (2003). Racial Differences in DSM Diagnosis Using a Semi-Structured Instrument: The Importance of Clinical Judgment in the Diagnosis of African Americans. Journal of Health and Social Behavior, 44(3), 237-256. Retrieved from http://www.jstor.org/stable/1519777
Park, J., & Moghaddam, B. (2016;2017;). Impact of anxiety on prefrontal cortex encoding of cognitive flexibility. Neuroscience, 345, 193-202. doi: 10.1016/j.neuroscience.2016.06.013
Romero-Acosta, K., Penelo, E., Noorian, Z., Ferreira, E., & Domenech-Llaberia, E. (2014). Racial/ethnic differences in the prevalence of internalizing symptoms: Do latin-american immigrant show more symptomatology than Spanish native-born adolescents? Journal of Health Psychology, 19(3), 381-392. doi: 10.1177/1359105312471568
Rose, M., & Devine, J. (2014). Assessment of patient-reported symptoms of anxiety. Dialogues in Clinical Neuroscience, 16(2), 197-211.
Shaffer, D, Fisher, P., Lucas, C., Dulcan, M., & Schwab-Stone, M. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV)
Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 28-38.
Shamir-Essakow, G., Ungerer, J. A., & Rapee, R. M. (2005). Attachment, behavioral inhibition, and anxiety in preschool children. Journal of Abnormal Child Psychology, 33(2), 131-143. doi: 10.1007/s 10802-005-1822-2
Strakowski, S. M., Flaum, M., Amador, X., Bracha, H. S., Pandurangi, A. K., Robinson, D., & Tohen, M. (1996). Racial differences in the diagnosis of psychosis. Schizophrenia Research, 21(2), 117-124. doi: 10.1016/0920-9964(96)00041-2
Towe-Goodman, N. R., PhD, Franz, L., MBChB, Copeland, W., PhD, Angold, A., MRCPsych, & Egger, H., MD. (2014). Perceived family impact of preschool anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 53(4), 437-446. doi: 10.1016/j .jaac.2013.12.017


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Weeks, M., Coplan, R. J., & Kingsbury, A. (2009). The correlates and consequences of early appearing social anxiety in young children. Journal of Anxiety Disorders, 23(7), 965-972. doi:10.1016/j.janxdis.2009.06.006
Wu, K. D., & Wyman, S. V. (2016). Examination of racial differences in assessment of OCD symptoms and obsessive beliefs. Journal of Obsessive-Compulsive and Related Disorders, 10, 10-18. doi: 10.1016/j.jocrd.2016.04.008


Appendix A
Demographic Questionnaire
L.F. Kubicek 14-0007 v-8.28.14 Demographics Questionnaire
This questionnaire concerns you and your child. We realize that this is a detailed questionnaire, but please try to answer as many of the questions as possible.
Child’s date of birth
Child’s gender
o Male o Female
Which racial group(s) describe(s) your child? (select all that apply)
o American Indian or Alaska Native o Asian
o Black or African American o Hispanic or Latino
o Native Hawaiian or Other Pacific Islander o White
o Other (please specify) ________________________________
Your date of birth
Your gender
o Male
o Female
Which racial group(s) describe(s) you? (select all that apply)
o American Indian or Alaska Native o Asian
o Black or African American o Hispanic or Latino
o Native Hawaiian or Other Pacific Islander o White


o Other (please specify) _________________
What is your relationship to this child?
o Biological parent o Adoptive parent o Stepparent o Foster parent
o Other family relative (please specify)
o Other (please specify)
What language do you usually speak when you are at home or with your family?
o English o Spanish
o Other (please specify)________________________________________
What is your child’s primary language?
o English o Spanish
o Other (please specify)________________________________________
What is the highest level of education you have completed?
o Less than high school o High school diploma or GED o Associates degree o Some college (no degree) o Bachelor’s degree o Master’s degree o Professional school degree o Doctoral degree
What is your marital status?
o Single o Married
o Living with a partner o Separated o Divorced o Widowed


Currently Employed?
o Yes
o No
Occupation?__________________________________________
If the child has a second primary caregiver (either someone living in a partnership with you the home, or someone else who is sharing guardianship of the child with you), complete the information below:
Caregiver #2 date of birth
Gender
o Male o Female
Which racial group(s) describe(s) this person? (select all that apply)
o American Indian or Alaska Native o Asian
o Black or African American o Hispanic or Latino
o Native Hawaiian or Other Pacific Islander o White
o Other (please specify) __________________________________________________
Currently Employed?
o Yes
o No
Occupation?_________________________________
What is this person’s relationship to the child?
o Biological parent o Adoptive parent o Stepparent o Foster parent
o Other family relative (please specify)


o
Other (please specify)
What is this person’s highest level of education?
o Less than high school o High school diploma or GED o Associates degree o Some college (no degree) o Bachelor’s degree o Master’s degree o Professional school degree o Doctoral degree
What is this person’s marital status?
o Single o Married
o Living with a partner o Separated o Divorced o Widowed
Including this child, what is the total number of children (under age 18) in the household where he/she is currently living?
What is the total number of adults (age 18 or older) in the household where he/she is currently living?
What is the annual income of this household? (please select one) o Under $5,000
o Under $10,000 ($5,000 -$9,999) o Under $15,000 ($10,000 -$14,999) o Under $20,000 ($15,000 -$19,999) o Under $25,000 ($20,000 - $24,999) o Under $35,000 ($25,000 -$34,999) o Under $50,000 ($35,000 -$49,999) o Under $75,000 ($50,000 - $74,999) o Under $100,000 ($75,000-$99,999) o $100,000 and over


Does your child have any ongoing physical health problems that have been diagnosed by a health care worker (for example, asthma, diabetes, etc.)?
o Yes
o No
If Yes, explain_____________________________________________________________________
Is your child limited in any way in any activities because of physical, mental, or emotional problems?
o Yes
o No
If Yes, explain_____________________________________________________________________
Does your child now have any health problems that require him/her to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
o Yes
o No
If Yes, explain__________________________________________
Health insurance questions from the National Survey on Children’s Health
Does your child have any kind of health care coverage, including health insurance, prepaid plans such as HMO’s, or government plans such as Medicaid?
o Yes
o No
Is your child insured by Medicaid or the Children’s Health Insurance Program, sometimes called CHIP Plus?
o Yes
o No


Full Text

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RACIAL DIFFERENCES IN ANXIETY SYMPTOMS AM O NG SCHOOL AGE YOUTH By ELIZABETH DAVIS B.A . , University of Colorado, Denver, 2014 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Psychology School Psychology Program 2019

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ii This thesis for the Doctor of Psychology degree by Elizabeth Davis has been approved for the School Psychology Program by Bryn Harris, Chair Franci Crepeau Hobson Rachel Stein Date: May 18 , 2019

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iii Da vis, Elizabeth (Psy.D, School Psychology) Racial Differences in Anxiety Symptoms Among School Aged Youth Thesis directed by Ass ociate Professor Bryn Harris ABSTRACT Data was collected in 201 4 and 2015 by principle investigator Dr. Lorraine Kubicek , Ph.D. as part of the Project to Learn about Youth Mental Health (PLAY MH). The study was funded by the Disability Research and Dissemination Center, University of South Carolina School of Medicine and the Center for Disease Control. Parents of 250 stud ents completed the phone interview that included the demographic questionnaire (Kubicek et. al., 2016) and the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC IV) (Shaffer, et al., 2000) . It was hypothesized that students who identified as n on white would have lower symptom counts of both agoraphobia and generalized anxiety disorder. Two one way analysis of variance (ANOVA) tests were conducted on mean symptom counts of agoraphobia and generalized anxiety disorder , identified on the DISC IV, by race , identified on the demographic questionnaire . Significance was found for symptom counts of agoraphobia by race and symptom counts of generalized anxiety disorder by race . The agoraphobia hypothesis was not supported , African American stu dents ha d the highest mean symptom count of agoraphobia. The generalized anxiety disorder hypothesis was partially supported because white students had the highest mean symptom count, however those results were only statistically significant when compared to Hispanic students . Approved: Bryn Harris

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iv DEDICATION have been able to complete this capstone project or graduate program.

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v ACKNOWLEDGEMENTS I would like to acknowledge Dr. Lorraine Kubiche k , Dr. Nuri Reyes, Kristina Hightshoe and JFK Partners for their support in this research project .

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vi TABLE OF CONTENTS CHAPTER I. ... 1 Research Questions and Hypothesis 3 II. 5 5 Symptoms of Anxiety and Diagnosis 6 7 Differences Among Racial Groups 7 Mental Health Treatment of Minorities 9 III. 10 Data Collection and Measures ... . .. 10 NIMH Diagnostic Interview Schedule for Children IV..10 3 Participant s . 1 3 . .1 4 4 III. .. .1 5 5 7 V. DISCUSSION AND FUTURE DIRECTIONS .. 1 9 1 9 Limitations and .. 20 2 1 . 2 2 APPENDIX . . 6

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CHAPTER I INTRODUCTION Pr oblem and Significance Over the last several decades, the prevalence of anxiety disorders has been steadily increasing and is now the seventh most common condition diagnosed worldwide (Rose & Devine, 2014). According to the National Institute of Mental Health, in the United Sta tes an estimated 31.9% of adolescents aged 13 18 have a diagnosable anxiety disorder; this includes panic disorder, generalized anxiety disorder, agoraphobia, specific phobia, social anxiety disorder, post traumatic stress disorder, obsessive compulsive di sorder, and separation anxiety disorder (NIMH, 2004). While some of the anxiety experienced by these individuals is mild to moderate, 8.3% were severely impaired by their anxiety (NIMH, 2004). Research using the National Comorbidity Survey Replication f ound that the median age of onset of anxiety is 11 years old (Kessler, et al. 2005). Anxiety disorders are one of the most untreated conditions of childhood ( Towe Goodman et. al., 2015; Mazzone et. al., 2007). Only 72% of children aged three to 18 receiv e any treatment for their anxiety ( Towe Goodman et. al., 2015). Psychiatric conditions like anxiety, depression, and Obsessive Compulsive Disorder (OCD), lead to greater disability than chronic illness, costing the United States about $300 billion each ye ar (Coleman et. al., 2016). Struggling with anxiety can lead to school refusal in younger children and an increased risk of drop out for adolescents (Berg, 1992; Kessler, Foster, Saunders, & Stang, 1995), both with severe socioeconomic, educational, and social consequences. Mazzone et al. (2007) found that students with higher anxiety ratings on a self report anxiety measure were more likely to

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have lower grades in school. Ialongo et. al. (1995) explain that lower grades and poor school performance coul d be do to concentration problems and overall avoidance of new tasks in children with anxiety . When a child avoids new and challenging school work because they are afraid to fail, they may fall further behind their peers as time progresses because they lack prerequisite knowledge or skills ( Ialongo et. al., 1995) . Anxiety, specifically social anxiety, in school age children can also hinder the development of important social skills ( Weeks, Coplan, & Kingsbury, 2009). Thi s can lead to more negative reactions to social situations, low self esteem and more difficulty making and sustaining friendships ( Weeks, Coplan, & Kingsbury, 2009). Anxiety during childhood or adolescence can also lead to anxiety, depression, suicidali ty, substance abuse disorders and poor psychosocial functioning in adulthood (Latzman, et al., 2011 ; Bittner , 2007). Its symptoms can cause major stress and have a negative impact on the individual and their family ( Towe Goodman et. al., 2015 ). In the United States suicide is the 10 th leading cause of death for people of any age (NIMH). However, it is the third leading cause of death for youth aged 10 to 14 and the second leading cause of death for youth aged 15 24 (NIMH). Research has also shown that a school aged child with any psychiatric condition has a negative impact on family functioning, including: increased worrying about the child, additional expenses, strain on family relationships, restricted activities, and a decrease in parental adjus tment ( Towe Goodman et. al., 2015). A nxiety at any age can lead to changes in the brain itself. C ognitive impairments in the prefrontal cortex have been reported in children and adults with anxiety ( Park, & Moghaddam,

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2016;2017 ) . Children and adults who suffer from anxiety can experience difficulty with flexibility and decision making ( Park, & Moghaddam, 2016;2017 ) . They may also be more distracted by irrelevant stimuli than peers who do not have anxiety ( Park, & Moghaddam, 201 6;2017 ) . Children who experience anxiety also report many somatic symptoms like life (Weeks, Coplan, & Kingsbury, 2009). Research suggests that children of color in the United States are less likely to experience psychiatric disorders than other school aged children . Several stud ies have show n that Hispanics , Asians and African Americans were at a lower risk of experiencing generalized anxiety disorder t han whites ( Breslau et. al., 2006 ; Grant, et al., 2005 ). Studies like these suggest that people of color have some protective factors that develop early in life that reduce their risk for developing anxiety disorders ( Breslau, et. al., 2006 ). However, some speculate that this difference is instead due to assessments and diagnostic practices being less likely to diagnose people of color. More research in this ar ea needs to be done to ensure that cultural differences in conditions like anxiety are being identified, diagnosed and treated at the same rate as whites . Changing the rate of identification and diagnosis could have a lasting positive impact on many facto rs of the life. Research Questions and Hypotheses The goal of the present study is to examine differences in the number of parent reported symptoms of Generalized Anxiety Disorder and Agoraphobia as measured by the NIMH Diagnostic Interview Schedule for Children IV (NIMH DISC IV ; Shaffer, et al., 2000 )

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experienced by individuals of different racial backgrounds as measured by a demographic questionnaire (K u bice k et. al., 2015) . The NIMH DISC IV consists of questions regarding symptoms and diagnostic criteria f or each disorder . For generalized anxiety disorder, parents could endorse up to 12 symptoms. For agoraphobia, parents could endorse up to four symptoms. It is hypothesized that individuals who identify as non white will have lower counts of diagnostic symptoms of a goraphobia and g eneralized a nxiety d isorder than their white peers .

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CHAPTER II LITERATURE REVIEW History of Anxiety Anxiety is an evolutionary advantage, it was necessary for survival and told a person to stay away from dangerous situations ( Crocq , 2015 ) . However, when this anxiety interferes wi th everyday life and without adequate stimuli it becomes a n extremely troubling condition ( Rose & Devine, 2014 ) . In the fourth and fifth centuries BCE philosophers and physicians be g an documenting normal and pathological forms of fear and anxiety (Horwitz, 2013) . In the 17 th century Robert Burton wrote about anxiety in his book The Anatomy of Melancholy , which encapsulated the negative e ffect s o f internalizing symptoms ( Crocq , 2015 ; Bandelow & Michaelis, 2015 ). Melanchol ia today could be broken down and separated into a number of diagnoses including anxiety. In the 18 th century, p anic attacks we re classified as a symptom of melancholia instead of as a separate disorder (Crocq, 2015) . All anxiety disorders were termed phobias in the DSM I and this diagnosis was not specific to children ( Huberty, 2012) . until the DSM II that had a specific category that could be diagnosed in child hood ( Huberty, 2012 ) . T his inclusion was the beginning of the movement to diagnose and treat anxiety disorders in children ( Huberty, 2012 ) . The DSM III was the first to identify anxiety as a sperate condition and included many sub categories of anxiety ( Crocq , 2015) . The DSM III also included three child specific anxiety disorders: avoidant disorder of childhood and adolescence , overanxious disorder, and separation anxiety disorder ( Huberty, 2012 ). The DSM V utilized neurobiological, genetic, and

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psychological features to separate and diagnose subcategories of anxiety and was the first to use brain function as a part of the diagnosis ( Crocq , 2015). Symptoms of Anxiety and Diagnosis Today , the DSM V identifies four main subtypes of anxiety disorders including generalized anxiety disorder, phobic disorders, panic disorders, and post traumatic stress disorder (Rose & Devine , 2014 ) . E ach anxiety disorder can only be diagnosed when the cause of the anxiety is not due to a substanc e or another mental disorder ( American Psychiatric Association [APA] , 2013 ). There are differences between each anxiety disorder relating to the objects or types of situations that cause the anxiety (American Psychiatric Ass ociation [APA], 2013). Currently the m ajority of studies focus on racial differences in symptoms of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder and Conduct Disorder. F ew studies have focus ed on racial differences in symptoms of Generalized Anxiety Disorder and Agoraphobia in school aged youth . Therefor e , this study will focus on the symptoms of these disorders specifically. Generalized Anxiety Disorder is a persistent and excessive anxiety a about several domains including school and work performance that the individual finds difficult to co n trol ( American Psychiatric Association [APA], 2013 ). Individuals experiencing Generalized An x iety Disorder will have some physical symptoms as well . Some of these physical symptoms include sleep disturbance, feeling restless, muscle tension, being easily fatigued and difficulty concentrating ( American Psychiatric Association [APA], 2013 ).

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Agoraphobia is classified by an individual feel ing anxious or fearful about at least two of the following situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside the home alone ( American Psychiatric Association , 2013 ). This fear is due to the person believing that escape or assistance might be difficult if panic occurs , making the person likely to avoid all situations that could cause the anxiety ( American Psychiatric Association [APA] , 2013 ) . Anxiety in Young Children It is rare that children aged zero to four are identified with an anxiety disorder ( Huberty, 2012 ) . However, symptoms of separation anxiety are often seen when young children are exposed to new situations, but symptoms usually s top after a few days ( Huberty, 2012 ). A c cording to Lavigne et. al. ( 2009) , less than 1% of preschool students showed symptoms of generalized anxiety disorder. However, a ccording to Huberty ( 2012 ), generalized anxiety disorder onset can occur at any age, and affects 3% of children. Shamir Essakow, Ungerer, & Rapee (2005), found that anxiety symptoms were most common in young children who have anxious mothers, were behaviorally inhibited, and inse curely attached. La vigne et. al. (2009) found no significant differences in rates if anxiety between races. Differences Among Racial Groups As the United States population grows, so does its diversity (Wu & Wyman, 2016). According to the United States Census, there are over 300 million people in the United states. The majority of the population ( 65.8% ) are white, 2.1% African American, 0.9% American

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Indian or Alaska Native, 0.3% Asian , 4.6% two or more races, and 26.2% id entify as another race (U . S . Census, 2016 ). The U.S. Census Bur eau also predicts that the United States will become more diverse as time goes on. Many studies suggest that racial differences exist between symptoms of diagnosable psychiatric conditions including m ood d isorders, s chizophrenia, o bsessive c ompulsive d isorder (OCD), d epression, a nxiety, e ating d isorders and aggression (Latzman et al., 20 11; Wu, & Wyman, 2016; McLaughlin, et . al. , 2007; Romero Acosta, et al., 2014 ; Neighbors et. al., 2003 ). Coleman et. al., (2016) found that African Americans were almost twice as likely to be diagnosed with schizophrenia than whites . Chen, Killeya Jones, & Vega (2005) found that the adolescent Latino population had significantly higher rates of any anxiety disorder when compared t o European America n youths. It was also reported that Mexican American youth had higher rates of anxiety disorders than African American or European American youth ( Chen, Killeya Jones, & Vega ; 2005) . Asnaani, et. al., (2010) found that Hispanic and Asian Americans were less likely to meet diagnostic criteria for many anxiety disorders when compared to white Americans. African Americans were less likely to be identified with g eneralized a nxiety d isorder, and s ocial a nxiety d isorder, but more likely to be diagnosed with Post Traumatic Stress Disorder when compared to white, Hispanic and Asian Americans ( Asnaani, et. al., 2010 ). Compton, Nelson, & March ( 2000) , reported that African American students were more likely to report symptoms of separation anxiety than whites . Differences in rates of specific anxiety disorders by race have not been published .

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Coleman et. al. (2016) found that all people of color (African American, Asian, and Latino/a) , with the exception of Native Amer icans, had lower rates of diagnosed psychiatric conditions than whites . T here are many theories that try to describe the reason for the discrepancy . Some believe that there are true differences in rates of the mental illnesses , others theorize that the instruments used to diagnose disorders and the use of clinical judgment are less likely to identify people of color (Lancaster et al., 2015 ; Neighbors et. al., 2003 ) . Another theory is that there is a view of white people as les s ill and clinicians see psychiatric symptoms in minorities as more serious than in whites (Strakowski et. al., 1996). Others say that at least part of the difference is due to a difference in presentation of symptoms between racial groups and the lack of culturally specific presentations of mental illness being listed in the diagnostic manual (Strakowski et. al., 1996; Lancaster et al., 2015). Breslau et. al. (2006) , stated that this is due to reduced lifetime risk for psychiatric disorders in people of color . Regardless of the reason, h aving such differences among diagnosis can have a negative impact on the treatment and outcome of patients of color because there are few er people of color being referred for and receiving treatment that could i mpact their mental health outcome s ( Neighbors et. al., 2003 ) . Mental Health Treatment of Minorities It has been reported that people of color are less likely to seek help for their mental health needs, receive a lower quality of care and have less access to services than white Americans ( Eack & Newhill , 2012) . Lack of medical insuranc e and limited health literacy are more common among people of color and can also subtract from the ir likelihood to seek treatment. It was also found that primary care physicians are less likely to identify the mental health problems

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of African Americans a nd Hispanics when compared to whites ( Borowsky et. al., 2000 ) . This could have a significant impact on the rates at which they are referred for and receive treatment for their mental illness es . When treatment is given , Eack & Newhill (2012) reported tha t African Americans showed less improvement in their symptoms than their white peers with a similar severe diagnosis . Furthermore, significantly fewer numbers of the African Americans in this study were able to return to work after being disch arged from treatment ( Eack & Newhill , 2012) . These findings point out the intense need to improve the diagnosis and treatment disparities between people of color and whites in the United States. It is important that this disparity be addressed to ensure that all people needing treatment will have better care and better long term outcomes.

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CHAPTER III METHODS Data Collection and Measures Data was collected in 201 4 and 2015 by principle investigator Dr. Lorraine Kubicek, P h .D. as part of the Project to Learn about You t h Mental Health (PLAY MH). The study was funded by the Disability Research and Dissemination Center, University of South Carolina School of Medicine and t he Center for Disease Control. The grant given to the principle investigator was titled Prevalence, Treated Prevalence, and Co Occurrence of Internalizing, Externalizing, and Tic Disorders in [State omitted] School Aged Youth D ata was collected using a two stage design. In the first stage, 858 teachers completed the Behavior Assessment System for Children, Behavioral and Emotional Screening system (BASC 2 BESS) ( Kamphaus & Reynolds , 2007) to screen 4,183 students from a stratif ied random sample in one public school district in the m ountain w est region if the United States . The BASC 2 BESS is a brief screening form that consists of 25 30 question s and can be filled out by parents, students or teachers ( Kettler et al., 2017) . It assesses a broad range of strengths and weaknesses within internalizing, externalizing, school problems, and adaptive skills ( Kettler et al., 2017) . Reliability for all forms ranges from 0.90 to 0.97 ( Kettler et al., 2017) . Using the scores from the BASC 2 BESS teacher form , all s tudents were placed into one of two groups : the student s with the highest scores were place d in the high risk group and students with the lowest scores w ere placed in the low risk group . In step two, randomly

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selected parents of 600 students from each group where invited to participate in a phone interview that was focused on the mental health of their child. These interviews w ere conducted in either English or Spanish . Spanish interviews were conducted by clinicians fluent in both English and Spanish . Of the parents who were invited to participate, 250 completed the phone inte rview. Demographic this paper. NIMH Diagnostic Interview Schedule for Children IV During the interview the parents completed the NIMH Diagnostic Interview Schedule for Children IV ( NIMH DISC IV) (Shaffer, et al., 2000) and a demographic questionnaire that was developed for this study (Kubicek et. al., 201 6 ) . The NIMH DISC IV is a structured interview for parents of children aged six to 17 , available in both English and Spanish . The DISC IV consists of over 2, 000 questions , however only questions relevant to the family are asked . It covers most internalizing, externalizing and tic disorders using criteria from the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition ( DSM IV ) and International Classification of Diseases Tenth Edition ( ICD 10 ) . The DISC IV explores possible symptoms of 34 diagnoses in 26 diagnostic sections ( Fisher, Lucas, L., Lucas , C., Sarsfield, and Shaffer , 200 6). These sections are arranged into mod ule s A through F. Included in Module A are Anxiety Disorders: Social Phobia, Separation Anxiety Disorder, Specific Phob i a, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Selective Mutism, Obsessive Compulsive Disorder, and Post Traumatic Stress Disorder ( Fisher, Lucas, L., Lucas , C., Sarsfield, and Shaffer , 2006) . Modules B through F include Mood disorders, Schizophrenia,

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Disruptive Behavior Disorders, Alco h ol and Substance Abuse Disorders and Miscellaneous Disorders ( Fisher, Lucas, L., Lucas , C., Sarsfield, and Shaffer , 2006) . The DISC IV assesses the prevalence of symptoms in t hree time formats: over the last 12 months , over the last four weeks and over the last 2 weeks ( Fisher, Lucas, L., Lucas , C., Sarsfield, and Shaffer , 2006). Th e 12 month time period may be less reliable because of how distant some of the symptoms may be, however it does allow the researcher to examine symptoms over the course of an entire school yea r ( Fisher, Lucas, L., Lucas , C., Sarsfield, and Shaffer , 2006) . For this reason, only the 12 month time period will be used for this study. According to Shaffer, Fisher, Lucas, C., Dulcan, & Schwab Stone, (2000). The DISC IV is an acceptable and convenient way to assess and identify many different mental health diagnoses. Retests given by clinicians showed that the DISC IV had moderate to good diagnostic reliability ( Shaffer, Fisher, Lucas, C., Dulcan, & Schwab Stone, 2000 ) . Fair to Moderate agreement (K=0.4 to <0.8 ) was observed for parent reports for generalized anxiety ( K = . 65) ( Bravo , et. al., 2001) . When comparing the DISC IV to previous versions, the DISC IV compares favorably . When given to Chinese adolesc ents in Hong Kong, the DISC IV was also seen as reliable, identifying internalizing and externalizing disorders at a rate similar to previous stu dies using other measures ( Leung et. al., 2008). The Spanish version of the DISC IV was developed by Glorisa Canino, Ph.D. at the University of Puerto Rico ( Bravo , et. al., 2001 ) . An international Spanish Advisory group also consulted on the creation of the Spanish DISC IV ( Shaffer, Fisher, Lucas, C., Dulcan, & Schwab Stone, 2000). According to one study, the Spanish version of the parent and self report

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interviews w ere reliable across time frames for most disorders evaluated in the DISC IV ( Bravo , et. al., 2001) . However, no studies currently exist on its reliability on the American population. On both the Spanish and English version of the DISC IV parents were more r eliable reporters of younger children than of older children ( Bravo , et. al., 2001). Demographic Questionnaire The d emographic questionnaire (Appendix A ) was a short survey consisting of questions about , the education level , marital status , number of children in their home, primary language spoken at home, income, relationship to the child and health or . All data was collected from parent or caregiver report as part of the phone interview that also included the DISC IV . P articipants The data was collected from one public school district in the mountain west region of the United States, consisting of more than 3 0 ,000 students between kindergarten and 12 th grade. Of the 250 participants who completed the phone interview in 2014 and 2015 , 1.2% was American Indian or Alaska Native, 16.5% was Black or African American, 1.6% was Asian, 49.8% was Hispanic or Latino/a, 12% was white, 2.4% was other, and 16.5% id entified more than one race. T his sample is generally congruent with the US population with a slight overrepresentation of Hispanic students and an underrepresentation of Asian and white students (U.S. Census Bureau, 2016) . The sample was also representative of the district, however there is a large

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overrepresentation of students who identify as more than one race in this study. The American Community Survey , conducted by the United States Census, gathers detailed information from the general population about their household . The survey indicated that approximately 30% of the students in this district do not speak any English at home ; o f those 30%, 66% sp o k e Spanish (Kubicek et. al., 201 6 ) . For the purposes of this study, only families that speak either English or Spanish were chosen to take part in the phone interview (stage 2). Data Analysis AN OVA To answer the research question s race and one way analysis of variance tests w ere conducted. Parent rep orted race s included were American Indian, Black or African American, Asian, Hispanic, White, Other, or Multi racial. Total number of symptoms reported by parents were reported as s ymptom counts

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CHAPTER IV RESULTS Agoraphobia Assumptions were tested, and the Test of Independence was met. The test of normality was violated however, ANOVA is robust to this due to the large sample size in this study. The test of Homogeneity of Variance was also violated therefore a Games Howell post hoc test was conducted to analyze specific differences between racial groups. A main effect was found for agoraphobia symptom counts by race, F (6, 236) = 3.16, p<.01, eta=.07 (Table 1) . The effect size (eta = .07) is considered medium. Table 1. Agoraphobia and Race ANOVA Sum of Squares df Mean Square F p value Between Groups 3.18 6 .53 3.16 .005 Within Groups 39.56 236 .17 Total 42.74 242 Post hoc tests were conducted to explore difference between groups using Games Howell. At a 95% confidence level, difference was seen between American Indian and African American students, p=.02 with African American student having higher symptom counts, between American Indian and Hispanic students, p<.01 with Hispanic students having higher symptom counts, between African American and students who were identified as another race, p=.02, with African American students having higher symptom counts, between Asian and Hispanic students, p<.01, with Hispanic students having higher symptom counts, and between Hispanic students and students who identified as another race, p<.01 with Hispanic students

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having higher symptom counts. Results that include Asian , American Indian , and students who were identified as should be interpreted with caution due to the small sample size of those races . These differences can be seen in the means plot (Figure 1) and the Discriptives table below (Table 2) . Figure 1 . Agoraphobia Means Plot Table 2. Agoraphobia Descriptive Statistics n Mean Std. Deviation Std. Error American Indian 3 .00 .000 .000 African American 37 .41 .686 .113 Asian 4 .00 .000 .000 Hispanic 122 .16 .386 .035 White 30 .10 .305 .056 Other 6 .00 .000 .000 Multi Racial 41 .05 .218 .034

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Total 243 .16 .420 .027 Generalized Anxiety Disorder Assumptions were tested, and the Test of Independence and the test of Homogeneity of Variance were met. The test of normality was violated however, ANOVA is robust to this due to the large sample size in this study. A main effect was found for generalize d anxiety disorder symptom count by race, F (6, 236) = 2.83 , p = .01, eta=.07 (Table 3 ). The effect size (eta = .07) is considered medium. Table 3. Generalized Anxiety Disorder ANOVA Sum of Squares df Mean Square F p Value Between Groups 90.13 6 15.02 2.8 3 .01 Within Groups 1253.94 236 5.31 Total 1344.07 242 Post At a 95% confidence level, a difference w as seen between white and Hispanic students, p=.05, with white students having higher symptom counts. These differences can be s een in the means plot (Figure 2 ) and the descriptives table (Table 4 ) below.

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Figure 2. Generalized Anxiety Disorder Means Plot Table 4. Generalized Anxiety Disorder Discriptives N Mean Std. Deviation Std. Error American Indian 3 1.67 1.528 .882 African American 37 2.92 2.361 .388 Asian 4 .75 1.500 .750 Hispanic 122 1.89 2.357 .213 White 30 3.30 2.452 .448 Other 6 .83 1.602 .654 Multi Racial 41 2.49 2.135 .333 Total 243 2.27 2.357 .151

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CHAPTER V DISCUSSION AND FUTURE DIRECTIONS Discussion Over the last several decades, the prevalence of anxiety disorders has been steadily increasing and is now the seventh most common condition diagnosed worldwide (Rose & Devine, 2014). A nxiety is one of the most untreated mental illnesses in the United States and can have severe social, emotional and socioeconomic consequences ( Towe Goodman et. al., 2015; Mazzone et. al., 2007 ; Berg, 1992; Kessler, Foster, Saunders, & Sta ng, 1995 ) . Many studies suggest that racial differences exist between symptoms of diagnosable psychiatric conditions including a nxiety (Latzman et al., 2011; Wu, & Wyman, 2016; McLaughlin, et. al. , 2007; Romero Acosta, et al., 2014 ; Neighbors et. al., 2003 ). However, few studies exist that examine the differences between race and reported symptoms of diagnosable anxiety disorders like generalized anxiety disorder and agoraphobia . The purpose of the current study was to examine differences in symptom counts of generalized anxiety disorder and agoraphobia by race. It was hypothesized that individuals who identify as non white will have lower counts of diagnostic symptoms of agoraphobia and generalized anxiety disorder than their white peers. Th e hypothesis was not supported for agoraphobia ; parents of Af r ican American students reported the highest mean symptom counts and Hispanic students had the second highest mean symptom counts . This contradicts previous research that stated that people of color would report fewer symptoms of mental health disorders. The hypothesis was partially supported for generalized anxiety disorder because parents of white

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students reported the highest mean symptom count, however those results were only statistically significant when compared to Hispanic students. Limitations & Future Directions This study included 250 parent part icipants, however a limited number of participants identified American Indian, Pacific Islander , and Asian a s the race. This means that results regarding those samples should be interpreted with caution. Previous studies ha ve stated that parents are more reliable reporters of symptoms of anxiety and depression (Bravo, et. al., 2001). H owever, those same studies also state that parents are more reliable when reporting symptoms of younger children than adolescents (Bravo et. al ., 2001) . The current study included participants in kindergarten through 12 th grade, therefore results of older children may be less reliable. Different forms of measurement, like self report or multiple informants , should be used to increase the overall validity in this study. While the Spanish version of the DISC IV has been studied extensivly in Puerto Rico its validity has not been studied in the United States. While it is seen as a valid measure in Puerto Ri co, without having data about its validity in the United States means that the results of the interviews conducted in Spanish should also be interpreted with caution. More research needs to be done using Spanish speaking individuals within the United Stat es before t he DISC IV Spanish version can be considered valid and reliable. Future studies should include larger populations of all races to examine possible differences not seen in this study . It may also be beneficial to add more variables to discover

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m ore differences; socioeconomic status, age, and gender in connection with symptoms should be considered . Future studies could also examine differences between individuals with clinically significant symptoms. Learning more about who is most likely and least likely to present with clinically significant symptoms could show who is being diagnosed and who is be ing missed. This research could have a lasting impact on the diagnostic prosses. Implications for School Psychologists The prevalence and impact anxiety disorders have on school aged children in ever present in our society today. When children experie nce symptoms of anxiety it is important that school psychologists have the ability and resources to provide interventions and support s for students . These interventions will provide students the opportunities and skills to lessen the impact anxiety could have on their lives. While budgets for mental health continue to shrink, it will be important for school professionals to continue to advocate for the mental health needs of all students to ensure that these services will continue to be available. It will be important for school psychologists to continue to educate themselves about the racial differences in symptoms of mental illnesses to ensure t hat all students are iden tified and receiv e interventions that benefit them. School psychologists have to look at their students through a multicultural lense to ensure that student s of color receive an identification when School Psychologists need to continue to monitor patterns and social changes that could influence rates of identification of students in their schools . Being able to i dentifying and provid e supports for all students who need it will have a large positive effect on the lives of the students of all school psychologists.

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REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC . Asnaani, A., Richey, J. A., Dimaite, R., Hinton, D. E., & Hofmann, S. G. (2010). A cross ethnic comparison of lifetime prevalence rates of anxiety disorders. The Journal of nervous and mental disease , 198(8), 55 1. Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in clinical neuroscience , 17(3), 327. Berg I., (1992), Absence from school and mental health . British Journal of Psychiatry , 161 pp. 154 166 Bittner, A., Egger, H. L., Erkanli, A., Jane Costello, E., Foley, D. L., & Angold, A. (2007). What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry , 48(12), 1174 1183. doi:10.1111/j.1469 7610.2007.01812.x Borowsky, S. J., Wells, K. B. (2000). Who is at risk of nondetection of mental health problems in primary care ?. Journal of general internal medicine , 15(6), 381 388. Bravo, M., Ribera, J., Rubio Stipec, M ., Canino, G., Shrout, P., Ramírez, R., ... & Taboas, A. M. (2001). Test retest reliability of the Spanish version of the Diagnostic Interview Schedule for Children (DISC IV). Journal of abnormal child psychology, 29(5), 433 444. Breslau, J., Aguilar Gaxio la, S., Kendler, K. S., Su, M., Williams, D., & Kessler, R. C. (2006). Specifying race ethnic differences in risk for psychiatric disorder in a USA national sample. Psychological Medicine, 36(1), 57 68. doi:10.1017/S0033291705006161 Chen, K. W., Killeya Jo nes, L. A., & Vega, W. A. (2005). Prevalence and co occurrence of psychiatric symptom clusters in the U.S. adolescent population using DISC predictive scales. Clinical Practice and Epidemiology in Mental Health : CP & EMH , 1(1), 22 22. doi:10.1186/1745 0179 1 22 Coleman, K. J., Stewart, C., Waitzfelder, B. E., Zeber, J. E., Morales, L. S., Ahmed, A. T., . . . Simon, G. E. (2016). Racial ethnic differences in psychiatric diagnoses and treatment across 11 health care systems in the mental health research network. Psychiatric Services , 67(7), 749 757. doi:10.1176/appi.ps.201500217 Compton, S. N., Nelson, A. H., & March, J. S. (2000). Social phobia and separation anxiety symptoms in community and clinical samples of children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 39(8), 1040 1046.

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Crocq, M. (2015). A history of anxiety: From hippocrates to DSM. Dialogues in Clinical Neuroscience, 17(3), 319. Davidson J.R.T, Hughes D.L, George L.K, Blazer D.G . (1993), The epidemiology of social phobia: findings from the Duke Epidemiologic Catchment study . Psychological Medicine , 23 pp. 709 718 Eack, S. M., & Newhill, C. E. (2012). Racial disparities in mental health outcomes after psychiatric hospital discharge among individuals with severe mental illness . Social Work Research , 36(1), 41 52. doi:10.1093/swr/svs014 Fisher, Lucas, L., Lucas, C., Sarsfield, and Shaffer . (2006). Interviewer Manual. Columbia University DISC Development Group. Grant, B., Has in, D., Stinson, F., Dawson, D., June Ruan, W., Goldstein, R., . . . Huang, B. (2005). Prevalence, correlates, co morbidity, and comparative disability of DSM IV generalized anxiety disorder in the USA: Results from the National Epidemiologic Survey on Alc ohol and Related Conditions. Psychological Medicine, 35(12), 1747 1759. doi:10.1017/S0033291705006069 . Horwitz, A. V. (2013). Anxiety: A short history. Baltimore: Johns Hopkins University Press. Huberty, T. J. (2012). Anxiety and depression in children and adolescents: Assessment, intervention, and prevention. New York, NY: Springer. Ialongo, N., Edelsohn, G., Werthamer Larsson, L., Crockett, L., & Kellam, S. (1995). The significance of self reported anxious symptoms in first grade children: Prediction to a nxious symptoms and adaptive functioning in fifth grade. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 36(3), 427 437. doi:10.1111/j.1469 7610.1995.tb01300.x Kamphaus, R. W., & Reynolds, C. R. (2007). Behavior Assessment System for Children Second Edition (BASC 2): Behavioral and Emotional Screening System (BESS). Bloomington, MN: Pearson. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime Prevalence and Age of Onset Distributions of DSM IV Disord ers in the National Comorbidity Survey Replication. Archives of General Psychiatry . 2005;62(6):593 602. doi:10.1001/archpsyc.62.6.593 Kessler, R. C., Berglund, P. A., Foster, C. L., & Saunders, W. B. (1997). Social consequences of psychiatric disorders, II: Teenage parenthood. The American Journal of Psychiatry , 154(10), 1405.

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Kessler R.C. , McGonagle K.A. , Zhao S , Nelson C.B. , Hughes M. , Eshleman S. , Wittehen H.U . , Kendler K.S . (1994) ; Lifetime and 12 month prevalence of DSM III R psychiatric disorders in the United States: results from the National Comorbidity Survey . Archives of General Psychiatry, 51 pp. 8 19 Kettler, R. J., Feeney Kettler, K. A., & Dembitzer, L. (2017). Social, emotional, and behavioral screening: A comparison of two measures and two methods across informants. Journal of School Psychology , 64, 93 108. doi:10.1016/j.jsp.2017.05.002 Kubicek L.F. , Hightshoe, K. D., Moody E. J., Reyes N. M., Davidson S. L., Rosenberg S. A., (201 6 ) Prevalence and Treatment of Mental Health Disorders and Developmental Disabilities: A Comparison of High and Low Risk Colorado School Aged Youth. Lancaster, S. L., Melka, S. E., Klein, K. P., & Rodriguez, B. F. (2015). Ethnicity and anxiety: A psychometric evaluation of the STICSA. Measurement and Evaluation in Counseling and Development , 48(3), 163 176. doi:10.1177/0748175615578757 Latzman, R. D., Naifeh, J. A., Watson, D ., Vaidya, J. G., Heiden, L. J., Damon, J. D., . . . Young, J. (2011). Racial differences in symptoms of anxiety and depression among three cohorts of students in the southern united states. Psychiatry, 74(4), 332 348. doi:10.1521/psyc.2011.74.4.332 Lavign e J. V., LeBailly S. A., Hopkins J., Gouze K. R. & Binns H. B., (2009) The Prevalence of ADHD, ODD, Depression, and Anxiety in a Community Sample of 4 Year Olds, Journal of Clinical Child & Adolescent Psychology , 38:3, 315 328, DOI: 10.1080/15374410902851382 Leung, P. W. L., Hung, S., Ho, T., Lee, C., Liu, W., Tang, C., & Kwong, S. (2008). Prevalence of DSM IV disorders in chinese adolescents and the effects of an impairment criterion: A pilot community study in hong kong. European Ch ild & Adolescent Psychiatry , 17(7), 452 461. doi:10.1007/s00787 008 0687 7 Mazzone, L., Ducci, F., Scoto, M. C., Passaniti, E., D'Arrigo, V. G., & Vitiello, B. (2007). The role of anxiety symptoms in school performance in a community sample of children and adolescents. BMC Public Health , 7(1), 347 347. doi:10.1186/1471 2458 7 347 McLaughlin, K. A., Hilt, L. M., & Nolen Hoeksema, S. (2007). Racial/Ethnic differences in internalizing and externalizing symptoms in adolescents. Journal of Abnormal Child Psychol ogy , 35(5), 801 816. doi:10.1007/s10802 007 9128 1 Merikangas, K. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity survey replication adolescent supplement (NCS A ). J Am Acad emic Child Adolesc ent Ps ychiatry , 49(10), 980 989. doi:10.1016/j.jaac.2010.05.017

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National Alliance on Mental Illness ( NAMI ) . (n.d.). Retrieved from https://www.nami.org/Learn More/Mental Health By the Numbers National Institute of Mental Health (NIMH). Any Anxiety Disorder. (n.d.). Retrieved March 14, 2018, from https://www.nimh.nih.gov/health/statistics/any anxiety disorder.shtml Neighbors, H., Trierweiler, S., Ford, B., & Muroff, J. (2003). Racial Difference s in DSM Diagnosis Using a Semi Structured Instrument: The Importance of Clinical Judgment in the Diagnosis of African Americans . Journal of Health and Social Behavior , 44(3), 237 256. Retrieved from http://www.jstor.org/stable/1519777 Park, J., & Moghadda m, B. (2016;2017;). Impact of anxiety on prefrontal cortex encoding of cognitive flexibility . Neuroscience , 345, 193 202. doi:10.1016/j.neuroscience.2016.06.013 Romero Acosta, K., Penelo, E., Noorian, Z., Ferreira, E., & Domènech Llaberia, E. (2014). Racia l/ethnic differences in the prevalence of internalizing symptoms: Do latin american immigrant show more symptomatology than spanish native born adolescents? Journal of Health Psychology , 19 (3), 381 392. doi:10.1177/1359105312471568 Rose, M., & Devine, J. ( 2014). Assessment of patient reported symptoms of anxiety. Dialogues in Clinical Neuroscience, 16(2), 197 211. Shaffer, D, Fisher, P., Lucas, C., Dulcan, M., & Schwab Stone, M. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC IV) Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC IV): description, differences from previous versions, and reliability of some common diagnose s. Journal of the American Academy of Child & Adolescent Psychiatry , 39(1), 28 38. Shamir Essakow, G., Ungerer, J. A., & Rapee, R. M. (2005). Attachment, behavioral inhibition, and anxiety in preschool children. Journal of Abnormal Child Psychology , 33(2), 131 143. doi:10.1007/s10802 005 1822 2 Strakowski, S. M., Flaum, M., Amador, X., Bracha, H. S., Pandurangi, A. K., Robinson, D., & Tohen, M. (1996). Racial differences in the diagnosis of psychosis. Schizophrenia Research , 21(2), 117 124. doi:10.1016/0920 9964(96)00041 2 Towe Goodman, N. R., PhD, Franz, L., MBChB, Copeland, W., PhD, Angold, A., MRCPsych, & Egger, H., MD. (2014). Perceived family impact of preschool anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 53(4), 437 446. doi:10.1016/j.jaac.2013.12.017

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U.S. Census Bureau. (2016) World Population Review. Retrieved from http://worldpopulationreview.com/countries/united states popula tion/ Weeks, M., Coplan , R. J., & Kingsbury, A. (2009). The correlates and consequences of early appearing social anxiety in young children. Journal of Anxiety Disorders , 23(7), 965 972. doi:10.1016/j.janxdis.2009.06.006 Wu, K. D., & Wyman, S. V. (2016). Examination of racial differences in assessment of OCD symptoms and obsessive beliefs. Journal of Obsessive Compulsive and Related Disorders , 10 , 10 18. doi:10.1016/j.jocrd.2016.04.008

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Appendix A Demographic Questionnaire L.F. Kubicek 14 0007 v 8.28.14 Demographics Questionnaire This questionnaire concerns you and your child. We realize that this is a detailed questionnaire, but please try to answer as many of the questions as possible. o Male o Female Which racial group(s) describe(s) your child? (select all that apply) o American Indian or Alaska Native o Asian o Black or African American o Hispanic or Latino o Native Hawaiian or Other Pacific Islander o White o Other (please specify) ______________________________________________ Your date of birth Your gender o Male o Female Which racial group(s) describe(s) you? (select all that apply) o American Indian or Alaska Native o Asian o Black or African American o Hispanic or Latino o Nativ e Hawaiian or Other Pacific Islander o White

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o Other (please specify) ______________________________________________ What is your relationship to this child? o Biological parent o Adoptive parent o Stepparent o Foster parent o Other family relative (please specify) ________________________________________________ o Other (please specify) ________________________________________________ What language do you usually speak when you are at home or with your family? o English o Spanish o Other (please specify) _________________________________ o English o Spanish o Other (please specify) _________________________________ What is the highest level of education you have completed? o Less than high school o H igh school diploma or GED o Associates degree o Some college (no degree) o o o Professional school degree o Doctoral degree What is your marital status? o Single o Married o Living with a partner o Separated o Divorced o Widowe d

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Currently Empl oyed? o Yes o No Occupation? _____________________________________ If the child has a second primary caregiver (either someone living in a partnership with you in the home, or someone else who is sharing guardianship of the child with you), complete the information below: Caregiver #2 date of birth Gender o Male o Female Which racial group(s) describe(s) this person? (select all that apply) o American Indian or Alaska Native o Asian o Black or African American o Hispanic or Latino o Native Hawaiian or Other Pacific Islander o White o Other (please specify) ___ ___________________________________________ Currently Employed? o Yes o No Occupation? _____________________________________ o Biological parent o Adoptive parent o Stepparent o Foster parent o Other family relative (please specify) ________________________________________________

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o Other (please specify) ________________________________________________ o Less than high school o High school diplo ma or GED o Associates degree o Some college (no degree) o o o Professional school degree o Doctoral degree o Single o Married o Living with a partner o Separated o Divorced o Widowed Including this child, what is the total number of children (under age 18) in the household where he/she is currently living? What is the total number of adults (age 18 or older) in the household where he/she is currently living? What is the annual income of this household? (pl ease select one) o Under $5,000 o Under $10,000 ($5,000 $9,999) o Under $15,000 ($10,000 $14,999) o Under $20,000 ($15,000 $19,999) o Under $25,000 ($20,000 $24,999) o Under $35,000 ($25,000 $34,999) o Under $50,000 ($35,000 $49,999) o Under $75,000 ($50,000 $74,999) o Under $100,000 ($75,000 $99,999) o $100,000 and over

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Does your child have any ongoing physical health problems that have been diagnosed by a health care worker (for example, asthma, diabetes, etc.)? o Yes o No If Yes, explain_______ _______________________________________________________ Is your child limited in any way in any activities because of physical, mental, or emotional problems? o Yes o No If Yes, explain______________________________________________________________ Does yo ur child now have any health problems that require him/her to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? o Yes o No If Yes, explain______________________________________ Health insurance questions from the N Does your child have any kind of health care coverage, including health insurance, prepaid plans o Yes o No Health Insurance Program, sometimes called CHIP Plus? o Yes o No