Anxiety Symptoms in Diabetes Scale for Adolescents (ASDS-A)

Abstract

The Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A), developed by Rechenberg, Szalacha, & Bugajski in 2023, is a specialized self-report instrument designed to quantify anxiety symptoms specific to the challenges of living with Type 1 diabetes (T1D) in adolescents. The scale’s initial development was grounded in a qualitative study involving T1D adolescents aged 12 to 16 years, ensuring that the item content accurately reflected the unique stressors associated with the condition.

An extensive initial draft of 50 items was generated, subsequently refined to 15 items following an expert review that established strong face and content validity. The definitive psychometric evaluation, conducted on a sample of adolescents with T1D (aged 12 to 16 years), utilized a principal component analysis. This analysis identified a robust single factor, resulting in a final 14-item scale after one item (Item 14) was removed due to low factor loading. The ASDS-A demonstrates excellent internal consistency and strong concurrent validity, making it a reliable and rapid assessment tool, typically completed in 15 minutes or less.

Keywords

Adolescents, Anxiety Symptoms, Face Validity, Hypoglycemia, Self-Management, Type 1 Diabetes, Psychometrics, Rating Scale.

Authors

Kaitlyn Rechenberg, Laura Szalacha, Andrew Bugajski

Purpose

The primary purpose of the ASDS-A is to provide a reliable, dedicated measure for assessing the unique burden of diabetes-specific anxiety experienced by adolescents diagnosed with Type 1 diabetes. This scale is crucial because general anxiety measures often fail to capture the specific cognitive and emotional distress related to chronic illness management.

As a self-report instrument, the ASDS-A allows clinicians and researchers to accurately identify and quantify unique anxiety experiences, such as fear of acute complications (e.g., severe hypoglycemia), social stigma, and adherence difficulties. The scale supports tailored psychological interventions aimed at improving self-management and overall mental health outcomes in this specific age group.

Construct

The ASDS-A measures the construct of Diabetes-Specific Anxiety Symptoms in adolescents. This is defined as the set of emotional, cognitive, and physical symptoms of distress that arise directly from the daily demands, risks, and social implications of managing Type 1 diabetes.

The items cover critical domains of diabetes-related distress, including worries about blood sugar levels (e.g., getting too low while sleeping), social concerns (embarrassment related to treatment devices or needing to interrupt activities), and the perceived burden of the disease on family members. The scale is designed to capture the specific ways T1D interferes with typical adolescent development and social functioning.

Validity

The scale’s construct validity and concurrent validity were established through rigorous analysis of its correlation with nine closely related constructs, including general psychological distress and diabetes-specific quality of life (QOL) measures.

Concurrent Validity Findings: The ASDS-A scores exhibited strong and appropriate correlations with established instruments, confirming its validity:

• Generalized Anxiety Disorder-7 Scale (GAD-7): A significant positive correlation (r = .493, p < .001) demonstrated that higher diabetes-specific anxiety is associated with elevated general anxiety levels.

• Patient Health Questionnaire-2 Scale (PHQ-2): A strong positive correlation (r = .51, p < .001) suggested a meaningful relationship between diabetes-specific anxiety and depressive symptoms.

• Diabetes-Specific Pediatric Quality of Life Scale (PedsQOL 3.0) Subscales: The ASDS-A consistently showed strong negative correlations, indicating that increased anxiety is linked to poorer QOL outcomes:

  • Diabetes symptoms (r = −.581, p < .001)

  • Treatment barriers (r = −.595, p < .001)

  • Treatment adherence (r = −.536, p < .001)

  • Worry (r = −.694, p < .001)

  • Communication (r = −.660, p < .001)

• Total PedsQOL 3.0 Score: A significant positive correlation with the total score (r = .655, p < .001) further supported that higher ASDS-A scores predict lower overall quality of life in this population.

Reliability

The reliability of the ASDS-A was evaluated using the measure of internal consistency. The resulting Cronbach’s alpha coefficient was reported as .896. This value exceeds the threshold for acceptable reliability and indicates excellent internal consistency, confirming that the 14 items are highly intercorrelated and function cohesively to measure the underlying construct of diabetes-specific anxiety.

Factor Analysis

A Principal Component Analysis (PCA) was executed to investigate the factor structure of the ASDS-A. Although the initial analysis extracted two components with eigenvalues greater than 1, the results strongly favored a single-factor solution.

The eigenvalue of the first component (6.106) was overwhelmingly dominant, being more than four times greater than the second component (1.41). Both the eigenvalue ratio and the visual evidence provided by the Scree plot supported the conclusion that a single component was sufficient to explain the data structure, accounting for 43.61% of the total variance. Following this analysis, Item 14 was removed from the scale due to its insufficient factor loading of .287, finalizing the ASDS-A as a 14-item instrument.

Instrument

Test Type: Original self-report rating scale

Format: The ASDS-A is a 14-item measure utilizing a 5-point Likert-type scale, ranging from “strongly disagree” to “strongly agree.” Total scores range from a minimum of 14 to a maximum of 52. The administration method is electronic, and the test items are available in the source literature.

Language Available: English

Population Group: Human; Male; Female.

Age Group: Primarily targets Adolescence (13-17 years). The psychometric evaluation specifically focused on adolescents with Type 1 Diabetes aged 12 to 16 years.

Population Details: The validation study sample consisted of adolescents with Type 1 Diabetes located in the United States.

Test Methodology: The development and evaluation employed various test methodologies, including Test Validity (Concurrent Validity, Construct Validity, Content Validity), Test Reliability (Internal Consistency), and Factor Analysis (Principal Component Analysis).

Keywords

Diabetes-Specific Anxiety, Adolescence, Type 1 Diabetes (T1D), Psychometrics, Self-Report, Hypoglycemia, Quality of Life, Likert-type Scale, Principal Component Analysis.

Authors

Author ORCID Identifier: orcid.org/0000-0002-4504-6980 (Laura Szalacha)

Affiliation Email addresses: [email protected] (Kaitlyn Rechenberg)

Correspondence Address: University of South Florida, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, Florida, United States, 33612

Permissions & Fee and Test Year

Permissions: Contact Publisher

Fee: No

Commercial: No

Test Year: 2023

References

Rechenberg, K., Szalacha, L., & Bugajski, A. (2023). A self-report measure of diabetes-specific anxiety symptoms for adolescents. Children’s Health Care, 52(2), 123–137. doi.org/10.1080/02739615.2022.2047970

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.

Richardson, L. P., et al. (2010). The Patient Health Questionnaire-2 (PHQ-2) for screening for depression in adolescents. Journal of Adolescent Health, 46(3), 239-243.

Varni, J. W., et al. (2003). The PedsQL 3.0 Diabetes Module: Reliability and validity of a diabetes-specific quality of life measure for children and adolescents with type 1 diabetes. Diabetes Care, 26(5), 1430–1436.

Items of the Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The ASDS-A is a 14-item measure. Note that Item 14 was dropped from the final scale due to low factor loading, but is listed below for informational context alongside the other items considered during development. Items are rated on a 5-point Likert-type scale (strongly disagree to strongly agree).

Test Location: 2022-45415-001, Table 2, Page 129 of the source reference.

1. When I am afraid, I feel like I might throw up.

2. I am embarrassed when I have to leave class to manage my diabetes.

3. I am embarrassed by my insulin pump.

4. People judge me because I have diabetes.

5. When I am afraid it is difficult to breathe.

6. I keep my blood sugar high on purpose when I’m out with my friends.

7. I worry about my mom because it’s stressful to have a teenager with diabetes.

8. I worry about my dad because it’s stressful to have a teenager with diabetes.

9. I worry a lot about my blood sugar getting too low.

10. I worry a lot about my blood sugar getting too low while I’m sleeping.

11. *I feel embarrassed when I have to interrupt an activity to manage my diabetes.

12. *I do not worry about my A1C.

13. *When I’m at school, I forget to manage my diabetes.

14. *I don’t worry about my diabetes too much.

15. *I like telling people about my diabetes.

Note: Items marked with an asterisk (*) are reversed scored. Item 14 was dropped from the final 14-item scale due to a low factor loading (.287).