Eastern Area Health Education Center

Anxiety

Ages: 31 to 83 months (2.5-6.5 years) 

TERMS OF USE: https://www.scaswebsite.com/ Permission received for use by primary care providers.

COST: No fee but subject to change at any time. Refer to website above prior to use. 

Description: This scale is a parent report questionnaire of 29-34 items developed to assess the severity of anxiety symptoms. This scale includes subscales for OCD, social anxiety, separation anxiety, physical injury fears, and generalized anxiety with a total possible score of 112. Questions 30-34 only need to be answered if a parent answers “yes” to question 29 and are for clinical usage only.

PDF: Preschool Anxiety Scale

Scoring information: Preschool Anxiety Scale Scoring Instructions

Recommendations: “This scale can provide an indication of whether children are showing elevated levels of anxiety and should be used in combination with a clinical diagnostic interview if a diagnosis is required”.

Languages: English, Spanish (European), Chinese, German, Syrian (Arabic), Armenian, Danish, French, Hebrew, Portuguese, Russian, Slovenian, Turkish

Autism Spectrum Disorder

Ages: 16 – 30 months 

TERMS OF USE: M-CHAT-R/F™ – Guidelines for Use (mchatscreen.com) – As noted on the instrument website for clinician purposes, you are welcome to incorporate this instrument into your EMR for patient purposes free of charge as long as, “…just for use in your own office’s medical record. You must follow the requirements that you do not alter the instrument’s name, instructions, items, item order, or the copyright notice at the bottom….”

COST: No fee but subject to criteria found on website above. 

Description:  This is an updated version of the MCHAT. This updated screener is a 20-item questionnaire used to assess risk for autism spectrum disorders. While the primary goal of this instrument was to detect as many cases of ASD as possible, it lead possibly to high false positive rates if using the questionnaire only.  The revised version has a decreased rate of false positives. The screener should be filled out by the parent or caregiver.

PDF: M-CHAT-R/F Questionnaire and Interview Downloads

Scoring information: M-CHAT-R/F Scoring Guide

Recommendations: This screener must be used in its entirety. The authors of the instrument note it was previously highly sensitive, resulting in a high false positive rate, therefore the structured follow up interviews offered by the authors should be employed. Even with false positives there may be other developmental concerns that are not necessarily autism spectrum disorder and should be followed up on.

Ages: For caregivers. Administer when the infant is 1, 2, 4, and 6 months of age 

TERMS OF USE: Copyrighted material. If used, provider must: attribute correctly and respect the copyright by quoting the names of the authors, the title, and the source in the paper in all reproduced copies.

COST: No fee but must follow criteria found at the bottom of the screener. 

Description: This screener is a 10 item self-report scale to be used with a primary caregiver (validated for mothers and fathers) of an infant to indicate if that caregiver has symptoms found to be typical in depression and anxiety. This screener is not intended to diagnose and is focused on the cognitive elements of depression, excluding the physical symptoms that are often experienced during pregnancy and after childbirth. This instrument can be used for fathers with a lower cut off (equal to or greater than 8).

PDF: Edinburgh Postnatal Depression Screen

Scoring information: Edinburgh Scoring Guide

Recommendations: This screener is to be completed with a health professional. It is recommended that a practice have an integrated behavioral health clinician to follow up with a positive screen or a strong referral process in place if needed.

Languages available: multiple (20+)

Ages: For caregivers 

TERMS OF USE: Multidimensional Scale of Perceived Social Support (MSPSS) (gzimet.wixsite.com) – According to the instrument website, free to use as long as the following reference is credited.

“Zimet, GD, Dahlem, NW, Zimet SG, Farley, GK – The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 1988, 52:30-41.”

COST: No fee but subject to criteria found on website above.  

Description: A 12 item self-report measure including three sub-scales: family, friends, and significant other.

PDF: Multidimensional Scale of Perceived Social Support

Scoring information: Scoring Instructions [2nd page of document]

Recommendations: Used extensively but continuing to undergo adaptations so that it is culturally relevant for collectivist cultures vs. the individualistic culture in which it was created.

Languages available: Thai, Malaysian, Swedish, Polish, Chinese, Spanish – several others per the measure website.

Ages: For caregivers when the youngest child is between birth and 8 years 

TERMS OF USE:   https://cssp.org/wp-content/uploads/2018/08/PAPF-User-Guide.pdf – Usage permission noted in the User Guide (second page/Title Page) – This guide is in the public domain. Permission to reproduce is not necessary.

Suggested citation: Kiplinger, V. L. & Harper Browne, C. (2014, September). Parents’ Assessment of Protective

Factors: User’s guide and technical report. Washington, DC: Center for the Study of Social Policy.

COST: No fee. 

Description: A parent/caregiver self-report of a 35-item survey instrument developed within the Strengthening Families Approach and Protective Factors Framework, to assess the presence, strength, and growth of parents’ self-reported beliefs, feelings, and behaviors. Utilizes a Likert scale of “this is not at all like me or what I believe” which is the 0 value through “this is very much like me or what I believe” which is a value of 4.

PDF:  Parents Assessment of Protective Factors

Scoring information: PAPF Scoring Sheet  After scoring, the following scores can be reported: protective factor index (total score), parental resilience (PR, items 11-19), social connections (SC, items 20-28), concrete support in times of need (CS, items 29-37), social and emotional competence of children (SE, items 38-46). Designed to be hand-scored. Average scores should be used as the subscale and PFI scores. A scoring sheet is provided in the User Guide. 

Recommendations: Caregiver should have at least a fifth grade reading level. Designed to be self-administered, but a staff person may administer. No formal training is required. If delivered by a staff person, the User’s Guide should be reviewed before administering in a practice.

Languages: Spanish

Ages: 4-16 years 

TERMS OF USE: Available for free use per Massachusetts General Hospital.  Website indicates that it is “broadly available” and also states that Mental Health America provides the PSC with online score reports for free. Mental Health America online version of PSC.

COST: No fee. 

Description: This is a brief 35 item parent-report questionnaire to help identify and assess changes in emotional and behavioral problems in children over time. It is not intended to be diagnostic. It is designed to fit into the workflow of a pediatric practice. It can also be used in mental health practices.

PDF: English / Spanish

Scoring information: Extensive scoring instructions and subscale will need to be summarized in a created pdf document for upload. However, items are rated on a Likert scale of 0-2 and the total score is calculated by adding the 35 individual scores with a total score possible of 0 to 70. Complete instructions are here: Scoring Instructions “A score of 28+ identifies children as being at risk (Jellinek et al., 1999; Murphy et al., 2016)” 

Recommendations: Parents are able to take this questionnaire prior to the visit, at check-in, as well as during the pediatric visit.  If score is in the “at-risk” range, discuss symptoms further with patient/family; consider offering a follow-up visit for further evaluation with primary care provider or referral to a mental health professional. Watchful waiting is also a recommended approach depending on the severity and capacity for the family to seek additional support and referrals. Depending on a patient’s cultural group, it should be kept in mind that the absence of a positive screen does not indicate an absence of problems. 

Languages available: 24 languages available, pictorial version, and shortened 17-item version. Cut-off scores will vary depending on the translation version.

Ages: Third grade and older 

TERMS OF USE: The RCADS and its derivative works (inclusive of translations) are intellectual property owned and copyrighted by Chorpita and Spence. They are available for use through Dr. Chorpita’s UCLA resource page at no cost to users (www.childfirst.ucla.edu/resources/ ), but such use does not imply a perpetual free license to any individual or institution.

CLICK on USER GUIDE for all instructions and disclaimers:  See page 5 https://www.childfirst.ucla.edu/wp-content/uploads/sites/163/2022/01/RCADSUsersGuide20220125.pdf

COST: No fee but subject to change at any time. Refer to User Guide for any updated criteria. 

Description: A 25-item questionnaire self-report with three scores: total anxiety, total depression, and total anxiety and depression. The caregiver version assesses the caregiver’s report of symptoms. The brief 25 item version is produced from the longer 47 item questionnaire, which include many of the items from the Spence Children’s Anxiety Scale and items representing depressive symptoms from the DSM.

PDF: Brief RCADS-Child Version Brief RCADS-Caregiver Version

Scoring information: Questionnaire Translations and Scoring Instructions

Recommendations:  See User Guide.

Languages available: English, Dutch, Finnish, Hindi, Spanish, Swedish

Ages: 11-17 years 

TERMS OF USE: Craske M, Wittchen U, Bogels S, Stein M, Andrews G, Lebeu R. Copyright © 2013 American Psychiatric Association. All rights reserved.  This material can be reproduced without permission by researchers and by clinicians for use with their patients.

COST: No fee. 

Description: Part of the American Psychiatric Association’s “emerging measures” effort in 2013, this screener is intended to be used at the initial patient interview and ongoing to enhance clinical decision making. APA is asking for any research that is done to be shared with them at this link http://www.dsm5.org/Pages/Feedback-Form.aspx A 10 -item questionnaire designed to be self-administered by the child after being given a diagnosis of generalized anxiety disorder. The measure itself may be used to track status over time. Clinicians should review each question with the patient as well.

PDF: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Severity-Measure-For-Generalized-Anxiety-Disorder-Child-Age-11-to-17.pdf

Scoring information: Items are rated on a five-point scale with a total range of score from 0 to 40 with the higher the score indicating an increase in severity. Items should be given a raw score. Clinicians should also calculate an average score which then provides them an overall severity perspective on a five-point scale.

Recommendations:  N/A

Languages available: English

Ages: 8-12 years

TERMS OF USE: https://www.scaswebsite.com/ – Information from the site, including the Spence Children’s Anxiety Scales, may currently be downloaded and used free of charge by researchers and individual practitioners. Commercial organizations and for-profit clinical services should contact the author to discuss a commercial license arrangement before use. Not-for-profit and government agencies should seek prior permission from the author to use the scale within their organizations, and a charge may apply.

COPYRIGHT: The scales are copyrighted to the author and may not be reprinted in full in any publication nor resold for commercial purposes. The scales are copyrighted documents not in the public domain. They cannot be modified, such as changing the wording of questions, the response format, nor by adding or removing questions. The creation of translations of the scales into other languages or for conversion into electronic format requires prior approval from the author.

COST: No fee but subject to change at any time.

Description: A 44-item scale to assess anxiety with domains indicating generalized anxiety, panic/agoraphobia, social phobia, separation anxiety, obsessive compulsive disorder, and physical injury fears. It  takes approximately 10 minutes to complete. Children rate the frequency of their experience on a scale of 1-4. It is not intended to be a diagnostic instrument when used in isolation of other clinical judgment.

PDF: https://www.scaswebsite.com/wp-content/uploads/2021/07/scas.pdf

Scoring information: Scoring Instruction Website

Recommendations: If the child needs assistance reading, the scale may be read aloud by an adult if the reading is objective, and questions are read without influence. Scoring interpretation for boys and girls is noted by the author as different and should be interpreted with the appropriate norming data.

Languages available: Many translations available.

Ages: 6-12 years 

TERMS OF USE: https://www.nichq.org/resource/nichq-vanderbilt-assessment-scales – This link is for public domain permission for first edition only. Since the first edition, there have been two subsequent editions: the 2^nd Edition (2011) and 3^rd Edition (2019).

COST: No fee if you use the first edition. 

Description: The link above reflects the first edition of the assessment. There is both a parent and teacher assessment. The most current version of this assessment, which also includes parent and teacher informant assessments, is available for purchase from the American Academy of Pediatrics Bookstore.

PDF: Vanderbilt Assessment First Edition and Scoring Instructions

Scoring Information: Instructions on scoring included in PDF

Recommendations: The most current (2019) recommendations from the AAP in diagnosis ADHD can be found https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?autologincheck=redirected

Languages available: English

Ages: 8 -14 years 

TERMS OF USE: The DSRS-C may be freely used for clinical or research purposes provided due acknowledgement is made about its origin. https://effectiveservices.force.com/s/measure/a007R00000v8SEFQA2/birleson-depression-selfrating-scale-for-children

COST: No fee. 

Description: The DSRS-C is a self-administered 18 item instrument that asks the child to reflect on the past week. If children have difficulty reading the questions, the clinician may read them aloud.

PDF: Instrument PDF

Scoring Information: Instructions on scoring included in PDF

Recommendations: The instrument may be used together with other information from parents, school, or other sources to make a clinical diagnosis of children who may be suffering from depressive symptoms. It is not intended to be used as the sole means of diagnosis.

Languages available: English and the instrument has been translated into 10 other languages.

References:  Birleson P. (1981) The Validity of Depressive Disorder in Childhood and the Development of a Self-Rating Scale: A Research Report. J. Child Psychology Psychiatry 22, 73/88. Birleson P. Hudson I, Grey-Buchanan D, Wolff S. (1987) Clinical Evaluation of a Self-Rating Scale for Depressive Disorder in Childhood (Depression Self-Rating Scale). J. Child Psychology Psychiatry 28, 43/60.

Ages: 11 years and older

TERMS OF USE: This tool is copyrighted by Columbia Teen Screen but may be used at no cost with permission from the authors. Contact Prudence Fisher.

COST: No fee.

Description: The Columbia Depression Scale (DCS) is a 22-item self-report that screens adolescents ages 11 and older for both depression and suicide.  Questions focus on feelings & behaviors over the past four weeks. There are parallel instruments for youth and parents.

PDF: https://www.mdaap.org/pdf/Bi_Ped_CDSteen.pdf

Scoring information: Scoring directions provide a level of risk and percentage of youth who score within each risk range.

Ages: 12-22 years 

TERMS OF USE: Permission to use the KADS: The KADS is available freely for use but may not be sold, copied or otherwise distributed without the express written consent of Dr. Stan Kutcher. Permission granted by author for use by providers through this webpage.

COST: No fee. 

Description: This scale is a self-report depression scale designed to diagnose and assess the severity of adolescent depression. Questions consider the life of the adolescent within the last week and are asked to rate frequency from “hardly ever at 0” to “all of the time at 3.” There is a 16 item version, an 11 item version, as well as a 6-item version.

PDF: PDF of the 11-item Version
           Link includes 6 item version in English
           Link includes 6 item version in Spanish

Scoring Information:  No clinical thresholds are provided. The higher the score, the more presence of depressive symptoms.

Recommendations: All scores should be considered within the context of the baseline assessment.

Languages available: English and Spanish

Ages: 11-17 years

TERMS OF USE: freely accessible through the American Academy of Child and Adolescent Psychiatry. The following article speaks to the similarity between the PHQ9 and the PHQ9 modified for Adolescents. The other links include language indicating it is in the public domain along with the other set of PHQ instruments. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556930/ https://www.bmedreport.com/wp-content/uploads/2010/07/PHQ-9-Administration-Manual.pdf https://www.phqscreeners.com/terms https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/health-services-providers/thsteps/ths-patient-health-questionnaire-instr.pdf

COST: No fee.

Description:  A brief screener for depression in adolescents that is slightly modified to reflect age-appropriate language, of the PHQ9. The instrument can be self-administered.

PDF: PHQ-9 Modified for Adolescents

Scoring information: This instrument is scored on a 0 to 3 scale with 3 being “nearly every day” for depression symptoms. See PDF for instructions on scoring guidance with diagnoses.

Recommendations: Self-assessment that is then scored by a professional 

Languages available: English and Spanish

Ages: 9-17 years 

TERMS OF USE: Original content as well as existing translations are licensed by and can be obtained from Mapi Research Trust on behalf of Wiley as per the following process:

Academic users, Individual Practitioners (no funding)

You may access the questionnaire and/or its available translations directly online (see tutorial). Should you not see the Download button, please contact us. Funded academic users, healthcare organizations, commercial users & IT companies Fees may apply to your project. Submit your request (see tutorial). Our PROVIDE team will get back to you with the needed information and license agreement in a timely manner.

COST: No fee.

Description: A 13-item scale that has both a youth and a parent component, with identical questions. Items are rated on a 0 to 4 Likert Scale, and it is best described as a measurement of functional impairment.

PDF: Youth Version  
           Parent Version

Scoring Information: Items are scored 0 to 4, total score ranging from 0 to 52, with a total of 15 or more on a parent’s scale indicating impairment.

Recommendations: Languages available: English and Spanish

Ages: 4-16 years

TERMS OF USE: freely accessible; see the following link: https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist

COST: No fee.

Description: Brief questionnaire to recognize psychosocial problems and improve treatment in children. Assesses changes in emotional and behavioral problems in children. Scoring info listed with downloadable forms.

PDF:https://screening.mhanational.org/screening-tools/parent/ for parental assessment of child

Scoring information: Each item receives zero, one, or two points. With the scores on all 35 items summed for the total score. A score of 28 or above indicates some psychosocial impairment in children ages 6-17. See Mass General website above for more details.

Recommendations: This screener can be administered at any point in pediatric care but generally used during well-child visits. No one recommendation for administration; can be administered prior to the visit, at check-in; during the visit; or outside the visit.

Languages available: English, Chinese, Japanese, Spanish, Pictoral

Ages: 12-17 years

TERMS OF USE: freely accessible through the NIH National Institute of Drug Abuse

COST: No fee.

Description: A brief screener often used in pediatric settings that identifies problematic tobacco, alcohol, and marijuana use in adolescents. The screener asks frequency questions for the past year use of alcohol, tobacco, and marijuana. Patients who report using any of these three substances are then asked questions about additional substance use. If a PDF or hard copy of the instrument is used, clinicians should note that the order of the questions depends on the age of the child. For children 12-14 years of age, questions regarding friend use are asked first to converse in a less threatening way. For adolescents 15 and above (as well as 14 years old but in high school), the questions regarding personal use are asked first. The version on the NIDA website will automate the questions.

Online Link to instrument: https://nida.nih.gov/ast/bstad/#/

Scoring information: On the website version responses are automatically categorized into levels of risk with each risk level being mapped onto suggested clinical actions. Follow up screeners and additional assessment might be recommended but links are provided. Validity of Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use (2014) Pediatrics Article

Recommendations: This instrument can be used as part of an SBIRT algorithm. It is intended for use under a medical provider’s supervision and is not intended to guide self-assessment or take the place of a healthcare provider’s clinical judgement.

Languages available: English only

Ages: 12-18 years

TERMS OF USE: Must receive permission before use. Reproduction of the instrument will be granted after submission of the provider request. Go to CRAFFT website for detailed instructions. 

COST: No fee after following specific instructions found on website.

Description: The CRAFFT is a behavioral health screening tool for use with children and adolescents. The CRAFFT is meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted. This tool is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents. There is a clinician interview form and a self-administered version. More information is available on the main CRAFFT website.

PDF: Reproduction of the instrument will be granted after submission of the provider request.

Scoring information: Scoring algorithm 

Recommendations: The self-administered version is recommended. It is recommended that the adolescent complete it independently to ensure more truthful reporting. Additional administration information.

Languages available: Translated into over 30 languages.

Ages: 12-18 years

TERMS OF USE: Must receive permission before use: Reproduction of the instrument will be granted after submission of the provider request. Go to CRAFFT website for detailed instructions. Copyright information and criteria are the same as the CRAFFT (2.1). Follows the same restrictions and criteria. Go to website for full details and criteria to meet to reproduce and to receive permission.

COST: No fee. Must receive permission before using.

Description: Similar to the CRAFFT above, however includes information around nicotine and tobacco use. More information is available on the main CRAFFT website.

PDF: Reproduction of the instrument will be granted after submission of the provider request.

Scoring information: Scoring algorithm

Recommendations: It is recommended that the adolescent complete it independently to ensure more truthful reporting. Additional administration information.

Languages available: Translated into over 30 languages.

Ages: Adolescents

TERMS OF USE: freely accessible – https://nida.nih.gov/ast/s2bi/#/

COST: No fee.

Description: This instrument is a brief screening focused on alcohol, tobacco, synthetic drug, and marijuana use among adolescents with information about how to discuss interventions for clinicians. Online form provides immediate suggestions and resources once completed.

PDF: https://www.mcpap.com/pdf/S2Bi%20Toolkit.pdf more extensive pdf for clinicians or other healthcare providers which includes the questionnaire, sample scenarios, and outlines for plans to reduce or eliminate substance use. https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3542.html pdf for screener only download https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA1099.html pdf for provider toolkit only download

Scoring information: N/A; brief questionnaire. For answers other than “never,” there is information on how to discuss reducing or stopping use of substances.

Languages available: English only

Ages: 5 years and older 

TERMS OF USE: Copyright by The Research Foundation for Mental Hygiene, Inc. Freely accessible, though for reprints and inquiries on training, see contact information below. Written permission granted to EAHEC to post on this webpage from Dr. Kelly Posner. For reprints of the C-SSRS contact Kelly Posner, Ph.D., New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032; inquiries and training requirement contact posnerk@nyspi.columbia.edu.

COST: No fee.

Description: A tool that supports suicide risk assessment through a series of items and answers that helps users identify whether someone is at risk for suicide and assess the severity and immediacy of that risk. Completion of a 30-minute, on-line training is necessary to use the tool and provides a two-year certification. More information on the administration of the scale can be found on the main CSSRS website

PDF: http://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf

Scoring information: N/A 

Recommendations: For use by those who have received training on how to administer this assessment. https://practiceinnovations.org/resources/scorm/cssrs this is an online training module for the C-SSRS. The Lighthouse Project website has protocols and suggestions for use in healthcare settings, as well as other settings. See this link for additional information and helpful downloads.

Languages available: 140 languages available

Disclaimer:

This scale is intended to be used by individuals who have received training in its administration. The questions contained in the Columbia-Suicide Severity Rating Scale are suggested probes. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgment of the individual administering the scale.

Ages: 8 years and older

TERMS OF USE: freely accessible through NIH, see website below: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials#:~:text=The%20Ask%20Suicide%2DScreening%20Questions%20(ASQ)%20toolkit%20is%20designed,above%20for%20risk%20of%20suicide.

COST: No fee.

Description:  Developed by the NIH, as a four-question screener that is very brief to administer. If the patient screens positive there should be additional follow up (Brief Suicide Safety Assessment) and assessment by a trained clinician.

PDF: Ask Suicide-Screening Questions Instrument

Scoring information: A yes to one or more of the questions indicates risk.

Recommendations: It is recommended that the parent or caregiver not be present when screening youth. If the parent insists on being present it is recommended to proceed ahead with the screener however any other visitors should be asked to leave the exam room. There is a freely accessible online toolkit with clinical pathways to follow when a positive screen is indicated and a script for requesting that the caregiver step out of the room for the screen.

Languages available: Multiple

Ages: 8 years and older who can read independently 

TERMS OF USE: Free to clinicians and researchers through this website:  https://www.childrenandwar.org/projectsresources/measures https://www.corc.uk.net/outcome-experience-measures/child-revised-impact-of-events-scale-cries/

COST: No fee. 

Description: To be self-administered and should take approximately 5-10 minutes to complete. For children to measure re-experiencing and avoidance of a traumatic event and the feelings to which it gave rise. Consists of 4 items measuring Intrusion and 4 items measuring Avoidance.

PDF: https://www.corc.uk.net/media/1268/cries_selfreported.pdf

Scoring Information: Self-completed, can be administered in groups if needed. 8 items on a scale Not at all = 0, Rarely = 1, Sometimes = 3, Often = 5. Two Subscales – Intrusion = sum of items 1+3+6+7; Avoidance = sum of items 2+4+5+8.

Recommendations: A total score of 17 indicates a potential diagnosis of PTSD, however, do not make a clinical diagnosis from scores on the self-completed scales alone. A thorough structured interview to assess presence and severity of stress symptoms and child’s overall social functioning should be conducted.

Languages available: English, Arabic, Bangla, Bosnian, Brazilian/Portuguese, Chinese (traditional & simplified), Danish, Dutch, Farsi, Finish, French, German, Greek, Hindi, Indonesian, Japanese, Kurdish/Sorani, Malaysia (Bahasa), Nepali, Norwegian, Portuguese, Italian, Russian, Spanish, Swedish, Turkish, Ukrainian

Ages: 6-18 years

TERMS OF USE: Free to use without permission. https://www.childrenandwar.org/wp-content/uploads/2020/11/CPTCI-25-item-CPTCI-S-10-item.pdf – See author note of permission to use on pdf link.

COST: No fee.

Description: To assess how a child has been thinking and feeling since a frightening event. Available in 10 or 25 question option.

Scoring information:  Scoring 1, 2, 3, 4 (for Don’t agree at all, Don’t agree a bit, Agree a bit, and Agree a lot, respectively). No reverse scored items. For 25-item screen CPTCI 2 sub-scales for “disturbing and permanent change” (13 items including items 4, 6, 8, 13, 14, 16, 17, 19, 20, 21, 22, 23, 24) and “feeble person in a scary world” (12 items including items 1, 2, 3, 5, 7, 9, 10, 11, 12, 15, 18, 25). For the 10-item screener CPTCI-S – 2 sub-scales for “permanent and disturbing change” (6 items; items 1, 3, 6, 8, 9, 10) and “fragile person in a scary world” (4 items; items 2, 4, 5, 7). 

Recommendations: Screens for trauma-related cognitions that could be considered problematic, but not to be used for assessing post-traumatic stress. 

Languages available: English, Arabic, Bengali, Brazilian Portuguese, Chinese Mandarin, Danish, Dutch, Farsi, French, German, Hindi, Indonesian, Italian, Russian, Swedish

Ages: 11-14 years 

TERMS OF USE: requires materials to be purchased before use. Go to website:   https://shop.aap.org/bright-futures-tool-and-resource-kit-2nd-edition/

COST: $375.00, for Members, subject to change at any time. Go to website for current pricing. 

Description: Provides pediatric providers with an organized compilation of current forms and materials that relate to preventative health supervision and health screening for infants, children, and adolescents. Requires purchase of materials, $375

Scoring information: largely interview-based and does not have a systematic scoring system

Recommendations:  For use by pediatric clinicians at well-child visits but includes forms that can be filled out by the parent and child prior to the visit.

Languages available: English and Spanish

Ages: 5-19 years

TERMS OF USE: Requires a purchase for the materials to be used by clinicians and other professionals.

Go to website: https://www2.fasoutcomes.com/Content.aspx?ContentID=12

COST: Go to website for current cost.

Description: Described as the gold standard for assessing youth’s day to day functioning, this practitioner completed tool can be used both as an assessment and as a measurement of improvement over time. Measures domains such as school, thinking problems, behavior towards others, self-harm, mood/emotions, substance use, home, community, as well as two questions addressing caregiver well-being. Website states completed in approximately 10 minutes, but no special indication for use in primary care.

Scoring Information: Available online with purchase – see website. Scores are calculated instantly, and a profile is provided with clinical markers. The software also provides space to create goals or a treatment plan that can be provided to the family/patient.

Ages: 9-12 years (Older Child); 13-18 years (Standard)

TERMS OF USE: Requires a purchase for the materials to be used by clinicals and other professionals. Go to website: https://possibilitiesforchange.org/pricing/

COST: For full access and pricing information, please go to their website references above.

Description:  This screener identifies youths most at risk for dropping out of school and uses factors such as discrimination, abuse, and access to tangible needs (i.e., food, water, electricity) that contribute to morbidity, mortality, and social problems

PDF: https://possibilitiesforchange.org/raaps-assessment-preview/ you can preview the form, but you must enter in your information first. For full access to the screener and resources you must contact for pricing

Scoring information: N/A; online program that scores automatically

Languages available: English and Spanish

Ages: Third grade and older

TERMS OF USE: The RCADS and its derivative works are intellectual property owned and copyrighted by Chorpita and Spence. They are available for use through Dr. Chorpita’s UCLA resource page at no cost to users (www.childfirst.ucla.edu/resources/), but such use does not imply a perpetual free license to any individual or institution.

CLICK on USER GUIDE:  See page 5, https://www.childfirst.ucla.edu/wp-content/uploads/sites/163/2022/01/RCADSUsersGuide20220125.pdf

COST: No fee but subject to change at any time.

Description: A 25-item questionnaire self-report with three scores: total anxiety, total depression, and total anxiety and depression. The caregiver version assesses the caregiver’s report of symptoms. The brief 25-item version is produced from the longer 47-item questionnaire which included many of the items from the Spence Children’s Anxiety Scale and items representing depressive symptoms from the DSM.

PDF: Brief RCADS-Child Version Brief RCADS-Caregiver Version

Scoring information: Questionnaire Translations and Scoring Instructions 

Recommendations:  N/A

Languages available: English, Dutch, Finnish, Hindi, Spanish, Swedish

Ages: 8-18 years

TERMS OF USE: The following quote is found at the bottom of the instrument/form: “The SCARED is available at no cost at www.pediatricbipolar.pitt.edu under resources/instruments. January 19, 2018”

COST: No fee but subject to change at any time.

Description: A 41-item questionnaire available both online and printed versions for child and parent to measure child anxiety. It includes four domains including panic/somatic, separation anxiety, generalized anxiety, and school phobia. There is a screener for the child and parent to complete. It should take approximately 10 minutes to complete.

PDF: English Screener with Scoring Included

Scoring information: see above

Recommendations:  For children ages 8 to 11, it is recommended to have an adult sit with them while they answer in case they have any questions. 

Languages available: Multiple languages available from the website.

Ages: 11-17 years

TERMS OF USE: Craske M, Wittchen U, Bogels S, Stein M, Andrews G, Lebeu R. Copyright © 2013 American Psychiatric Association. All rights reserved.  This material can be reproduced without permission by researchers and by clinicians for use with their patients.

COST: No fee.

Description: Part of the American Psychiatric Association’s “emerging measures” effort in 2013. Intended to be used at the initial patient interview and ongoing to enhance clinical decision making. APA is asking for any research that is done to be shared with them at this link http://www.dsm5.org/Pages/Feedback-Form.aspx The item itself is a 10-item questionnaire designed to be self-administered by the child AFTER being given a diagnosis of generalized anxiety disorder. The measure itself may be used to track status over time. Clinicians should review each question with the patient as well.

PDF: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Severity-Measure-For-Generalized-Anxiety-Disorder-Child-Age-11-to-17.pdf 

Scoring information: Items are rated on a five-point scale with a total range of score from 0 to 40 with the higher the score indicating the increase in severity. Items should be given a raw score. Clinicians should also calculate an average score which then provides them an overall severity perspective on a five-point scale.

Recommendations:  N/A 

Languages available: English

Ages: 13-18 years

TERMS OF USE: https://www.scaswebsite.com/ – Information from the site, including the Spence Children’s Anxiety Scales, may currently be downloaded and used free of charge by researchers and individual practitioners.

COPYRIGHT: The scales are copyrighted to the author and may not be reprinted in full in any publication nor resold for commercial purposes. The scales are copyrighted documents and are not in the public domain. They cannot be modified, such as changing the wording of questions, the response format, nor by adding or removing questions. The creation of translations of the scales into other languages or for conversion into electronic format requires prior approval from the author.

COST: No fee but subject to change at any time.

Description: A 44-item scale to assess anxiety with domains indicating generalized anxiety, panic/agoraphobia, social phobia, separation anxiety, obsessive compulsive disorder, and physical injury fears. Should take approximately 10 minutes to complete. Children rate the frequency of their experience on a scale of 1-4. It is not intended to be a diagnostic instrument when used in isolation of clinical judgment.

PDF: https://www.scaswebsite.com/wp-content/uploads/2021/07/scas.pdf

Scoring information: Scoring Instruction Website

Recommendations: If the child needs assistance reading, the scale may be read aloud by an adult as long as the reading is objective, and questions are read without influence. Scoring interpretation for boys and girls is noted, by the author, as different and should be interpreted with the appropriate norming data.

Languages available: Many translations available.

Ages: 8 -14 years

TERMS OF USE: The DSRS-C may be freely used for clinical, or research purposes provided due acknowledgement is made about its origin. See, https://effectiveservices.force.com/s/measure/a007R00000v8SEFQA2/birleson-depression-selfrating-scale-for-children

COST: No fee. 

Description: The DSRSC- is a self-administered 18 item instrument that asks the child to reflect on the past week. If children have difficulty reading the questions, the clinician may read them aloud.

PDF: Instrument PDF

Scoring Information: Instructions on scoring included in PDF.

Recommendations: The instrument may be used together with other information from parents, school, or other sources to make a clinical diagnosis and to identify children who may be suffering from depressive symptoms. It is not intended to be used as the sole means of diagnosis.

Languages available: English and the instrument has been translated into 10 other languages.

References: Birleson P. (1981) The Validity of Depressive Disorder in Childhood and the Development of a Self-Rating Scale: A Research Report. J. Child Psychology Psychiatry 22, 73/88. Birleson P. Hudson I, Grey-Buchanan D, Wolff S. (1987) Clinical Evaluation of a Self-Rating Scale for Depressive Disorder in Childhood (Depression Self-Rating Scale). J. Child Psychology Psychiatry 28, 43/60.

Ages: 11 years and older

TERMS OF USE: This tool is copyrighted by Columbia Teen Screen but may be used at no cost with permission from the authors. Contact Prudence Fisher.

COST: No fee.

Description: The Columbia Depression Scale (DCS) is a 22-item self-report that screens adolescents ages 11 and older for both depression and suicide.  Questions focus on feelings & behaviors over the past four weeks. There are parallel instruments for youth and parents.

PDF: https://www.mdaap.org/pdf/Bi_Ped_CDSteen.pdf

Scoring information: Scoring directions provide a level of risk and percentage of youth who score within each risk range.

Ages: 12-22 years

TERMS OF USE:  Permission to use the KADS: The KADS is available freely for use but may not be sold, copied or otherwise distributed without the express written consent of Dr. Stan Kutcher. Permission granted by author for use by providers through this webpage.

COST: No fee. 

Description: This scale is a self-report depression scale designed to diagnose and assess the severity of adolescent depression. Questions consider the life of the adolescent within the last week and are asked to rate frequency from “hardly ever at 0” to “all of the time at 3.” There is a 16 item version, an 11 item version, as well as a 6-item version.

PDF: PDF of the 11-item Version Link includes 6 item version in English Link includes 6 item version in Spanish

Scoring Information:  No clinical thresholds are provided, simply the higher the score the more of the presence of depressive symptoms.

Recommendations: All scores should be considered within the context of the baseline assessment.

Languages available: English and Spanish

Ages: 9-17 years

TERMS OF USE: Original content as well as existing translations are licensed by and can be obtained from Mapi Research Trust on behalf of Wiley as per the following process:

Academic users, Individual Practitioners (no funding)

You may access the questionnaire and/or its available translations directly online (see tutorial). Should you not see the Download button, please contact us. From the website: “Funded academic users, healthcare organizations, commercial users & IT companies, fees may apply to your project. Submit your request (see tutorial). Our PROVIDE team will get back to you with the needed information and license agreement in a timely manner.”

COST: No fee. 

Description: A 13 item scale that has both a youth and a parent component which have identical questions. Items are rated on a 0 to 4 Likert scale, and it is best described as a measurement of functional impairment.

PDF: Youth Version
           Parent Version

Scoring Information: Items are scored 0 to 4, total score ranging from 0 to 52, with a total of 15 or more on a parent’s scale indicating impairment.

Recommendations:

Languages available: English and Spanish

Reference: Bird, H. R., Shaffer, D., Fisher, P., Gould, M. S., et al. (1993). The Columbia Impairment Scale (CIS): Pilot findings on a measure of global impairment for children and adolescents. International Journal of Methods in Psychiatric Research, 3(3), 167–176.

Below excerpted from Child and AdolescentPsychiatry: The Essentials, (2005), Edited by Kathleen Myers and Keith Cheng, pg. 41, Chapter 3, Rating Scales

Ages: 4-16 years

TERMS OF USE: freely accessible – see https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist

COST: No fee.

Description: Brief questionnaire to recognize psychosocial problems and improve treatment in children. Assesses changes in emotional and behavioral problems in children. Scoring info listed with downloadable forms

PDF: https://screening.mhanational.org/screening-tools/parent/ for parental assessment of child

Scoring information: Each item receives zero, one, or two points. With the scores on all 35 items summed for the total score. A score of 28 or above indicates some psychosocial impairment in children ages 6-17. See Mass General website above for more details

Recommendations: Can be administered at any point in pediatric care but generally used during well-child visits. No one recommendation for administration; can be administered prior to the visit, at check-in; during the visit; or outside the visit.

Languages available: English, Chinese, Japanese, Spanish, Pictoral

Ages: 12-17 years

TERMS OF USE: freely accessible through the NIH National Institute of Drug Abuse

COST: No fee.

Description: A brief screener often used in pediatric settings that identifies problematic tobacco, alcohol, and marijuana use in adolescents. The screener asks frequency questions for past year use of alcohol, tobacco, and marijuana. Patients who report using any of these three substances are then asked questions about additional substance use. If a PDF or hard copy of the instrument is used, clinicians should note that the order of the questions depends on the age of the child. For children 12-14 years of age, questions regarding friend use are asked first as a way to enter into the conversation in a less threatening way. For adolescents 15 and above (as well as 14 years old but in high school), the questions regarding personal use are asked first. The version on the NIDA website will automate the questions.

Online Link to instrument: https://nida.nih.gov/ast/bstad/#/

Scoring information: On the website version responses are automatically categorized into levels of risk with each risk level being mapped onto suggested clinical actions. Follow up screeners and additional assessment might be recommended but links are provided. Validity of Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use (2014) Pediatrics Article

Recommendations: This instrument can be used as part of an SBIRT algorithm. It is intended for use under a medical provider’s supervision and is not intended to guide self-assessment or take the place of a healthcare provider’s clinical judgement.

Languages available: English only

Ages: 12-18 years

TERMS OF USE: Must receive permission before use. Reproduction of the instrument will be granted after submission of the provider request. Go to CRAFFT website for detailed instructions.

COST: No fee but permission to use is required first. 

Description: The CRAFFT is a behavioral health screening tool for use with children and adolescents through age 20. The CRAFFT is meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted. This tool is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents. There is a clinician interview form and a self-administered version. More information is available on the main CRAFFT website.

PDF: Reproduction of the instrument will be granted after submission of the provider request.

Scoring information: Scoring algorithm

Recommendations: The self-administered version is recommended. It is recommended that the adolescent complete it independently to ensure more truthful reporting. Additional administration information.

Languages available: Translated into over 30 languages.

Ages: 12-18 years

TERMS OF USE: Must receive permission before use: Reproduction of the instrument will be granted after submission of the provider request. Go to CRAFFT website for detailed instructions. Copyright information and criteria are the same as the CRAFFT (2.1). Follows the same restrictions and criteria. Go to website for full details and criteria to meet to reproduce and receive permission.

COST: No fee. Must receive permission before using.

Description: Similar to the CRAFFT above, however includes information around nicotine and tobacco use. More information is available on the main CRAFFT website.

PDF: Reproduction of the instrument will be granted after submission of the provider request.

Scoring information: Scoring algorithm

Recommendations: It is recommended that the adolescent complete it independently to ensure more truthful reporting. Additional administration information.

Languages available: Translated into over 30 languages.

Ages: Adolescents

TERMS OF USE: freely accessible – https://nida.nih.gov/ast/s2bi/#/

COST: No fee.

Description: This instrument is a brief screening focused on alcohol, tobacco, synthetic drug, and marijuana use among adolescents with information about how to discuss interventions for clinicians. Online form provides immediate suggestions and resources once completed.

PDF: https://www.mcpap.com/pdf/S2Bi%20Toolkit.pdf more extensive pdf for clinicians or other healthcare providers which includes the questionnaire, sample scenarios, and outlines for plans to reduce or eliminate substance use. https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3542.html pdf for screener only download https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA1099.html pdf for provider toolkit only download

Scoring information: N/A; brief questionnaire. For answers other than “never,” there is information on how to discuss reducing or stopping use of substances.

Languages available: English only

Ages: 8 years and older

TERMS OF USE: Instrument readily available on the NIMH website. Go to https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials#:~:text=The%20Ask%20Suicide%2DScreening%20Questions%20(ASQ)%20toolkit%20is%20designed,above%20for%20risk%20of%20suicide.

COST: No fee.

Description: This screener includes 4 questions and takes less than a minute to administer. Successfully identified 97% of youth ages 10 to 21 years who were at risk for suicide when a minimum of one question was answered yes.

PDF: NIMH Ask Suicide-Screening Questions

Scoring information: If a patient answers yes to any of the questions they are considered a positive screen and should be assessed for acuity. If the patient answers yes to any of the first four questions then the fifth question should be asked. If the answer to the fifth question is asked, then a full mental health recommendation is recommended, and the patient should not leave until evaluated for safety. Scoring Information

Recommendations: Recommended to be conducted without the parent/guardian present. The NIMH website includes additional information on clinical pathways appropriate for medical settings. ASQ Toolkit

Languages available: Additional translations located here

Ages: 5 years and older

TERMS OF USE: Copyright by The Research Foundation for Mental Hygiene, Inc. Permission granted by Kelly Posner to EAHEC for use on this webpage; Freely accessible. For reprints and inquiries on training see below:

For reprints of the C-SSRS contact Kelly Posner, Ph.D., New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032; inquiries and training requirements contact posner@nyspi.columbia.edu.

COST: No fee.

Description: A tool that supports suicide risk assessment through a series of items and answers that helps users identify whether someone is at risk for suicide and assess the severity and immediacy of that risk. Completion of a 30-minute, on-line training is necessary to use the tool and provides a two-year certification. More information on the administration of the scale can be found on the main CSSRS website

PDF: http://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf

Scoring information: N/A

Recommendations: For use by those who have received training on how to administer this assessment. https://practiceinnovations.org/resources/scorm/cssrs this is an online training module for the C-SSRS. The Lighthouse Project website has protocols and suggestions for use in healthcare settings, as well as other settings. See this link for additional information and helpful downloads.

Languages available: 140 languages available

Disclaimer:

This scale is intended to be used by individuals who have received training in its administration. The questions contained in the Columbia-Suicide Severity Rating Scale are suggested probes. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgement of the individual administering the scale.

Ages: 8 years and older who read independently

TERMS OF USE: Free to clinicians and researchers through this website: https://www.childrenandwar.org/projectsresources/measures https://www.corc.uk.net/outcome-experience-measures/child-revised-impact-of-events-scale-cries/

COST: No fee.  

Description: For children to measure re-experiencing and avoidance of a traumatic event and the feelings to which it gave rise. Consists of 4 items measuring Intrusion and 4 items measuring Avoidance.

PDF: Instructions and Scale

Scoring Information: Self-completed, can be administered in groups if needed. 8 items on a scale Not at all = 0, Rarely = 1, Sometimes = 3, Often = 5. Two Subscales – Intrusion = sum of items 1+3+6+7; Avoidance = sum of items 2+4+5+8.

Recommendations: Do not make a clinical diagnosis from scores on the self-completed scales alone but through structured interview to assess presence and severity of stress symptoms and child’s overall social functioning.

Languages available: English, Arabic, Bangla, Bosnian, Brazilian/Portuguese, Chinese (traditional & simplified), Danish, Dutch, Farsi, Finish, French, German, Greek, Hindi, Indonesian, Japanese, Kurdish/Sorani, Malaysia (Bahasa), Nepali, Norwegian, Portuguese, Italian, Russian, Spanish, Swedish, Turkish, Ukrainian

Ages: 6-18 years

TERMS OF USE: Free to use without permission. For further information on the CPTCI: Please contact Richard Meiser-Stedman (r.meiser-stedman@uea.ac.uk) See author note of permission to use on pdf link provided.

COST: No fee.

Description: To assess how a child has been thinking and feeling since a frightening event

PDF: Post-Traumatic Cognitions Inventory

Scoring information: see article for more information

Recommendations: 25 or 10 question option.  Screens for trauma-related cognitions that could be considered problematic, but not to be used for assessing post-traumatic stress.

Languages available: English, Arabic, Bengali, Brazilian Portuguese, Chinese Mandarin, Danish, Dutch, Farsi, French, German, Hindi, Indonesian, Italian, Russian, Swedish  See author note of permission to use on above PDF.

Ages: 5-19 years

TERMS OF USE: Requires a purchase for the materials to be used by clinicians and other professionals.

Go to website: https://www2.fasoutcomes.com/Content.aspx?ContentID=12

COST: Go to website for current cost.

Description: Described as the gold standard for assessing youth’s day to day functioning, this practitioner completed tool can be used both as an assessment and as a measurement of improvement over time. Measures domains such as school, thinking problems, behavior towards others, self-harm, mood/emotions, substance use, home, community, as well as two questions addressing caregiver well-being. Website states completed in approximately 10 minutes, but no special indication for use in primary care.

Scoring Information: Available online with purchase. Scores are calculated instantly, and a profile is provided with clinical markers. The software also provides space to create goals or a treatment plan that can be provided to the family/patient.

Ages: 9-12 years (Older Child); 13-18 years (Standard)

TERMS OF USE: Requires a purchase for the materials to be used by clinicals and other professionals. Go to website: https://possibilitiesforchange.org/pricing/

Description: identifies youths most at risk for dropping out of school and uses factors such as discrimination, abuse, and access to tangible needs (i.e., food, water, electricity) that contribute to morbidity, mortality, and social problems

PDF: https://possibilitiesforchange.org/raaps-assessment-preview/ you can preview the form, but you must enter in your information first. For full access to the screener and resources you must contact for pricing https://possibilitiesforchange.org/pricing/

Scoring information: N/A; online program that scores automatically

Languages available: English and Spanish