Screening Tools
The following is a list of recommended screening tools for children and adolescents presenting symptoms of various mental disorders. These tools may be used to identify children that may benefit from a diagnostic assessment. Screening tools alone are not enough for diagnosis.
Strengths and Difficulties
Recommended as a tool to be used broadly to guide discussions and to focus on treatment targets with an awareness of the patient’s strengths. This tool identifies emotional and behavioral problems as well as protective prosocial behaviors (strengths) that can be leveraged.
Strengths and Difficulties Questionnaires
Eating Disorder
SCOFF: A mnemonic that is useful to identify symptoms of eating disorders. It includes an assessment of the following domains: Sick, Control, One, Fat, and Food.
Depression
Patient Health Questionnaire-9 (PHQ-9): May be used to screen for depression. It should be noted that a question on suicidal ideation exists on the PHQ-9. If the adolescent states that they are experiencing suicidal ideation a follow up clinical interview must be conducted to ensure their safety.
Patient Health Questionnaire-9
Children’s Depression Rating Scale
Children’s Depression Rating Scale: May be used as a follow up to screening to detect presence of depression symptoms and specify severity.
Children's Depression Rating Scale
Trauma and Post Traumatic Stress Disorder (PTSD)
Pediatric Traumatic Stress Screening Tool: This screening tool was developed to identify symptoms meeting the diagnostic criteria for PTSD in children and adolescents. The severity of symptoms is determined by summing the numeric scores for items 1–12: 0–10 indicates mild or no risk; 11–20 indicates a moderate risk; scores of 21 or greater indicate a severe risk.
Pediatric Traumatic Stress Screening Tool
Child and Adolescent Trauma Screen (CATS): a brief screening instrument used to measure potentially traumatic events and PTSD. The CATS is based on the DSM-5 criteria for PTSD.
ISTSS - Posttraumatic Stress Disorder Checklist
International Society for Traumatic Stress Studies (ISTSS): Based on screening results, there are a variety of assessment tools available to conduct an assessment for acute stress, trauma, and PTSD.
Suicide
Ask Suicide-Screening Questions (ASQ): A free screening tool, validated by the National Institute of Mental Health (NIMH), with 4 yes/no questions, as well as a fifth question indicating acuity in those who answered yes to one of the first four questions. The ASQ is intended to be delivered verbatim, and directly with the child or adolescent being screened.
Columbia-Suicide Severity Rating Scale (C-SSRS): The C-SSRS may be used as a follow up to the ASQ. This is particularly useful if the child or adolescent answers yes to one or more of the first four questions, but answers no to the fifth question.
Brief Suicide Safety Assessment (BSSA): Designed to serve as a follow up to a positive ASQ screening, the BSSA is used to assess suicide risk further. This is particularly useful if the child or adolescent answers yes to one or more of the first four questions, but answers no to the fifth question.
Substance-Related and Addictive Behavior Screening Tools
Screening, Brief Intervention, and Referral to Treatment (SBIRT): An evidence-based approach developed for use in primary care settings to identify when patients are at risk of substance-related needs that require early intervention and treatment services. SBIRT may be utilized as part of universal screening for all patients and can help identify the severity of substance use, but also can reinforce abstinence.
CRAFFT: A mnemonic that can be used to screen for substance-related difficulties. It includes questions pertaining to the following domains: Car, Relax, Alone, Forget, Friends, Trouble.
Anxiety Disorders
The Screen for Child Anxiety Related Emotional Disorders (SCARED): A 41 item Likert scale assessment that is delivered to both the child or adolescent and parent(s). A score of 25 or above is indicative of a possible anxiety disorder, however the scale can also be scored in parallel with various specific anxiety disorders listed in the DSM-5. Depending on how various items are scored, the assessment can indicate if the child or adolescent is possibly presenting with panic disorder, significant somatic symptoms, generalized anxiety disorder (GAD), separation anxiety disorder, social anxiety disorder, and/or school avoidance.
Severity Measure for Generalized Anxiety Disorder (GAD-7): A 10 item self-report scale that assesses the presence and possible severity of GAD in children and adolescents.
Attention Deficit/Hyperactivity Disorder (ADHD)
Vanderbilt Assessment Scales: Each section of the Vanderbilt Assessment Scales reflect the symptoms of ADHD, oppositional-defiant disorder, conduct disorder, mood concerns, academic performance, and classroom behavioral performance. The assessment specifically asks about a child’s behaviors within the past 6 months, and information can initially be obtained from parents as well as teachers.
SNAP-IV: Questions pertaining to inattention and hyperactivity are included in the SNAP-IV, which is an abbreviated version of the Swanson, Nolan, and Pelham (SNAP) assessment. This can be used to assess the possibility of ADHD in a child or adolescent.
Screening Tools for Multiple Mental Health Disorders
HEADSSS Psychosocial Assessment: The HEADSS assessment is mnemonic which includes the following domains: Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/Depression, and Safety. This tool is commonly used by providers to assess domains of psychosocial functioning that contain risk factors and protective factors for adolescent medical and mental health. The HEADSSS assessment is suggested during the assessment of the following mental health disorders: eating disorders, and trauma and post-traumatic stress disorder (PTSD).
Additional Tools
Youth Mania Rating Scale (YMRS)