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Douglas R.

Coombs, MD
520 East Medical Drive #301
Bountiful, Utah 84010
Phone (801)292-1464
Fax (801)292-1465

Date__________________

Dear Parent/Guardian,

This ADHD evaluation includes information from school as well as home. Please fill out the the following home
screening scales and return them to our office one week before your office visit.

Attached, please find:


Structured Parent Interview
Vanderbilt Parent Assessment Scale
Home Symptom Screening Scale
Depression Scale for Children
Screen for Child Anxiety (CHILD)
Screen for Child Anxiety (PARENT)

Please complete these forms as soon as you can find time to do so thoroughly. If there is additional information
that you consider pertinent, please provide this on an additional sheet or call us at the office. As soon as you
have completed the forms, please either mail them, fax them, or return them in person one week before your
office visit.

Please bring a quiet toy or activity for your child to play with during the consultation process of the exam.

***Not all insurances will cover the cost of reviewing, scoring or interpreting this packet.
You will be responsible for any costs not covered by your insurance plan***

Sincerely,

Douglas R. Coombs, MD, FAAP


Lisa Sharp, RN, FNP, BC
Gina M. Capps, RN, CPNP
Stacey A. Bushell, MSN, CPNP
Kim Webb, RN, CPNP
Brian J. Holdstock, MSN, CFNP
STRUCTURED PARENT INTERVIEW

__________________________________________________________________________________________
Pateint Name Grade Age Date

__________________________________________________________________________________________
Form Completed By Relationship

______________________________________________________________________________________
School Name/ Contact School Phone # School Fax #
__________________________________________________________________________________________
Parents or legal guardians should complete the following questionnaire. This feedback will provide valuable information to the school regarding your child and his/her
current school-related difficulties. All information will be kept confidential. If you do not wish to respond to an item on the interview form, just write "no response" in
the space provided or out to the side.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
SECTION ONE - FAMILY INFORMATION

Mother's name _________________________________ Father's name _______________________________

Marital status of child's parents: [ ] Unmarried [ ] Married [ ] Separated [ ] Divorced (for how long?)____________

[ ] Remarried (name of step parents)_________________________________________


Number of sibling residing in the home:

Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
Name___________________________________________________ Age____________
SECTION TWO - PREGNANCY / DELIVERY

General health during pregnancy:


[ ] Excellent [ ] Good [ ] Poor (please explain)____________________________________________

During your pregnancy, indicate if you often used:


[ ] Cigarettes [ ] Alcohol [ ] Other drugs [ ] None of the above

Pregnancy was: [ ] Without complications [ ] With complications (please explain)______________________


__________________________________________________________________________________________

Delivery was: [ ] Without complications [ ] Induced [ ] C-Section [ ] Other ________________________

Infants health at birth was: [ ] Excellent [ ] Good [ ] Poor (please explain) ______________________________
__________________________________________________________________________________________
SECTION THREE - CHILD'S DEVELOPMENTAL HISTORY

Please place a mark through the box if your child had difficulty in any of these areas during the first three years
of life:
[ ] Poor eye contact [ ] Didn't get along well with peers [ ] Overly fearful
[ ] Colicky / irritable [ ] Difficulty adjusting to schedules (eating, sleeping, etc.) [ ] Difficult to comfort
[ ] Sleep problems [ ] Resisted affection from others [ ] Overactive
[ ] Threw tantrums [ ] Resisted changes in schedules [ ] Accident prone
[ ] Stubborn

Overall, as a toddler, I would describe my child's temperament as (check one):


[ ] Extremely difficult [ ] Difficult [ ] Average [ ] Very easy

Indicate the age at which your child developed the following skills:
_____Crawling _____Toilet training _____Riding a bike _____Getting dressed without help
_____Walking _____First words _____Ability to complete simple chores independently

SECTION FOUR - CHILD'S MEDICAL HISTORY

Family physician ____________________________________________ Phone # _______________________

Please place a mark through the box if your child has had any of the following medical conditions:
[ ] Asthma _________________________ [ ] Chronic ear infections ____________________________
[ ] Allergies ________________________ [ ] Hearing loss ____________________________________
[ ] Bedwetting ______________________ [ ] Vision problems _________________________________
[ ] Diabetes ________________________ [ ] Poor motor coordination __________________________
[ ] Seizure disorder __________________ [ ] Sleep problems__________________________________
[ ] Surgeries (for what?) __________________________ [ ] Appetite problems (under / over eats) ________________________________
[ ] Head trauma_____________________ [ ] Serious injuries (broken bones, stitches, etc) ___________________________

Overall, I would describe my child's current level of health as being: [ ] Excellent [ ] Good [ ] Poor

My child is currently taking the following medications:


Name of medication ______________________________ For what condition? ____________________
Name of medication ______________________________ For what condition? ____________________
Name of medication ______________________________ For what condition? ____________________
Name of medication ______________________________ For what condition? ____________________
Name of medication ______________________________ For what condition? ____________________
Name of medication ______________________________ For what condition? ____________________

SECTION FIVE - FAMILY HISTORY

Please check the box if either of the child's biological parents have experienced any of the following conditions:
[ ] Attention Deficit / Hyperactivity Disorder [ ] Obsessive-compulsive disorder
[ ] Learning disablities / Academic underachievement [ ] Autism / Asperger's syndrome
[ ] Communication disorders / disablities [ ] Tourette's syndrome
[ ] Depression [ ] Substance abuse
[ ] Anxiety disorder(s) [ ] Criminal misconduct
Please check the box if any of the child's biological siblings have experienced any of the following conditions:
[ ] Attention Deficit / Hyperactivity Disorder [ ] Obsessive-compulsive disorder
[ ] Learning disablities / Academic underachievement [ ] Autism / Asperger's syndrome
[ ] Communication disorders / disablities [ ] Tourette's syndrome
[ ] Depression [ ] Substance abuse
[ ] Anxiety disorder(s) [ ] Criminal misconduct

SECTION SIX - CHILD'S EDUCATIONAL HISTORY

Please list any previous schools your child has attended:


Name of school ________________________________________City___________________________
Name of school ________________________________________City___________________________
Name of school ________________________________________City___________________________
Name of school ________________________________________City___________________________
Name of school ________________________________________City___________________________

Please place a mark through the box if the item is true about your child. If unsure about an item, leave it blank.
[ ] My child has been previously evaluated for school-related problems ___________________________
[ ] My child has had to repeat a grade ______________________________________________________
[ ] My child has difficulty learning academic material _________________________________________
[ ] My child has difficulty following school rules _____________________________________________
[ ] My child has difficulty forming friendships at school _______________________________________
[ ] My child resists going to school and/or complains about disliking school _______________________
[ ] My child has received counseling at school _______________________________________________
[ ] My child is or has been in special education ("resource") _______________________________________
[ ] My child has (or has had) a 504 plan ____________________________________________________
[ ] My child has a medical condition that may affect his/her ability to succeed at school - please describe:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Please describe any additional information about your child's school history that you feel might be helpful
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

SECTION SEVEN - CURRENT BEHAVIORAL CONCERNS


Please check the boxes that describe a current concern that you have about your child:

Behavior
[ ] Overactive / always on the go [ ] Can't play quietly
[ ] Impulsive - acts without thinking about behavioral consequences [ ] Doesn't complete tasks or chores
[ ] Distractible - shifts focus from one activity to another [ ] Disorganized - frequently loses things
[ ] Difficulty complying to rules and expectations [ ] Forgetful - has trouble following directions
[ ] Talks too much - interrupts others [ ] Impatient - difficult waiting for turns
Compliance to Rules and Social Norms
[ ] Refuses to comply with adults and rules [ ] Destroys property
[ ] Argues with adults [ ] Dishonest - lies, cheats, steals
[ ] Throws tantrums [ ] Bullies - threatens others
[ ] Seems angry / vindictive [ ] Physically aggressive toward others - gets in fights

General Mood
[ ] Cries often or without apparent reason [ ] Loss of appetite
[ ] Irritable / Moody [ ] Excessive fatigue / Loss of energy
[ ] Complains of having no friends [ ] Doesn't seem to enjoy activities that used to be fun
[ ] Complains about feeling unloved [ ] Expresses suicidal thoughts ("I don't want to live")
[ ] Can't sleep at night / sleeps too much during the day

Anxiety Level
[ ] Worries excessively (e.g., sickness, weather, safety, school) [ ] Difficulty separating from parents
[ ] Difficulty sleeping [ ] Difficulty concentrating
[ ] Doesn't seem to enjoy activities that used to be fun [ ] Restless / Easily agitated
[ ] Expresses suicidal thoughts ("I don't want to live anymore") [ ] Loss of energy / Easily fatigued
[ ] Complains of headaches, stomachaches, nausea when not appearing sick

Peer Relationships
[ ] Complains that "nobody likes me" [ ] Has difficulty sharing and cooperating with others
[ ] Bossy - has to have own way [ ] Teases others
[ ] Doesn't follow rules when playing games [ ] Bullies others
[ ] Sore loser [ ] Doesn't show concern for the welfare of others
[ ] Argues and fights with peers

School Performance
[ ] Academic deficits - not learning as quickly as classmates [ ] Low test scores
[ ] Behavior problem - disruptive / does not follow rules [ ] Excessive absences / tardiness
[ ] Fails to complete classwork and homework [ ] Social problems - has few friends at school
[ ] Resists going to school

SECTION EIGHT - ADDITIONAL INFORMATION

Please use the lines below to indicate your child's individual strengths and positive personality characteristics:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please use the lines below to provide additional information about your child that may be of importance to the
school:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Thank you for providing this information.


When you have completed the questionnaire(s), please return them to our office
at least one week prior to your scheduled appointment.
If you have any questions, please contact our office at (801) 292-1464.
NICHQ Vanderbilt Assessment Scale—Parent Informant
NICHQ Vanderbilt Assessment Scale—PARENT Informant
Today’s Date: __________ Child’s Name: _________________________________ Date of Birth: ___________
Parent’s Name: _______________________________________ Parent’s Phone Number: __________________

Direction: Each rating should be considered in the context of what is appropriate for the age of your child
When completing this form, please think about your child’s behaviors in the past 6 months.
Is this evaluation based on a time when the child: [ ] was on medication [ ] was not on medication [ ] not sure?
Symptoms Never Occasionally Often Very Often
1. Does not pay attention to details or makes careless mistakes 0 1 2 3
with, for example, homework
2. Has difficulty keeping attention to what needs to be done 0 1 2 3
3. Does not seem to listen when spoken to directly 0 1 2 3
4. Does not follow through when given directions and fails to finish activities 0 1 2 3
(not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities 0 1 2 3
6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 1 2 3
mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 1 2 3
or books)
8. Is easily distracted by noises or other stimuli 0 1 2 3
9. Is forgetful in daily activities 0 1 2 3
10. Fidgets with hands or feet or squirms in seat 0 1 2 3
11. Leaves seat when remaining seated is expected 0 1 2 3
12. Runs about or climbs too much when remaining seated is expected 0 1 2 3
13. Has difficulty playing or beginning quiet play activities 0 1 2 3
14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3
15. Talks too much 0 1 2 3
16. Blurts out answers before questions have been completed 0 1 2 3
17. Has difficulty waiting his or her turn 0 1 2 3
18. Interrupts or intrudes in on others’ conversations and/or activities 0 1 2 3
19. Argues with adults 0 1 2 3
20. Loses temper 0 1 2 3
21. Actively defies or refuses to go along with adults’ requests or rules 0 1 2 3
22. Deliberately annoys people 0 1 2 3
23. Blames others for his or her mistakes or misbehaviors 0 1 2 3
24. Is touchy or easily annoyed by others 0 1 2 3
25. Is angry or resentful 0 1 2 3
26. Is spiteful and wants to get even 0 1 2 3
27. Bullies, threatens, or intimidates others 0 1 2 3
28. Starts physical fights 0 1 2 3
29. Lies to get out of trouble or to avoid obligations (ie, “cons” others) 0 1 2 3
30. Is truant from school (skips school) without permission 0 1 2 3
31. Is physically cruel to people 0 1 2 3
32. Has stolen things that have value 0 1 2 3
The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be
variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality
Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD.
Revised – 1102 HE0350
Symptoms Never Occasionally Often Very Often
33. Deliberately destroys others’ property 0 1 2 3
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0 1 2 3
35. Is physically cruel to animals 0 1 2 3
36. Has deliberately set fires to cause damage 0 1 2 3
37. Has broken into someone else’s home, business, or car 0 1 2 3
38. Has stayed out at night without permission 0 1 2 3
39. Has run away from home overnight 0 1 2 3
40. Has forced someone into sexual activity 0 1 2 3
41. Is fearful, anxious, or worried 0 1 2 3
42. Is afraid to try new things for fear of making mistakes 0 1 2 3
43. Feels worthless or inferior 0 1 2 3
44. Blames self for problems, feels guilty 0 1 2 3
45. Feels lonely, unwanted, or unloved; complains that 0 1 2 3
“no one loves him or her”
46. Is sad, unhappy, or depressed 0 1 2 3
47. Is self-conscious or easily embarrassed 0 1 2 3
Somewhat
Above of a
Performance Excellent Average Average Problem Problematic
48. Overall school performance 1 2 3 4 5
49. Reading 1 2 3 4 5
50. Writing 1 2 3 4 5
51. Mathematics 1 2 3 4 5
52. Relationship with parents 1 2 3 4 5
53. Relationship with siblings 1 2 3 4 5
54. Relationship with peers 1 2 3 4 5
55. Participation in organized activities (eg, teams) 1 2 3 4 5
Comments:

__________________________________________________________________________________________________
For Office Use Only
Total number of questions scored 2 or 3 in questions 1–9: ______________________________
Total number of questions scored 2 or 3 in questions 10–18: ____________________________
Total Symptom Score for questions 1–18:___________________________________________
Total number of questions scored 2 or 3 in questions 19–26: ____________________________
Total number of questions scored 2 or 3 in questions 27–40: ____________________________
Total number of questions scored 2 or 3 in questions 41–47: ____________________________
Total number of questions scored 4 or 5 in questions 48–55:_____________________________
Average Performance Score:______________________________________________________
3 NICHQ Vanderbilt Assessment Scale—PARENT Informant, continued
The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be
variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality
Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD.
11-19/Rev1102 HE0350
Home Symptom / Impairment Screening Scale
TOM SCREME SYMP
ENING SCALE

____________________________________________________________________________________________________________
Name Grade Age Date
_________________________________________________________________________________________________
Form Completed By Relationship
_________________________________________________________________________________________________
School Name/Contact School Phone # School Fax #

Home Symptom Screening Scale


The HOME SYMPTOM SCREENING SCALE should be completed by the child's parent / legal guardian. This scale will provide a preliminary
assessment of your child's ADHD symptoms. Please rate each behavior according to the degree of problem the student is currently experiencing at
home. When complete, add the ratings for each domain. Then add the three domain scores to obtain a to tal scale score. After t reatment is
ini tiated, the
scale should be administered again to determine t reatment effects on level of symptoms.
BEHAVIOR DOMAINS No Problems =0 Mild Problem =1 Mod. Problem =2 Severe Problem =3
Is easily distracted
Has difficulty following directions
Distractibility

Has difficulty sustaining attention


Shifts from one activity to another
Does not seem to listen
Loses materials
DOMAIN SCORE___________

Has difficulty waiting for turns


Impulsivity

Engages in dangerous activities


Interrupts or intrudes
Blurts out answers to questions
DOMAIN SCORE___________
Hyperactivity

Fidgets or squirms in a chair


Has difficulty playing quietly
Talks excessively
DOMAIN SCORE___________
TOTAL SCALE SCORE____________
(Add 3 Domain Scores) .

Home Impairment Scale


The HOME IMPAIRMENT SCALE should be completed by the child's parent / legal guardian. It will provide a preliminary measure of the child's level of
impairment. When complete, add the ratings for each domain. Then add the four domain scores to obtain a to tal scale score. The domain and to tal
scale scores provide a baseline estimate of the child's degree of impairment at home. After t reatment is ini tiated, the scale should be administered
again to determine t reatment effects on level of impairment.
BEHAVIOR DOMAINS No Problems =0 Mild Problem =1 Mod. Problem =2 Severe Problem =3
Performs chores
Home Responsibilities

Does homework
Takes care of personal property
Meets time demands
Follow directions
Practices lessons (dance, music...)
Is self-reliant
DOMAIN SCORE___________
Follows home rules
Controls anger
Respect for authority figures
Home Behavior

Respect for home property


Uses inappropriate language
Is dishonest (steals, lies, cheats)
Problems with police
Traffic tickets/accidents
Substance abuse
DOMAIN SCORE___________

Relates well to others


Cooperates in groups/games
Social Relationships

Teases others
Is teased by others
Withdrawn from classmates
Aggressive toward other children
Respect for others' property
Respect for others' feelings
DOMAIN SCORE___________

Has sleeping problems


Complains of aches and pains
Wets the bed
Emotional Domain

Doesn't seem to enjoy anything


Cries for no apparent reason
Appears agitated/irritable
Stays inside too much
Is excessively fearful/anxious
Talks about (or does) running away
Talks about/has attempted suicide
Feels unliked or unloved
DOMAIN SCORE___________
TOTAL SCALE SCORE____________
(Add 4 Domain Scores) .

Note: Some students display symptoms of ADHD without experiencing impairment. To receive a diagnosis of ADHD, there must be impairment in two or
more settings (school, home, and/or work). This scale assesses impairment in one domain only.
Screen for Child Anxiety Related Disorders (SCARED)
Parent Version—Pg. 1 of 2 (To be filled out by the PARENT)

Name:______________________________________
Date:_______________________________________

Directions:
Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is “Not True or
Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for your child. Then for each
statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please
respond to all statements as well as you can, even if some do not seem to concern your child.

0 1 2
Not True or Somewhat Very True
Hardly True or or Often
Ever True Sometimes True
True
1. When my child feels frightened, it is hard for him/her to breathe. O O O
2. My child gets headaches when he/she is at school. O O O
3. My child doesn’t like to be with people he/she doesn’t know well. O O O
4. My child gets scared if he/she sleeps away from home. O O O
5. My child worries about other people liking him/her. O O O
6. When my child gets frightened, he/she feels like passing out. O O O
7. My child is nervous. O O O
8. My child follows me wherever I go. O O O
9. People tell me that my child looks nervous. O O O
10. My child feels nervous with people he/she doesn’t know well. O O O
11. My child gets stomachaches at school. O O O
12. When my child gets frightened, he/she feels like he/she is going crazy. O O O
13. My child worries about sleeping alone. O O O
14. My child worries about being as good as other kids. O O O
15. When he/she gets frightened, he/she feels like things are not real. O O O
16. My child has nightmares about something bad happening to his/her O O O
parents.
17. My child worries about going to school. O O O
18. When my child gets frightened, his/her heart beats fast. O O O
19. He/she gets shaky. O O O
20. My child has nightmares about something bad happening to him/her. O O O
21. My child worries about things working out for him/her. O O O
22. When my child gets frightened, he/she sweats a lot. O O O
23. My child is a worrier. O O O
24. My child gets really frightened for no reason at all. O O O
25. My child is afraid to be alone in the house. O O O
Screen for Child Anxiety Related Disorders (SCARED)
Parent Version—Pg. 2 of 2 (To be filled out by the PARENT)

0 1 2
Not True or Somewhat Very True
Hardly True or or Often
Ever True Sometimes True
True
26. It is hard for my child to talk with people he/she doesn’t know well. O O O
27. When my child gets frightened, he/she feels like he/she is choking. O O O
28. People tell me that my child worries too much. O O O
29. My child doesn’t like to be away from his/her family. O O O
30. My child is afraid of having anxiety (or panic) attacks. O O O
31. My child worries that something bad might happen to his/her parents. O O O
32. My child feels shy with people he/she doesn’t know well. O O O
33. My child worries about what is going to happen in the future. O O O
34. When my child gets frightened, he/she feels like throwing up. O O O
35. My child worries about how well he/she does things. O O O
36. My child is scared to go to school. O O O
37. My child worries about things that have already happened. O O O
38. When my child gets frightened, he/she feels dizzy. O O O
39. My child feels nervous when he/she is with other children or adults and
he/she has to do something while they watch him/her (for example: read O O O
aloud, speak, play a game, play a sport.)
40. My child feels nervous when he/she is going to parties, dances, or any O O O
place where there will be people that he/she doesn’t know well.
41. My child is shy. O O O

SCORING:
A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific.
A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.
A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.
A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.
A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.
A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.
Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra
McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pgh. (10/95). E-mail: birmaherb@msx.upmc.edu
Screen for Child Anxiety Related Disorders (SCARED)
Child Version—Pg. 1 of 2 (To be filled out by the CHILD)

Name:________________________________________
Date:_________________________________________
Directions:
Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or
“Somewhat True or Sometimes True” or “Very True or Often True” for you. Then for each sentence, fill in one circle that corresponds
to the response that seems to describe you for the last 3 months.

0 1 2
Not True or Somewhat Very True
Hardly True or or Often
Ever True Sometimes True
True
1. When I feel frightened, it is hard to breathe. O O O
2. I get headaches when I am at school. O O O
3. I don’t like to be with people I don’t know well. O O O
4. I get scared if I sleep away from home. O O O
5. I worry about other people liking me. O O O
6. When I get frightened, I feel like passing out. O O O
7. I am nervous. O O O
8. I follow my mother or father wherever they go. O O O
9. People tell me that I look nervous. O O O
10. I feel nervous with people I don’t know well. O O O
11. I get stomachaches at school. O O O
12. When I get frightened, I feel like I am going crazy. O O O
13. I worry about sleeping alone. O O O
14. I worry about being as good as other kids. O O O
15. When I get frightened, I feel like things are not real. O O O
16. I have nightmares about something bad happening to my parents. O O O
17. I worry about going to school. O O O
18. When I get frightened, my heart beats fast. O O O
19. I get shaky. O O O
20. I have nightmares about something bad happening to me. O O O
21. I worry about things working out for me. O O O
22. When I get frightened, I sweat a lot. O O O
23. I am a worrier. O O O
24. I get really frightened for no reason at all. O O O
25. I am afraid to be alone in the house. O O O
26. It is hard for me to talk with people I don’t know well. O O O
27. When I get frightened, I feel like I am choking. O O O
Screen for Child Anxiety Related Disorders (SCARED)
Child Version—Pg. 2 of 2 (To be filled out by the CHILD)

0 1 2
Not True or Somewhat Very True
Hardly True or or Often
Ever True Sometimes True
True
28. People tell me that I worry too much. O O O
29. I don’t like to be away from my family. O O O
30. I am afraid of having anxiety (or panic) attacks. O O O
31. I worry that something bad might happen to my parents. O O O
32. I feel shy with people I don’t know well. O O O
33. I worry about what is going to happen in the future. O O O
34. When I get frightened, I feel like throwing up. O O O
35. I worry about how well I do things. O O O
36. I am scared to go to school. O O O
37. I worry about things that have already happened. O O O
38. When I get frightened, I feel dizzy. O O O
39. I feel nervous when I am with other children or adults and I have to do
something while they watch me (for example: read aloud, speak, play a game, O O O
play a sport.)
40. I feel nervous when I am going to parties, dances, or any place where O O O
there will be people that I don’t know well.
41. I am shy. O O O

SCORING:
A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific.
A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.
A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.
A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.
A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.
A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.
*For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting
with an adult in case they have any questions.
Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra McKenzie, Ph.D., Western
Psychiatric Institute and Clinic, University of Pgh. (10/95). E-mail: birmaherb@msx.upmc.edu
Center for Epidemiological Studies
Depression Scale for Children (CES-DC)

Number ________________

Score __________________
Name _____________________________

INSTRUCTIONS
Below is a list of the ways you might have felt or acted. Please check how much you have felt this way during the past week.

DURING THE PAST WEEK Not At All A Little Some A Lot


1. I was bothered by things that usually don’t bother me. _____ _____ _____ _____
2. I did not feel like eating, I wasn’t very hungry. _____ _____ _____ _____
3. I wasn’t able to feel happy, even when my family or _____ _____ _____ _____
friends tried to help me feel better.
4. I felt like I was just as good as other kids. _____ _____ _____ _____
5. I felt like I couldn’t pay attention to what I was doing. _____ _____ _____ _____

DURING THE PAST WEEK Not At All A Little Some A Lot


6. I felt down and unhappy. _____ _____ _____ _____
7. I felt like I was too tired to do things. _____ _____ _____ _____
8. I felt like something good was going to happen. _____ _____ _____ _____
9. I felt like things I did before didn’t work out right. _____ _____ _____ _____
10. I felt scared. _____ _____ _____ _____

DURING THE PAST WEEK Not At All A Little Some A Lot


11. I didn’t sleep as well as I usually sleep. _____ _____ _____ _____
12. I was happy. _____ _____ _____ _____
13. I was more quiet than usual. _____ _____ _____ _____
14. I felt lonely, like I didn’t have any friends. _____ _____ _____ _____
15. I felt like kids I know were not friendly or that _____ _____ _____ _____
they didn’t want to be with me.

DURING THE PAST WEEK Not At All A Little Some A Lot


16. I had a good time. _____ _____ _____ _____
17. I felt like crying. _____ _____ _____ _____
18. I felt sad. _____ _____ _____ _____
19. I felt people didn’t like me. _____ _____ _____ _____
20. It was hard to get started doing things. _____ _____ _____ _____
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