complete parent packet

8/14/2019 Complete Parent Packet

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Douglas R. Coombs, MD520 East Medical Drive #301

Bountiful, Utah 84010

Phone (801)292-1464Fax (801)292-1465

Date__________________

Dear Parent/Guardian,

This ADHD evaluation includes information from school as well as home. Please fill out the the following hom

screening scales and return them to our office one week before your office visit.

Attached, please find:Structured Parent Interview

Vanderbilt Parent Assessment ScaleHome 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 youhave 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, BCGina M. Capps, RN, CPNP

Stacey A. Bushell, MSN, CPNP

Kim Webb, RN, CPNPBrian J. Holdstock, MSN, CFNP


2/15

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)______________________________

__________________________________________________________________________________________


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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 he

_____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? ____________________


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


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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


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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 fight

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:

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________


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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.


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NICHQ Vanderbilt Assessment ScaleParent InformantNICHQ Vanderbilt Assessment ScalePARENT Informant

Todays Date: __________ Childs Name: _________________________________ Date of Birth: ___________

Parents Name: _______________________________________ Parents 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 childs 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 2 320. 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 bevariations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright 2002 American Academy of Pediatrics and National Initiative for Childrens Healthcare Quality

Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD.Revised 1102 HE0350


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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 2 335. 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 elses 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 2 340. 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 19: ______________________________

Total number of questions scored 2 or 3 in questions 1018: ____________________________

Total Symptom Score for questions 118:___________________________________________

Total number of questions scored 2 or 3 in questions 1926: ____________________________

Total number of questions scored 2 or 3 in questions 2740: ____________________________Total number of questions scored 2 or 3 in questions 4147: ____________________________

Total number of questions scored 4 or 5 in questions 4855:_____________________________

Average Performance Score:______________________________________________________

3 NICHQ Vanderbilt Assessment ScalePARENT Informant, continuedThe information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may bevariations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright 2002 American Academy of Pediatrics and National Initiative for Childrens Healthcare QualityAdapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD.

11-19/Rev1102 HE0350


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Home Symptom / Impairment Screening ScaleTOM SCREME SYMPENING 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 t he child's parent / lega l guard ian. This scale wi l l p rovide a pre liminaryassessment of your child's ADHD symptoms. Please rate each behavior according to the degree of problem the student is currently experiencing athome. When complete, add the ratings for each domain. Then add the three domain scores to obtain a total scale score. After treatment isinitiated, thescale should be administered again to determine treatment effects on level of symptoms.

BEHAVIOR DOMAINS No Problems =0 Mild Problem =1 Mod. Problem =2 Severe Problem =3

Dis

tractibility

Is easily distracted

Has difficulty following directions

Has difficulty sustaining attention

Shifts from one activity to another

Does not seem to listen

Loses materials

DOMAIN SCORE___________

Impulsivity

Has difficulty waiting for turns

Engages in dangerous activities

Interrupts or intrudes

Blurts out answers to questions


Hyperactivity

Fidgets or squirms in a chair

Has difficulty playing quietly

Talks excessively


TOTAL SCALE SCORE____________(Add 3 Domain Scores) .

Home Impairment Scale

The HOME IMPAIRMENT SCALE should be comple ted by the chi ld's parent / legal guardian. It wi ll provide a prel iminary measure of t he chi ld's level o fimpairment. When complete, add the ra tings for each domain. Then add the four domain scores to obtain a total scale score. The domain and to talscale scores provide a baseline estimate of the child's degree of impairment at home. After treatment is initiated, the scale should be administeredagain to determine t reatment ef fects on level of impairment.

BEHAVIOR DOMAINS No Problems =0 Mild Problem =1 Mod. Problem =2 Severe Problem =3

HomeResponsibilities

Performs chores

Does homework

Takes care of personal property

Meets time demands

Follow directions

Practices lessons (dance, music...)

Is self-reliant



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HomeBe

havior

Follows home rules

Controls anger

Respect for authority figures

Respect for home property

Uses inappropriate language

Is dishonest (steals, lies, cheats)

Problems with police

Traffic tickets/accidents

Substance abuse


SocialRelationships

Relates well to others

Cooperates in groups/games

Teases others

Is teased by others

Withdrawn from classmates

Aggressive toward other children

Respect for others' property

Respect for others' feelings


Emotion

alDomain

Has sleeping problems

Complains of aches and pains

Wets the bed

Doesn't seem to enjoy anything

Cries for no apparent reason

Appears agitated/irritableStays inside too much

Is excessively fearful/anxious

Talks about (or does) running away

Talks about/has attempted suicide

Feels unliked or unloved


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 ormore settings (school, home, and/or work). This scale assesses impairment in one domain only.


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Screen for Child Anxiety Related Disorders (SCARED)Parent VersionPg. 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

Not True or

Hardly

Ever True

1

Somewhat

True or

Sometimes

True

2

Very True

or Often

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 doesnt like to be with people he/she doesnt 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 doesnt 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

parents.

O O O

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


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Screen for Child Anxiety Related Disorders (SCARED)Parent VersionPg. 2 of 2 (To be filled out by the PARENT)

0

Not True or

HardlyEver True

1

Somewhat

True orSometimes

True

2

Very True

or OftenTrue

26. It is hard for my child to talk with people he/she doesnt 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 doesnt 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 doesnt know well. O O O

33. My child worries about what is going to happen in the future. O O O34. 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

aloud, speak, play a game, play a sport.)

O O O

40. My child feels nervous when he/she is going to parties, dances, or any

place where there will be people that he/she doesnt know well.

O O O

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 of7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder orSignificant Somatic Symptoms.

A score of9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.

A score of5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.

A score of8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.

A score of3 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: [email protected]


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Screen for Child Anxiety Related Disorders (SCARED)Child VersionPg. 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

Not True or

Hardly

Ever True

1

Somewhat

True or

Sometimes

True

2

Very True

or Often

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 dont like to be with people I dont 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 dont know well. O O O

11. I get stomachaches at school. O O O12. 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 dont know well. O O O

27. When I get frightened, I feel like I am choking. O O O


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Screen for Child Anxiety Related Disorders (SCARED)Child VersionPg. 2 of 2 (To be filled out by the CHILD)

0Not True or

Hardly

Ever True

1Somewhat

True or

Sometimes

True

2Very True

or Often

True

28. People tell me that I worry too much. O O O

29. I dont 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 dont 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,

play a sport.)

O O O

40. I feel nervous when I am going to parties, dances, or any place where

there will be people that I dont know well.

O O O

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 of7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder orSignificant Somatic Symptoms.

A score of9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.

A score of5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.

A score of8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.

A score of3 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 sittingwith 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: [email protected]


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