The screening tools listed here can be used to: a) help screen children and adolescents for mental health concerns and b) monitor treatment progress.
The BHIPP team is available to consult with PCPs regarding the use of standardized mental health or substance use screening tools in their practices. Please remember:
For more information about administration and scoring of screening tools related to six common mental health conditions, please refer to the sections below:
This tool is used to identify symptoms including disruptive behavior, inattention, impulsivity and hyperactivity in different settings for children age 6-12 years old. It includes a 55-item parent-report form as well as a 43-item teacher form. The forms are free and require approximately 10 minutes to complete.
For more information and to download the VANDERBILT: click here
Adverse Childhood Experiences
ACE-Q: Center for Youth Wellness Adverse Childhood Experiences Questionnaire
This brief tool assesses adverse childhood experiences that may impact physical and mental health of children and adolescents. There are separate parent-report versions for children (ages 0-12) and teens (ages 13-19) in both English and Spanish. A teen self-report version is also available.
For additional information and to access the ACE-Q: click here
PEARLS: The Pediatric ACEs and Related Life Events Screener
The Pediatric ACEs and Related Life Events Screener (PEARLS) was developed for use in primary care, is free to use, and can be completed in 5 minutes. The PEARLS is appropriate for use in youth ages 0-19. There are three versions of the screening tool including a child (0-11) report to be completed by the caregiver, an adolescent (12-19) self-report and an adolescent caregiver report. The PEARLS is available in 17 languages.
For more information and to access the PEARLS: click here
Generalized Anxiety Disorder 7-item (GAD-7)
The GAD-7 was developed for use in primary care to assess for generalized anxiety symptoms and is appropriate for use with children ages 12 and older. This 7-item screening tool takes 1-2 minutes to complete and a score of 10 or higher indicates moderate to severe anxiety symptoms.
For more information and to access the GAD-7: click here
Preschool Anxiety Scale
The Preschool Anxiety Scale is used to screen for elevated levels of anxiety in children ages 3-6. It includes a 28-item parent-report form and a 22-item teacher-report form that assess six domains of anxiety including generalized anxiety, panic/agoraphobia, separation anxiety, social phobia, OCD, and physical injury fears. There are 5 additional questions relating to traumatic experiences that are for clinical use only and not factored into scoring. The scale takes about 2 minutes to score.
To access the Preschool Anxiety Scale: click here
For information on how to score the Preschool Anxiety Scale: click here
To access the Preschool Anxiety Scale scoring sheet: click here
Revised Child Anxiety and Depression Scale (RCADS)
The RCADS screening tool provides a more detailed report of child anxiety symptoms including assessment of separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, and low mood or major depressive disorder. Providers may use the subscales to assess for specific anxiety disorders or use the total scale which includes the subscales and consists of 47-items. This tool is appropriate for use in children ages 8-18 and both self-report and parent versions are available.
For more information and to access the RCADS: click here
Screen for Child Anxiety Related Emotional Disorders (SCARED)
This tool screens children and adolescents age 8 and older for anxiety disorders. There is a 41-item parent-report form and a 41-item self-report form and each takes about 5 minutes to complete. For children ages 8-11, it is recommended that the provider explain all questions, or have the child answer the questionnaire sitting with an adult in case they need help answering or understanding any items.
For more information and to download the SCARED: click here
M-CHAT-R/F: Modified Checklist for Autism in Toddlers, Revised, With Follow-Up
The M-CHAT-R/F is a validated screening tool designed for use with toddlers age 16 months - 30 months of age, to assess risk for autism spectrum disorders (ASD). The 20-item parent-report form can be administered and scored as part of a well-child check-up or used by specialists or other professionals to assess risk for ASD. The M-CHAT can be scored in less than two minutes.
*Note: this tool was developed to maximize sensitivity and may lead to a false positive score, meaning not all children who score at risk will be diagnosed with ASD. However, those scoring at risk should be evaluated for other developmental delays or disorders.
For more information about screening for autism and to download the MCHAT and scoring instructions (available in multiple languages): click here
CES-DC: The Center for Epidemiological Studies Depression Scale for Children
This tool screens children and adolescents age 8-17 for depression. The 20-item self-report form takes only a few minutes to complete and a brief time for the provider to score. Possible scores range from 0 to 60 and higher scores indicate increased levels of possible depression.
For more information and to download the CES-DC: click here
PHQ-9: Patient Health Questionnaire 9 Depression Screening Tool
The PHQ-9 screens adolescents (11-17 years old) and adults for depression. It is a brief self-report form, which takes only a few minutes to complete and a brief time for the provider to score. This tool is available in several languages.
To download the version of the PHQ-9 that has been modified for use with teens: click here
Preschool Feelings Checklist
The Preschool Feelings Checklist was developed for use in primary care settings with children ages 3-6, to screen for depression. This 16-item parent-report form can be scored quickly by the provider. To score the measure, sum all items in which the respondent selected yes. A score of 3 or more indicates the need for further mental health evaluation.
To access the Preschool Feelings Checklist: click here
For additional information about the development and scoring of this tool: click here
General Screening Tools
Pediatric Symptom Checklist (PSC)
The Pediatric Symptom Checklist is a brief psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. Two versions of the tool exist, the parent-report version (PSC) which can be used for children beginning at age 6 and the youth self-report (Y-PSC) which can be administered to adolescents ages 11 and up. Following positive screening results it is recommended that the child be referred for evaluation by a mental health professional.
For more information about the PSC or the Y-PSC and to download the tool: click here
Strengths and Difficulties Questionnaire (SDQ)
The SDQ is a 25-item behavioral screening tool for children 3-16 years old to assess psychosocial functioning. It includes five subscales – four of which tap into social, emotional, and behavioral difficulties the child may be having and one which focuses on the child’s prosocial behavior. The SDQ may be completed by parents, teachers or self-report and is available in multiple languages. Higher scores on the four difficulty subscales indicate greater impairment. While hand scoring is possible, the developers recommend using their website for scoring.
To access the SDQ: click here
For more information about scoring this tool: click here
Edinburgh Postnatal Depression Scale (EPDS)
The Edinburg Postnatal Depression Scale is a 10-item questionnaire used to evaluate postpartum depression. Mothers who score above 13 on the scale may be experiencing significant depressive symptoms and should be referred for additional evaluation and treatment.
To access the EPDS: click here
Pediatric Intake Form
The Pediatric Intake Form is a brief questionnaire completed by families of pediatric patients regarding family history and functioning. The questionnaire directly assesses parental depression, parental substance use, domestic violence, child maltreatment and social supports. To monitor family and parental well-being, it is recommended to administer this form annually.
To access the Pediatric Intake Form: click here
Perinatal Anxiety Screening Scale (PASS)
The Perinatal Anxiety Screening Scale assesses a broad range of anxiety symptoms for pregnant and new mothers. The questionnaire is 31-items and can be completed and scored in 10 minutes. A score below 20 signifies minimal anxiety, 21-41 represents mild to moderate anxiety, and 42 or more signifies severe anxiety. Additional referral for evaluation and treatment should be provided as appropriate.
To access the PASS: click here
Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)
Parental PTSD symptoms have an impact on parental well-being and parenting behaviors which may negatively impact pediatric patients. For parents that have been exposed to a traumatic event, the PC-PTSD-5 is a 5-item screening tool developed for use in primary care to assess adult PTSD symptoms. For parents that score a 4 or higher, providers should consider offering mental health referrals.
For more information and to access the PC-PTSD-5: click here
The BEARS screens for sleeping problems based on 5 major sleep domains and age range
For more information and to download the tool: Click here
Social Determinants of Health
Safe Environment for Every Kid (SEEK)
The SEEK Parent Questionnaire-R (PQ-R) is a 16-item questionnaire to screen for prevalent and targeted psychosocial problems such as parental depression and substance use. A 'yes' to any question indicates a positive screen.
For more information and to download the tool: Click here
The WECARE Survey screens for unmet social needs and determines whether parents would like assistance with any of their unmet needs. This 10-item self-report form takes only a few minutes to complete and a brief time for the provider to score.
For more information and to download: Click here
Protocol for Responding to and Assessing Patient Assets, Risks and Experiences (PRAPARE)
PRAPARE is a 21-item questionnaire that assesses four core measures: personal characteristics, family/home, money/resources, and social/emotional health. This form takes around 5 minutes to complete and is translated in 25+ languages.
For more information and to download the tool: Click here
The CRAFFT is a 6-item self-report form used to screen for high risk alcohol and other drug use disorders simultaneously. It is designed to assess whether a more in-depth assessment around alcohol or other drug use is warranted. The CRAFFT is recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents, ages 12-21.
For more information about the CRAFFT and to download the tool: click here
Screening to Brief Intervention (S2BI)
The S2BI is an online screening tool created by NIDA to assess substance use in adolescents ages 12 and above. The S2BI assesses use of common drugs such as tobacco, alcohol, and marijuana, in addition to prescription drugs that were not prescribed to the patient, and illegal drugs such as ecstasy, cocaine and K2. The screening tool is brief and can be completed by the patient or clinician. The results are automatically analyzed and categorized into levels of risk with corresponding clinical suggestions.
To access the S2BI: click here
Suicide Risk Assessment
Ask Suicide-Screening Questions (ASQ)
The Ask Suicide-Screening Questions (ASQ) is a 5-item self-report questionnaire designed to assess suicide risk. Suicidal ideation is best assessed by first meeting with the patient alone as they are more likely to respond openly. A “yes” to any of the 5 ASQ items requires further assessment to determine the appropriate response. PCPs should inquire about: past and present suicidal thoughts/gestures, whether the youth has a detailed plan, and whether they have access to lethal means. After assessment, pediatric patients should be made aware that their responses will need to be shared with family members and other healthcare professionals, as necessary. The PCP should then bring the family in to create a safety plan together with the youth. Contact emergency services if imminent danger to self or others is suspected.
For more information and to access the ASQ: click here
To access a safety plan template: click here
Child Stress Disorders Checklist – Short Form (CSDC-SF)
This 4-item screening tool can be completed by a parent, physician, or nurse to assess acute stress symptoms of posttraumatic stress disorder in children ages 6-18. Higher scores indicate greater risk for current and future traumatic stress diagnoses (i.e., acute stress disorder or posttraumatic stress disorder).
For more information and to access the CSDC-SF: click here
Child Trauma Screening Questionnaire (CTSQ)
Following a potentially traumatic event, this screening tool can be completed by children ages 7-16 to assess for risk of developing posttraumatic stress disorder. The 10-item screening tool is available for free at the link below.
To access the CTSQ: click here
For more information about the development and scoring of this tool: click here
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