Screening Tools
Illinois DocAssist offers guidance on selecting and using primary care friendly screening tools. Some tools have a cost associated with their use but most are free and accessible on-line. These instruments assist in the early identification of problematic behaviors and social-emotional functioning that may indicate a mental health problem. Illinois DocAssist encourages the use of general screening tools for all pediatric and perinatal patients to help identify mental health problems. If you have questions about screening tools and their use, please call 1-866-986-2778.
Screening Tools Heading link
-
General
Ages and Stages Questionnaire: Social-Emotional-2nd edition (ASQ:SE-2) – Parents complete the short, simple questionnaires at eight designated age intervals: 6, 12, 18, 24, 30, 36, 48, and 60 months.
- Age: 0-5
- Administered by: Parent
- Cost: $295 for complete photocopiable kit
- Additional Information: Available in Spanish. Healthcare and Family Services (HFS) approved tool.
Pediatric Symptom Checklist (PSC) – A 35 item questionnaire to screen for cognitive, emotional and behavioral problems.
PSC & Y-PSC (Parent & Youth Report)
- Age: 4-16
- Administered by: Parent (page 2), Youth aged 11+ (page 3)
- Cost: None
- Additional Information: Available in over 25 languages and a pictorial version available in three languages.
Strengths and Difficulties Questionnaire (SDQ) – A 25 item questionnaire to identify and assess changes in emotional and behavioral problems in children. The SDQ covers a broad range of emotional and behavioral issues and is designed to provide assessment of psychosocial functioning. Hand scoring information is available, however, the developers recommend using the online scoring system available through their website.
- Age: 2-4, 4-10, 11-17, 18+
- Administered by: Parent, Teacher, Youth (ages 11-16)
- Cost: None
- Additional Information: Available in over 40 languages and in sign language; Follow up questionnaire also available.
-
ADHD
Vanderbilt ADHD Diagnostic Rating Scale – Screen for inattention, hyperactivity/impulsivity, combined inattention and hyperactivity subtype, oppositional defiant and conduct disorders, anxiety or depressive symptoms.
Vanderbilt – Parent version (English); Vanderbilt – Parent version (Spanish); Vanderbilt –Teacher version
- Age: 6 +
- Administered by: Parent, Teacher
- Cost: None
-
Anxiety
Screen for Childhood Anxiety Related Emotional Disorders (SCARED) – A 41-item questionnaire that can be used to identify children and adolescents who require further evaluation or treatment for anxiety disorders. The tool does not identify OCD or trauma related anxiety.
SCARED – Parent and Child Versions
- Administered by: Parent, Youth (6th grade reading level)
- Cost: None
- Additional Information: Available in over 10 languages
Spence Children’s Anxiety Scale (SCAS) – A 44-item scale that assesses six domains of anxiety and the severity of symptoms. The scale does not identify trauma related anxiety.
SCAS – Preschool Scale; Parent Version; Child Version
- Age: 3-6, 7-18
- Administered by: Parent, Youth (6th grade reading level)
- Cost: None
- Additional Information: Available in over 30 languages
-
Autism
Modified Checklist for Autism in Toddlers Revised (M-CHAT-R) and (M-CHAT-R/F) – A two-stage parent-report screening tool to assess risk for Autism Spectrum Disorder (ASD). The first stage, the M-CHAT-R, can be administered and scored as part of a well-child care visit. The primary goal of the M-CHAT-R is to detect as many cases of ASD as possible. Therefore, not all children who score at risk will be diagnosed with ASD. If the child screens positive on the M-CHAT-R, the second stage is to select the failed Follow-Up items on the M-CHAT-R/F.
- Age: 16-30 months
- Administered by: Parent
- Cost: None
- Additional Information: Available in over 30 languages
Childhood Autism Rating Scale, Second Edition (CARS2) –
Childhood Autism Rating Scale | Second Edition is a brief rating scale that helps identify autism in children. CARS2 offers an easy-to-use tool that helps distinguish from developmentally disabled children who are not autistic, giving quantifiable ratings based on direct behavior observation.
- Administered through professional rating scale and parent questionnaire
- Cost: Kit Includes Manual (Print), 25 Standard Version Rating Booklets (Print), 25 High Functioning Individuals Rating Booklets (Print), 25 Questionnaires for Parents or Caregivers (Print) :$308
-
Depression
Center for Epidemiological Studies Depression Scale for Children (CES-DC) – A 20-item self-report screening tool to detect the presence of depressive symptoms. Higher scores warrant further evaluation.
- Age: 6 – 17
- Administered by: Youth, Parent
- Cost: None
Preschool Feelings Checklist
- Age: 3 – 6
- Administered by: Parent
- 16 questions (yes/ no)
- Cost: None
Patient Health Questionnaire (PHQ) – A 9-item self report tool to assess depression and includes additional questions on suicidality and adolescent dysthymia. The PHQ-9A has been validated for use with adolescents.
PHQ-9A for adolescents – English; Spanish
- Age: 13 – 18
- Administered by: Youth
- Cost: None with permission
-
Eating Disorders
SCOFF Questionnaire– The SCOFF is a free, five question measure that can assist identifying patients with eating disorders. The questions can be administered verbally or in writing. A positive response to two or more indicates that a patient needs a more comprehensive assessment.
-
Sleep
BEARS Sleep Screening Tool– A five item screening tool that can be used in the pediatric setting to identify pediatric sleep issues.
- Age: Preschool through Adolescence
- Administred by: Clinician
- Cost: Free
Children’s Sleep Habits Questionnaire– A parent report tool that assists in identifying children with sleep issues. The questionnaire has 22 items and asks parents to recall behaviors over the past week.
Children’s Sleep Habits Questionnaire
- Age: 4 through 10 years
- Administered by: Self report of parent
- Cost: Free
- Additional information: The tool can be used with different populations including children with autism, ADHD and intellectual disability.
Adolescent Sleep Hygiene Scale– Assesses sleep of adolescents over the past month and identifies issues with daytime sleepiness, bedtime resistance, sleep anxiety, sleep duration and sleep onset delay. The 33 item scale assesses behaviors across eight subscales.
Adolescent Sleep Hygiene Scale
- Age: 12 and older
- Administered by: Self report
- Cost: Free
-
Substance Misuse
In addition to the following recommended tools below, Illinois DocAssist has a free webinar available to educate providers and clinicians on motivational interviewing and pediatric substance misuse.
CRAFFT: Car, Relax, Alone, Forget, Friends, Trouble – CRAFFT can be self-administered or used as a questionnaire with the provider/clinician to screen for substance use disorders.
- Age: 14+
- Administered by: Self or Clinical Staff
- Cost: None
- Additional Information: Available in 19 languages; Healthcare and Family Services (HFS) approved tool.
Screening to Brief Intervention (S2BI) – Online tool that asks a single frequency question for past year’s use of the three substances most commonly used by adolescents. For each substance, responses can be categorized into levels of risk. Each risk level maps onto suggested clinical actions summarized on the results screen.
- Age: 12+
- Administered by: Clinical Staff
- Cost: None
-
Suicide
Ask Suicide-Screening Questions (ASQ) Toolkit– The National Institute of Mental Health (NIMH) created a toolkit for providers to assist in screening children for suicide in the pediatric office. The ASQ is an evidenced based screening tool for children 8 and older containing 4 yes or no questions developed to assess suicidal ideation and behavior. A positive screen result on the ASQ will flag a patient who needs further risk assessment. The ASQ was developed in the pediatric ED with 96.9% sensitivity, 87.6% specificity, and takes 20 seconds to administer. Providers can visit the NIMH to watch a short video on using the ASQ with children and adolescents. The ASQ toolkit also provides guidance on implementing and intervening with patients in the pediatric office as well as handout for parents.
- Age: 8 and above
- Administered by: Provider
- Cost: None
-
Non-Suicidal Self Harm
The SOARS model is for medical providers to use as a brief screening and assessment of Non-suicidal self harm (NSSI). Each letter of SOARS represents an area to assess: Suicidal ideation; Onset, frequency, and methods; Aftercare; Reasons; and Stage of change. Using theory, research, and consideration of real-world practice, it highlights the most important questions to ask, the reasoning for these questions, and recommendations for how to ask them. Before screening and assessing NSSI, however, an important step for medical providers is to first evaluate their own values and beliefs about NSSI.
- Age: Adolescents (no specific age indicated)
- Administered by: Provider
- Cost: None
The Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) – The Non-Suicidal Self-Injury-Assessment Tool (NSSI-AT) is a web-based measure of NSSI designed to assess primary (such as form, frequency, and function) and secondary (including but not limited to NSSI habituation; contexts in which NSSI is practiced; and NSSI perceived life interference, treatment, and impacts) NSSI characteristics for research purposes.
- Age: Validated on a university population (young adults under age 26)
- Administered by: Self
- Cost: None
The Brief Non-Suicidal Self-Injury Assessment Tool (BNSSI-AT) – B-NSSI-AT is the brief version of the NSSI-AT, an assessment tool created by Cornell Research Program on Self-Injury and Recovery. The use of this tool is described in more detail here: (Validity and reliability of the non-suicidal self-injury assessment test, NSSI-AT) and can be used to assess primary NSSI characteristics, such as form, frequency, and function, as well as secondary characteristics (such as habituation, context in which NSSI is practiced, and perceived life interference, treatment and impact). This assessment is primarily used in research, but may also be useful in service settings.
- Age: No age indicated
- Administered by: Self
- Cost: None
The Self-Harm Inventory – The Self-Harm Inventory, a measure that was developed for the assessment of self-harm behavior, is one-page in length, takes five or less minutes to complete, and is free-of-charge. Studies indicate that the Self-Harm Inventory does the following: 1) screens for the lifetime prevalence of 22 self-harm behaviors; 2) detects borderline personality symptomatology; and 3) predicts past mental healthcare utilization. Hopefully, more efficient assessment of self-harm behavior will lead to more rapid intervention and resolution.
- Age: No age indicated
- Administered by: Self
- Cost: None
The Screen for Nonsuicidal Self-Injury (SNSI) – The initial development and validation study provides support for the SNSI as a brief, efficient, and psychometrically robust screen for identifying NSSI behaviors in primary care settings among clinically diverse patients. The SNSI was developed to screen for common NSSI behaviors, including those with high prevalence among male adults and veterans, in order to address the persistent under-identification of NSSI within this group.
- Age: Validated on 18 and older as of now
- Administered by: Self or Provider
- Cost: None
-
Trauma
Life Events Checklist (LEC-5) – Self-report measure designed to screen for potentially traumatic events in a respondent’s lifetime. The assessment included 16 events known to potentially result in Posttraumatic Stress Disorder. The newest version, LEC-5 has minimal differences from the original LEC and few psychometric differences are expected. The self-report measure gathers information about traumatic experiences and does not have a formal scoring protocol.
- Age: 9-17
- Administered by: Youth
- Cost: None
The Children’s Revised Impact of Events Scale (CRIES 13) – A brief 13-item child-friendly measure designed to screen children at risk for Posttraumatic Stress Disorder (PTSD).
- Age: 8+ who are able to read independently
- Administered by: Youth
- Cost: None
- Additional Information: Available in English and 25 additional languages at the Children & War Foundation website. (Link to Measures page under downloads)
The Child Stress Disorders Checklist-Short Form (CSDC-SF)– A four item tool to assess stress reactions in injured children. The tool is easy to use and does not require specialized training in administration or interpretation. The tool helps identify youth at risk for traumatic stress reactions.
- Age: 6+
- Administered by: Parent
- Cost: None
The Children’s Somatization Inventory (CSI-24) A self-report questionnaire that can be given to youth and their parents or caregivers. The tool measures the intensity of a child’s somatic complaints over a two week period. The tool has been found to be reliable and valid for use with different populations.
CSI-24 (Link Currently Unavailable)
- Age: 8-17 years old
- Administered by: Youth, parent or clinician
- Cost: None
-
Perinatal Depression
Patient Health Questionnaire (PHQ9) – A 9-item self-report questionnaire that identifies depressive symptoms in adults. The questionnaire requires approximately 5 minutes to complete and score. Items are linked to DSM V criteria and can be used to assess and track treatment response.
Patient Health Questionnaire (PHQ-9) ENGLISH
- Group: Adult general population
- Administered By: Self
- Cost: None
- Additional Information: Available in over 40 languages
Edinburgh Postnatal Depression Scale (EPDS) – A 10-item self-report questionnaire that identifies depressive symptoms specifically in pregnant women and new mothers. The questionnaire requires approximately 5 minutes to complete and score.
Edinburgh Postnatal Depression Scale (EPDS) ENGLISH & SPANISH
- Group: Pregnant women and teens
- Administered By: Self
- Cost: None
- Additional Information: Alternative Languages available in this 200+ page document with 18 validated translations and several that have not been validated.
Disclaimer Heading link
Illinois DocAssist developed this list of recommended screening tools through consideration of cost and ease of use in the primary care setting. This is not an exhaustive list of all recommended socio-emotional and mental health screening or assessment tools. These tools are not diagnostic, but rather can assist in early identification of problematic behaviors and social emotional functioning that may indicate the need for further evaluation. For further information or assistance with using screening and assessments with children, adolescents and perinatal women, please contact Illinois DocAssist at 866-9862778.