child anxiety scale

Discussion in 'General Parenting Archives' started by -, Apr 11, 2003.

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    CHILDREN'S ANXIETY SCREENING SCHEDULE



    David B. Goldstein, Ph.D.



    Parents: Please answer all of the following questions.

    NAME OF CHILD: ________________________________________________
    DATE OF BIRTH: __________ AGE: ____________ SEX________

    GRADE: ________________ SCHOOL: _______________________



    This Questionnaire has been completed by: Mother____ Father____ Other (Please Describe your relationship)__________________________



    1. My child has many fears.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    2. My child seems to have difficulty falling asleep.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    3. My child has some unusual rituals (washing , counting, checking, etc.).

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    4. My child has nightmares.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    5. My child has experienced a traumatic event (e.g. a near death experience or witnessing the near death or death of a loved one.)

    Yes____ No____ I don’t know____

    If yes, please explain:



    6. My child attempts to avoid school or some other situation.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    7. My child has a specific and intense fear of:

    a. ____thunder, lightning, or inclement weather

    b. ____insects or bugs

    c. ____animals

    d. ____the dark

    e. ____people other than family or close friends

    f. ____heights

    g. ____unfamiliar situations

    h. ____germs or illness

    i. ____being physically harmed/attacked/kidnapped

    j. ____separating from a parent

    k. ____dying

    l. ____other, please explain:

    m. ____ My child has no unusual/intense fear.



    8. My child worries about little things.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    9. My child is shy.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    10. My child worries about talking to others.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    11. My child tells me he or she has stomach aches or headaches.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    12. My child complains about a lump in his or her throat.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    13. My child frets before starting something new.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    14. My child has told me his or her heart is pounding or racing.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    15. My child will not go into another room without someone else there.

    Never/Rarely____ Sometimes____ Often____ I don’t know____



    16. My child sleeps by him or herself in his or her own bed.

    Never/Rarely____ Sometimes____ Often____ I don’t know____







    Guidelines for Scoring the Children'€™s
    Anxiety Screening Schedule


    A referral to a child psychiatrist, child psychologist or other specialist qualified to diagnose anxiety disorders appears indicated if:



    - If the child is 6 years old or younger and the parent endorses 8 or more of the 16 items as occurring €œOften€ (except item #16 which would need to be considered if the parent endorsed the item as occurring Never/Rarely).

    - If the child is 7 years old or older and the parent endorses 4 or more items as occurring €œOften (except item #16 which would need to be considered if the parent endorsed the item as occurring €œNever/Rarely).



    Or



    - 9 or more items occurring €œSometimes or €œOften€ (except item #16 which would need to be considered if the parent endorsed the item as occurring Sometimes€ or €œNever/Rarely€).

    ________________________________

    The Children's Anxiety Screening Schedule © was Excerpted from the Developmental Screening and Referral Inventory by David B. Goldstein, Ph.D., 1999.
     
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