Guest
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 donât know____
2. My child seems to have difficulty falling asleep.
Never/Rarely____ Sometimes____ Often____ I donât know____
3. My child has some unusual rituals (washing , counting, checking, etc.).
Never/Rarely____ Sometimes____ Often____ I donât know____
4. My child has nightmares.
Never/Rarely____ Sometimes____ Often____ I donât 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 donât know____
If yes, please explain:
6. My child attempts to avoid school or some other situation.
Never/Rarely____ Sometimes____ Often____ I donât 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 donât know____
9. My child is shy.
Never/Rarely____ Sometimes____ Often____ I donât know____
10. My child worries about talking to others.
Never/Rarely____ Sometimes____ Often____ I donât know____
11. My child tells me he or she has stomach aches or headaches.
Never/Rarely____ Sometimes____ Often____ I donât know____
12. My child complains about a lump in his or her throat.
Never/Rarely____ Sometimes____ Often____ I donât know____
13. My child frets before starting something new.
Never/Rarely____ Sometimes____ Often____ I donât know____
14. My child has told me his or her heart is pounding or racing.
Never/Rarely____ Sometimes____ Often____ I donât know____
15. My child will not go into another room without someone else there.
Never/Rarely____ Sometimes____ Often____ I donât know____
16. My child sleeps by him or herself in his or her own bed.
Never/Rarely____ Sometimes____ Often____ I donât 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 Often (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 Often (except item #16 which would need to be considered if the parent endorsed the item as occurring Never/Rarely).
Or
- 9 or more items occurring Sometimes or Often (except item #16 which would need to be considered if the parent endorsed the item as occurring Sometimes or Never/Rarely).
________________________________
The Children's Anxiety Screening Schedule © was Excerpted from the Developmental Screening and Referral Inventory by David B. Goldstein, Ph.D., 1999.
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 donât know____
2. My child seems to have difficulty falling asleep.
Never/Rarely____ Sometimes____ Often____ I donât know____
3. My child has some unusual rituals (washing , counting, checking, etc.).
Never/Rarely____ Sometimes____ Often____ I donât know____
4. My child has nightmares.
Never/Rarely____ Sometimes____ Often____ I donât 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 donât know____
If yes, please explain:
6. My child attempts to avoid school or some other situation.
Never/Rarely____ Sometimes____ Often____ I donât 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 donât know____
9. My child is shy.
Never/Rarely____ Sometimes____ Often____ I donât know____
10. My child worries about talking to others.
Never/Rarely____ Sometimes____ Often____ I donât know____
11. My child tells me he or she has stomach aches or headaches.
Never/Rarely____ Sometimes____ Often____ I donât know____
12. My child complains about a lump in his or her throat.
Never/Rarely____ Sometimes____ Often____ I donât know____
13. My child frets before starting something new.
Never/Rarely____ Sometimes____ Often____ I donât know____
14. My child has told me his or her heart is pounding or racing.
Never/Rarely____ Sometimes____ Often____ I donât know____
15. My child will not go into another room without someone else there.
Never/Rarely____ Sometimes____ Often____ I donât know____
16. My child sleeps by him or herself in his or her own bed.
Never/Rarely____ Sometimes____ Often____ I donât 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 Often (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 Often (except item #16 which would need to be considered if the parent endorsed the item as occurring Never/Rarely).
Or
- 9 or more items occurring Sometimes or Often (except item #16 which would need to be considered if the parent endorsed the item as occurring Sometimes or Never/Rarely).
________________________________
The Children's Anxiety Screening Schedule © was Excerpted from the Developmental Screening and Referral Inventory by David B. Goldstein, Ph.D., 1999.
