David B. Goldstein, Ph.D., Director
6401 Poplar Avenue,  Suite 306
Memphis, TN 38119
Phone: (901) 869-0520; Toll Free:1-888-646-MIND (6463); Fax: (901) 853-9661
URL: http://www.mind-steps.com  Email:
davidgoldstein715@msn.com

 

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 “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.