Screening and Measurement

Primary care clinicians are taught to engage in a complex process of clinical reasoning to identify illness. This process is no different for mental health conditions.

In the clinical assessment tool kit is an understanding of the epidemiology of diagnoses, awarenss of the range of diagnostic candidates, and a host of available tests and knowledge of test characteristics. 

Screening tools improve both the efficiency and comprehensiveness of the clinical encounter and are increasingly linked to value-based care. In this section we cover formalized screening procedures and tools used for specific disorders. 

Evidence Based Assessment

Pediatricians think statistically and sequentially, adding assessment information, weighing dynamic factors, and applying a clinical decision making model. 

The Evidence Based Assessment model provides clear steps to the process of prediciting, prescribing treatment, and tracking the progress.

Steps 1 and 2 in Evidence Based assessment is identifying the prevelance or base rate of disorders. This graph includes the common disorders, with data compiled from multiple sources (Breslau et al., 2017; Francés et al., 2022; Kessler et al., 2005; Merikangas et al., 2010; Patel et al., 2018; Solmi et al., 2021). 

Step 3 of the Evidence Based Assessment Model should include weighing known risk factors that migth increase the liklihood of disorder. Family mental history is very important to ask about because of elevated genetic and correlated enviormental factors.

Parental history of any psychiatric diagnosis is associated with increased incidence rates of mental illness. Odds Ratios (OR) indicate elevated risk of disorder in youth with parents with history of illness. Reported OR for common disorders include ADHD (4-9 OR), Anxiety Disorder (2-6 +OR), and Depression (3-13 +OR) (Martin et al. 2018; Rappe et al 2012; Telman et al. 2017; Rice et al. 2012).

Step 4, 5, and 6 Typically, our team recommends using a broad mental health measure built to detect multiple conditions. If there is elevated concern, a targeted measure for a specific condition (e.g. anxiety, depression) would be employed. This is called sequential screening and it essentially zeros in on a subgroup of a population through a brief set of consecutive screens, reducing the likelihood of false positives and false negatives. 

Next we'll identify measures and psychometric properties to support implementation in the pediatric practice. 

Broad Measures

Broad measures screen for multiple mental health symptoms and are optimally employed as an initial measure that might detect possible concerns. Positive results should received subsequent targeted screening related to specific concerns. 

Measure Informant Cut-offs Sensitivity/Specificity

Patient Symptom Checklist – 17
Age 4-17
Items 17

Total Score:    ≥ 15
Internalizing:  ≥ 5
Externalizing:  ≥ 7
Attention:       ≥ 7
Total Score:     73%/74%
Internalizing:   52%/74%
Externalizing:   62%/89%
Attention:        59%/91%

Strengths and Difficulties Questionnaire (SDQ) 
Age 2-18+
Items 25

Total Score:        ≥ 15
Emotional (Anx): ≥ 5
Conduct (ODD):  ≥ 3
Conduct (CD):    ≥ 4
Inattention/HI:   ≥ 6
Total Score:         81%/42%
Emotional (Anx):  75%/51%
Conduct (ODD):   84%/66%
Conduct (CD):     89%/63%
Inattention/HI:    95%/32%

ADHD Tools

Here are freely available targeted measures developed to assess ADHD and Oppositional Defiant Disorder/Conduct Disorder

Measure Informant Cut-offs Sensitivity/Specificity
Items: 26
Age: 6-18

Parent or Teacher

ADHD IN:  Parent > 2.56; Teacher > 1.78

ADHD H/I: Parent > 1.78; Teacher > 1.44

ADHD CT:  Parent > 2.00; Teacher > 1.67

ODD:        Parent > 1.38; Teacher > 1.88

Summed scale score, divided number of items in scale

NICHQ Vanderbilt
Items: 55 (P), 44 (T)
Age: 6-12



ADHD Combined: > 6

ODD Total: > 10

ADHD Combined: 67%/86%

ODD Total:          88%/85%

Note: NICHQ Parent Vanderbilt positive cutoff requires 6 of 18 items on the Combined Inattention/Hyperactivity scale be recorded as 2 or 3 and at least one 4 or 5 rating on the performance scale

Anxiety Tools

Targeted anxiety measures free for use. 

Measure Informant Cut-offs Sensitivity
Screen for Child Anxiety and Related Disorders (SCARED)
Items: 41
Age: 8-17
Total Score:  ≥ 25
Panic:  ≥ 7
GAD:  ≥ 9
Separation Anx:  ≥ 5
Social Anx: ≥ 8
School Avoidance: ≥ 3

Parent Total:  65%/99%
Parent GAD:   77%/90%
Parent Social: 79%/92%

Youth Total:   64%/92%
Youth GAD:   54%/91%
Youth Social: 64%/84%

SPENCE Child Anxiety
Items: 44
Age: 3-6; 8-15
T Score:  ≥ 60
(T-Score, M = 50; SD 10)
Generalized Anxiety Disorder (GAD-7)
Items: 7
Age: 12+
Total Score: ≥ 10  
Patient Reported Outcomes Measurement System - Fixed Length Short Form (V2)
Age: 5-17
Parent T-Score:  ≥ 62
Youth T-Score:    ≥ 63
(T-Score, M = 50; SD 10)

Depression Tools

Here are targeted depression measures that are free for use. 

Measure Informant Cut-offs Sensitivity/Specificity

Short Moods & Feelings Questionnaire (SMFQ)

Items: 13 
Age: 8-18

Total Score: ≥ 11 Parent Total: 65%/99%
Youth Total:  64%/92%

Patient Health Questionnaire

Items: 9
Age: 11+

T Score: ≥11 89.5%/77.5%

Patient Reported Outcomes Measurement System (PROMIS - Depression)

Items: 8 (6)
Age: 5-17

Parent T-Score:  ≥ 60.5
Youth T-Score:    ≥ 62.5

(T-Score, M = 50; SD 10)


Other Targeted Tools

Freely available targeted screening for primary care.

Measure Informant Domain Cut-offs Sensitivity/

Ask Suicide Questionnaire (ASQ -4)

Items: 4
Age: 10-18

Suicidality Any "Yes" response results in further assessment  100%/87.9%

Columbia Suicide Severity Risk Scale (Primary Care)

Items: 2+
Age: 10-18

Suicidality  Any "Yes" response results in further assessment   


Items: 9
Age: 12-21

Substance Use/
T Score : ≥2 Any substance use disorder: 76%/94%

Screening to Brief Intervention (S2BI)

Items: 9
Age: 12-17

Substance Use/
Affirmative response to frequency in past year Any substance use disorder: 90%/94%

Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)

Items: 5+
Age: 12-17

Substance Use/Abuse Risk of use of alcohol, tobacco, and marijuana 

≥6 days of tobacco use 95%/97%
≥2 days of alcohol use 96%/85%
≥2 days of marijuana use 80%/93%

Eating Attitudes Test-26

Items: 26
Age: 8-13

Disordered Eating Total Score: ≥20  


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