Screening and Rating Tools

Screening assessments/tools are helpful to establish a client’s baseline and monitor symptoms, or the progress throughout treatment and care. Screenings assist in confirming a disorder and ruling out other concerns, therefore, standardized clinical rating scales are very important with chronic illnesses but be mindful of how they are NOT technically diagnostic:

Alzheimer’s Disease: Mini Status Exams/MMSE (cons: may not pick up on small cognitive decline changes/questions are too specific). VAMC SLUMS Examination: The Saint Louis University Mental Status Examination (SLUMS) is a method of screening for Alzheimer’s and other kinds of dementia. It was designed as an alternative screening test to the widely used Mini-Mental State Examination (MMSE). (cons: maybe culturally biased; have to assume the patient knows what a “stockbroker” is and the fairy tale of “Jack and Jill”).  Montreal Cognitive Assessment (MOCA) is more general, less biased, and can track which part of the brain is affected plus you can be registered on the website to find an MOCA test specifically for your patient culture/language. According to alz.org, do not start treatment for mild neurocognitive disorder (previously mild cognitive impairment)/ADLS not affected. Repeat MOCA/SLUMS every 6 months.

ADULT ADHD Screening: Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Tool…pretty straightforward and I use it all the time for my treated and/or undiagnosed populations.

ADHD (Children): Vanderbilt Questionnaire– free and also for parents and teachers. Other children screenings: Conner’s Parent-Teacher Rating Scale, Barkley Home Situations Questionnaire, & Wender Utah dysregulation (adults)…these tools are patent ($$$). ADHD symptoms can be related to environmental factors, genetics, or dysregulation of dopamine in the prefrontal cortex/basal ganglia and norepinephrine deficiencies, and screening tools can be helpful in tracking the severity. Vision and hearing should also be checked.

Anxiety: Generalized Anxiety Disorder Scale (GAD-7) This is a 7-question tool that can help you begin to explore whether the feelings, thoughts, or behaviors the client may be experiencing are anxiety. It can also help you monitor the severity and response to treatment.

Depression: Patient Health Questionnaire (PHQ-9) This is a simple 9-question tool that can help you begin to explore whether the feelings, thoughts, or behaviors could be depression. It can also help you monitor the severity and response to treatment.

Delerium Assessment: The Confusion Assessment Method (CAM) (download) is a standardized evidence-based tool that enables clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. The CAM includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment.

Dementia Assessment: (Mini-Mental Status Exams)

Sleep: don’t forget to stress the importance of having proper sleep.

Insomnia Severity Index: This is a 7-question tool that assesses current sleeping habits and problems related to sleep. It can help you begin to explore the role that sleep and possible sleep problems play in daily life.

Sleep Assessment Questionnaire (SAQ): This is a 6-question tool that can help you keep track of the amount of sleep you get each day, as well as your sleepiness throughout the day.

Substance Use:

CAGE: A tool for evaluating the signs of substance abuse. This is a simple 4-question tool that can help you determine signs of substance abuse or dependency. CAGE Tool (download)

 –University of Michigan

Other Measures to Consider:

  • BPRS (annually): The Brief Psychiatric Rating Scale (BPRS) is one of several tools that help researchers study people with schizophrenia and related psychotic disorders. They use it to track changes in symptoms over time. –WebMD
  • FEPS-FS (annually)The First Episode Psychosis Services Fidelity Scale (FEPS-FS) is a psychiatric services rating scale that has been developed to assess the degree to which First Episode Psychosis Services (FEPS) deliver evidence-based practices. –Univ. of Calgary 
  • MIRECC GAF (quarterly): The MIRECC GAF measures occupational functioning, social functioning, and symptom severity on three subscales for schizophrenic illnesses. – U.S. Veterans
  • PANSS (annually): The Positive and Negative Syndrome Scale (PANSS™) is based on findings that schizophrenia comprises at least two distinct syndromes: the positive syndrome, consisting of productive symptoms; and the negative syndrome, consisting of deficit features. It is useful when developing treatment plans because you can focus on the type of symptoms the patient is experiencing. –MHS assessments
  • SCID (baseline): Babies born with Severe Combined Immunodeficiency (SCID) appear normal at birth but cannot fight infection. They may die before 1 year of age without medical treatment. If SCID is diagnosed early in life, before the onset of infection, a bone marrow transplant can successfully treat the disorder. –CDC
  • WHODAS 2.0 (6 months): A generic assessment instrument for health and disability. –WHO

Additional Measures and Tools

Used appropriately as part of a broader assessment, screening tools give clinicians a common language and objective metric. They provide a consistent approach to testing for the presence or absence of a disorder and help patients receive effective treatment.

These self-reports are sensitive, and research support. The generic measures cover a broad range of psychiatric or substance use orders while specific measures target a particular disorder. Click on the links below to download the screening tools as PDFs. Be sure to download the Guide for Using the Screening Measures.

Generic Measures

Specific Measures

-Behavioral Health Evolution

Autism Spectrum & Developmental Disorders

The American Academy of Pediatrics (AAP) recommends that all children be screened for developmental delays and disabilities during regular well-child doctor visits at 9 months, 18 months, and 24 (or 30) months. Additional screening might be needed if a child is at high risk for developmental problems because of preterm birth or low birth weight. In addition, all children should be screened specifically for ASD during regular well-child doctor visits at 18 months and 24 months, with additional screening needed if a child is at high risk for ASD (e.g., having a sibling with an ASD) or if symptoms are present:

Parent report (SCREENING)

The Clinician (SCREENING)

The Clinician (DIAGNOSTIC & OTHER)

Other Screenings Resources 

Additional Links 

SAMHSA Screening Tools

Despite the high prevalence of mental health and substance use problems, too many Americans go without treatment — in part because their disorders go undiagnosed. Regular screenings in primary care and other healthcare settings enable earlier identification of mental health and substance use disorders, which translates into earlier care. Screenings should be provided to people of all ages, even the young and the elderly. –SAMHSA

DRUG AND ALCOHOL USE

  • “Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide” is designed to help healthcare professionals quickly identify youth at risk for alcohol-related problems. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) developed the guide in collaboration with the American Academy of Pediatrics, a team of underage drinking researchers and clinical specialists, and practicing health care professionals.
  • Substance Use Screening and Assessment Database: a resource created by the Alcohol and Drug Abuse Institute Library at the University of Washington is intended to help clinicians and researchers find instruments used for screening and assessment of substance use and substance use disorders. Instruments whose validity and reliability have been well-studied are marked with a star.
  • SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders for use in community settings.
  • AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire that screens for hazardous or harmful alcohol consumption. Developed by the World Health Organization (WHO), the test correctly classifies 95% of people into either alcoholics or non-alcoholics. The AUDIT is particularly suitable for use in primary care settings and has been used with a variety of populations and cultural groups. It should be administered by a health professional or paraprofessional.
  • NIDAMED is a comprehensive Physicians’ Outreach Initiative that gives medical professionals tools and resources to screen their patients for tobacco, alcohol, illicit drugs, and nonmedical prescription drug use. Developed by the National Institute on Drug Abuse, NIDAMED resources include an online screening tool, a companion quick reference guide, and a comprehensive resource guide for clinicians.
  • DAST-10(Drug Abuse Screen Test) is a 10-item, yes/no self-report instrument that has been condensed from the 28-item DAST and should take less than 8 minutes to complete. The DAST-10 was designed to provide a brief instrument for clinical screening and treatment evaluation and can be used with adults and older youth.

BIPOLAR DISORDER

SUICIDE RISK

  • The Columbia-Suicide Severity Rating Scale (C-SSRS): is a questionnaire used for suicide assessment. It is available in 114 country-specific languages. Mental health training is not required to administer the C-SSRS. Various professionals can administer this scale, including physicians, nurses, psychologists, social workers, peer counselors, coordinators, research assistants, high school students, teachers, and clergy. Learn more about the C-SSRS and how it can be used.
  • SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) was developed in collaboration with the Suicide Prevention Resource Center and Screening for Mental Health.

Last Updated 11/2023

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