Screen for Child Anxiety Related Disorders
Child Version - Page 1 of 2 (To be filled out by the CHILD)
Name
First Name
Last Name
Today's Date
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Month
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Day
Year
Date
Directions
Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for you. Then for each sentence, fill in one circle that corresponds to the response thatseems to describe you for the last 3 months.
When I feel frightened, it is hard for me to breathe
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I get headaches when I am at school
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I don’t like to be with people I don’t know well
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I get scared if I sleep away from home
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about other people liking me
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel like passing out
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am nervous
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I follow my mother or father wherever they go
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
People tell me that I look nervous
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I feel nervous with people I don’t know well
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I get stomachaches at school
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel like I am going crazy
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about sleeping alone
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about being as good as other kids
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel like things are not real
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I have nightmares about something bad happening to my parents
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about going to school
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, my heart beats fast
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I get shaky
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I have nightmares about something bad happening to me
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about things working out for me
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I sweat a lot
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am a worrier
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I get really frightened for no reason at all
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am afraid to be alone in the house
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
It is hard for me to talk with people I don’t know well
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel like I am choking
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
People tell me that I worry too much
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I don’t like to be away from my family
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am afraid of having anxiety (or panic) attacks
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry that something bad might happen to my parents
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I feel shy with people I don’t know well
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about what is going to happen in the future
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel like throwing up
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about how well I do things
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am scared to go to school
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I worry about things that have already happened
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
When I get frightened, I feel dizzy
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport)
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
I am shy
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
*For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions.Developed by Boris Birmaher, MD, Suneeta Khetarpal, MD, Marlane Cully, MEd, David Brent, MD, and Sandra McKenzie, PhD. Western Psychiatric Institute and Clinic, University of Pgh. (10/95). Email: birmaherb@msx.upmc.edu
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