How to Use the Child/Adolescent Psychiatry Screen (CAPS)
Child/Adolescent Psychiatry Screen (CAPS)

If you suspect your child has a mental health condition and are not sure what symptoms are most troublesome, the Child/Adolescent Psychiatry Screen can provide an initial indicator of areas for further investigation.

This is only a preliminary screening tool. Do not assume that a particular “score” means a child has a particular disorder; many people have symptoms like those described in this screening tool, but do not have a “disorder.” Diagnoses should be made only by a trained clinician after a thorough assessment. Symptoms suggestive of suicidal or harmful behaviors warrant immediate attention by a trained clinician.

• Answer all items in the checklist , using the appropriate column to indicate the frequency of each symptom.

• Examine the columns to determine if certain clusters of items have more “Moderate” or “Severe” responses. Don’t panic: having a high (or low) number of moderate or severe responses in any section does NOT mean that your child has this disorder. It just means that these symptoms should be discussed with a trained clinician familiar with these disorders so that you can make sense of these symptoms (and determine the best course of action to address them).

• Symptoms have been arranged in the following sections/clusters to help identify areas for discussion with a trained clinician:

• Use the results for a focused conversation with your child’s primary care clinician, mental health clinician, or with school staff about options to improve your child’s mental health. If particular sections receive mostly moderate and severe answers, show and describe these to your clinician. At that time, it may be useful to show and describe the “Past” column, since some symptoms tend to predict certain other symptoms or clarify other factors to consider.

• Consider obtaining additional screening tools and rating scales for more detailed assessment. Many of these are described and/or accessible from www.schoolpsychiatry.org.
  

Child’s Name:______________________________________
Date of Birth :_________________
Male _____ Female _____
Form Completed By:_________________________________
Relationship to Child:________________________________

For each item below, check the one category that best describes your child during the past 6 months.

None = the child never or very rarely exhibits this behavior.
Mild = the child exhibits this behavior approximately once per week, and few others notice or complain about this behavior.
Moderate = the child exhibits this behavior at least three times per week, and others notice or comment on this behavior.
Severe = the child exhibits this behavior almost daily, and multiple others complain about this behavior.
Past = the child used to have significant problems with this behavior, but not during the past 6 months.

1. Has difficulty separating from parents* (* = or major caregiver/guardian)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

2. Worries excessively about losing or harm occurring to parents*
 _____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

3. Worries about being separated from parent* (getting lost or kidnapped)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

4. Resists going to school or elsewhere because of fears of separation
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

5. Resists being alone or without parents*
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

6. Has difficulty going to sleep without parent nearby
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

7. Physical complaints (headache, stomach ache, nausea) when anticipating separation
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

8. Has discrete periods of intense fear that peak within 10 minutes
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

9. Has excessive, unreasonable fear of a specific object or situation
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

10. Has recurrent thoughts that cause marked distress (e.g., fears germs)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

11. Driven to perform repetitive behaviors (e.g., handwashing, doing things 3 times)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

12. Has recurrent, distressing recollections of past difficult or painful events
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

13. Worries excessively about multiple things (e.g., school, family, health, etc.)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

14. Goes to the bathroom at inappropriate times or places
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

15. Makes noises, and is often unaware of them
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

16. Makes repetitive, sudden, nonrhythmic movements
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

17. Fails to pay close attention to details or makes careless mistakes
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

18. Has difficulty sustaining attention during play or school activities
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

19. Does not seem to listen when spoken to directly
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

20. Does not follow through on instructions; fails to finish schoolwork/chores
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

21. Has difficulty organizing tasks and activities
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

22. Loses things necessary for tasks are activities (toys, pencils, etc.)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

23. Is easily distracted easily by irrelevant stimuli
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

24. Is forgetful in daily activities
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

25. Is fidgety or squirms in seat
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

26. Has difficulty remaining seated
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

27. Runs or climbs excessively; is restless
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

28. Talks excessively
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

29. Blurts out answers before questions have been completed
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

30. Has difficulty waiting turn
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

31. Interrupts or intrude on others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

32. Episodes of unusually elevated or irritable mood
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

33. During this episode, grandiosity or markedly inflated self-esteem (Superhero )
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

34. During this episode, is more talkative than usual/seems pressured to keep talking _____ _____ _____ _____ ____
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

35. During this episode, races from thought to thought
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

36. During this episode, is very distractible
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

37. During this episode, excessively involved in things (too religious, hypersexual)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

38. During this episode, dangerous involvement in pleasurable activity (spending, sex)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

39. Depressed or irritable mood most of the day, most days for at least 1 week
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

40. Loss of interest in previously enjoyable activities
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

41. Notable change in appetite (not when dieting or trying to gain weight)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

42. Difficulty falling or staying asleep, or sleeping excessively through the day
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

43. Others notice child is sluggish or agitated most of the time
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

44. Loss of energy nearly every day
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

45. Feelings of worthlessness or inappropriate guilt nearly every day
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

46. Thinks about dying or wouldn’t care if died
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

47. Smokes cigarettes, drinks alcohol, OR abuses drugs (Circle all that apply)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

48. Has bad things happen when under the influence of substances
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

49. Has made unsuccessful efforts to stop using a substance
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

50. Is excessively worried about gaining weight, even though underweight
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

51. If female, has stopped having menstrual cycles (after regularly having)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

52. Thinks he/she is fat, even though not overweight (pulls skin and claims is fat, etc.)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

53. Engages in binging and purging (eats excessively, then vomits or uses laxatives)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

54. Bullies, threatens, or intimidates others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

55. Initiates physical fights
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

56. Uses weapons that could harm others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

57. Has been physically cruel to animals
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

58. Has shoplifted or stolen items
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

59. Has deliberately set fires
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

60. Has deliberately destroyed others’ property
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

61. Lies to obtain goods or to avoid obligations
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

62. Stays out at night despite parental prohibitions
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

63. Has run away from home overnight on at least two occasions
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

64. Is truant from school
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

65. Loses temper
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

66. Actively defies or refuses to comply with adult rules
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

67. Deliberately annoys others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

68. Blames others for his/her mistakes or misbehavior
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

69. Easily annoyed by others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

70. Is spiteful or vindictive
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

71. Has unusual thoughts that others cannot understand or believe
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

72. Hears voices speaking to him/her that others don’t hear
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

73. Does poorly at sports or games requiring physical coordination skills
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

74. Has difficulty at school with: reading, writing, math, spelling (Circle all that apply)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

75. Had delayed speech or has limited language now
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

76. Avoids eye contact during conversations
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

77. Does not follow when others point to objects
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

78. Shows little interest in others; emotionally out of sync with others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

79. Difficulty starting, stopping conversation; continues talking after others lose interest
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

80. Uses unusual phrases, possibly over and over (speaks Disney or movie lines)
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

81. Does not engage in make-believe play; plays more alone than with others
_____None     _____None      _____Mild     _____Moderate    _____Severe       ____Past

82. Unusual preoccupations with objects or unusual routines (lines up 100’s of cars, etc.)
_____None      _____Mild     _____Moderate    _____Severe       ____Past

83. Difficulty with transitions; may be inflexible about adhering to routines or rules
_____None      _____Mild     _____Moderate    _____Severe       ____Past

84. Shows unusual physical mannerisms (hand-flapping, shrieks, objects in mouth, etc.)
_____None      _____Mild     _____Moderate    _____Severe       ____Past

85. Unusual preoccupations (schedules, own alphabet, weather reports, etc.)
_____None      _____Mild     _____Moderate    _____Severe       ____Past

Thank you for answering each of these items. Please list any other symptoms that concern you:

© Copyright 2004 Jeff Q. Bostic: This screen may be freely used by individuals, clinicians, or schools, but may not be used for profit or for proprietary purposes .