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Spence Children's Anxiety Scale – Child (SCAS- Child)

Instructions: Please tap to button to show how often each of these things happen to you. There are no right or wrong answers.

Never Sometimes Often Always

1 I worry about things 0 1 2 3

2 I am scared of the dark 0 1 2 3

3 When I have a problem, I get a funny feeling in my stomach

0 1 2 3

4 I feel afraid 0 1 2 3

5 I would feel afraid of being on my own at home

0 1 2 3

6 I feel scared when I have to take a test

0 1 2 3

7 I feel afraid if I have to use public toilets or bathrooms

0 1 2 3

8 I worry about being away from my parents

0 1 2 3

9 I feel afraid that I will make a fool of myself in front of people

0 1 2 3

10 I worry that I will do badly at my school work

0 1 2 3

11 I am popular amongst other kids my own age

0 1 2 3

12 I worry that something awful will happen to someone in my family

0 1 2 3

13 I suddenly feel as if I can’t breathe when there is no reason for this

0 1 2 3

14 I have to keep checking that I have done things right (like the switch is off, or the door is locked)

0 1 2 3

15 I feel scared if I have to sleep on my own

0 1 2 3

16 I have trouble going to school in the mornings because I feel nervous or afraid

0 1 2 3

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Never Sometimes Often Always

17 I am good at sports 0 1 2 3

18 I am scared of dogs 0 1 2 3

19 I can’t seem to get bad or silly thoughts out of my head

0 1 2 3

20 When I have a problem, my heart beats really fast

0 1 2 3

21 I suddenly start to tremble or shake when there is no reason for this

0 1 2 3

22 I worry that something bad will happen to me

0 1 2 3

23 I am scared of going to the doctors or dentists

0 1 2 3

24 When I have a problem, I feel shaky 0 1 2 3

25 I am scared of being in high places or lifts (elevators)

0 1 2 3

26 I am a good person 0 1 2 3

27 I have to think of special thoughts to stop bad things from happening (like numbers or words)

0 1 2 3

28 I feel scared if I have to travel in the car, or on a Bus or a train

0 1 2 3

29 I worry what other people think of me

0 1 2 3

30 I am afraid of being in crowded places (like shopping centres, the movies, buses, busy playgrounds)

0 1 2 3

31 I feel happy 0 1 2 3

32 All of a sudden I feel really scared for no reason at all

0 1 2 3

33 I am scared of insects or spiders 0 1 2 3

34 I suddenly become dizzy or faint when there is no reason for this

0 1 2 3

35 I feel afraid if I have to talk in front of my class

0 1 2 3

36 My heart suddenly starts to beat too quickly for no reason

0 1 2 3

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Never Sometimes Often Always

37 I worry that I will suddenly get a scared feeling when there is nothing to be afraid of

0 1 2 3

38 I like myself 0 1 2 3

39 I am afraid of being in small closed places, like tunnels or small rooms

0 1 2 3

40 I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order)

0 1 2 3

41 I get bothered by bad or silly thoughts or pictures in my mind

0 1 2 3

42 I have to do some things in just the right way to stop bad things happening

0 1 2 3

43 I am proud of my school work 0 1 2 3

44 I would feel scared if I had to stay away from home overnight

0 1 2 3

45 Is there something else that you are really afraid of?

0 Yes

0 No

46 If you are afraid of something else please write down what it is. How often are you afraid of this thing?

Developer Reference: Spence, S.H. (1997). Structure of anxiety symptoms among children: A confirmatory factor- analytic study. Journal of Abnormal Psychology, 106(2), 280-297.

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A. Thomas McLellan, Ph.D. Deni Carise, Ph.D.

Thomas H. Coyne, MSW T. Ron Jackson, MSW

Remember: This is an interview, not a test

≈Item numbers circled are to be asked at follow-up.≈ ≈Items with an asterisk * are cumulative and should be rephrased at

INTRODUCING THE ASI: Introduce and explain the seven potential problem areas: Medical, Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and Psychiatric. All clients receive this same standard interview. All information gathered is confidential; explain what that means in your facility; who has access to the information and the process for the release of information. There are two time periods we will discuss: 1. The past 30 days 2. Lifetime Patient Rating Scale: Patient input is important. For each area, I will ask you to use this scale to let me know how bothered you have been by any problems in each section. I will also ask you how important treatment is for you for the area being discussed. The scale is: 0 – Not at all 1 – Slightly 2 – Moderately 3 – Considerably 4 – Extremely Inform the client that he/she has the right to refuse to answer any question. If the client is uncomfortable or feels it is too personal or painful to give an answer, instruct the client not to answer. Explain the benefits and advantages of answering as many questions as possible in terms of developing a comprehensive and effective treatment plan to help them.

Please try not give inaccurate information!

INTERVIEWER INSTRUCTIONS: 1. Leave no blanks. 2. Make plenty of Comments (if another person reads this ASI, they

should have a relatively complete picture of the client's perceptions of his/her problems).

3. -9 = Question not answered. -8 = Question not applicable.

4. Terminate interview if client misrepresents two or more sections. 5. When noting comments, please write the question number. HALF TIME RULE: If a question asks the number of months, round up periods of 14 days or more to 1 month. Round up 6 months or more to 1 year. CONFIDENCE RATINGS:⇒ Last two items in each section. ⇒ Do not over-interpret. ⇒ Denial does not warrant misrepresentation. ⇒ Misrepresentation = overt contradiction in information.

Probe, cross-check and make plenty of comments!

HOLLINGSHEAD CATEGORIES: 1. Higher execs, major professionals, owners of large businesses. 2. Business managers if medium sized businesses, lesser professions, i.e.,

nurses, opticians, pharmacists, social workers, teachers. 3. Administrative personnel, managers, minor professionals, owners/

proprietors of small businesses, i.e., bakery, car dealership, engraving business, plumbing business, florist, decorator, actor, reporter, travel agent.

4. Clerical and sales, technicians, small businesses (bank teller, bookkeeper, clerk, draftsperson, timekeeper, secretary).

5. Skilled manual – usually having had training (baker, barber, brakeperson, chef, electrician, fireman, machinist, mechanic, paperhanger, painter, repairperson, tailor, welder, police, plumber).

6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook, drill press, garage guard, checker, waiter, spot welder, machine operator).

7. Unskilled (attendant, janitor, construction helper, unspecified labor, porter, including unemployed).

ALCOHOL/DRUG USE INSTRUCTIONS: The following questions refer to two time periods: the past 30 days and lifetime. Lifetime refers to the time prior to the last 30 days. ⇒ 30 day questions only require the number of days used. ⇒ Lifetime use is asked to determine extended periods of use. ⇒ Regular use = 3+ times per week, binges, or problematic irregular use in which normal activities are compromised. ⇒ Alcohol to intoxication does not necessarily mean "drunk", use the words “to feel or felt the effects", “got a buzz”, “high”, etc. instead of intoxication. As a rule of thumb, 3+ drinks in one sitting, or 5+ drinks in one day defines “intoxication". ⇒ How to ask these questions: → “How many days in the past 30 have you used….?” → “How many years in your life have you regularly used….?”

{Module Name} Module

Addiction Severity Index – 5th Edition Clinical/Training Version

LIST OF COMMONLY USED DRUGS: Alcohol: Beer, wine, liquor Methadone: Dolophine, LAAM Opiates: Pain killers = Morphine, Diluaudid, Demerol, Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4, Robitussin, Fentanyl Barbiturates: Nembutal, Seconal, Tuinol, Amytal, Pentobarbital, Secobarbital, Phenobarbital, Fiorinol Sed/Hyp/Tranq: Benzodiazepines = Valium, Librium, Ativan, Serax Tranxene, Xanax, Miltown, Other = ChloralHydrate (Noctex), Quaaludes Dalmane, Halcion Cocaine: Cocaine Crystal, Free-Base Cocaine or “Crack,” and “Rock Cocaine” Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin, Preludin, Methamphetamine, Speed, Ice, Crystal Cannabis: Marijuana, Hashish Hallucinogens: LSD (Acid), Mescaline, Mushrooms (Psilocybin), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstacy Inhalants: Nitrous Oxide, Amyl Nitrate (Whippits, Poppers), Glue, Solvents, Gasoline, Toluene, Etc. Just note if these are used: Antidepressants, Ulcer Meds = Zantac, Tagamet Asthma Meds = Ventoline Inhaler, Theodur Other Meds = Antipsychotics, Lithium

{Module Name} Module

Addiction Severity Index – 5th Edition Clinical/Training Version

Agency Name: ___________________________ Site Name: ______________________________

ID #: __ __ __ __ __ __ Date: __ __ / __ __ / __ __ __ __

GENERAL INFORMATION COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

GENERAL INFORMATION G1. ID Number __________________________ G4. Date of Admission

mm/dd/yyyy __ __ /__ __ /__ __ __ __

G5. Date of Interview

mm/dd/yyyy __ __ /__ __ /__ __ __ __

G6. Time Begun

Use 24 hr clock; code hours:minutes ___ ___ : ___ ___

G7. Time Ended Use 24 hr clock; code hours:minutes

___ ___ : ___ ___ HRS MINS

G8. Class 1 – Intake 2 – Follow-up

___

G9. Contact Code ___ 1 – In person 2 – Telephone (Intake ASI must be in person)

G10. Gender 1 – Male 2 – Female

___

G99. Treatment Episode Number ___ ___

G11. Interviewer Code Number ___ ___ ___

G12. Special 1 – Patient terminated 2 – Patient refused 3 – Patient unable to respond

___

G14. How long have you lived at your current address?

__ __ / __ __ YRS MOS

G15. Is this residence owned by you or your family? 0 – No 1 – Yes

___

G16. Date of birth __ __ /__ __ /__ __ __ __ mm/dd/yyyy

G17 Of what race do you consider yourself? ___ 1 – White (not Hisp) 5 – Asian/Pacific 2 – Black (not Hisp) 6 – Hispanic-Mexican 3 – American Indian 7 – Hispanic-Puerto Rican 4 – Alaskan Native 8 – Hispanic-Cuban 9 – Unknown G18. Do you have a religious preference? ___ 1 – Protestant 4 – Islamic 2 – Catholic 5 – Other 3 – Jewish 6 – None G19. Have you been in a controlled environment in

the past 30 days? ___

1 – No 4 – Medical tx 2 – Jail/prison 5 – Psychiatric tx 3 – Alcohol or drug tx 6 – Other A place, theoretically, without access to drugs/alcohol. G20. How many days? ___ ___

If G19 is No, code -8. Refers to total number of days detained in the past 30 days.

MEDICAL STATUS

M1. *

How many times in your life have you been hospitalized for medical problems? ___ ___

Include O.D.’s and D.T.’s. Exclude detox, alcohol/drug, psychiatric treatment and childbirth (if no complications). Enter the number of overnight hospitalizations for medical problems.

M2. How long ago was your last hospitalization for __ __ / __ __ a physical problem? YRS MOS If no hospitalizations in Question M1, then code -8 / -8.

MEDICAL COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

INTERVIEWER SEVERITY RATING M9. How would you rate the patient’s need for medical

treatment? Refers to the patient’s need for additional medical treatment.

___

M4. Are you taking any prescribed medication on a regular basis for a physical problem? 0 – No 1 – Yes

___

If Yes, specify in comments. Medication prescribed by a MD for medical conditions; not psychiatric medicines. Include medicines prescribed whether or not the patient is currently taking them. The intent is to verify chronic medical problems.

M5. Do you receive a pension for a physical disability? 0 – No 1 – Yes ___

If Yes, specify in comments. Include Workers’ compensation, exclude psychiatric disability.

M6. How many days have you experienced medical problems in the past 30 days? ___ ___

Include flu, colds, etc. Include serious ailments related to drugs/alcohol, which would continue even if the patient were abstinent (e.g., cirrhosis of liver, abscesses from needles, etc.).

For Questions M7 & M8, ask patient to use the Patient Rating Scale M7. How troubled or bothered have you been by these

medical problems in the past 30 days? Restrict response to problem days in Question M6.

___

M8. How important to you now is treatment for these medical problems? If client is currently receiving medical treatment, refer to the need for additional medical treatment by the patient.

___

CONFIDENCE RATINGS Is the above information significantly distorted by:

M10. Patient’s misrepresentation? 0 – No 1 – Yes

___

M11. Patient’s inability to understand? 0 – No 1 – Yes

___

M3. Do you have any chronic medical problems which continue to interfere with your life? 0 – No 1 – Yes

___

If Yes, specify in comments. A chronic medical condition is a serious physical condition that requires regular care (i.e., medication, dietary restriction) preventing full advantage of their abilities.

EMPLOYMENT/SUPPORT STATUS

E1. * Education completed GED = 12 years, note in comments. Include formal education only.

__ __ / __ __ YRS MOS

EMPLOYMENT/SUPPORT COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

E2. * Training or technical education completed Formal, organized training only. For military training, only include training that can be used in civilian life (i.e., electronics, computers).

__ __ MOS

E3. Do you have a profession, trade, or skill? 0 – No 1 – Yes ___

Employable, transferable skill acquired through training. If Yes, specify: __________________________________

E6. How long was your longest full-time job? Full-time = 35+ hours weekly; does not necessarily mean most recent job.

__ __ / __ __ YRS MOS

E10. Usual employment pattern, past 3 years? ___ 1 – Full time (35+ hours) 5 – Military service 2 – Part time (regular hours) 6 – Retired/disability 3 – Part time (irregular hours) 7 – Unemployed 4 – Student 8 – In controlled environment Answer should represent the majority of the last 3 years, not just the most

recent selection. If there are equal times for more than one category, select that which best represents the current situation.

E4. Do you have a valid driver’s license? 0 – No 1 – Yes ___

Valid license; not suspended/revoked.

E5. Do you have an automobile available for use? 0 – No 1 – Yes

___

If answer to E4 is No, then E5 must be No. Does not require ownership, only requires availability on a regular basis.

E7. * Usual (or last) occupation ___ Specify Use Hollingshead Categories Reference Sheet

E11. How many days were you paid for working in the past 30 days? ___ ___

Include “under-the-table” work, paid sick days and vacation.

E8. Does someone contribute to your support in any way? 0 – No 1 – Yes

___

Is patient receiving any regular support (i.e., cash, food, housing) from family/ friend. Include spouse’s contribution; exclude support by an institution.

E9. Does this support constitute the majority of your support? 0 – No 1 – Yes

___

If E8 is No, then E9 is -8.

EMPLOYMENT/SUPPORT COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

INTERVIEWER SEVERITY RATING E22. ___ How would you rate the patient’s need for

employment counseling?

EMPLOYMENT/SUPPORT STATUS (cont) For questions E12-E17:

How much money did you receive from the following sources in the past 30 days?

E12. Employment Net or “take home” pay, include any “under the table” money.

$___ ___,___ ___ ___

E13. Unemployment compensation $___ ___,___ ___ ___ E14. Welfare

Include food stamps, transportation money provided by an agency to go to and from treatment.

$___ ___,___ ___ ___

E15. Pension, benefits or social security Include disability, pensions, retirement, veteran’s benefits, SSI & workers’ compensation.

$___ ___,___ ___ ___

E16. Mate, family or friends Money for personal expenses (i.e., clothing); include unreliable sources of income. Record cash payments only, include windfalls (unexpected), money from loans, legal gambling, inheritance, tax returns, etc.

$___ ___,___ ___ ___

E17. Illegal Cash obtained from drug dealing, stealing, fencing stolen goods, illegal gambling, prostitution, etc. Do not attempt to convert drugs exchanged to a dollar value.

$___ ___,___ ___ ___

E18. How many people depend on you for the majority of their food, shelter, etc.? ___ ___

Must be regularly depending on patient; do include alimony/child support, do not include the patient or self-supporting spouse, etc.

E19. How many days have you experienced employment problems in the past 30? ___ ___

Include inability to find work, if they are actively looking for work, or problems with present job in which that job is jeopardized.

For Questions E20 & E21, ask patient to use the Patient Rating Scale E20. How troubled or bothered have you been by these

employment problems in the past 30 days? If the patient has been incarcerated or detained during the past 30 days, they cannot have employment problems. In that case, code -8.

___

E21. How important to you now is counseling for these employment problems? Stress help in finding or preparing a job, not giving them a job.

___

CONFIDENCE RATINGS Is the above information significantly distorted by: E23. Client’s misrepresentation?

0 – No 1 – Yes ___

E24. Client’s inability to understand? 0 – No 1 – Yes

___

ALCOHOL/DRUGS Route of Administration Types:

1 – Oral 2 – Nasal 3 – Smoking 4 – Non-IV injection 5 – IV Note the usual or most recent route. For more than one route, choose the most

severe. The routes are listed from least severe to most severe. A.

Past 30 Days

B. Lifetime (Years)

C. Route of Admin

D1. Alcohol (any use at all) ___ ___ ___ ___

D2. Alcohol (to intoxication) ___ ___ ___ ___

D3. Heroin ___ ___ ___ ___ ___

D4. Methadone ___ ___ ___ ___ ___

D5. Other Opiates/Analgesics ___ ___ ___ ___ ___

D6. Barbiturates ___ ___ ___ ___ ___

D7. Other Sedatives/Hypnotics/ Tranquilizers

___ ___ ___ ___ ___

D8. Cocaine ___ ___ ___ ___ ___

D9. Amphetamines ___ ___ ___ ___ ___

D10. Cannabis ___ ___ ___ ___ ___

D11. Hallucinogens ___ ___ ___ ___ ___

D12. Inhalants ___ ___ ___ ___ ___

D13.

More than one substance per day Including alcohol

___ ___ ___ ___

D15. How long was your last period of voluntary abstinence from this major substance?

___ ___ MOS

Last attempt of at least one month, not necessarily the longest. Periods of hospitalization/incarceration do not count. Periods of antabuse, methadone, or naltrexone use during abstinence do count. 00 = never abstinent

D16. How many months ago did this abstinence end? If D15 = 0, then D16 = -8, 00 = Still abstinent

___ ___ MOS

ALCOHOL/DRUGS COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

D14. ___ ___

According to the interviewer, which substance is/are the major problem? Interviewer should determine the major drug or drugs of abuse. Code the number next to the drug in questions D1-D12, or: 00 = no problem 15 = alcohol & one or more drugs 16 = more than one drugs but no alcohol. Ask patient when not clear.

ALCOHOL/DRUG COMMENTS (Include the question number with your notes)

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

INTERVIEWER SEVERITY RATING How would you rate the patient’s need for treatment for: D32. Alcohol problems ___

D33. Drug problems ___

How many times in your life have you been treated for:

D19.* Alcohol abuse? ___ ___

D20.* Drug abuse? ___ ___ Include detoxification, halfway houses, in/outpatient counseling,

and AA or NA (if 3+ meetings within one month period).

How many of these were detox only?

D21.* Alcohol? If D19 = 0, then D21 = -8

___ ___

D22.* Drugs? If D20 = 0, then D22 = -8

___ ___

How much money would you say you spent during the past 30 days on:

D23. Alcohol? $___ ___,___ ___ ___ D24. Drugs? $___ ___,___ ___ ___ Only count actual money spent. What is the financial burden caused by

drugs/alcohol?

D25. How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days? Include AA/NA

___ ___

How many days in the past 30 have you experienced: D26. Alcohol problems? ___ ___

D27. Drug problems?