The NICHQ Vanderbilt Assessment Scales are used to help diagnose and monitor ADHD symptoms in children aged 6-12. The scales include a parent version and a teacher version with both intended for completion. The initial assessment screens for symptoms that meet criteria for both inattentive and hyperactive ADHD, and also includes symptom screens for the following comorbidities: oppositional-defiant disorder, conduct disorder, and anxiety/depression. The follow-up scales assess the first 18 core ADHD symptoms but not the co-morbid symptoms. The Vanderbilt Scale is free for use and available in English and Spanish.
Implementation Tool: Measures
Short Mood and Feelings Questionnaire (SMFQ)
The SMFQ is a child and parent self-report survey used to measure depressive symptoms in children and young adults aged 6-17. Several peer-reviewed studies have found the SMFQ to be a reliable and valid measure of depression in children. It is free for use and translations are available in multiple languages; however, there is not reliability or validity data for all of the translations.
Screen for Child Anxiety Related Disorders (SCARED)
The SCARED is a child and parent self-report instrument used to screen for childhood anxiety disorders including general anxiety disorder, separation anxiety disorder, panic disorder and social phobia. In addition, it assesses symptoms related to school phobia. The SCARED consists of 41 items and 5 factors that parallel the DSM-IV classification of anxiety disorders. It is free for use and available in other languages.
PHQ-9 Depression Scale Questionnaire
The PHQ-9 is a measurement tool providers can use to ensure measurement-based treatment to target within Collaborative Care. This concise nine-item health questionnaire can function as a screening tool, aids in diagnosis, and measures treatment response.
Advantages of the PHQ-9
- It is shorter than other depression rating scales
- Multiple administration options (in person by a clinician, by telephone, or self-administered by the patient)
- Facilitates diagnosis of major depression
- Assesses symptom severity
- Well-validated and documented in a variety of populations
- Directly based on the nine diagnostic criteria for major depressive disorder in the DSM-5
- Valid for use in adolescents as young as 12 years of age
How to Use the PHQ-9
At the initial visit, the PHQ-9 aids in the diagnosis and identification of potential depressive symptoms. At follow-up visits, it measures treatment response. The Questionnaire can be clinician or self-administered.
Scoring the PHQ-9
The PHQ-9 is a tool to assist clinicians in identifying and diagnosing major depression. It has a maximum score of 27. Elevated scores strongly correlate with a major depression diagnosis. However, it’s essential to remember that not everyone with a high PHQ-9 score will have major depression. Trained clinicians must make the final diagnosis.
Patient Health Questionnaire 2 (PHQ-2)
The Patient Health Questionnaire 2 (PHQ-2) effectively screens large groups for depression. It consists of the first two questions on the PHQ-9. If the patient responds affirmatively to either question on the PHQ-2, the PHQ-9 should be administered. No permission is required to reproduce, translate, display, or distribute the PHQ-2.
PHQ-9 Questionnaire and Translations
The PHQ-9, translations of the measure, and an instruction manual are available at www.phqscreeners.com. No permission is required to reproduce, translate, display, or distribute the PHQ-9.
Protocols for Suicide Prevention
The PHQ-9 asks about suicidal ideation, and clinics should have a plan in place for when a patient scores positive on this question. The Protocols for Suicide Prevention in Primary Care assists clinics in refining existing protocol(s) for responding to patients who present with suicidality or violent behavior.
PHQ-9 Aids
Introducing the PHQ-9
To increase staff comfort in discussing the PHQ-9 with patients, the AIMS Center provides the Helping Clinic Staff Talk about the PHQ-9 tool. This resource equips clinic staff to administer the PHQ-9 by addressing commonly asked patient questions.
PHQ-9 Visual Answer Aid
This answer aid visually represents the PHQ-9 answer scale: English | Spanish.
Brief Pain Inventory (BPI)
The Brief Pain Inventory is a medical questionnaire used to measure pain, developed by the Pain Research Group of the WHO Collaborating Centre for Symptom Evaluation in Cancer Care.
AUDIT-C
The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument.
Generalized Anxiety Disorder subscale (GAD-7)
The Generalized Anxiety Disorder (GAD) subscale of the Patient Health Questionnaire (GAD-7) is a quick and easy tool to help identify patients with anxiety and monitor treatment response. The GAD-7 is available free for clinical use in a variety of languages at the link below.
Patient Health Questionnaire 2 (PHQ-2)
The Patient Health Questionnaire 2 (PHQ-2) is used by some clinicians and organizations to screen patients for undiagnosed depression. The PHQ-2 consists of the first two questions asked on the PHQ-9. If the patient responds affirmatively to either of the two items on the PHQ-2, the following seven questions on the PHQ-9 are asked. This can be a particularly effective way to screen large groups of people for depression. *
* Li, MM, Friedman, B, Conwell, Y, Fiscella, K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in Identifying Major Depression in Older People. Journal of the American Geriatric Society. 2007; 55:596-602
PHQ-9 Visual Answer Aid (Spanish)
This answer aid is a visual representation of the PHQ-9 answer scale in Spanish. Behavioral Health Care Managers can use this resource alongside the PHQ-9 during screening to get a fuller understanding of how their patient is feeling.
PHQ-9 Visual Answer Aid
This answer aid is a visual representation of the PHQ-9 answer scale. Behavioral Health Care Managers can use this resource alongside the PHQ-9 during screening to get a fuller understanding of how their patient is feeling.