Pediatric Mental Health Screening: PHQ-A, SCARED, C-SSRS, and Vanderbilt ADHD Tools

Summary

• PSC-17 (17 items, ages 6-16, score ≥15 positive) serves as the first-layer universal screen at well-child visits [5].
• PHQ-A (9 items, 0-27) screens for depression. Cutoffs: 5-9 mild/monitor, 10-14 mild-moderate, 15-19 refer, ≥20 urgent psychiatric evaluation [1].
• SCARED (41 items, five subscales) screens for anxiety. Total ≥25 indicates significant anxiety [2].
• C-SSRS is used whenever a patient endorses suicidal ideation on any screen, scored 0 (no ideation) to 5 (suicidal behavior) [3].
• Vanderbilt ADHD Rating Scale requires parent and teacher forms, with a positive screen defined as ≥6 items rated "often"/"very often" on the inattention or hyperactivity/impulsivity subscale plus ≥1 problematic performance item, mirroring DSM-5 criteria [4].
• Approximately half of anxious children also meet criteria for depression; screen for both when either is suspected [2].

Caution. A positive response to PHQ-A item 9 (thoughts of being better off dead or self-harm) requires immediate suicide risk assessment regardless of the total score [1].

Depression: PHQ-A

The PHQ-A is a 9-item instrument covering symptoms over the preceding 2 weeks, with a total score range of 0-27 [1].

Clinical pearl. A positive response on item 9 triggers immediate suicide risk assessment on the spot, independent of the total score [1].

Open the PHQ-A Calculator →

Anxiety: SCARED

SCARED is a 41-item instrument, administered in approximately 10 minutes, with five subscales [2]:

A total score ≥25 indicates clinically significant anxiety and warrants further workup [2]. Subscale patterns guide the clinical picture: elevated panic/somatic scores suggest panic attacks, elevated social anxiety suggests peer-related fear, and elevated school avoidance suggests school refusal, a distinct clinical entity.

Clinical pearl. Roughly half of children who screen positive for anxiety also screen positive for depression. Administer both SCARED and PHQ-A when either condition is suspected [2].

Open the SCARED Calculator →

Suicide risk: C-SSRS

The C-SSRS is the reference instrument for suicide risk assessment once a patient endorses suicidal ideation on any screening tool [3].

Category 5 includes self-injurious acts such as cutting or overdose when accompanied by suicidal intent; these are classified as suicidal behavior rather than non-suicidal self-injury [3].

Indications for full C-SSRS administration:

• Any positive response to a suicide screening question
• Depression
• Anxiety
• Substance use
• Any acute psychiatric crisis

Caution. A score of 4 (intent plus plan) warrants hospitalization [3].

Open the C-SSRS Calculator →

ADHD: Vanderbilt Rating Scale

The Vanderbilt ADHD Rating Scale is a 55-item instrument administered in both parent and teacher forms [4]. Both forms are required because symptom expression can differ by setting.

Subscales (each item scored 0-3: never, occasionally, often, very often):

A positive screen requires ≥6 items rated "often" or "very often" on either the inattention subscale or the hyperactivity/impulsivity subscale, plus ≥1 performance item rated "problematic." This threshold mirrors DSM-5 criteria requiring ≥6 symptoms in at least one domain with functional impairment [4].

Caution. Symptoms confined to a single setting (for example, present at home but absent at school) do not meet criteria. Cross-setting confirmation and documented functional impairment are both required [4].

Obtain a baseline score before initiating medication and recheck at 2-4 weeks to assess treatment response.

Open the Vanderbilt ADHD Calculator →

Universal screening: PSC-17

The PSC-17 is a 17-item instrument, administered in approximately 2 minutes, validated for ages 6-16 [5]. It is suited to universal screening at well-child visits.

A score ≥15 indicates a positive screen. The instrument is sensitive but not specific: a positive result indicates that a problem is likely present without identifying which domain is affected [5].

Open the PSC-17 Calculator →

Screening workflow

Management after a positive screen

• Assess safety immediately.
• Involve parents/guardians.
• Provide the 988 Suicide and Crisis Lifeline.
• Schedule follow-up within one week.
• If initiating an antidepressant, counsel on the SSRI black box warning for increased suicidality, particularly during weeks 1-4.
• Maintain heightened surveillance for emergent suicidality during the initial weeks of SSRI therapy.

References

1. Richardson LP, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123. doi:10.1542/peds.2010-0852
2. Birmaher B, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36(4):545-553. doi:10.1097/00004583-199704000-00018
3. Posner K, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266-1277. doi:10.1176/appi.ajp.2011.10111704
4. Wolraich ML, et al. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. J Pediatr Psychol. 2003;28(8):559-567. doi:10.1093/jpepsy/jsg046
5. Gardner W, et al. Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample. J Am Acad Child Adolesc Psychiatry. 2007;46(5):611-618. doi:10.1097/chi.0b013e318032384b