Child/Adolescent Psychiatric Screen (CAPS)

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.

Personal Information

Date

Enter today's date/date form is submitted

YYYY

Child's Name

First Name

Last Name

Email Address

Date of Birth

YYYY

Sex

Form Completed By:

Relationship to Child:

Screening

1. Has difficulty separating from parents* (* = or major caregiver/guardian)

2. Worries excessively about losing or harm occurring to parents*

3. Worries about being separated from parent* (getting lost or kidnapped)

4. Resists going to school or elsewhere because of fears of separation

5. Resists being alone or without parents*

6. Has difficulty going to sleep without parent nearby

7. Physical complaints (headache, stomach ache, nausea) when anticipating separation

8. Has discrete periods of intense fear that peak within 10 minutes

9. Has excessive, unreasonable fear of a specific object or situation

10. Has recurrent thoughts that cause marked distress (e.g., fears germs)

11. Driven to perform repetitive behaviors (e.g., handwashing, doing things 3 times)

12. Has recurrent, distressing recollections of past difficult or painful events

13. Worries excessively about multiple things (e.g., school, family, health, etc.)

14. Goes to the bathroom at inappropriate times or places

15. Makes noises, and is often unaware of them

16. Makes repetitive, sudden, non-rhythmic movements

17. Fails to pay close attention to details or makes careless mistakes

18. Has difficulty sustaining attention during play or school activities

19. Does not seem to listen when spoken to directly

20. Does not follow through on instructions; fails to finish schoolwork/chores

21. Has difficulty organizing tasks and activities

22. Loses things necessary for tasks are activities (toys, pencils, etc.)

23. Is easily distracted easily by irrelevant stimuli

24. Is forgetful in daily activities

25. Is fidgety or squirms in seat

26. Has difficulty remaining seated

27. Runs or climbs excessively; is restless

28. Talks excessively

29. Blurts out answers before questions have been completed

30. Has difficulty waiting turn

31. Interrupts or intrude on others

32. Episodes of unusually elevated or irritable mood

33. During this episode, grandiosity or markedly inflated self-esteem (Superhero)

34. During this episode, is more talkative than usual/seems pressured to keep talking

35. During this episode, races from thought to thought

36. During this episode, is very distractible

37. During this episode, excessively involved in things (too religious, hypersexual)

38. During this episode, dangerous involvement in pleasurable activity (spending, sex)

39. Depressed or irritable mood most of the day, most days for at least 1 week

40. Loss of interest in previously enjoyable activities

41. Notable change in appetite (not when dieting or trying to gain weight)

42. Difficulty falling or staying asleep, or sleeping excessively through the day

43. Others notice child is sluggish or agitated most of the time

44. Loss of energy nearly every day

45. Feelings of worthlessness or inappropriate guilt nearly every day

46. Thinks about dying or wouldn’t care if died

47. Smokes cigarettes, drinks alcohol, OR abuses drugs (Circle all that apply)

48. Has bad things happen when under the influence of substances

49. Has made unsuccessful efforts to stop using a substance

50. Is excessively worried about gaining weight, even though underweight

51. If female, has stopped having menstrual cycles (after regularly having)

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

53. Engages in binging and purging (eats excessively, then vomits or uses laxatives)

54. Bullies, threatens, or intimidates others

55. Initiates physical fights

56. Uses weapons that could harm others

57. Has been physically cruel to animals

58. Has shoplifted or stolen items

59. Has deliberately set fires

60. Has deliberately destroyed others’ property

61. Lies to obtain goods or to avoid obligations

62. Stays out at night despite parental prohibitions

63. Has run away from home overnight on at least two occasions

64. Is truant from school

65. Loses temper

66. Actively defies or refuses to comply with adult rules

67. Deliberately annoys others

68. Blames others for his/her mistakes or misbehavior

69. Easily annoyed by others

70. Is spiteful or vindictive

71. Has unusual thoughts that others cannot understand or believe

72. Hears voices speaking to him/her that others don’t hear

73. Does poorly at sports or games requiring physical coordination skills

74. Has difficulty at school with: reading, writing, math, spelling (Circle all that apply)

75. Had delayed speech or has limited language now

76. Avoids eye contact during conversations

77. Does not follow when others point to objects

78. Shows little interest in others; emotionally out of sync with others

79. Difficulty starting, stopping conversation; continues talking after others lose interest

80. Uses unusual phrases, possibly over and over (speaks Disney or movie lines)

81. Does not engage in make-believe play; plays more alone than with others

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

83. Difficulty with transitions; may be inflexible about adhering to routines or rules

84. Shows unusual physical mannerisms (hand -flapping, shrieks, objects in mouth, etc.)

85. Unusual preoccupations (schedules, own alphabet, weather reports, etc.)