CHILDREN`S ANXIETY RATING SCALE (CARS)

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PEDIATRIC ANXIETY RATING SCALE (PARS)

Version 1.2 July 11, 1997

This instrument was developed by the Research Units of Pediatric Psychopharmacology (RUPPs) at

Johns Hopkins Medical Institutions, Mark A. Riddle, M.D., PI, and at the College of Physicians and Surgeons,

Columbia University, Laurence L. Greenhill, PI. This effort was funded by the National Institute of Mental

Health, Benedetto Vitiello, M.D., Project Officer. Helpful consultation was provided by Prudence Fisher,

Ph.D., Columbia University.

Please obtain permission to use, copy or cite this instrument from Dr. Riddle (410.955.2320) or Dr.

Greenhill (212.960.2340).

INSTRUCTIONS

Overview: The Pediatric Anxiety Rating Scale (PARS) is to be used to rate the severity of anxiety in children and adolescents, ages 6 to 17 years. The PARS has two sections: the symptom checklist and the severity items.

The symptom checklist is used to determine the child’s repertoire of symptoms during the past week. The 7severity item is used to determine severity of symptoms and the PARS total score.

Symptoms include in the rating are commonly observed in patients with the following disorder, panic disorder and specific phobia. Obviously, there is considerable overlap in symptoms among these anxiety disorders. Symptoms specific to obsessive compulsive disorder and post traumatic stress disorder are not included.

The time frame for the PARS rating is the past week. Only those symptoms endorsed for the past week are included in the symptom checklist and rated on the severity items.

The respondents should be the same for each rating on the same subject. For example, in a treatment trial, where the PARS may be administered multiple times to the same child, it is important that the same primary caregiver (e.g., mother) be present at each rating. If both parents are present for the first rating, both should be present for subsequent ratings.

The format of the interview: The goal of the interview is to elicit as much information as possible about the child’s level of anxiety. To achieve this goal, it is necessary to obtain information from both the child and the primary caregiver (at least). The clinician combines all information from all informants to make the ratings.

Usually, for pre-teens, the interviewer starts with the parent(s) alone and subsequently interviews the child alone. For teenagers, the reverse order is generally preferred (adolescent first, followed by the parent(s)).

With some families, it may be preferable to interview the child and parent(s) together. Both should be told in advance that they will have an opportunity, if indicated, to speak alone with the interviewer. The order and procedure for interviews should remain constant throughout multiple ratings.

Symptom Checklist: The symptom checklist is the first of the two major sections of the PARS. The goal of the checklist is to document the array of the patient’s symptoms that will be used to establish severity during the ratings of severity items. Thus, the symptom checklist is not to be used to establish severity.

Use items as probes to elicit the patient’s complete symptom repertoire. Elicit information from both child and parent(s). Use your best judgement to combine information from all informants. Remember, symptoms occurring during the past week only are to be recorded.

Severity Ratings: Using all of the symptoms endorsed for the past week, rate severity of symptoms for each of the 7 severity items. Use the anchors for each item to assist the child and parent in establishing severity.

Respondents may wonder whether the severity items are rating an average for the past week, or the worst day, or worst time, etc. The severity items are meant to elicit information about average symptom severity over the past week. Record all scores in whole numbers; in-between scores (e.g., 1.5) are not permitted.

Follow-up Evaluations: Eliciting information about the symptom lisst can be much more efficient during subsequent ratings of the same subject. The interviewer can use the symptom checklist from the prior rating as a guide. For a follow-up rating, the interviewer can describe to the subject the symptoms that were endorsed at the prior rating. Then the interviewer asks if there have been any new symptoms during the past week. Finally, the interviewer uses the probes to be sure that no symptoms have been overlooked. However, since the subject will be familiar with the probes from prior assessments, the probes can be reviewed rapidly, with the expectation that they will not be endorsed.

Scoring: The total score for the PARS is total of the 7 severity items. The total score ranges from 0 to 35.

(Codes “8” and “9” are not included in the summation.) For clinical trials, severity is based on the sum of items

#2,3,5,6, and 7.

Sample Probes for the Symptom List: Social interactions or performance situations: During the past week, have you (has s/he) worried about or avoided social situaitons? Let me give you some examples (refer to list).

During the past week, have you (has s/he) been shy about or refused to do things in public? Let me give you some more examples.

Separation Anxiety

: Some children worry about being away from their mother or father. What about you (your child)? Some children do things to make sure they stay near their mother or father? What about you

(your child)? Let me give you examples.

Generalized Anxiety: Some people worry about a lot of different things. What about you (your child)?

What about during the past week? Let me give you some examples.

Specific Phobia: Do you worry about or have fears of animals (e.g. dog), etc?

Physical Signs/ Symptoms: Sometimes children notice feelings or changes in their bodies when they are anxious or worried? What about you? Let me give examples.

PEDIATRIC ANXIETY RATING SCALE (PARS)

SYMPTOM CHECKLIST

Instructions: Fill in the blanks with “1” (yes), “2” (no), or “9” (other, e.g., unable or unwilling to answer)

SOCIAL INTERACTIONS or PERFORMANCE SITUATIONS Parent Child Rater

1. Has fear of and/or avoids participating in group activities. ______ ______ ______

2. Has fear of and/or avoids going to a party or social event.

3. Has fear of and/or avoids talking with a stranger.

4. Has fear of and/or avoids talking on the phone.

5. Reluctant or refuses to talk in front of a group.

6. Reluctant or refuses to write in front of other people.

7. Reluctant or refuses to eat in public.

8. Reluctant or refuses to use a public bathroom.

9. Reluctant or refuses to change into gym clothes or bathing suit

with others present.

SEPARATION

10. Worry about harm happening to attachment figures.

11. Worry about harm befalling self, including the fear of dying.

12. Distress when separation occurs or is anticipated.

13. Fear or reluctance to be alone.

14. Reluctance or refusal to go to school or elsewhere.

15. Complaints of physical symptoms when separation occurs or is anticipated.

16. Reluctance or refusal to go to sleep alone.

17. Reluctance or refusal to sleep away from home.

18. Nightmares with a separation theme.

19. Clings to parent, or follows parent around the house.

GENERALIZED

20. Excessive worry about everyday or real-life problems.

21. Restlessness or feeling keyed-up or on edge.

22. Easily fatigued.

23. Difficulty concentrating or mind going blank.

24. Irritability.

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25. Muscle tension or nonspecific tension.

26. Sleep disturbance, especially difficulty falling asleep.

27. Dread or fearful anticipation (nonspecific).

SPECIFIC PHOBIA

28. Animal: Specify _____________________________

29. Natural environment:

(e.g., heights, storms) Specify: _____________________

30. Blood-injection-injury: Specify: _________________

31. Situational

(e.g., airplane, elevator): Specify: __________________

ACUTE PHYSICAL SIGNS & SYMPTOMS

32. Blushing.

33. Feels paralyzed.

34. Trembling or shaking.

35. Feels dizzy, unsteady, lightheaded or going to pass out.

36. Palpitations or pounding heart.

37. Difficult breathing.

(sensation of shortness of breath, smothering or choking).

38. Chills or hot flashes.

39. Sweating.

40. Feels sick to stomach, nausea or abdominal distress.

41. Recurrent urge to go to bathroom.

42.Chest pain or discomfort.

44. Problems swallowing or eating.

43. Paresthesias

(numbness or tingling sensation in fingers, toes, or perioral region).

OTHER

45. Crying spells when in anxiety-provoking situations.

46. Temper tantrums when in anxiety-provoking situations.

47. Needs to flee certain anxiety-provoking situations.

48. Keeps distance from other people.

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49. Fear of losing control or going crazy.

50. Derealization (feeling of unreality)

______ ______ or depersonalization (detached from oneself).

Other anxiety symptoms:

______ ______

Specify: ___________________________________

Specify: ___________________________________

Specify: ___________________________________

SEVERITY ITEMS

Instructions: For each item circle the number that best characterizes the patient during the past week.

1.

Overall Number of Anxiety Symptoms (Circle code for past week only)

Not applicable

Does not know

No symptoms

1 symptom

2.

2-3 symptoms

4-6 symptoms

7-10 symptoms

More than 10 symptoms

Overall Frequency of Anxiety Symptoms

Not applicable

Does not know

No symptoms

1 or 2 days a week

3 or 4 days a week

5 or 6 days a week

Daily

Several hours every day

3.

Overall Severity of Anxiety Feelings

Not applicable

Does not know.

None. No anxious symptoms.

Minimal: Very transient discomfort. Not clinically significant.

______

______

8

9

0

1

3

4

5

1

2

Code

8

9

0

3

4

5

1

2

8

9

0

Mild:

Moderate:

Severe:

Extreme:

4.

Overall Severity of Physical Symptoms of Anxiety

Not applicable

Does not know

None. No physical symptoms of anxiety.

Minimal: Very transient physical symptoms of anxiety. Symptoms are not, or are hardly noticeable by others. Not clinically significant.

Mild: Few physical symptoms: no lasting impact.

Borderline clinical significance. Intermediate between 1and 3. `

Moderate: Persistent physical symptoms of anxiety, especially during exposure

to the feared situation(s). Symptoms are noticeable by others and significantly

interfere with his/her ability to function in the situation.

Severe: Marked physical symptoms of substantial clinical significance.

Intermediate between 3 and 5.

Extreme:

Transient discomfort that is mildly disturbing. Borderline clinical significance. Intermediate between 1and 3.

Clearly nervous when anticipating or confronting the anxiety-provoking situation(s). Often unable to overcome these feelings.

These feelings impact on well-being.

Very distressed when anxious or when anticipating or confronting the anxiety-provoking situation (s). Usually unable to overcome this feeling.

Intermediate between 3 and 5.

Feels wretched when anticipating or confronting anxiety-provoking situation(s). Often or almost totally unable to overcome this fear. Very marked impact on well being.

Severe and persistent physical symptoms of anxiety, especially during exposure to the feared situations(s). Symptoms are very obvious to others and often result in inability to function in the situation.

5.

Overall Avoidance of Anxiety-Provoking Situations

NOTE: Rate all avoidance here; include school, home, activities, etc. in rating

Not applicable

Does not know

None. Does not avoid the anxiety-provoking situation(s).

Minimal: Very occasionally avoids the anxiety-provoking situation(s).

Avoided situation(s) is/are not critical to his/her well-being.

Mild: Avoids anxiety-provoking situation(s) some of the time but no important situation is consistently avoided. Borderline clinical significance. Intermediate between 1 and 3.

2

3

4

5

8

9

0

1

2

3

4

5

8

9

0

1

2

Moderate: Avoid anxiety-provoking situation(s) frequently.

At least one important situation is avoided.

Severe: Avoids anxiety-provoking situation most of the time or more than one important situation is consistently avoided.

Intermediate between 3 and 5.

Extreme:

6.

Avoids all or almost all anxiety-provoking situations.

Interference with Family Relationships and/or Performance at Home

Not applicable

Does not know

None. No interference.

Minimal: Very transient interference. No impact on relationships with family members or performance (tasks, etc.) at home.

Mild: Slight impact on relationships or performance outside of the home.

Borderline clinical significance. Intermediate between 1 and 3.

Moderate: Clear interference. Either performance of tasks at home or frequency or quality of interaction with family members is affected: he/she might withdraw from interaction, or might be avoided/rejected by family members, or might have many conflicts with them.

Severe: Marked interference in relationships with family members and/or performance at home. Of substantial clinical significance.

Intermediate between 3 and 5.

Extreme:

Mild:

Totally or almost totally unable to maintain appropriate family relationship and/or function at home.

7.

Interference with Peer and Adult Relationships &/or Performance Outside of Home.

NOTE: Out-of-home functioning includes school (not avoidance), activities, etc

Not applicable

Does not know

None. No interference.

Minimal: Very transient interference. No impact on relationships with peers or teachers or other adults outside of the home. No impact on functioning outside of home, e.g., attending and performing group activities.

Slight impact on relationships or performance outside of the home.

Borderline clinical significance. Intermediate between 1 and 3.

Moderate: Clear interference. Either performance outside of the home or frequency or quality of peer or adult interactions is affected: he/she might withdraw from interaction, or might be avoided/rejected by peers or adults, or might have conflicts with them.

3

4

5

2

3

4

5

2

3

8

9

0

1

8

9

0

1

Severe:

Extreme:

Marked interference in relationship with peers or adults outside of home and/or performance outside of home. Of substantial clinical significance.

Intermediate between 3 and 5.

Totally or almost totally unable to maintain appropriate peer or adult relationship and/or function outside of home.

4

5

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