DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17
Johnny
Child’s Name: _________________________________
9
Age: ____
X Male Female
Sex:
Date:___________
MOTHER
Relationship with the child: _________________________________________________________________
Instructions (to the parent or guardian of child): The questions below ask about things that might have bothered your child. For each
question, circle the number that best describes how much (or how often) your child has been bothered by each problem during the
past TWO (2) WEEKS.
None
I.
II.
III.
IV.
During the past TWO (2) WEEKS, how much (or how often) has your child…
1. Complained of stomachaches, headaches, or other aches and pains?
2.
Said he/she was worried about his/her health or about getting sick?
3.
Had problems sleeping—that is, trouble falling asleep, staying asleep, or
waking up too early?
4.
Had problems paying attention when he/she was in class or doing his/her
homework or reading a book or playing a game?
5.
Had less fun doing things than he/she used to?
6.
Seemed sad or depressed for several hours?
V. & 7.
VI. 8.
Seemed more irritated or easily annoyed than usual?
VII.
Started lots more projects than usual or did more risky things than usual?
9.
Seemed angry or lost his/her temper?
10. Slept less than usual for him/her, but still had lots of energy?
VIII. 11. Said he/she felt nervous, anxious, or scared?
IX.
X.
12. Not been able to stop worrying?
Said he/she couldn’t do things he/she wanted to or should have done,
13.
because they made him/her feel nervous?
Said that he/she heard voices—when there was no one there—speaking
14.
about him/her or telling him/her what to do or saying bad things to him/her?
Said that he/she had a vision when he/she was completely awake—that is,
15.
saw something or someone that no one else could see?
Said that he/she had thoughts that kept coming into his/her mind that he/she
16. would do something bad or that something bad would happen to him/her or
to someone else?
Said he/she felt the need to check on certain things over and over again, like
17.
whether a door was locked or whether the stove was turned off?
Seemed to worry a lot about things he/she touched being dirty or having
18.
germs or being poisoned?
Said that he/she had to do things in a certain way, like counting or saying
19.
special things out loud, in order to keep something bad from happening?
Slight
Mild Moderate Severe Highest
Not at Rare, less Several More than Nearly Domain
all than a day days
half the
every
Score
or two
days
day (clinician)
O0
0
O
0
O
1
2
3
4
1
2
3
4
1
2
3
4
1
2
O3
4
1
2
3
4
1
2
3
4
2
3
4
3
4
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
O0
1
2
3
4
O0
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
0
O0
O0
0
1
0
1
O0
0
O
O0
O0
O0
O0
O
2
O
1
O0
0
O
0
O
In the past TWO (2) WEEKS, has your child …
XI.
XII.
20. Had an alcoholic beverage (beer, wine, liquor, etc.)?
Yes
X
No
Don’t Know
21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco?
Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy),
22. hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or
methamphetamine (like speed)?
Used any medicine without a doctor’s prescription (e.g., painkillers [like
23. Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like
sleeping pills or Valium], or steroids)?
In the past TWO (2) WEEKS, has he/she talked about wanting to kill
24.
himself/herself or about wanting to commit suicide?
25. Has he/she EVER tried to kill himself/herself?
Yes
X
No
Don’t Know
Yes
X
No
Don’t Know
Yes
X
No
Don’t Know
Yes
X
No
Don’t Know
Yes
X
No
Don’t Know
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
Case Study: Johnny
Johnny is a 9 year old boy brought to the emergency room where you are employed as a crisis
therapist. The patient was transported by a crisis mobile team who was called by the school. The
evaluation by the ER physician as well as the urine drug screen is unremarkable: there are no
acute or chronic concerns with this patient. In the chart, you note the DSM-5 Parent/GuardianRated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17 form completed by the mother
(attached). Admission paperwork identifies that Johnny has had numerous visits to the
principal’s office in the past year, all triggered by various disruptive behaviors.
Today’s crisis started when Johnny refused to follow directions regarding an in-class assignment.
When the teacher attempted to redirect his behavior things escalated rapidly: Johnny yelled at the
teacher, cursed at him using vulgar language, and when the teacher grabbed him by the shoulders
to take him to the principal’s office Johnny impulsively stabbed the teacher in the arm with a
pencil he was clenching in his hand. Johnny was escorted to the principal’s office who
immediately called the police and Johnny’s parents. The police officer was compelled to contact
the county crisis hotline who dispatched a crisis mobile team. The crisis clinicians made the
determination that Johnny is a danger to others and he must be taken immediately to the nearest
emergency room for emergency psychiatric evaluation. Johnny has refused to speak to the ER
physician or his nurse.
You gather most of your clinical information from his mother who is at the bedside. Johnny’s
mother reports that he has always been a clever, charming, and very playful boy. She informed
that for the past year Johnny has been increasingly stubborn, repeatedly challenging his mother’s
and his teacher’s authority when compliance with home and/or classroom rules is required.
Johnny used to be an A+ student. For the past year, however he has been averaging Bs in most
subjects, grades that he earned effortlessly.
His mother repeatedly assures you that his drop in grades is not due to lack of intellectual ability
but rather because Johnny prefers playing over any type of work. His mother denies any changes
in sleep, appetite, or any mood fluctuations. Furthermore, his mom reports that Johnny is a
healthy and happy boy who is interested in sports, the outdoors, videogames, and that he wishes
to become a software engineer when he grows up. She reports that the school counselor has
mentioned that Johnny may be suffering from ADHD or even bipolar disorder. The thought of
these diagnoses appear very disturbing to Johnny’s mom. She quickly assures you that she has
not observed Johnny to ever struggle with depression, or distractibility, and reports that he has
always been a good sleeper. She reports that Johnny has never made any statements amounting
to thoughts or impulses to harm self or others.
Johnny’s mother presents shaken by today’s events and she assures you that she will seek any
treatment you recommend. At this time, Johnny looks up at you and with tears in his eyes; he
states that he did not mean to stab his teacher explaining that he just got mad when he grabbed
him. Johnny’s mother listens then states that while he obeys her most of the times, he has always
been obedient to his father, who is a traveling salesman. In fact, Johnny has never challenged his
© 2015. Grand Canyon University. All Rights Reserved.
father and, on the weekends when he is around, Johnny manages to catch up with his schoolwork
in record time and enjoy spending most of his time with his father.
© 2015. Grand Canyon University. All Rights Reserved.
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