Clinical Screening Questionnaires
Clinical Screening Questionnaires Training - page 1/10
Global Appraisal of Individual Needs: Short Screener (GAIN-SSS)
Introduction
The Kessler Psychological Distress Scale (K-10) is a global measure of psychological distress based on questions about anxiety and depressive symptoms in the most recent 30 days. There are 10 items. It is a brief self-report by youth, a widely used and accepted screening instrument, and available in a variety of languages.
Why are we asking youth to complete this questionnaire?
The K-10 shows superior performance as a screener for mental health disorders, especially affective disorders (e.g., depression, anxiety). Youth will often come to a hub due to mental health issues, and we want to be able to measure these and see any changes across time, and share this information with youth. Basically, measuring psychological distress in youth is effective in order to monitor their mental health at a certain point in time and over time, to be able to apply this information to determine the best interventions.
Research on the K-10 has been broad and extensive in both the general population and clinical samples, and for both monitoring mental health and measuring intervention outcomes. Studies have established the reliability and validity of the K-10 across a number of different settings.
Responding to youth asking why they are being asked to complete this:
This questionnaire is designed to screen for worrying and sadness in ten questions. Each question refers to an emotional state (e.g., nervous, depressed) and you choose the answer that best describes you on a five point scale. It helps us get a sense of how you’re currently doing, and then you can decide if there’s something that you think you might want to talk about here.
Clinical questionnaire:
At the hub, when youth are provided the questionnaire on an iPad (or possibly in hard copy form), they receive the following instructions:
| The following questions ask about how YOU have been feeling during the past week. For each sentence, please select the response that best describes how often you had this feeling. |
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1. During the last week, about how often did you feel tired out for no good reason?
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2. During the last week, about how often did you feel nervous?
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3. During the last week, about how often did you feel so nervous that nothing could calm you down?
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4. During the last week, about how often did you feel hopeless?
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5. During the last week, about how often did you feel restless or fidgety?
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6. During the last week, about how often did you feel so restless you could not sit still?
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7. During the last week, about how often did you feel depressed?
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8. During the last week, about how often did you feel that everything was an effort?
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9. During the last week, about how often did you feel so sad that nothing could cheer you up?
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10. During the last week, about how often did you feel worthless?
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Youth are asked to check off how much of the time in the past 30 days they have been feeling each way (ranging from none, to a little, to some, to most, to all of the time).
When do youth respond to these questions?
Young people are asked to complete this questionnaire at their first visit, and subsequent visits of 30 or more days. If young people’s subsequent visit is between 8-29 days later, they complete the similar K10W (Kessler Psychological Distress Scale (Past Week)). The K10W consists of the same exact questions and scoring as the K-10 - the instructions simply ask youth how they have been feeling during the past week instead of the past 30 days.
Neither of these questionnaires is completed if youth visit the hub for service 7 or fewer days after their last visit.
What if youth don’t understand the question?
If a young person requires assistance with an item due to developmental, cognitive, language, or other issues, try to provide these supports:
- Read all items aloud exactly as printed word for word, at an appropriate pace;
- If there is some misunderstanding, repeat the item;
- Determine which word is confusing and define the word, but try not to reword the question (it may alter the meaning of the question, as well as the response); and
- Do not suggest answers.
Scoring/results:
How can I go over results with youth?
Scoring is automatically calculated on the YWHO Data Collection platform, not by the service provider. (If the youth has not completed all questions, the platform will not automatically generate a score).
- Scores are attached to each of the youth’s 10 responses where 1 = none of the time, 5 = all of the time
- Scores are added up and can range from a total low of 10 to a maximum of 50
- Low scores indicate low levels of psychological distress and high scores indicate high levels of psychological distress
- Scores can be viewed over time with the YWHO Data Collection platform progress tracker
In general:
- Youth who respond most commonly with the “Some of the time” (3), “Most of the time” (4), or “All of the time” (5) categories are in need of a more detailed assessment and, in combination with results on other screeners and clinical judgment, possibly more intense services.
- Youth who rate most commonly “None of the time” (0) or “A little of the time” (1) may also benefit from information to raise awareness of the conditions of depression and anxiety, and early intervention strategies to address potential mental health issues.
| K10/K10W Score | Distress Severity |
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| <20 | Likely to be well; no feelings of distress |
| 20 - 24 | Likely experiencing mild distress; mild depression and/or anxiety disorder |
| 25 - 29 | Likely experiencing moderate distress; moderate depression and/or anxiety disorder |
| 30 - 50 | Likely experiencing severe distress; severe depression and/or anxiety disorder |
*Research has suggested that the optimal cut-point for a psychological disorder is 24.
Please remember that these screening instruments, or any of them, operate in isolation. Please take into account findings from other screening questionnaires, and use your clinical judgment and discussions with youth and their families to make the most appropriate decisions regarding assessment and interventions available at your specific YWHO site.
Video:
Clinical Screening Questionnaires
Global Appraisal of Individual Needs: Short Screener (GAIN-SSS)
