Published by the Association of State and Territorial Health Officials (ASTHO), this document contains the most recent (2014) guidelines for the screening, referral, and treatment of Neonatal Abstinence Syndrome.
Type: Screening Tools and Protocols
T-ACE
T-ACE is a measurement tool with four questions that are significant identifiers of risk drinking (i.e., alcohol intake sufficient to potentially damage the embryo/fetus). The T-ACE is completed at intake. The T-ACE score has a range of 0-5. The value of each answer to the four questions is totaled to determine the final T-ACE score. Included on the Healthy Start National Evaluation Program Survey.
CAGE-AID
Commonly used, 5-question tool that screens for drug and alcohol use/abuse. The CAGE-AID Assessment is a quick questionnaire to help determine if further assessment is needed. If a person answers yes to two or more questions, a complete assessment is advised. Included on the Healthy Start National Evaluation Program Survey.
AUDIT (Alcohol Use Disorders Identification Test)
10-item questionnaire that screens for hazardous or harmful alcohol consumption. Developed by the World Health Organization (WHO), it correctly classifies 95% of people into either alcoholics or non-alcoholics. The AUDIT has been used with a variety of populations and cultural groups. It should be administered by a health professional or paraprofessional. Included on the Healthy Start National Evaluation Program Survey.
Patient Health Questionnaire-9 (PHQ-9)
Nine item questionnaire for patients to measure depressive symptoms over the past two weeks. Questions are linked to the DSM-IV depression criteria, and therefore scores can be used to track changes in depression as a response to treatment. Included on the Healthy Start National Evaluation Program Survey
Patient Health Questionnaire-2 (PHQ-2)
Two question screening tool to measure the frequency of depressed mood and anhedonia over the past two weeks. Includes the first two questions from the PHQ-9. Included on the Healthy Start National Evaluation Program Survey.
Montgomery-Åsberg Depression Rating Scale (MADRS)
A ten-item diagnostic questionnaire used with patients with mood disorders to measure severity of depressive episodes.
Hamilton Depression Rating Scale (HAM-D)
One of the oldest and most frequently used screening questionnaires to measure the severity of and change in depressive symptoms among adults in an inpatient setting.
Center for Epidemiologic Studies Depression Scale Revised CESD-R
The CESD-R is a screening test for depression and depressive disorder. The CESD-R measures symptoms defined by the American Psychiatric Association’ Diagnostic and Statistical Manual (DSM-V) for a major depressive episode. The scale is well known and remains as one of the most widely used instruments in the field.
BDI-FastScreen
The BDI-FastScreen is a 7-item self-reporting instrument used to quickly screen for depression in adolescents and adults. The screen can identify depression while excluding symptoms that might be related to medical problems, and was specifically designed for evaluating depression in patients whose behavioral and somatic symptoms attributable to biological, medical, alcohol and/or substance abuse problems may confound diagnosis.