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. DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17 Child’s Name: _________________________________ Age: ____ Sex:  Male  Female Date:___________ 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. During the past TWO (2) WEEKS, how much (or how often) has your child… None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) I. 1. Complained of stomachaches, headaches, or other aches and pains? 0 1 2 3 4 2. Said he/she was worried about his/her health or about getting sick? 0 1 2 3 4 II. 3. Had problems sleeping—that is, trouble falling asleep, staying asleep, or waking up too early? 0 1 2 3 4 III. 4. Had problems paying attention when he/she was in class or doing his/her homework or reading a book or playing a game? 0 1 2 3 4 IV. 5. Had less fun doing things than he/she used to? 0 1 2 3 4 6. Seemed sad or depressed for several hours? 0 1 2 3 4 V. & VI. 7. Seemed more irritated or easily annoyed than usual? 0 1 2 3 4 8. Seemed angry or lost his/her temper? 0 1 2 3 4 VII. 9. Started lots more projects than usual or did more risky things than usual? 0 1 2 3 4 10. Slept less than usual for him/her, but still had lots of energy? 0 1 2 3 4 VIII. 11. Said he/she felt nervous, anxious, or scared? 0 1 2 3 4 12. Not been able to stop worrying? 0 1 2 3 4 13. Said he/she couldn’t do things he/she wanted to or should have done, because they made him/her feel nervous? 0 1 2 3 4 IX. 14. Said that he/she heard voices—when there was no one there—speaking about him/her or telling him/her what to do or saying bad things to him/her? 0 1 2 3 4 15. Said that he/she had a vision when he/she was completely awake—that is, saw something or someone that no one else could see? 0 1 2 3 4 X. 16. Said that he/she had thoughts that kept coming into his/her mind that he/she would do something bad or that something bad would happen to him/her or to someone else? 0 1 2 3 4 17. Said he/she felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off? 0 1 2 3 4 18. Seemed to worry a lot about things he/she touched being dirty or having germs or being poisoned? 0 1 2 3 4 19. Said that he/she had to do things in a certain way, like counting or saying .

1. 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.
DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom
Measure—Child Age 6–17
Child’s Name: _________________________________ Age:
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.
During the past TWO (2) WEEKS, how much (or how often) has
your child…
None
Not at
all
Slight

2. Rare, less
than a day
or two
Mild
Several
days
Moderate
More than
half the
days
Severe
Nearly
every
day
Highest
Domain
Score
(clinician)
I. 1. Complained of stomachaches, headaches, or other aches
and pains? 0 1 2 3 4
2. Said he/she was worried about his/her health or about getting
sick? 0 1 2 3 4
II.
3.

3. Had problems sleeping—that is, trouble falling asleep, staying
asleep, or
waking up too early?
0 1 2 3 4
III.
4.
Had problems paying attention when he/she was in class or
doing his/her
homework or reading a book or playing a game?
0 1 2 3 4
IV. 5. Had less fun doing things than he/she used to? 0 1 2 3 4
6. Seemed sad or depressed for several hours? 0 1 2 3 4
V. &
VI.
7. Seemed more irritated or easily annoyed than usual? 0 1 2 3 4
8. Seemed angry or lost his/her temper? 0 1 2 3 4
VII. 9. Started lots more projects than usual or did more risky
things than usual? 0 1 2 3 4
10. Slept less than usual for him/her, but still had lots of
energy? 0 1 2 3 4
VIII. 11. Said he/she felt nervous, anxious, or scared? 0 1 2 3 4
12. Not been able to stop worrying? 0 1 2 3 4

4. 13.
Said he/she couldn’t do things he/she wanted to or should have
done,
because they made him/her feel nervous?
0 1 2 3 4
IX.
14.
Said that he/she heard voices—when there was no one there—
speaking
about him/her or telling him/her what to do or saying bad things
to him/her?
0 1 2 3 4
15.
Said that he/she had a vision when he/she was completely
awake—that is,
saw something or someone that no one else could see?
0 1 2 3 4
X.
16.
Said that he/she had thoughts that kept coming into his/her mind
that he/she
would do something bad or that something bad would happen to
him/her or
to someone else?
0 1 2 3 4

5. 17.
Said he/she felt the need to check on certain things over and
over again, like
whether a door was locked or whether the stove was turned off?
0 1 2 3 4
18.
Seemed to worry a lot about things he/she touched being dirty
or having
germs or being poisoned?
0 1 2 3 4
19.
Said that he/she had to do things in a certain way, like counting
or saying
special things out loud, in order to keep something bad from
happening?
0 1 2 3 4
In the past TWO (2) WEEKS, has your child …
21. Smoked a cigarette, a cigar, or pipe, or used snuff or
22.
Used drugs like marijuana, cocaine or crack, club drugs (like
ecstasy),
hallucinogens (like LSD), heroin, inhalants or solvents (like
glue), or
methamphetamine (like speed)?

6. Don’t Know
23.
Used any medicine without a doctor’s prescription (e.g.,
painkillers [like
Vicodin], stimulants [like Ritalin or Adderall], sedatives or
tranquilizers [like
sleeping pills or Valium], or steroids)?
XII.
24.
In the past TWO (2) WEEKS, has he/she talked about wanting
to kill
himself/herself or about wanting to commit suicide?
Johnny
MOTHER
9 X
O
O
O
O
O

7. O
O
O
O
O
O
O
O
O
O
O
O
O
O
X
X
X
X
X
X
Case Study: Johnny

8. 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/Guardian-Rated 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

9. 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 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.
© 2015. Grand Canyon University. All Rights Reserved.