Why use it

Pediatric delirium affects 10–30% of PICU patients and is associated with prolonged mechanical ventilation, longer ICU stay, increased mortality, and long-term cognitive and behavioral sequelae. Unlike adult delirium tools, CAPD requires no patient verbal participation and is validated for all developmental ages including infants and preverbal children. It can be completed in under 2 minutes and has demonstrated sensitivity of 94% and specificity of 79% for delirium at a cutpoint of ≥9.

About

The Cornell Assessment of Pediatric Delirium (CAPD) is a validated, observation-based delirium screening instrument designed for use in the pediatric intensive care unit (PICU) across the full developmental spectrum — from premature neonates to adolescents. Developed at Weill Cornell Medicine and validated in 2014, it was specifically designed to overcome the limitations of adult delirium tools (RASS, CAM-ICU) when applied to children who cannot verbally communicate. The CAPD consists of 8 behavioral observation items rated by nurses during routine care interactions, requiring no patient verbal participation. Four items assess behaviors that a non-delirious child would display (reverse-scored), and four assess behaviors associated with delirium that a non-delirious child would not display. A score ≥9 defines delirium.

When to use

Routine delirium screening for all PICU patients (recommended every 8–12 hours per shift)
Any child in ICU with altered mental status, unusual agitation, or behavioral changes
Post-cardiac surgery or post-sedation reassessment
Neonates and infants where adult-derived tools are invalid
Children receiving sedatives, analgesics, or corticosteroids — all major delirium risk factors
Research studies evaluating delirium incidence, risk factors, or interventions in pediatric populations

Formula

CAPD Score = Sum of 8 items (each 0–4 points) NEVER BEHAVIORS (reverse-scored; absence = delirium): Item 1: Eye contact with caregiver Item 2: Purposeful actions Item 3: Awareness of surroundings Item 4: Communicates needs/wants 4 = Never | 3 = Rarely | 2 = Sometimes | 1 = Often | 0 = Always ALWAYS BEHAVIORS (direct-scored; presence = delirium): Item 5: Restlessness Item 6: Inconsolability Item 7: Underactivity (hypoactive) Item 8: Slow response to interactions 0 = Never | 1 = Rarely | 2 = Sometimes | 3 = Often | 4 = Always Total range: 0–32 CAPD < 9: Delirium absent CAPD ≥ 9: Delirium present

Pearls & pitfalls

Items 1–4 are "NEVER behaviors" for a healthy child — score them INVERSELY: 4 = Never (worst, child never shows the behavior) to 0 = Always (best, child shows it always).
Items 5–8 are "ALWAYS behaviors" for a delirious child — score them DIRECTLY: 0 = Never (best) to 4 = Always (worst).
CAPD ≥ 9 achieves sensitivity 94%, specificity 79%, AUC 0.91 compared to gold-standard DMS-IV-TR criteria (Traube 2014).
CAPD is valid across all PICU age groups — from term newborns to adolescents — unlike PAED or CAM-ICU.
Hypoactive delirium (withdrawal, lethargy) is more common than hyperactive delirium in PICU and is frequently missed without structured screening.
CAPD captures hypoactive delirium through items 1–4 (absence of purposeful behaviors) — a critical advantage over the PAED scale.
Family engagement: Parents can help complete CAPD by reporting on their child's baseline behaviors, improving accuracy.
Sedation level should be recorded alongside CAPD: CAPD is valid at RASS −2 to +2 in adults; apply only when child is arousable to voice or touch.
Prevention strategies with strongest evidence: early mobility, family-centered care, minimal sedation, sleep promotion (ABCDEF bundle adapted for pediatrics).

Next steps

CAPD ≥ 9 (Delirium): Implement non-pharmacological interventions (sleep hygiene, family presence, minimize restraints, reorientation, normalize light/dark cycle). Evaluate and treat modifiable causes (pain, urinary retention, constipation, metabolic disturbance, medication). Consult pediatric psychiatry or neurology if refractory. Pharmacological management (quetiapine or haloperidol in refractory cases per institutional protocol). CAPD < 9: Continue regular monitoring (every 8–12 hours); reassess with any status change.

Evidence

Traube C et al. (Crit Care Med 2014) validated CAPD in 111 children ages 0–21 years in PICU. Sensitivity 94%, specificity 79%, AUC 0.91 at cutpoint ≥9 vs. DSM-IV-TR criteria. Interrater reliability ICC = 0.80. Smith HA et al. (Crit Care Med 2016) confirmed validity across developmental stages. Bettencourt A et al. (2020) demonstrated CAPD ≥9 associated with increased PICU LOS and adverse outcomes. Endorsed by SCCM and ESICM pediatric delirium working groups.

References

Traube C et al. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU. Crit Care Med. 2014;42(3):656-663. — link
Smith HA et al. Delirium: An emerging frontier in the management of critically ill children. Crit Care Clin. 2013;29(3):619-639. — link
Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse. 2017;37(3):e9-e18. — link

Cornell Assessment of Pediatric Delirium (CAPD)

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