Form No number No number Testing NHIS Children's Mental Health Services Questions

Attachment 2 -- CHILDREN’S MENTAL HEALTH SERVICES QUESTIONNAIRE (Instrument to be cognitively tested)

OMB #0920-0222; Expiration Date: 02/28/10

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

CHILDREN’S MENTAL HEALTH SERVICES QUESTIONNAIRE

When you agreed to be a part of this study, we talked about your child who is [age] years old. These questions are about that child. Could you tell me this child’s first name?

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, OR CERTAINLY TRUE for (Child's name).

CMB.020_01.000

Is generally well behaved, usually does what adults request

___ Not true ____ Somewhat true ____ Certainly true

CMB.020_02.000

has many worries, or often seems worried

___ Not true ____ Somewhat true ____ Certainly true

CMB.020_03.000

is often unhappy, depressed or tearful

___ Not true ____ Somewhat true ____ Certainly true

CMB.020_04.000

gets along better with adults than with other (children/youth)

___ Not true ____ Somewhat true ____ Certainly true

CMB.020_05.000

has good attention span, sees chores or homework through to the end

___ Not true ____ Somewhat true ____ Certainly true

(Show Card 1)

CMB 030_00.000

Overall, do you think that (child's name) has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

No

Yes, minor difficulties

Yes, definite difficulties

Yes, severe difficulties

Note to interviewers

(All participants should answer yes to some degree to CMB 030, above. If the response is no, probe to confirm that the child has no difficulties with any of the domains mentioned above. If necessary, then probe to determine if the participant has another child between 4 and 17 years old who has any difficulties. If none, terminate interview.)

QUESTIONS TO BE TESTED

Do the difficulties interfere with or limit (child’s name) being able to get along in your family, in school, or in daily activities?

No

Yes, minor amount

Yes, definite amount

Yes, severe amount

Mental Health Services

1. During the past 6 months, did you talk with anyone or did anyone talk with you about (NAME’s) difficulties with emotions, concentration, behavior, or being able to get along with others?

A. Yes

B. No (IF “NO”, probe to explore whether the participant talked with anyone about this—including friends, doctors, teachers, spiritual advisors—even informally. We are especially interested in finding out if anyone answers “no” to this question but has “yes” responses to subsequent questions about receiving any services.)

C. Refused

D. Don’t know

Note to interviewers: one issue we are exploring is whether it is better to say “help or treatment” or “services” in some of the questions that follow. Please alternate the wording, randomly picking one or the other.

2. During the past 6 months, did (NAME) receive [help or treatment/services] for difficulties with emotions, concentration, behavior, or being able to get along with others from any of the following people? (READ EACH; CHECK ALL THAT APPLY).

A. Family and/or friends

B. School counselor, school psychologist, school nurse, school social worker, or school teacher

C. Mental health professional such as psychiatrist, psychologist, social worker, or psychiatric nurse

D. Pediatrician or other family doctor

E. Some other kind of practitioner or healer, for example, someone who uses acupuncture, massage, herbs, biofeedback, or chiropractic medicine

F. Religious or spiritual counselor

G. Any other (please specify_________________)

Do not read:

H. Refused

I. Don’t know

The next question is about places where children and adolescents live away from home in order to get [help or treatment/services] for difficulties with emotions, concentration, behavior, or being able to get along with others.

3. During the past 6 months, did (NAME) live away from home in a place to get [help or treatment/services] for difficulties with emotions, concentration, behavior, or being able to get along with others?

A. Yes. – Continue with 3.1

B. No

C. Refused

D. Don’t know

3.1. Did (NAME) live in a …(READ EACH, CHECK ALL THAT APPLY)

a. Hospital

b. Residential Treatment Center

c. Foster care home

d. Detention center or training school

e. Another type of special school

f. Any other (please specify________________________)

g. Refused

h. Don’t know

Now I’d like to ask about places where children and adolescents get help or treatment/alternate services while living at home.

4. During the past 6 months, where did (NAME) receive [help or treatment/services] for difficulties with emotions, concentration, behavior, or being able to get along with others? Was this… (READ EACH, CHECK ALL THAT APPLY).

A. At school (If yes, continue with 4.1)

4.1. Was this a special school?

a. Yes

b. No

c. Refused

d. Don’t know

(Probe for interpretations of “special school.”)

B. In your home, for example, from a visiting teacher or counselor

C In a hospital emergency room, crisis center, or emergency shelter

D. In a hospital day treatment program

E. In an office, clinic or center that specializes in mental health care

F. In an office clinic or center that offers general or other health care

G. In another kind of office, clinic or center

H. Over the internet, or in a self-help group

I. Any other place? (Please specify_______________________)

(Do not read)

J. Refused

K. Don’t know

5. During the past 6 months, was (NAME) either prescribed medication or taking prescription medication for difficulties with emotions, concentration, behavior, or being able to get along with others from any of these people?

A. Yes – (Continue with 5.1)

B. No

C. Refused

D. Don’t know

5.1. Who prescribed the medication? Was it a mental health professional, such as a psychiatrist, a pediatrician or other family doctor, or someone else? (ACCEPT MULTIPLE RESPONSES)

1. A mental health professional, such as a psychiatrist

2. A pediatrician or other family doctor

3. Or someone else (please specify__________________ )

4. Refused

5. Don’t know

Interviewer: If participant answered yes to any responses in Q2, read “additional” in the question below—otherwise, omit.

6. During the past 6 months, did you delay getting (additional) [help or treatment/services] for (NAME’s) difficulties with emotions, concentration, behavior, or being able to get along with others?

A. Yes—Continue with 6.1, below

B. No

C. Refused

D. Don’t know

6.1. Why? (CHECK ALL THAT APPLY) OPEN-ENDED, CODING BY INTERVIEWER

a. Concern about the cost

b. Lack of information about available help or treatment

c. Bad experiences with previous help or treatment/fear or

dislike of mental health providers

d. Fear of out of home placement or loss of parental rights

e. Shame, self-consciousness/fear of what others might think

f. Can’t get an appointment

g. Too difficult to get to the provider, e.g. too far away, don’t have

transportation]

h. Other, specify_______________________

i. Refused

j. Don’t know

IF PARTICIPANT REPORTED MORE THAN ONE PROVIDER/SETTING AT Q4, CONTINUE WITH Q7; ELSE, SKIP TO INTRO BEFORE Q8

You said that during the past 6 months, (NAME) received [help or treatment/services] from more than one person or place. There are agencies and people who help families and caregivers find and organize the help or treatment of children and adolescents with difficulties with emotions, concentration, behavior or being able to get along with others. These agencies and people may also work on service plans, act on your behalf, and provide supportive counseling.

7. During the past 6 months, did you or (NAME) receive this type of help/service from any individual or agency?

A. Yes—Continue with 7.1, below

B. No

C. Refused

D. Don’t know

7.1. Which agency or people provided this help? (CHECK ALL THAT APPLY) OPEN ENDED, CODING BY INTERVIEWER

a. Child welfare/social services/family and child services agency

b. School or educational system

c. Mental health agency

d. Private mental health professional

e. Public health agency

f. Juvenile justice agency or court system

g. Private insurance service

h. Family or friend

i. child’s pediatrician or general doctor

j. patient advocacy groups (like CHADD)

k Other, specify_____________________

l. Refused

k. Don’t know

IF PARTICIPANT REPORTED ANY PROVIDER/SETTING AT Q4, CONTINUE WITH Q8, OTHERWISE TERMINATE INTERVIEW

8. During the past 6 months, how did (NAME’s) [help or treatment/services] get paid for?

(READ EACH; CHECK ALL THAT APPLY).

A. Private health insurance

B. School system

C. Self or family (out of pocket or co-payment)

D. Medicaid or SCHIP (CHIP/Child Health Insurance Program)

E. Military health care (TRICARE/VA/CHAMP-VA), State sponsored health

plan, Medicare or other government program

F. Indian Health Service

If none, ask: Was the [help or treatment/services] free?

____ Yes

____ No—Who paid for the [help or treatment/services]?

Please specify_____________________

G. Refused

H. Don’t know

CARD 1

Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1. No

2. Yes, minor difficulties

3. Yes, definite difficulties

4. Yes, severe difficulties

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