Survey of Pathways to Diagnosis and Services mail questi

Attachment 3: SPDS mail questionnaire

According to the Paperwork Reduction Act (PRA) of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0920-0406. The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments about the accuracy of the time estimate(s) or suggestions for improving this form please write to: CDC Reports Clearance Officer, 1600 Clifton Road, MS-D74, Atlanta, GA 30333; call 404-639-4794; or send an email to omb@cdc.gov.

Form approved

Data collection conducted under contract to the CDC by NORC at the University of Chicago. OMB No. 0920-0406

Exp. Date 04/30/11

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Part A (for ages 6-10 years). For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please base your answers on your child's behavior over the last 6 months.

	Not True	Somewhat True	Certainly true
Considerate of other people's feelings			
Restless, overactive, cannot stay still for long			
Often complains of headaches, stomach-aches or sickness			
Shares readily with other children, for example toys, treats, pencils			
Often loses temper			
Rather solitary, prefers to play alone			
Generally well behaved, usually does what adults request			
Many worries or often seems worried			
Helpful if someone is hurt, upset or feeling ill			
Constantly fidgeting or squirming			
Has at least one good friend			
Often fights with other children or bullies them			
Often unhappy, depressed or tearful			
Generally liked by other children			
Easily distracted, concentration wanders			
Nervous or clingy in new situations, easily loses confidence			
Kind to younger children			
Often lies or cheats			
Picked on or bullied by other children			
Often offers to help others (parents, teachers, other children)			
Thinks things out before acting			
Steals from home, school or elsewhere			
Gets along better with adults than with other children			
Many fears, easily scared			
Good attention span, sees chores or homework through to the end			

Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behavior or being able to get on with other people?	No	Yes- minor difficulties	Yes- definite difficulties	Yes- severe difficulties
				

27. If you answered “Yes” to question 26, please answer the following questions about these difficulties. If you answered “No” to question 26, please skip to Part B of this questionnaire.

How long have these difficulties been present?	Less than a month	1-5 months	6-12 months	Over a year
				
Do the difficulties upset or distress your child?	Not at all	Only a little	Quite a lot	A great deal
				
Do the difficulties interfere with your child’s everyday life in the following areas?
	Not at all	Only a little	Quite a lot	A great deal
HOME LIFE				
FRIENDSHIPS				
CLASSROOM LEARNING				
LEASURE ACTIVITIES				
Do the difficulties put a burden on you or the family as a whole?	Not at all	Only a little	Quite a lot	A great deal
				

Items in Part A are from the Strengths and Difficulties Questionnaire (© Robert Goodman, 2005)

Part A (for ages 11-17 years). For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please base your answers on your child's behavior over the last 6 months.

	Not True	Somewhat True	Certainly true
Considerate of other people's feelings			
Restless, overactive, cannot stay still for long			
Often complains of headaches, stomach-aches or sickness			
Shares readily with other youth, for example CD’s, games, food			
Often loses temper			
Would rather be alone than with other youth			
Generally well behaved, usually does what adults request			
Many worries or often seems worried			
Helpful if someone is hurt, upset or feeling ill			
Constantly fidgeting or squirming			
Has at least one good friend			
Often fights with other youth or bullies them			
Often unhappy, depressed or tearful			
Generally liked by other youth			
Easily distracted, concentration wanders			
Nervous or clingy in new situations, easily loses confidence			
Kind to younger youth			
Often lies or cheats			
Picked on or bullied by other youth			
Often offers to help others (parents, teachers, other youth)			
Thinks things out before acting			
Steals from home, school or elsewhere			
Gets along better with adults than with other youth			
Many fears, easily scared			
Good attention span, sees chores or homework through to the end			

Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behavior or being able to get on with other people?	No	Yes- minor difficulties	Yes- definite difficulties	Yes- severe difficulties
				

26. If you answered “Yes” to question 26, please answer the following questions about these difficulties. If you answered “No” to question 26, please skip to Part B of this questionnaire.

How long have these difficulties been present?	Less than a month	1-5 months	6-12 months	Over a year
				
Do the difficulties upset or distress your child?	Not at all	Only a little	Quite a lot	A great deal
				
Do the difficulties interfere with your child’s everyday life in the following areas?
	Not at all	Only a little	Quite a lot	A great deal
HOME LIFE				
FRIENDSHIPS				
CLASSROOM LEARNING				
LEASURE ACTIVITIES				
Do the difficulties put a burden on you or the family as a whole?	Not at all	Only a little	Quite a lot	A great deal
				

Items in Part A are from the Strengths and Difficulties Questionnaire (© Robert Goodman, 2005)

Part B. On the following pages you will find another list of descriptions of children's behavior. Please indicate the extent to which the description applies to your child during the last two months.

• Please mark “clearly or often applies” if the description clearly applies to your child and/or if the behavior occurs regularly.

• Please mark “sometimes or somewhat applies” if the description applies to your child only slightly and/or if the behavior occurs infrequently.

• Please mark “does not apply” if the description does not apply to your child and/or the behavior does not occur.

Please fill in the questionnaire as you see your child, even if this view is not shared by others. Although you may be uncertain whether some behaviors apply to your child, please try to answer every question.

	Clearly or often applies	Sometimes or somewhat applies	Does not apply
Talks confusedly; jumps from one subject to another in speaking			
Only talks about things that are of concern for himself/herself			
Does not fully understand what is being said to him/her, i.e., tends to miss the point			
Frequently says things that are not relevant to the conversation			
Does not understand jokes			
Takes things literally, e.g., does not understand certain expressions			
Is exceptionally naive; believes anything you say			
Over-reacts to everything and everyone			
Draws excessive attention to him/herself			
Flaps arms/hands when excited			
Makes odd, fast movements with fingers or hands			
Sways to and fro			
Does not look up when spoken to			
Acts as if others are not there			
Lives in a world of his/her own			
Makes little eye contact			
Dislikes physical contact, e.g., does not want to be touched or hugged			
Does not seek comfort when he/she is hurt or upset			
Does not initiate play with other children			
Has little or no need for contact with others			
Does not respond to initiatives by others, e.g., does not play along when asked			
Is unusually sensitive to certain sounds, e.g., always hears certain sounds earlier than other people			
Is extremely pleased by certain movements and keeps doing them, e.g., turning around and around			
Smells objects			
Constantly feels objects			
Is fascinated by certain colors, forms, or moving objects			
Has difficulties doing two things simultaneously, e.g., he/she cannot dress and listen to parent at the same time			
Does things without realizing what stage of the activity he/she has reached (beginning, middle, ending)			
Does things without realizing the aim, e.g., constantly has to be reminded to finish things			
Shows sudden changes of mood			
Quickly gets angry			
Stays angry for a long time, e.g., when he/she does not get his/her way			
Cannot be made enthusiastic about anything; does not particularly like anything			
Does not show his/her feelings in facial expressions and/or bodily posture			
Does not appreciate danger			
Barely distinguishes between strangers and familiar people, e.g., readily goes with strangers			
Is disobedient			
Cannot be corrected in situations in which he/she has done something wrong			
Takes in information with difficulty			
Makes inconsiderate remarks, e.g., remarks that are painful to others			
Does not appreciate it when someone else is hurt or sad			
Makes a fuss over little things; “makes a mountain of a mole-hill”			
Does not know when to stop, e.g., goes on and on about things			
Is extremely stubborn			
Panics in new situations or if change occurs			
Remains clammed up in new situations or if change occurs			
Opposes change			
Gets lost easily, e.g., when out with someone			
Has no sense of time			

Items in Part B are from the Children’s Social Behavior Questionnaire (© University of Groningen, 2001)

Part C. Many of the previous questions have been about difficulties and problems. Now we want to ask about strengths and other good things. Each child has their own unique qualities and talents. Please rate your child on each of the skills below. Answer each question by circling a number from 1 through 5 (1 meaning skill is less of a strength and 5 meaning skill is more of a strength).

	Less of a Strength (1)	(2)	Somewhat A Strength (3)	(4)	More of a Strength (5)
Has an eye for detail	1	2	3	4	5
Is able to learn things easily	1	2	3	4	5
Has good computer skills	1	2	3	4	5
Has good math skills	1	2	3	4	5
Has good music skills	1	2	3	4	5
Has good artistic skills	1	2	3	4	5
Compliments family members when they accomplish something	1	2	3	4	5
Gets along with family members	1	2	3	4	5
Gets along with peers and friends of similar age	1	2	3	4	5
Speaks in a nice tone of voice when talking with others	1	2	3	4	5
Takes good care of things so they last	1	2	3	4	5
Uses free time at home in a good way	1	2	3	4	5
Is able to relax and enjoy life	1	2	3	4	5
Finishes the tasks [he/she] starts	1	2	3	4	5
Is good at physical activities like sports or exercising	1	2	3	4	5
Shows interest and curiosity in learning new things	1	2	3	4	5
Cares about doing well in school	1	2	3	4	5
Does all required homework	1	2	3	4	5
Displays appropriate emotions in most social settings	1	2	3	4	5
Is happy with who [he/she] is	1	2	3	4	5

What is your relationship to this child?	Mother	Father	Other
			

Thank you very much for your help!