Form 14 Child Mental Health--Line 14

Attachment 3j Child Mental Health (2 minutes)
Page 1 of 4

2010 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 24-Jul-09
Question ID:

CMB.010_00.000 Instrument Variable Name:

CMHCOPY

QuestionnaireFileName:

Sample Child

* The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.

QuestionText:

* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as indicated
below.
* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies may
use these questions without charge and without seeking separate permission provided the wording is not modified, all the
questions are retained, and Dr. Goodman's copyright is acknowledged.
* Enter 1 to Continue.
Enter 1 to continue

1
UniverseText:

Sample children GE 4

SkipInstructions:

<1> [goto CMHMF_1]

___________________________________________________________________________________________________________________________
Question ID:

CMB.020_01.000 Instrument Variable Name:

QuestionText:

CMHMF_1

QuestionnaireFileName:

Sample Child

(book) C7
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 [fill1: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is generally well behaved, usually does what adults request.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

<1-3,R,D> [goto CMHMF_2]

Page 2 of 4

2010 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 24-Jul-09
Question ID:

CMB.020_02.000 Instrument Variable Name:

CMHMF_2

QuestionnaireFileName:

Sample Child

(book) C7

QuestionText:

* Read if necessary.
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 [fill1: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...has many worries, or often seems worried.
Not true
Somewhat true
Certainly true
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample children GE 4

SkipInstructions:

<1-3,R,D> [goto CMHMF_3]

_________________________________________________________________________________________________________________________
Question ID:

CMB.020_03.000 Instrument Variable Name:

QuestionText:

CMHMF_3

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
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 [fill1: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is often unhappy, depressed, or tearful.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

<1-3,R,D> [goto CMHMF_4]

Page 3 of 4

2010 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 24-Jul-09
Question ID:

CMB.020_04.000 Instrument Variable Name:

CMHMF_4

QuestionnaireFileName:

Sample Child

(book) C7

QuestionText:

* Read if necessary.
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 [fill1: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...gets along better with adults than with other [fill3: children/youth].
Not true
Somewhat true
Certainly true
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample children GE 4

SkipInstructions:

<1-3,D,R> [goto CMHMF_5]

________________________________________________________________________________________________________________________
Question ID:

CMB.020_05.000 Instrument Variable Name:

QuestionText:

CMHMF_5

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
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 [fill1: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...has good attention span, sees chores or homework through to the end.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

<1-3,R,D> [goto CMHDIFF]

Page 4 of 4

2010 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 24-Jul-09
Question ID:

CMB.030_00.000 Instrument Variable Name:

QuestionText:

CMHDIFF

QuestionnaireFileName:

Sample Child

(book) C8
Overall, do you think that [fill1: SC name] has difficulties in any of the following areas: emotions, concentration, behavior,
or being able to get along with other people?

1
2
3
4
7
9

No
Yes, minor difficulties
Yes, definite difficulties
Yes, severe difficulties
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

<1-4,R,D> [goto SEEDIFF]

Page 1 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.001_00.000 Instrument Variable Name:

QuestionText:

DIFF6M

QuestionnaireFileName:

Sample Child

Has [fill: SC name] had any of these difficulties DURING THE PAST 6 MONTHS, that is since [fill month and year of 6
month reference period]?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17

SkipInstructions:

<1> [goto DIFFINTF] <2,R,D> [goto PRESCP6M]

Question ID:

24-Jul-09

CMS.005_00.000 Instrument Variable Name:

QuestionText:

DIFFINTF

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did the difficulties interfere with or limit [fill1: SC name] being able to get along in
your family, in school, or in daily activities?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who have at least minor difficulties with emotions, concentration, behavior, or being able to
get along with others

SkipInstructions:

<1> [goto DIFFDEG] <2,R,D> [goto PRESCP6M]

Question ID:

CMS.007_00.000 Instrument Variable Name:

QuestionText:

DIFFDEG

QuestionnaireFileName:

Sample Child

How much did these difficulties interfere with [fill: S.C. name] being able to get along in your family, in school, or in
daily activities? Would you say...
*Read categories below.

1
2
3
4
7
9

A lot
Some
A little
None
Refused
Don't know

UniverseText:

Sample children 4-17 whose difficulties interfere with child being able to get along in the family, school, or daily
activities

SkipInstructions:

<1-4,R,D> [goto PRESCP6M]

Page 2 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.010_00.000 Instrument Variable Name:

QuestionText:

24-Jul-09

PRESCP6M

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, was [fill1: S.C. name] prescribed medication or taking prescription medication for
difficulties with emotions, concentrations, behavior, or being able to get along with others?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17

SkipInstructions:

<1> [goto PMEDPED] <2,R,D> if CMHDIFF=1 and DIFF6M=2 then [goto next section]; else [goto NSDUH1]

Question ID:

CMS.012_01.000 Instrument Variable Name:

QuestionText:

PMEDPED

QuestionnaireFileName:

Sample Child

Who FIRST prescribed the medication? Was it
...A pediatrician or other family doctor?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who have been prescribed or have taken prescription medication in the past 6 months

SkipInstructions:

<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]; <2,R,D> [goto
PMEDPSY]

Question ID:

CMS.012_02.000 Instrument Variable Name:

QuestionText:

PMEDPSY

QuestionnaireFileName:

Sample Child

*Read if necessary.
Who FIRST prescribed the medication? Was it
...A psychiatrist, psychologist or other mental health professional?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician
or other family doctor

SkipInstructions:

<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]; <2,R,D> [goto
PMEDOTH]

Page 3 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.012_03.000 Instrument Variable Name:

QuestionText:

24-Jul-09

PMEDOTH

QuestionnaireFileName:

Sample Child

*Read if necessary.
Who FIRST prescribed the medication? Was it
...Someone else?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician,
family doctor, or mental health professional

SkipInstructions:

<1> [goto PMEDSP]; <2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto
NSDUH1]

Question ID:

CMS.012_04.000 Instrument Variable Name:

QuestionText:

PMEDSP

QuestionnaireFileName:

Sample Child

*Enter the person who prescribed the medication.

7

Refused
Don't know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician,
family doctor, or mental health professional

SkipInstructions:

if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]

Question ID:

CMS.013_00.000 Instrument Variable Name:

QuestionText:

1

NSDUH1

QuestionnaireFileName:

Sample Child

Sometimes students get treatment or counseling through the school system for DIFFICULTIES WITH emotions,
concentration, behavior, or being able to get along with others. This counseling is often provided by school social
workers, school psychologists, school nurse, school counselors, or school speech, occupational or physical therapists.
Continue

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto NSDUH2]

Page 4 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.014_00.000 Instrument Variable Name:

QuestionText:

NSDUH2

24-Jul-09
QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill: S.C. name] receive any treatment or counseling FROM A SCHOOL
SOCIAL WORKER, PSYCHOLOGIST, NURSE, COUNSELOR, OR SPEECH, OCCUPATIONAL OR PHYSICAL
THERAPIST?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<12,R,D> [goto NSDUH3]

Question ID:

CMS.015_00.000 Instrument Variable Name:

QuestionText:

NSDUH3

QuestionnaireFileName:

At any time DURING THE PAST 6 MONTHS did [fill1: S.C. name] attend a school for students with difficulties with
emotions, concentration, behavior, or being able to get along with others?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who did not receive treatment from a school representative

SkipInstructions:

<1,2,R,D> [goto NSDUH4]

Question ID:

Sample Child

CMS.016_00.000 Instrument Variable Name:

QuestionText:

NSDUH4

QuestionnaireFileName:

Sample Child

Regular schools sometimes provide programs for students with difficulties with emotions, concentration, behavior, or
being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] participate in a school program that was just for students with
these kinds of difficulties?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who did not receive treatment from a school representative

SkipInstructions:

<1> [goto NSDUH5] <2,R,D> if age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]

Page 5 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.017_00.000 Instrument Variable Name:

QuestionText:

24-Jul-09

NSDUH5

QuestionnaireFileName:

Sample Child

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

1

School teacher
Special Ed teacher
School counselor, psychologists, nurse or social worker
School speech, occupational or physical therapist
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample children 4-17 who participated in a special school program for these difficulties

SkipInstructions:

<1-4,R,D> age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]

Question ID:

CMS.020_01.000 Instrument Variable Name:

QuestionText:

TRETWHR1

QuestionnaireFileName:

Sample Child

Now I’d like to ask about places where children and adolescents receive treatment or counseling for difficulties with
emotions, concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At daycare, child care, or play group?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-6 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO1] <2,R,D> [goto TRETWHR2]

Page 6 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.020_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO1

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other
Refused
Don’t know

02
03
04
05
06
07
08
97
99
UniverseText:

Sample children 4-6 who received counseling at daycare, child care, or play group

SkipInstructions:

<1-7,R,D> [goto TRETWHR2] <8> [goto TRTWHRS1]

Question ID:

CMS.020_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS1

QuestionnaireFileName:

*Specify the other source of treatment or counseling at daycare, child care, or play group.

97

Refused
Don't know
verbatim

99
verbatim
UniverseText:

Sample children 4-6 who received counseling or treatment from other source

SkipInstructions:

[goto TRETWHR2]

Question ID:

Sample Child

CMS.021_01.000 Instrument Variable Name:

QuestionText:

TRETWHR2

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In an office, clinic or center in your community?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO2] <2,R,D> [goto TRETWHR3]

Page 7 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.021_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO2

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other

02
03
04
05
06
07
08
UniverseText:

Sample children 4-17 who received counseling at an office, clinic or community center

SkipInstructions:

<1-7,R,D> [goto TRETWHR3] <8> [goto TRTWHRS2]

Question ID:

CMS.021_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS2

QuestionnaireFileName:

*Specify the other source of treatment or counseling provided at an office, clinic of community center.

97

Refused
Don't know
verbatim

99
verbatim
UniverseText:

Sample children 4-17 who received counseling or treatment from other source

SkipInstructions:

[goto TRETWHR3]

Question ID:

Sample Child

CMS.022_01.000 Instrument Variable Name:

QuestionText:

TRETWHR3

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In your home, for example, from a visiting teacher or counselor?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO3] <2,R,D> [goto TRETWHR4]

Page 8 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.022_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO3

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other

02
03
04
05
06
07
08
UniverseText:

Sample children 4-17 who received counseling at home from visiting teacher or counselor

SkipInstructions:

<1-7,R,D> [goto TRETWHR4] <8> [goto TRTWHRS3]

Question ID:

CMS.022_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS3

QuestionnaireFileName:

*Specify the other source of treatment or counseling provided in the home.

7

Refused
Don't know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who received counseling or treatment from other source

SkipInstructions:

[goto TRETWHR4]

Question ID:

Sample Child

CMS.023_01.000 Instrument Variable Name:

QuestionText:

TRETWHR4

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In a hospital emergency room, crisis center, or emergency shelter?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO4] <2,R,D> [goto TRETWHR5]

Page 9 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.023_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO4

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other

02
03
04
05
06
07
08
UniverseText:

Sample children 4-17 who received counseling at hospital/ER/crisis center/shelter

SkipInstructions:

<1-7,R,D> [goto TRETWHR5] <8> [goto TRTWHRS4]

Question ID:

CMS.023_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS4

QuestionnaireFileName:

*Specify the other source of treatment or counseling provided in in hospital/ER/shelter.

7

Refused
Don't know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who received counseling or treatment from other source

SkipInstructions:

[goto TRETWHR5]

Question ID:

Sample Child

CMS.024_01.000 Instrument Variable Name:

QuestionText:

TRETWHR5

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At a day treatment program in a hospital or community?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO5] <2,R,D> [goto TRETWHR6]

Page 10 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.024_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO5

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other

02
03
04
05
06
07
08
UniverseText:

Sample children 4-17 who received counseling at day treatment program in a hospital or community

SkipInstructions:

<1-7,R,D> [goto TRETWHR6] <8> [goto TRTWHRS5]

Question ID:

CMS.024_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS5

QuestionnaireFileName:

*Specify the other source of treatment or counseling provided at day treatment program.

7

Refused
Don't know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who received counseling or treatment from other source

SkipInstructions:

[goto TRETWHR6]

Question ID:

Sample Child

CMS.025_01.000 Instrument Variable Name:

QuestionText:

TRETWHR6

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
Any other place?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO6] <2,R,D> [goto OVERNT6M]

Page 11 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.025_02.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETWHO6

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

01

School counselor, school nurse or school social worker
Speech, occupational or physical therapist
Psychiatrist, psychologist, social worker, psychiatric nurse
Pediatrician or family doctor
Acupuncturist, massage therapist, chiropractor
Religious or spiritual counselor
Probation or juvenile corrections officer or court counselor
Other

02
03
04
05
06
07
08
UniverseText:

Sample children 4-17 who received counseling at another place

SkipInstructions:

<1-7,R,D> [goto OVERNT6M] <8> [goto TRTWHRS6]

Question ID:

CMS.025_03.000 Instrument Variable Name:

QuestionText:

TRTWHRS6

*Specify the other source of treatment or counseling provided at other place.

7

Refused
Don't know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who received counseling or treatment from other source

SkipInstructions:

[goto OVERNT6M]

Question ID:

CMS.050_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

OVERNT6M

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill: S.C. name] stay overnight or longer in a hospital, any type of group home,
anytype of juvenile detention center, sometimes called juvie, or juvenile hall, youth prisons, training school or jail, foster
care home, or another special type of school to receive counseling or treatment for these difficulties?
Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have have at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto OVERWHCH] <2,R,D> [goto SH1]

Page 12 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.060_00.000 Instrument Variable Name:

QuestionText:

24-Jul-09

OVERWHCH

QuestionnaireFileName:

Sample Child

Which one?
*Read list if necessary.
*Enter all that apply, separate with commas.

1

Hospital
Residential treatment center
Foster care or therapeutic foster care home
In any type of juvenile detention center, sometimes called "juvie", prison or jail
In another place
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample children 4-17 who stayed overnight in a hospital or other overnight location for difficulties

SkipInstructions:

<1-5,R,D> [goto SH1]

Question ID:

CMS.070_00.000 Instrument Variable Name:

QuestionText:

SH1

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] take part in a self-help group for children and youth with these
difficulties?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto SH2]

Question ID:

CMS.080_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

SH2

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] use the Internet to seek treatment or counseling for these
difficulties?
Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto CASEM6M]

Page 13 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.100_00.000 Instrument Variable Name:

QuestionText:

24-Jul-09

CASEM6M

QuestionnaireFileName:

Sample Child

Parents and caregivers sometimes get help from people sometimes called case managers or care coordinators who help to
find or organize treatment for children's difficulties with emotions, etc.
*Read if necessary: This type of help is sometimes called care coordination or case management. People or agencies that
do this work might also help you develop a service plan, contact providers for you, and provide support to you in getting
the help your child or adolescent needs.
DURING THE PAST 6 MONTHS, did you or [fill1: S.C. name] receive this type of help from any individual or agency?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto CASEMWHO] <2,R,D> [goto TRPAYPHI]

Question ID:

CMS.110_00.000 Instrument Variable Name:

QuestionText:

CASEMWHO

QuestionnaireFileName:

Sample Child

Who provides help arranging or coordinating [fill1: S.C. name] care?
*Enter the MAIN answer.

01
02
03
04
05
06
07
08
09
10
97
99

Child welfare/social services/family and child services agency
School or educational system
Mental health agency
Private mental health professional
Juvenile justice agency or court system
Private insurance service
Family or friend
Pediatrician or other family doctor
Family or youth advocacy groups
Other
Refused
Don’t know

UniverseText:

Sample children 4-17 who received help from case managers/care coordinators in the past 6 months

SkipInstructions:

<1-10,R,D> [goto TRPAYPHI]

Page 14 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_01.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRPAYPHI

QuestionnaireFileName:

Sample Child

I'm going to read a list of ways that treatment and counseling get paid for. Please tell me who pays for [fill1: S.C. name]
treatment or counseling.
Private health insurance, such as insurance that comes with a job?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSCH]

Question ID:

CMS.120_02.000 Instrument Variable Name:

QuestionText:

TRPAYSCH

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
School system?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSLF]

Question ID:

CMS.120_03.000 Instrument Variable Name:

QuestionText:

TRPAYSLF

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
You or your family (sometimes called out of pocket or co-payment)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYMED]

Page 15 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_04.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRPAYMED

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
[fill2: fill with name of state Medicaid program]?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYCHP]

Question ID:

CMS.120_05.000 Instrument Variable Name:

QuestionText:

TRPAYCHP

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
[fill2: fill with name of state SCHIP/CHIP program]?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYMIL]

Question ID:

CMS.120_06.000 Instrument Variable Name:

QuestionText:

TRPAYMIL

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
Military health care?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSHP]

Page 16 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_07.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRPAYSHP

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
Some other state or county sponsored health plan, Medicare or other government program?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto TRPAYSP] <2,R,D> [goto TRPAYIHS]

Question ID:

CMS.120_08.000 Instrument Variable Name:

QuestionText:

TRPAYSP

QuestionnaireFileName:

*Enter the name of the state sponsored health plan, Medicare, or other government program.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who paid for treatment with a state sponsored health plan, etc.

SkipInstructions:

[goto TRPAYIHS]

Question ID:

Sample Child

CMS.120_09.000 Instrument Variable Name:

QuestionText:

TRPAYIHS

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
Indian Health Service?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYOTH]

Page 17 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_10.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRPAYOTH

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays for [fill1: S.C. name] treatment or counseling.
Some other source?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto TRPAYOTS]; <2,R,D> if TRPAYPHI=2,R,D and TRPAYSCH-=2,R,D and
TRPAYSLF=2,R,D and TRPAYMED=2,R,D and TRPAYCHP=2,R,D and
TRPAYMIL=2,R,D and TRPAYSHP=2,R,D and TRPAYIHS=2,R,D and
TRPAYOTH=2,R,D [goto TRETFREE]; else [goto TRETNEED]

Question ID:

CMS.120_11.000 Instrument Variable Name:

QuestionText:

TRPAYOTS

QuestionnaireFileName:

*Enter the name of the other source.

7

Refused
Don’t know
verbatim

9
verbatim
UniverseText:

Sample children 4-17 who paid for treatment with some other source

SkipInstructions:

[goto TRETNEED]

Question ID:

Sample Child

CMS.120_12.000 Instrument Variable Name:

QuestionText:
1
2
7
9

TRETFREE

QuestionnaireFileName:

Was ALL OF THE treatment or counseling [fill1: S.C. name] RECEIVED free?
Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who did not pay for treatment

SkipInstructions:

<1,2,R,D> [goto TRETNEED]

Sample Child

Page 18 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_00.000 Instrument Variable Name:

QuestionText:

24-Jul-09

TRETNEED

QuestionnaireFileName:

Sample Child

I'm going to read a statement. Tell me if it is NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE. DURING THE
PAST 6 MONTHS, has [fill1: S.C. name] needed treatment or counseling for difficulties with emotions, concentration,
behavior or being able to get along WITH OTHERS but didn't get it?

1

Not true
Somewhat true
Certainly true
Refused
Don't know

2
3
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto NTRTCOST] <2,R,D> [goto next section]

Question ID:

CMS.150_01.000 Instrument Variable Name:

QuestionText:

NTRTCOST

QuestionnaireFileName:

Sample Child

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Help was too expensive?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTLOC]

Question ID:

CMS.150_02.000 Instrument Variable Name:

QuestionText:

NTRTLOC

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You didn't know where to go?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTNEXP]

Page 19 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_03.000 Instrument Variable Name:

QuestionText:

24-Jul-09

NTRTNEXP

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had a negative experience with professionals?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTFEAR]

Question ID:

CMS.150_04.000 Instrument Variable Name:

QuestionText:

NTRTFEAR

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You are afraid or don't like professionals?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTLOSE]

Question ID:

CMS.150_05.000 Instrument Variable Name:

QuestionText:

NTRTLOSE

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid [fill1: S.C. name] would be taken from your home or that you would lose your parental rights or custody?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTSAY]

Page 20 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_06.000 Instrument Variable Name:

QuestionText:

24-Jul-09

NTRTSAY

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid of what your family or friends would say?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTWAIT]

Question ID:

CMS.150_07.000 Instrument Variable Name:

QuestionText:

NTRTWAIT

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had to wait a long time for an appointment?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTTRAN]

Question ID:

CMS.150_08.000 Instrument Variable Name:

QuestionText:

NTRTTRAN

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had no way to get there?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTINCV]

Page 21 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_09.000 Instrument Variable Name:

QuestionText:

24-Jul-09

NTRTINCV

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too inconvenient to use?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTFAR]

Question ID:

CMS.150_10.000 Instrument Variable Name:

QuestionText:

NTRTFAR

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too far away?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTCHNO]

Question ID:

CMS.150_11.000 Instrument Variable Name:

QuestionText:

NTRTCHNO

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
[fill1: S.C. name] did not want to go?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTOTH]

Page 22 of 22

DRAFT 2010 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_12.000 Instrument Variable Name:

QuestionText:

24-Jul-09

NTRTOTH

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Some other reason?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1> [goto NTRTSPEC] <2,R,D> [goto next section]

Question ID:

CMS.150_13.000 Instrument Variable Name:

QuestionText:
1
7
9

NTRTSPEC

QuestionnaireFileName:

Sample Child

*Specify the other reason.
Verbatim
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

[goto next section]