Parent Form

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

Attachment 4: Parent Report (for children ages 4-17)
Table of Contents
A.
B.
C.
D.
E.
F.
G.

Date of Birth and Race/ethnicity
Co-occurring
Treatment
Healthcare Transition (for parents of children ages 12-17 years only)
Cost and Service Use
Additional Demographic Questions
Clinical Assessment
a. Ask Suicide Screening Questions (ASQ)
b. Yale Global Tic Severity Scale (YGTSS)

Public reporting burden of this collection of information is estimated to average 45 minutes, 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 NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-24EG).

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Questions from national surveys and previously validated measures were prioritized for inclusion in the survey.
Question sources for the parent-report survey include the following instruments:
• National Survey of Children’s Health (NSCH) https://www.census.gov/content/dam/Census/programssurveys/nsch/tech-documentation/questionnaires/2023/2023_NSCH-T3_FINAL.pdf
• National Health Interview Survey (NHIS) (https://www.cdc.gov/nchs/nhis/)
• SEED Follow-Up Survey https://www.cdc.gov/autism/seed/follow-up.html
• National Survey on the Diagnosis and Treatment of ADHD and Tourette syndrome (NS-DATA)
https://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/ns_data/NS_DATA_Questionnaire.pdf
Additionally, there will be a 2-part clinical assessment (the clinical assessment is for the child, but the parent will provide
information and be present, so we are including the forms here, and have included these assessments as part of the
burden calculation for both the parent and the child).
a. Ask Suicide Screening Questions (ASQ)
b. Yale Global Tic Severity Scale (YGTSS)
We were mindful of the benefits of using previously tested and/or approved questions for adoption in our survey. All
above surveys and instruments underwent extensive pilot and field testing and/or were previously approved and fully
implemented in previous studies. Moreover, many of the questions we used are from surveys of nationally
representative samples of US children and adults. This holds an added benefit of allowing us to compare data collected
as part of this project to external prevalence rates for health indicators in the general U.S. population. In compiling
questions into a single survey, we made only minor revisions to some of these existing questions. For example, in our
survey we revised a question from CPS that referred to disability generally to ask about tic disorders, specifically. We
also added mention of mental health care, specifically, to questions on healthcare as this has been reported as a major
area of impact for individuals with tic disorders.
We have noted where each survey question originated (in the “Taken From” column). We have also annotated whether
modifications were made using yellow highlight. New questions and answers are highlighted in blue.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
A. Date of Birth and Race/ethnicity
Section Intro

Taken From

Completing the survey is voluntary. If you are not
comfortable answering a question, just leave it blank.

Revised from a previous project.

Proposed Question
Response options
Taken From
Note: Today’s date and the time stamp will be automatically populated by REDCap, and will not be seen by
respondents. Today’s date will be used to calculate age to make sure individual’s are completing the correct
form, and the time will be used in any notifications (if they are completing the wrong form or indicate selfharm or suicide) so the project staff will know which respondent endorsed those items (if multiple people
are completing the form at the same time). Age will also not be seen by the respondent.
What is this child’s date of birth? Month/Day/Year
Age is calculated in
REDCap based on
today’s date and
response to this
question. If the child
is over 18, the parent
will receive a
message to contact
study staff for the
correct form.
Please answer the following questions about your child.
Proposed Question
What is this child’s race and/or
ethnicity? Select all that apply.

Response options
 American Indian or Alaska Native. For
example, Navajo Nation, Blackfeet Tribe of
the Blackfeet Indian Reservation of
Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo
Community, Aztec, Maya, etc.
 Asian. For example, Chinese, Asian Indian,
Filipino, Vietnamese, Korean, Japanese, etc.
 Black or African American. For example,
African American, Jamaican, Haitian,
Nigerian, Ethiopian, Somali, etc.
 Hispanic or Latino. For example, Mexican,
Puerto Rican, Salvadoran, Cuban,
Dominican, Guatemalan, etc.
 Middle Eastern or North African. For
example, Lebanese, Iranian, Egyptian,
Syrian, Iraqi, Israeli, etc.

Taken From
HHS/OMB approved
method to ask R/E
questions.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Native Hawaiian or Pacific Islander. For
example, Native Hawaiian, Samoan,
Chamorro, Tongan, Fijian, Marshallese, etc.
 White. For example, English, German, Irish,
Italian, Polish, Scottish, etc.
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before going
to the next page. If you intentionally skipped the question(s), you can go to the next page.


B. Co-occurring
Questions and Response Options

Taken From

Has a doctor or other health care provider EVER
told you that this child has:

Question B: Does
this child currently
have the
condition?
[Skip logic: Only
those who respond
“Yes” to previous
question will be
asked Question B]

An anxiety disorder, such as
generalized anxiety disorder, panic
disorder, or a phobia?
Anxiety is a feeling of constant
worrying. Children with severe
anxiety problems may be
diagnosed as having anxiety
disorders.
Depression
Some common types of
depression include major
depression (or major depressive
disorder), bipolar depression,
dysthymia, post-partum
depression, and seasonal
affective disorder.
Autism or Autism Spectrum
Disorder?
Include diagnoses of Asperger’s
Disorder or Pervasive
Developmental Disorder (PDD).

Question C:
Would you
describe it as
mild, moderate
or severe?

Stem is from NHIS.
Follow up adapted
from NSCH, NSDATA, or NHIS.

[Skip logic: Only
those who
respond “Yes” to
question B will
be asked
Question C]
 Mild
NS-DATA with
 Moderate
minor edit to
 Severe
change "another"
to "an"




Yes
No




Yes
No




Yes
No




Yes
No





Mild
Moderate
Severe

NSCH. Help text
from NHIS.




Yes
No




Yes
No





Mild
Moderate
Severe

NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Attention Deficit Disorder or
Attention-Deficit/Hyperactivity
Disorder, that is, ADD or ADHD?
Obsessive-compulsive disorder or
OCD?








Mild
Moderate
Severe
Mild
Moderate
Severe

NSCH

Yes
No





Mild
Moderate
Severe




Yes
No





Mild
Moderate
Severe

Yes
No




Yes
No





Mild
Moderate
Severe

From NHIS
question that
combined a
number of anxiety
disorders.
NS-DATA
(deleted help text
because the
question is about
substance use
disorder and the
help text is about
substance abuse)
NSCH




Yes
No




Yes
No





Mild
Moderate
Severe

NS-DATA




Yes
No




Yes
No





Mild
Moderate
Severe

Self-injurious behavior?




Yes
No




Yes
No





Mild
Moderate
Severe

A concussion or brain injury?




Yes
No

SEED follow-up
survey, with
addition of severity
question.
SEED follow-up
survey, with
addition of severity
question.
Adapted from
NSCH.

Children with OCD feel the need to
check things repeatedly, or have
certain thoughts or perform routines
and rituals over and over.
Post-traumatic stress disorder or
PTSD?

Substance use disorder?
Substance abuse is the frequent use
of substances such as drugs that can
be physically dangerous and can
potentially lead to legal problems
and frequent social or interpersonal
problems.
Frequent or severe headaches,
including migraine?
A sleep disorder?
Examples of sleep disorders include
sleep apnea, insomnia, and
narcolepsy.
Eating disorder?

A concussion or brain injury is when
a blow or jolt to the head causes
problems such as headaches,
dizziness, being dazed or confused,
difficulty remembering or
concentrating, vomiting, blurred




Yes
No




Yes
No




Yes
No




Yes
No




Yes
No







Yes
No




NS-DATA, NHIS
(pulled from
anxiety question).

NSCH first asks
about whether they
sought care, and
then about if they
were told. Also,

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
vision, changes in mood or behavior,
or being knocked out.

addition of severity
question

Questions and Response Options
Has a doctor, other health care
provider, or educator EVER told
you that this child has:

Taken From
NSCH

Examples of educators are
teachers and school nurses.

Question B: Does this
child currently have
the condition?

Question C: Would you
describe it as mild,
moderate or severe?

[Skip logic: Only those
who respond “Yes” to
previous question will
be asked Question B]

[Skip logic: Only those who
respond “Yes” to Question B
will be asked Question C]

Behavioral or
conduct
problems?
Developmental
delay?




Yes
No




Yes
No











Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe

NSCH




Yes
No




Yes
No

Intellectual
disability
(formerly known
as mental
retardation)?




Yes
No




Yes
No

Speech disorder?




Yes
No




Yes
No





Mild
Moderate
Severe

NSCH

Language
disorder?




Yes
No




Yes
No





Mild
Moderate
Severe

NSCH

Learning
disability?




Yes
No




Yes
No





Mild
Moderate
Severe

NSCH
NSCH

Adapted:
split out into
two
questions
(speech and
language
separate)

Adapted:
split out into
two
questions
(speech and
language
separate)
NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

Questions and Response Options

Taken From

Has a doctor or other health care provider told you that this child currently has:
a. Allergies (such as food, drug, insect, seasonal, or other)?
 Yes
 No
b. Asthma?
 Yes
 No
c. Autoimmune disease (such as Type 1 Diabetes, Celiac, or
 Yes
 No
Juvenile Idiopathic Arthritis)?
d. Type 2 Diabetes?






e. Epilepsy or seizure disorder?
Questions and Response Options
Has this child ever shown
Question B: Does this child
extreme expression of
currently show extreme
anger, often to the point of
expression of anger?
uncontrollable rage that is
disproportionate to the
[Skip logic: Only those
situation at hand?
who respond “Yes” to
previous question will be
asked Question B]
 Yes
 Yes
 No
 No

Has this child ever had
sensory processing
problems?
For example, being
hypersensitive (overresponsive) to certain
sensations (like certain
lights, sounds, touch, tastes,
or smells) or hyposensitive
(under-responsive) and seek
out sensory input, to the
point that it causes distress.




Yes
No

Yes
No
Yes
No

Question C: Would you
describe it as mild,
moderate, or severe?
[Skip logic: Only those
who respond “Yes” to
question B will be
asked Question C]
 Mild
 Moderate
 Severe

NSCH
NSCH
NSCH
NSCH
NSCH
Taken From
Adapted from NS-DATA
question on intermittent
explosive disorder
Intermittent explosive
disorder? [HELP TEXT:
Intermittent explosive
disorder is a behavioral
disorder characterized
by extreme expression
of anger, often to the
point of uncontrollable
rage that is
disproportionate to the
situation at hand?
Edited from SEED
question asking about
sensory integration
disorder, which isn’t
recognized as a
disorder, so we are
rephrasing as problems
the adult might be
experiencing.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
[If the respondent skipped any questions in this section, they will see the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before going to
the next page. If you intentionally skipped the question(s), you can go to the next page.

C. Treatment for Tic Disorders and Related Conditions
Question
Response Options
The next questions ask about medications this child may be taking for a tic disorder
or related conditions.
Related conditions include things like ADHD, OCD, anxiety, depression, behavior
issues, or other mental health conditions.

Has this child ever taken medication for a tic
disorder or related conditions?
At what age did this child first start taking
medication for a tic disorder or related
conditions?
Is this child currently taking medication for a tic
disorder or related conditions?
What medications does this child currently take
for a tic disorder or related conditions?

 Yes [Go to TS_C1_2];
 No [Go to TS_C3_1];
Free text
Yes [Go to TS_C1_4];
No [Go to TS_C1_5
TS_C3_1];
Free text



Please list all.

Who usually makes sure this child takes their
medication for a tic disorder or related
conditions?






A parent or guardian
Another family member or
adult
The child
Other person (Please
specify relationship of
other person)

Taken From
NS-DATA (TS_C1_1).
NS-DATA only asks
about Tourette
syndrome but we are
interested in tic
disorders more
generally, and many
medications overlap for
what they are being
used to treat, so asking
about other related
conditions too.
NS-DATA TS_C1_1
NS-DATA TS_C1_2
NS-DATA TS_C1_3
NS-DATA
TS_C1_4_NEW
Original question had
multiple choice/select
all response options
(phone survey).
NS-DATA TS_C2_1
Original response
options:
(1) A PARENT OR
GUARDIAN
(2) ANOTHER FAMILY
MEMBER

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
(3) SOMEONE AT
SCHOOL
(4) A BABYSITTER OR
NANNY
(5) THE CHILD
(6) OTHER PERSON
‫ﺖ‬f yo u se le cte d "o th e r" fo r th e p re vio u s
q u e stio n , p le a se sp e cify wh o u su a lly m a ke s
su re th is ch ild ta ke s th e ir m e d ica tio n for a tic

Free text

In the past 12 months, was there a time when
this child resisted taking their medication for a
tic disorder or related conditions?




disorder or related conditions:

Yes
No

Added for REDCap
programming. This will
only be asked if
selected “other” for
previous question, and
a space will appear in
previous question. This
text will not show.
NS-DATA TS_C2_2

Do not include resistance solely due to physical
reasons such as being unable to swallow a pill.
The next questions ask about other treatments for a tic disorder or related
conditions.
Related conditions include things like ADHD, OCD, anxiety, depression, behavior
issues, or other mental health conditions.
Has this child ever received comprehensive
 Yes [GO TO TS_C3_1A;]
behavioral intervention for tics (CBIT) or habit
 No [GO TO TS_C3_2];
reversal therapy for a tic disorder?
 Don’t know [GO TO
TS_C3_2]
Is this child currently receiving comprehensive
 Yes [GO TO TS_C3_1B]
behavior intervention for tics (CBIT) or habit
 No [GO TO TS_C3_2];
reversal therapy for a tic disorder?
 Don’t Know
Has this child ever received school-based
 Yes [GO TO TS_C3_2A];
behavioral treatment, support, or
 No [GO TO TS_C3_3];
 Don’t Know [GO TO
accommodation for a tic disorder or related
TS_C3_3];
conditions?

NS-DATA

NS-DATA TS_C3_1

NS-DATA TS_C3_1A
NS-DATA TS_C3_2

Do not include CBIT or habit reversal therapy.
Is this child currently receiving school-based
behavioral treatment, support, or
accommodation for a tic disorder or related
conditions?





Yes
No
Don’t Know

NS-DATA TS_C3_2A

Do not include CBIT or habit reversal therapy.
Has this child ever received behavioral
treatment based outside of school for a tic
disorder or related conditions?




Yes [GO TO TS_C3_3A]
No [GO TO TS_C3_4]

NS-DATA TS_C3_3

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Do not include CBIT or habit reversal therapy.
Is this child currently receiving behavior
treatment based outside of school for a tic
disorder or related conditions?
Do not include CBIT or habit reversal therapy.
Has this child ever received any other
treatment for a tic disorder or related
conditions?
Please specify any other treatment this child
has ever received for a tic disorder or related
conditions:
Is this child currently receiving any other
treatment for a tic disorder or related
conditions?
Please specify any other treatment this child is
currently receiving for a tic disorder or related
conditions:






Don’t Know [GO TO
TS_C3_4]
Yes
No
Don’t Know

NS-DATA TS_C3_3A

Yes [GO TO Follow up];
No [GO TO TS_C3_5];
Don’t Know [GO TO
TS_C3_5]
Free text

NS-DATA TS_C3_4

Yes_[GO TO Follow up]
No [GO TO TS_C3_5];
Don’t Know [GO TO
TS_C3_5)
Free text

NS-DATA TS_C3_4A









Does this child currently have a formal
educational plan, such as an Individualized
Education Program, also called an IEP or a 504
plan?
Which one is it, an IEP or a 504 plan?





Note: This will only be
asked if selected “YES”
for previous question

Note: This will only be
asked if selected “YES”
for previous question
NS-DATA TS_C3_5






Yes [GO TO TS_C3_6];
No [GO TO TS_C4_3)
Don’t Know [GO TO
TS_C4_3)
IEP
504
Something else
Both IEP and 504 plan

Overall, how satisfied are you with this child’s
tic disorder treatment and management?
Would you say you are very satisfied,
somewhat satisfied, somewhat dissatisfied or
very dissatisfied?






Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

NS-DATA TS_C4_3

In the past year, has your child received any of
the following for any mental, emotional, or
behavioral problem, across settings (school,
doctor’s office)?





Parent training
Social skills training
Cognitive behavioral
therapy
Counseling (for example,
talk therapy or
psychotherapy)
Other (Please specify):
None of these

PLAY-MH (replaced
“his/her” with “any”)

Select all that apply.






NS-DATA TS_C3_6

Changed “Tourette
syndrome” to “tic
disorder”

Each of these
treatment types were
asked as separate
questions – propose
combining with “select
all that apply” response
options.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

If you selected “other” for the previous
question, please specify:

[REDCap is programmed so they
cannot choose “none of these” and
another option]
Free text

Note: This will only be
asked if “Other”
selected for previous
question
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before going to
the next page. If you intentionally skipped the question(s), you can go to the next page.

D.

Healthcare Transition (for parents of children age 12-17 years only)

Proposed Question

Response Options

1. Do any of this child’s doctors or other health care providers
 Yes
treat only children?
 No (skip to question 2)
a. [If yes,] Have they talked with you about when this child  Yes
will need to see doctors or other health care providers
 No
who treat adults?
2. Has this child’s doctor or other health care provider actively worked with this child to:
a. Make positive choices about their health.
 Yes
 No
For example, by eating healthy, getting regular exercise,  Don’t Know
not using tobacco, alcohol or other drugs, or delaying
sexual activity?
b. Gain skills to manage their health and health care.
 Yes
 No
 Don’t Know
For example, by understanding current health needs,
knowing what to do in a medical emergency, or taking
medications they may need?
c. Understand the changes in health care that happen at
 Yes
age 18.
 No
 Don’t Know
For example, by understanding changes in privacy,
consent, access to information, or decision-making?
3. Did you and this child receive a summary of your child’s
 Yes
medical history (for example, medical conditions, allergies,
 No
medications, immunizations)?
4. Have this child’s doctors or other health care providers
 Yes
worked with you and this child to create a plan of care to
 No (skip to question 5)
meet their health goals and needs?
a. [If yes,] Do you and this child have access to this plan of
 Yes
care?
 No
b. Does this plan of care address transition to doctors and
 Yes
other health care providers who treat adults?
 No

Taken
From
NSCH
NSCH
NSCH
NSCH

NSCH

NSCH

NSCH
NSCH
NSCH
NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

5. Eligibility for health insurance often changes in young
adulthood. Do you know how this child will be insured as they
become an adult?
a. [If no,] Has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this
child becomes an adult?
6. Do you have concerns about your child transitioning from
pediatric to adult healthcare providers to provide care
related to their tic disorder?






No, this child already
sees providers who
treat adults
Yes [If yes, skip to
question 6]
No
Yes
No

NSCH
NSCH

Yes [if yes, skip to
New
follow up a.]
 No (skip next question;
go to next section)
a. What are your main concerns?
Open ended (word limit:
New
125 words)
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before going
to the next page. If you intentionally skipped the question(s), you can go to the next page.


E. School, Cost, and Service Use
Question
DURING THE PAST 12 MONTHS, about how
many days did this child miss school
because of illness or injury? Include days
missed from any formal home schooling.

DURING THE PAST 12 MONTHS, about how
many days did this child miss school
because of behavior, mood, or tic related
concerns? Include days missed from any
formal home schooling.
Which of the following best describes your
current employment status?

Response Options
 No missed school days
(skip next question)
 1-3 days
 4-6 days
 7-10 days
 11 or more days
 This child was not
enrolled in school (skip
next question)
 No missed school days
 1-3 days
 4-6 days
 7-10 days
 11 or more days
 This child was not
enrolled in school
 Employed full-time
 Employed part-time
 Working WITHOUT pay
 Not employed but
looking for work
 Not employed and not
looking for work
 Retired

Taken From
NSCH

Adapted from NSCH

NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Does this child have another parent or
adult caregiver who lives in this household?
If yes (will be coded to skip), Which of the
following best describes this caregiver’s
current employment status?

Yes
No
Employed full-time
Employed part-time
Working WITHOUT pay
Not employed but
looking for work
 Not employed and not
looking for work
 Retired
DURING THE PAST 12 MONTHS, have you or other family members…
Left a job or taken a leave of
 Yes
absence because of this child’s
 No
health or health conditions?
Cut down on the hours you work
 Yes
because of this child’s health or
 No
health conditions?
Avoided changing jobs because of
 Yes
concerns about maintaining health
 No
insurance for this child?
Including co-pays and amounts reimbursed  $0 (No medical or healthfrom Health Savings Accounts (HSA) and
related expenses)
 $1-$249
Flexible Spending Accounts (FSA), how
 $250-$499
much money did you pay for this child’s
 $500-$999
medical, health, dental, and vision care
 $1,000-$5,000
DURING THE PAST 12 MONTHS?
 More than $5,000
Do not include health insurance
premiums or costs that were or will be
reimbursed by insurance or another source.
Including co-pays and amounts reimbursed  $0 (No medical or healthfrom Health Savings Accounts (HSA) and
related expenses)
Flexible Spending Accounts (FSA), how
 $1-$249
much money did you pay for this child’s
 $250-$499
mental health care including prescriptions
 $500-$999
 $1,000-$5,000
and office visits DURING THE PAST 12
 More than $5,000
MONTHS?
Do not include health insurance premiums
or costs that were or will be reimbursed by
insurance or another source.
The next questions are about your family's medical bills. Include bills for
doctors, dentists, hospitals, therapists, medication, equipment, and nursing
home or home care.
In the past 12 months, did anyone in your
 Yes
family have problems paying or were
 No
unable to pay any medical bills?
Does anyone in your family currently have
 Yes
any medical bills that you are unable to pay
 No
at all?







NSCH
NSCH

NSCH
NSCH
NSCH
NSCH
NSCH

NSCH

NHIS
NHIS
NHIS

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
If this child gets sick or has an accident,
how worried are you that your family will
be able to pay their medical bills? Are you
very worried, somewhat worried, or not at
all worried?
During the past 12 months, has medical
care BEEN DELAYED for this child because of
the cost?
During the past 12 months, was there any
time when this child needed medical care,
but DID NOT GET IT because of the cost?
At any time in the past 12 months, did this
child take prescription medication?





Very worried
Somewhat worried
Not at all worried

NHIS, adapted to say
“this child” instead of
the name




Yes
No




Yes
No




Yes
No

During the past 12 months, did you DELAY
filling a prescription for this child to save
money?
During the past 12 months, was there any
time when this child needed prescription
medication, but DID NOT GET IT because of
the cost?
During the past 12 months, has this child
been DELAYED in getting counseling or
therapy from a mental health professional
because of the cost?
During the past 12 months, was there any
time when this child needed counseling or
therapy from a mental health professional,
but DID NOT GET IT because of the cost?
During the past 12 months, has this child
been DELAYED in getting counseling or
therapy from a mental health professional
because you couldn’t get an appointment?
[If yes,] How long was the delay?




Yes
No




Yes
No

NHIS, adapted to say
“this child” instead of
the name
NHIS, adapted to say
“this child” instead of
the name
NHIS, adapted to say
“this child” instead of
the name
NHIS, adapted to say
“this child” instead of
the name
NHIS, adapted to say
“this child” instead of
the name




Yes
No

NHIS, adapted to say
“this child” instead of
the name




Yes
No

NHIS, adapted to say
“this child” instead of
the name




Yes
No (skip next question)

Adapted from NHIS
question above

During the past 12 months, how many
times has this child gone to a hospital
emergency room about their health?

 Less than 3 months
 3-6 months
 7-12 months
 More than 12 months
Free text

New question

NHIS (similar Q on
NSCH)

This includes emergency room visits that
resulted in a hospital admission.
During the past 12 months, has this child
 Yes
NHIS (similar Q on
been hospitalized overnight?
 No
NSCH)
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before
going to the next page. If you intentionally skipped the question(s), you can go to the next page.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

F. Additional Demographic Questions – Please answer the following questions about this child.
Question
What is this child’s sex?
Which of the following best represents how
your child thinks of themself?

Response Options
 Male
 Female

Gay (lesbian or gay)
Straight, this is not
gay (or lesbian or
gay)
 Bisexual
 Something else
 I don’t know the
answer
The next questions are about health insurance. Include health insurance
obtained through employment or purchased directly as well as government
programs like Medicare, Medicaid, and the Children's Health Insurance
Program that provide medical care or help pay medical bills.
Is this child covered by any kind of health
 Yes
insurance or some other kind of health care
 No [skip next
plan?
question]
What kinds of health insurance or health care
 Private health insurance
coverage does this child have? Is it...Private
 Medicare
 Medigap
health insurance, Medicare, Medicare
 Medicaid
supplement, Medicaid, Children's Health
 Children's Health
Insurance Program or CHIP, military related
Insurance Program (CHIP)
health care including TRICARE, CHAMPUS, VA
 Military related health
health care and CHAMP-VA, Indian Health
care: TRICARE
Service, a state-sponsored health plan, or
(CHAMPUS) / VA health
another government program?
care / CHAMP-VA
 Indian Health Service
Select all that apply.
 State-sponsored health
plan
 Other government
program
 No coverage of any type
Does this child have any of the following?
Serious difficulty concentrating,
 Yes
remembering, or making decisions
 No
because of a physical, mental, or
emotional condition
Serious difficulty walking or climbing
 Yes
stairs
 No



Taken From
From HHS/OMB
guidance. Edited for
parent report.
HHS/OMB guidance.
Edited for parent report

NHIS

NHIS
NHIS

[REDCap is programmed
so they cannot choose
“no coverage of any
type” and another
option]

NSCH
NSCH

NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
Difficulty dressing or bathing
Difficulty doing errands alone, such as
visiting a doctor’s office or shopping,
because of a physical, mental, or
emotional condition
Deafness or problems with hearing






Yes
No
Yes
No

NSCH
NSCH

 Yes
NSCH
 No
Blindness or problems with seeing,
 Yes
NSCH
even when wearing glasses
 No
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before
going to the next page. If you intentionally skipped the question(s), you can go to the next page.

Section Intro:
Please answer the following questions about yourself and your family.
Question
How are you related to this child?

What is the HIGHEST level of school you
have completed or the highest degree
you have received?

What is your marital status?

Response Options
 Biological or adoptive parent
 Step-parent
 Grandparent
 Foster parent
 Other: Relative
 Other: non-Relative
 Never attended/kindergarten only
 Grade 1-11
 12th grade, no diploma
 GED or equivalent
 High school Graduate
 Some college, no degree
 Associate degree: occupational,
technical, or vocational program
 Associate degree: academic program
 Bachelor's degree (Example: BA, AB,
BS, BBA)
 Master's degree (Example: MA, MS,
MEng, MEd, MBA)
 Professional school degree (Example:
MD, DDS, DVM, JD)
 Doctoral degree (Example: PhD, EdD)
 Married
 Not married, but living with a partner
 Never married
 Divorced
 Separated
 Widowed

Taken From
NSCH

NHIS
HHC.0350.00.1

NSCH

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
The following questions are about the
address where you currently live.
What is your current street address?
Example: 123 Main Street
What is the apartment or unit number
(skip if none)?
Example: Apt. 5a
In what city do you currently live?
In what state do you currently live?

Free Text

Free text
Free Text
[Drop down menu to select one]
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island

New

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX

[if not one of 50 states or D.C.]: Specify
other place (not US state) you live
What is your current zip code (for
address above)?
How many people are living or staying at
this address? Include everyone who
usually lives or stays at this address. Do
NOT include anyone who is living
somewhere else for more than two
months, such as a college student living
away or someone in the Armed Forces
on deployment.
What is your best estimate of your total
family income from all sources, before
taxes, in the last year?

Did anyone help you complete this
survey?

If you are interested in receiving project
updates in the future, please enter your
email address.

South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other (please specify)
Free text

New

Free text, validated in REDCap to match zip
code format (5 numbers)
Free text

NSCH

A. <$15,000
B. $15,000-$24,999
C. $25,000-49,999
D. $50,000-74,999
E. $75,000-99,999
F. $100,000-149,999
G. $150,000-199,999
H. $200,000 or higher
 Yes, someone helped me, but I completed
most of the survey on my own.
 Yes, someone helped me with all or most
of the survey.
 No, I completed the survey on my own.
 Free text

NHIS
Slightly
different
response
categories than
NHIS
New

New

You may decline to be re-contacted now
or at any time in the future.
[If the respondent skipped any questions in this section, they will receive the following message:]
You skipped one or more questions on this page. Please review and complete the question(s) before
going to the next page. If you intentionally skipped the question(s), you can go to the next page.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
G. Clinical Assessment
a. Ask Suicide Screening Questions (ASQ) (ages 9 years and older)
b. Yale Global Tic Severity Scale (YGTSS)
The clinical assessment is focused on the child but the parent will be present so the time is included in the
parent assessment, and therefore these measures are included as part of the parent burden estimate and
attached.

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
The following questions will be asked by a trained professional, not as part of the survey.
a.

Ask Suicide Screening Questions (ASQ) (these are in a separate REDCap form since they are not part of the
self-report survey; these questions will be asked by a healthcare provider or trained program staff member to
individuals with tic disorders aged 9-26 years with possible input from parent for children 9-17 years.

Question

Response Options

Taken From

Note to person administering the ASQ: Please provide the following information to the respondent before asking
the questions.
This survey asks about mental health and emotional well-being. If you answer that you have had suicidal
thoughts or behaviors, or purposely tried to hurt yourself, we may inform your doctor or other clinic staff. This
would be to ensure your safety and provide you with support and care.
By completing this survey, you accept and consent to this protocol. If you have concerns or need immediate
help, please tell the clinic staff.
1) In the past few weeks, have you wished you were dead?
 Yes
ASQ
 No
 Refused to answer
2) In the past few weeks, have you felt that you or your family
 Yes
ASQ
would be better off if you were dead?
 No
 Refused to answer
3) In the past week, have you been having thoughts about
 Yes
ASQ
killing yourself?
 No
 Refused to answer
4) Have you ever tried to kill yourself?
 Yes
ASQ
 No
 Refused to answer
[If yes to 4,]
Free text
ASQ
4a) How?
4b) When?
The patient answered "No" to questions 1 through 4; therefore,
 Ask question #5
Incorporated
screening is complete, and it is not necessary to ask question
 Finish the ASQ
from ASQ
#5. No intervention is necessary; however, clinical judgment
instructions,
can always override a negative screen.
within skip
pattern. ASQ
instructions
Do you want to ask the patient question #5 (Are you having
included
thoughts of killing yourself right now?) or finish the ASQ?
below.
[If “Yes” or “Refused” to any of the above (Q1-Q4)] This patient is
 Yes
ASQ
considered a positive screen. Ask question #5 to assess acuity.
 No
5) Are you having thoughts of killing yourself right now?

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
[If yes to Q5]
5b) Please describe:
[If yes to Q5]
Patient is acute positive screen (imminent risk identified)

Open ended

ASQ

Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for
patient's care.
Provide resources to all patients: 988 Suicide and Crisis Lifeline, 988 (call, text), https://988lifeline.org/ (and
relevant local information)
[If no to Q5]
Patient is non-acute positive screen (potential risk identified).
Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a
patient (or parent/guardian) refuses the brief assessment, this should be treated as an "against medical advice"
(AMA) discharge.
Alert physician or clinician responsible for patient's care.
Provide resources to all patients: 988 Suicide and Crisis Lifeline, 988 (call, text),
https://988lifeline.org/
Initials of person (staff/professional) completing ASQ
Open ended
Overview of ASQ - this information is included above, within skip logic, and only included here
for reference.
If patient answers "No" to all questions 1 through 4, screening is complete (not necessary to
ask question #5). No intervention is necessary (*Note: Clinical judgment can always override a
negative screen).
If patient answers "Yes" to any of questions 1 through 4, or refuses to answer, they are
considered a positive screen. Ask question #5 to assess acuity.
"Yes" to question #5 = acute positive screen (imminent risk identified)
Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until
evaluated for safety.
Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician
responsible for patient's care.
"No" to question #5 (but “Yes” or “Refused” to one of questions 1-4) = non-acute positive
screen (potential risk identified)
Patient requires a brief suicide safety assessment to determine if a full mental health
evaluation is needed. If a patient (or parent/guardian) refuses the brief assessment, this should

ASQ

Form Approved
OMB NO. 0920-24EG
Exp. Date XX/XX/20XX
be treated as an "against medical advice" (AMA) discharge.
Alert physician or clinician responsible for patient's care.
Provide Resources to All Patients:
• 988 Suicide and Crisis Lifeline, Call or Text 988
• Visit https://988lifeline.org to chat

ID #:

Y G T S S
Yale Global Tic Severity Scale
Yale Child Study Center

October 1992 version

1

NAME:

TODAY'S DATE :

/

/

RATER:

MOTOR TIC SYMPTOM CHECKLIST
Description of Motor Tic Symptoms. Motor tics usually begin in childhood and are characterized by
sudden jerks or movements, such as forceful eye blinking or a rapid head jerk to one side or the other.
The same tics seem to recur in bouts during the day and are worse during periods of fatigue and/or stress.
Many tics occur without warning and may not even be noticed by the person doing them. Others are
preceded by a subtle urge that is difficult to describe (some liken it to the urge to scratch an itch). In
many cases it is possible to voluntarily hold back the tics for brief periods of time. Although any part of
the body may be affected, the face, head, neck, and shoulders are the most common areas involved. Over
periods of weeks to months, motor tics wax and wane and old tics may be replaced by totally new ones.
Simple motor tics can be described as a sudden, brief, "meaningless" movement that recurs in bouts (such
as excessive eye blinking or squinting). Complex motor tics are sudden, stereotyped (i.e., always done in
the same manner) semi-purposeful (i.e., the movement may resemble a meaningful act, but is usually
involuntary and not related to what is occurring at the time) movements that involve more than one
muscle group. There may often be a constellation of movements such as facial grimacing together with
body movements. Some complex tics may be misunderstood by other people (i.e., as if you were
shrugging to say "I don't know"). Complex tics can be difficult to distinguish from compulsions; however,
it is unusual to see complex tics in the absence of simple ones. Often there is a tendency to explain away
the tics with elaborate explanations (e.g., “I have hay fever that has persisted” even though it is not the
right time of year). Tics are usually at their worst in childhood and may virtually disappear by early
adulthood, so if you are completing this form for yourself, it may be helpful to talk to your parents, an
older sibling, or a relative, as you answer the following questions.
• Age of first motor tics? ________________ years old
• Describe first motor tic: ________________________________________________
• Was tic onset sudden or gradual?

_______________________________________

• Age of worst motor tics? ________________ years old

Motor Tic Symptom Checklist
In the boxes on the left below, please check with a mark (x) the tics the patient
1) has EVER experienced
2) is CURRENTLY experiencing (during the past week)
State AGE OF ONSET (in years) if patient has had that behavior.
Also, in the tic descriptions below, please circle or underline the specific tics that the patient has
experienced (circle or underline the words that apply).
2

Ever

[In Years]
CurAge
rent
of
onset

The patient has experienced, or others have noticed, involuntary
and apparently purposeless bouts of:
-eye movements.
eye blinking, squinting, a quick turning of the eyes, rolling of the
eyes to one side, or opening eyes wide very briefly.
eye gestures such as looking surprised or quizzical, or looking to
one side for a brief period of time, as if s/he heard a noise.
-nose, mouth, tongue movements, or facial grimacing.
nose twitching, biting the tongue, chewing on the lip or licking the
lip, lip pouting, teeth baring, or teeth grinding.
broadening the nostrils as if smelling something, smiling, or other
gestures involving the mouth, holding funny expressions, or
sticking out the tongue.
-head jerks/movements.
touching the shoulder with the chin or lifting the chin up.
throwing the head back, as if to get hair out of the eyes.
-shoulder jerks/movements.
jerking a shoulder.
shrugging the shoulder as if to say "I don't know."
-arm or hand movements.
quickly flexing the arms or extending them, nail biting, poking with
fingers, or popping knuckles.
passing hand through the hair in a combing like fashion, or
touching objects or others, pinching, or counting with fingers for no
purpose, or writing tics, such as writing over and over the same
letter or word, or pulling back on the pencil while writing.
-leg, foot or toe movements.
kicking, skipping, knee-bending, flexing or extension of the ankles;
shaking, stomping or tapping the foot.
taking a step forward and two steps backward, squatting, or deep
knee-bending.

3

Ver

Ever

Current

Age
of
onset

The patient has experienced, or others have noticed, involuntary and
apparently purposeless bouts of:

Ver

-abdominal/trunk/pelvis movements.
tensing the abdomen, tensing the buttocks.
-other simple motor tics.
Please write example(s):

-other complex motor tics.
touching
tapping
picking
evening-up
reckless behaviors
stimulus-dependent tics (a tic which follows, for example, hearing a
particular word or phrase, seeing a specific object, smelling a
particular odor). Please write example(s):
____________________________________________________________
rude/obscene gestures; obscene finger/hand gestures.
unusual postures.
bending or gyrating, such as bending over.
rotating or spinning on one foot.
copying the action of another (echopraxia)
sudden tic-like impulsive behaviors. Please describe:
____________________________________________________________
tic-like behaviors that could injure/mutilate others. Please describe:
____________________________________________________________
self-injurious tic-like behavior(s). Please describe:
____________________________________________________________
-other involuntary and apparently purposeless motor tics (that do not fit in
any previous categories).
Please describe any other patterns or sequences of motor tic
behaviors:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
___________________________________________________________

4

Phonic (Vocal) Tics
Description of Phonic (or Vocal) Tic Symptoms Phonic tics usually begin in childhood,
typically after motor tics have already started, but they can be the first tic symptoms. They are
characterized by a sudden utterance of sounds such as throat clearing or sniffing. The same
tics seem to recur in bouts during the day and are worse during periods of fatigue and/or
stress. Many tics occur without warning and may not even be noticed by the person doing
them. Others are preceded by a subtle urge that is difficult to describe (some liken it to the
urge to scratch an itch). In many cases it is possible to voluntarily hold back the tics for brief
periods of time. Over periods of weeks to months, phonic tics wax and wane and old tics may
be replaced by totally new ones. Simple phonic tics are utterances of fast, meaningless sounds
whereas complex phonic tics are involuntary, repetitive, purposeless utterances of words,
phrases or statements that are out of context, such as uttering obscenities (i.e., coprolalia), or
repeating over and over again what other people have said (i.e., echolalia). Complex tics can
be difficult to distinguish from compulsions; however, it is unusual to see complex tics in the
absence of simple ones. Often there is a tendency to explain away the tics with elaborate
explanations (e.g., “I have hay fever that has persisted” even though it is not the right time of
year). Tics are usually at their worst in childhood and may virtually disappear by early
adulthood, so if you are completing this form for yourself, it may be helpful to talk to your
parents, an older brother or sister, or older relative, as you answer the following questions.

• Age of first vocal tics? ________________ years old.
• Describe first vocal tic: ________________________________________________
• Was tic onset sudden or gradual? _________________________________________
• Age of worst vocal tics? ________________ years old.

5

Phonic Tic Symptom Checklist
In the boxes on the left below, please check with a mark (x) the tics the patient
1) has EVER experienced
2) is CURRENTLY experiencing (during the past week)
State AGE OF ONSET (in years) if patient has had that behavior.
Also, in the tic descriptions below, please circle or underline the specific tics that the patient has
experienced (circle or underline the words that apply).
[In Years]

Ever Current

Age The patient has experienced, or others have noticed, bouts of
of involuntary and apparently purposeless utterance of:
onset
-coughing.
-throat clearing.
-sniffing.
-whistling.
-animal or bird noises.
-Other simple phonic tics. Please list:
-syllables. Please list:
-words. Please list:
-rude or obscene words or phrases. Please list:
-repeating what someone else said, either sounds, single words or
sentences. Perhaps repeating what’s said on TV (echolalia).
-repeating something the patient said over and over again
(palilalia).
-other tic-like speech problems, such as sudden changes in volume
or pitch. Please describe:

Describe any other patterns or sequences of phonic tic behaviors:

6

Ver

SEVERITY RATINGS
Motor

NUMBER
None
Single tic
Multiple discrete tics (2-5)
Multiple discrete tics (>5)
Multiple discrete tics plus as least one orchestrated pattern of multiple simultaneous or
sequential tics where it is difficult to distinguish discrete tics
Multiple discrete tics plus several (>2) orchestrated paroxysms of multiple simultaneous
or sequential tics that where it is difficult to distinguish discrete tics

o
o
o
o
o

o
o
o
o
o

0
1
2
3
4

o

o

5

Motor

FREQUENCY
NONE No evidence of specific tic behaviors
RARELY Specific tic behaviors have been present during previous week. These
behaviors occur infrequently, often not on a daily basis. If bouts of tics occur, they are
brief and uncommon.
OCCASIONALLY Specific tic behaviors are usually present on a daily basis, but there
are long tic-free intervals during the day. Bouts of tics may occur on occasion and are not
sustained for more than a few minutes at a time.
FREQUENTLY Specific tic behaviors are present on a daily basis. tic free intervals as
long as 3 hours are not uncommon. Bouts of tics occur regularly but may be limited to a
single setting.
ALMOST ALWAYS Specific tic behaviors are present virtually every waking hour of
every day, and periods of sustained tic behaviors occur regularly. Bouts of tics are
common and are not limited to a single setting.
ALWAYS Specific tic behaviors are present virtually all the time. Tic free intervals are
difficult to identify and do not last more than 5 to 10 minutes at most.

ABSENT
MINIMAL INTENSITY Tics not visible or audible (based solely on patient's private
experience) or tics are less forceful than comparable voluntary actions and are typically
not noticed because of their intensity.
MILD INTENSITY Tics are not more forceful than comparable voluntary actions or
utterances and are typically not noticed because of their intensity.
MODERATE INTENSITY Tics are more forceful than comparable voluntary actions but
are not outside the range of normal expression for comparable voluntary actions or
utterances. They may call attention to the individual because of their forceful character.
MARKED INTENSITY Tics are more forceful than comparable voluntary actions or
utterances and typically have an "exaggerated" character. Such tics frequently call
attention to the individual because of their forceful and exaggerated character.
SEVERE INTENSITY Tics are extremely forceful and exaggerated in expression. These
tics call attention to the individual and may result in risk of physical injury (accidental,
provoked, or self-inflicted) because of their forceful expression.

7

Phonic

o
o

o
o

0
1

o

o

2

o

o

3

o

o

4

o

o

5

Motor

INTENSITY

Phonic

Phonic

o
o

o
o

0
1

o

o

2

o

o

3

o

o

4

o

o

5

Motor

COMPLEXITY
NONE If present, all tics are clearly "simple" (sudden, brief, purposeless) in character.
BORDERLINE Some tics are not clearly "simple" in character.
MILD Some tics are clearly "complex" (purposive in appearance) and mimic brief
"automatic" behaviors, such as grooming, syllables, or brief meaningful utterances such
as "ah huh," "hi" that could be readily camouflaged.
MODERATE Some tics are more "complex" (more purposive and sustained in
appearance) and may occur in orchestrated bouts that would be difficult to camouflage
but could be rationalized or "explained" as normal behavior or speech (picking, tapping,
saying "you bet" or "honey", brief echolalia).
MARKED Some tics are very "complex" in character and tend to occur in sustained
orchestrated bouts that would be difficult to camouflage and could not be easily
rationalized as normal behavior or speech because of their duration and/or their
unusual, inappropriate, bizarre or obscene character (a lengthy facial contortion, touching
genitals, echolalia, speech atypicalities, longer bouts of saying "what do you mean"
repeatedly, or saying "fu" or "sh").
SEVERE Some tics involve lengthy bouts of orchestrated behavior or speech that would
be impossible to camouflage or successfully rationalize as normal because of their
duration and/or extremely unusual, inappropriate, bizarre or obscene character (lengthy
displays or utterances often involving copropraxia, self-abusive behavior, or coprolalia).

o
o
o

o
o
o

0
1
2

o

o

3

o

o

4

o

o

5

Motor

INTERFERENCE
NONE
MINIMAL When tics are present, they do not interrupt the flow of behavior or speech.
MILD When tics are present, they occasionally interrupt the flow of behavior or speech.
MODERATE When tics are present, they frequently interrupt the flow of behavior or
speech.
MARKED When tics are present, they frequently interrupt the flow of behavior or
speech, and they occasionally disrupt intended action or communication.
SEVERE When tics are present, they frequently disrupt intended action or
communication.

8

Phonic

Phonic

o
o
o
o

o
o
o
o

0
1
2
3

o

o

4

o

o

5

IMPAIRMENT
NONE
MINIMAL Tics associated with subtle difficulties in self-esteem, family life, social acceptance, or
school or job functioning (infrequent upset or concern about tics vis a vis the future, periodic,
slight increase in family tensions because of tics, friends or acquaintances may occasionally notice
or comment about tics in an upsetting way).
MILD Tics associated with minor difficulties in self-esteem, family life, social acceptance, or
school or job functioning.
MODERATE Tics associated with some clear problems in self-esteem family life, social
acceptance, or school or job functioning (episodes of dysphoria, periodic distress and upheaval in
the family, frequent teasing by peers or episodic social avoidance, periodic interference in school
or job performance because of tics).
MARKED Tics associated with major difficulties in self-esteem, family life, social acceptance, or
school or job functioning.
SEVERE Tics associated with extreme difficulties in self-esteem, family life, social acceptance, or
school or job functioning (severe depression with suicidal ideation, disruption of the family
(separation/divorce, residential placement), disruption of social tics - severely restricted life
because of social stigma and social avoidance, removal from school or loss of job).

o
o

0
10

o

20

o

30

o

40

o

50

SCORING
Number
(0-5)

Frequency
(0-5)

Intensity
(0-5)

Complexity
(0-5)

Interference
(0-5)

Motor Tic
Severity
Vocal Tic
Severity

Total Tic Severity Score = Motor Tic Severity + Vocal Tic Severity (0-50)

Total Yale Global Tic Severity Scale Score (Total Tic Severity Score +
Impairment) (0-100)

9

Total
(0-25)