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22-Feb-2008
QUESTIONNAIRE PACKET
PARENT PACKET about
YOUR CHILD (ages 12-18)
DATE: — — Month Day Year
DI TCEJBUS SITE ID FAMILY ID INDIVIDUAL ID
— —
CHILD’S SUBJECT ID SITE ID FAMILY ID INDIVIDUAL ID
— —
This packet contains questionnaires to be filled out by: ____________________________
The questions should be answered about your child: ______________________________
Survey Number: Year 1 Year 3 Year 5
Stressful Life Events Schedule - Parents
SLES: 11-Apr-2006
Please read each event and indicate if the event has occurred in your child's life during the past 12 months and how mucheffect it had on your child. If question is gender specific (e.g., my daughter or my son), skip the questions that do notapply to the gender of the child for who you are answering this questionnaire.
Did not
happen
Happened, but
had no effect at
all
Happened, had
a little effect
Happened, had
somewhat of an
effect
Happened, had a
lot of an effect
*
1. My child had trouble
with grades or
schoolwork.
2. My daughter started
her menstrual cycle
(period).
*
3. Child's parent(s)
were not home
because of work.
*4. Child's parent(s)
were fired from a job.
*5. Child's parents hit
each other.
*6. My child testified in
court.
7. My son's
girlfriend was
pregnant.
*8. Child's parent(s) have
problems at work.
* 9. My child was robbed.
* 10. My child got really badnews.
*11. My child was sexuallyhurt or touched in privateparts.
*12. My child changed
schools.
* 13. My child moved.
* 14. Our family had moneyproblems.
*15. My child's parent(s)
divorced or separated.
*16. My child's close friends orfamily members had troublewith the police.
*17. My child applied for a joband did not get hired.
* 18. My child's mom or dadremarried.
*19. My child was warned ordisciplined for work
performance.
* 20. A school did not acceptmy child.
*21. My child had a bad accidentor health problems.
*22. My child lived with a
boyfriend/girlfriend.
*23. Parents (including step-parents) had a baby or areexpecting a baby.
24. My child told someone really
Continue to rate whether these events happened to your child in the past 12 months and how much effect it had on your child.
Did not
happen
Happened, but
had no effect at
all
Happened,
had a little
effect
Happened, had
somewhat of an
effect
Happened, had
a lot of an
effect
SLES-P: Page 2
* bad news.
* 25. My child's close friend died.
* 26. My child started datingsomeone.
* 27. My child broke up with aboyfriend/girlfriend.
* 28. My child argued with aboyfriend/girlfriend.
* 29. My child had sex for the firsttime.
* 30. Someone moved out of mychild's house.
* 31. My child was in the hospitalor had an operation.
* 32. My child's close friend orfamily member was robbed.
* 33. My child's close friend orrelative was really sick.
* 34. My child had problems withsomeone at work.
* 35. My child fought more withparents.
* 36. My child argued more withother relatives (not parents).
* 37. A close relative died.
*38. My child tried out for asports team or club and did notmake it.
*39. Someone in my child's homeis having a baby (not my
parents).
*40. My child changed in physicalappearance and did not like it
(acne, etc.).
*41. My child was sexuallyharrassed at school or work.
Continue to rate whether these events happened to your child in the past 12 months and how much effect it had on your child.
Did not
happen
Happened, but
had no effect at
all
Happened,
had a little
effect
Happened, had
somewhat of an
effect
Happened, had
a lot of an
effect
SLES-P: Page 3
*42. My child broke off an
engagement.
*
43. My child's family had
problems buying or selling ahouse.
*
44. My child was
physically/sexually abused byhis/her boyfriend/girlfriend.
*45. My child was hurt or punchedby someone (not including
spanking).
*46. My child was caught
committing a crime.
*47. My child's close friend orfamily member was in the hospitalor had an operation.
48. My daughter
had an abortion.
* 49. My child was bullied at schoolor in my neighborhood.
*50. My child did badly on animportant test.
*
51. There were problems with mychild's house (overcrowded,
needs to be fixed up, mice orinsects).
* 52. My child stopped talking to agood friend.
* 53. My child fought with a goodfriend.
56. My child's job affected other
*54. My child had problems withfamily members, close friends, orclassmates.
*55. Someone new moved into mychild's house.
Continue to rate whether these events happened to your child in the past 12 months and how much effect it had on your child.
Did not
happen
Happened, but
had no effect at
all
Happened,
had a little
effect
Happened, had
somewhat of an
effect
Happened, had
a lot of an
effect
SLES-P: Page 4
* aspects of life (school, home life,social life).
* 57. My child's pet died or ranaway.
*58. My child's family member orclose friend saw a doctor abouthis/her feelings.
* 59. My child found out he/shewas adopted.
*60. My child's parent was out ofwork or not working.
*
61. My child lived with
someone other than his/hermom or dad.
* 62. My child had long termhealth problems.
*63. My child's neighborhoodwas not safe (violence,
crimes, gangs)
*64. My child's close friend orfamily member was hurt
badly.
* 65. My child had problemsbeing liked by classmates.
*66. My child's close friendsor family tried to hurt
themselves.
*67. My child's parents or
brother/sister died.
* 68. My child's parent wasfired from his/her job.
*69. My child's brother/sisterfought more with his/her
parents.
* 70. My child saw somethingbad happen.
71. My daughter
got pregnant.
* 72. My child's parents hadtrouble getting along.
*
73. My child's home was
damaged because of fire, flood,storm, tornado or other event.
* 74. My child stopped going toschool.
*75. My child fought with
someone at school.
* 76. My child fought more withhis/her brother/sister.
77. My son's
girlfriend had an
abortion.
*78. My child told someonethat he/she was bisexual orhomosexual.
*79. My child ran away fromhome.
* 80. Did any other problems or important things happen?
No Yes
Continue to rate whether these events happened to your child in the past 12 months and how much effect it had on your child.
Did not
happen
Happened, but
had no effect at
all
Happened,
had a little
effect
Happened, had
somewhat of an
effect
Happened, had
a lot of an
effect
SLES-P: Page 5
Rate:
84. Other event (specify):
If yes to 80, please describe and rate below.
81. Other event (specify):
Rate:
82. Other event (specify):
Rate:
Rate:
83. Other event (specify):
Happened, but
had no effect at
all
Happened,
had a little
effect
Happened, had
somewhat of an
effect
Happened, had
a lot of an
effect
Conflict Behavior Questionnaire - Parent Version
CBQ-P: 11-Apr-2006
Think back over the last 2 weeks at home. The statements below have to do with you and your child. Read the statement, and then decide if you believe the statement is true. If it is true, mark the circle for true, and if you believe the statement is not true, then mark the circle for false. You must mark the circle for either true or false, but never both for the same item. Please answer all items. Answer for yourself, without talking it over with your spouse. Your answers will not be shown to your child.
True False
* 1. My child is easy to get along with.
* 2. My child is receptive to criticism.
* 3. My child is well behaved in our discussions.
* 4. For the most part, my child likes to talk to me.
* 5. We almost never seem to agree.
* 6. My child usually listens to what I tell him/her.
* 7. At least three times a week, we get angry at each other.
* 8. My child says that I have no consideration of his/her feelings.
* 9. My child and I compromise during arguments.
* 10. My child often doesn't do what I ask.
* 11. The talks we have are frustrating.
* 12. My child often seems angry with me.
* 13. My child acts impatient when I talk.
* 14. In general, I don't think we get along very well.
* 15. My child almost never understands my side of an argument.
* 16. My child and I have big arguments about little things.
* 17. My child is defensive when I talk to him/her.
* 18. My child thinks my opinions don't count.
* 19. We argue a lot about rules.
* 20. My child tells me she/he thinks I am unfair.
Please click on "Submit"
Submit
powered by www.psychdata.com
School Sleep Habits Survey - Parent Form
SSHS-P: 11-Apr-2006
There are no right or wrong answers. Be careful to choose one answer that best describes the way your child's sleep hasbeen in the last two school weeks (unless otherwise instructed).
This set of questions has to do with your child's usual schedule on days when he/she has school.
* 1. What time does your son/daughter usually go to bed on school days? (List one time, not a range, such as 9:30, and
indicate AM or PM below.)
* AM PM
* 2. There are many reasons for doing things at one time or another. What is the main reason your child usually goes to bedat this time on school days? (choose one)
* 3. What time does your child usually wake up on school days? (List one time, not a range, such as 9:30, and indicate AM
or PM below.)
* AM PM
* 4. What is the main reason yourchild usually wakes up at this time on school days? (choose one)
He/she feels sleepy
He/she finishes his/her homework
His/her TV shows are over
His/her brother(s) or sister(s) go to bed
He/she finishes socializing
His/her bedtime is a set time
He/she gets home from his/her job
Other (Please Specify):
Noises or a pet wakes him/her up
The alarm clock wakes him/her up
Parents or other family members wake him/her up
He/she needs to go to the bathroom
I don't know; he/she just wakes up
Other (Please Specify)
* 5. Figure out how long your child usually sleep on a normal school night and fill it in here. (Do not include time he/shespends awake in bed. Indicate both hours and minutes as hours:minutes, such as 8:00, even if minutes are zero).
* 6. On school days, after your child goes to bed at night, about how long does it usually take him/her to fall asleep?Indicate your answer in number of minutes.
The next set of questions has to do with your child's usual schedule on days when he/she does not haveschool, such as on the weekend.
* 7. What time does your child usually go to bed on weekends? (List one time, not a range, such as 9:30, and indicate AM or
PM below.)
* AM PM
* 8. There are many reasons for doing things at one time or another. What is the main reason your child usually goes to bedat this time on weekends? (choose one)
* 9. What time does your child usually wake up on weekends? (List one time, not a range, such as 9:30, and indicate AM or
PM below.)
* AM PM
* 10. What is the main reason your child usually wakes up at this time on weekends? (choose one)
He/she feels sleepy
He/she finishes his/her homework
His/her TV shows are over
His/her brother(s) or sister(s) go to bed
He/she finishes socializing
His/her bedtime is a set time
He/she gets home from his/her job
Other (Please Specify):
Noises or a pet wakes him/her up
The alarm clock wakes him/her up
Parents or other family members wake him/her up
He/she needs to go to the bathroom
I don't know; he/she just wakes up
Other (Please Specify)
* 11. Think how long your child usually sleeps on a night when he/she does not have school the next day (such as aweekend night) and fill it in here. (Do not include time he/she spends awake in bed. Indicate both hours and minutes ashours:minutes, such as 8:00, even if minutes are zero).
* 12. On weekends, after he/she goes to bed at night, about how long does it usually take him/her to fall asleep? Indicateyour answer in number of minutes.
SSHS-P: Page 2
* 13. Some people wake up during the night. Others never do. How many times does your child usually wake up at night?
Never
Once
2 or 3 times
More than 3 times
I have no idea
* 14. People sometimes feel sleepy during the daytime. During daytime activities, how much of a problem does your childhave with sleepiness (feeling sleepy, struggling to stay awake)?
No problem at all
A little problem
More than a little problem
A very big problem
15. Some people take naps in the daytime every day, others never do. When does your child nap? (mark all that apply)
He/she never naps
He/she sometimes naps on school days
He/she never naps unless he/she is sick
* 17. In general, do you feel your child usually gets...
too little sleep?
enough sleep?
too much sleep?
* 18. Do you consider your child to be...
a good sleeper?
a poor sleeper?
* 19. How often do you think that your child gets enough sleep?
Never
Rarely
SSHS-P: Page 3
A big problem
He/she sometimes naps on weekends
Sometimes
Usually
Always
Questions 20-29 have to do with how your child might organize the timing of various activities if he/she wasfree to plan his/her day according to when he/she felt best. Please answer the questions based on his/her"feeling best" times.
* 20. Imagine: School is cancelled! He/she can get up whenever he/she wants to. When would he/she get out of bed?Between:
5:00 and 6:30 a.m.
6:30 and 7:45 a.m.
7:45 and 9:45 a.m.
9:45 and 11:00 a.m.
11:00 and noon
* 21. Is it easy for your child to get up in the morning?
No way!
Sort of
Pretty sasy
It's a cinch!
* 22. If gym class is set for 7:00 in the morning, how do you think you child will do?
His/her best!
Okay
Worse than usual
Awful!
* 23. The bad news: Your child has to take a two-hour test. The good news: Your child can take it when he/she thinkshe'll/she'll do the best. What time is that?
8:00 to 10:00 a.m.
11:00 a.m. to 1:00 p.m.
3:00 to 5:00 p.m.
7:00 to 9:00 p.m.
* 24. When does your child have the most energy to do his/her favorite things?
Morning! he/she is tired in the evening.
Evening more than morning.
* 25. You decided to let your child set his/her own bed time. What time would he/she pick? Between:
8:00 and 9:00 p.m.
10:15 p.m. and 12:30 a.m.
SSHS-P: Page 4
1:45 and 3:00 a.m.
* 26. How alert is your child in the first half hour he/she is up?
Out of it
A little dazed
Okay
Ready to take on the world
* 27. When does your child's body start to tell him/her it's time for bed (even if he/she ignores it)? Between:
8:00 and 9:00 p.m.
9:00 and 10:15 p.m.
1:45 and 3:00 a.m.
Morning more than evening.
Evening! He/she is tired in the morning.
12:30 and 1:45 a.m.
12:30 and 1:45 a.m.
10:15 p.m. and 12:30 a.m.
* 28. Say your child had to get up at 6:00 a.m. every morning: What would it be like?
Awful!
Not so great
Okay (if he/she had to)
Fine, no problem!
* 29. When your child wakes up in the morning how long does it take for him/her to be totally "with it"?
0 to 10 minutes
11 to 20 minutes
21 to 40 minutes
More than 40 minutes
Children's Affective Lability Scale - Parent Form
CALS-P: 11-Apr-2006
Directions: Fill in the circle on the scale next to each question that best describes your child's mood.
Never or
rarely
occurs
1-3 times
during the
month
1-3
times a
week
4-6
times a
week
1 or more
times a
day
* 1. Suddenly starts to cry for little or no apparent reason,
more so than other children his/her age.
* 2. It is hard to tell what will set him/her off into a a
blow-up of temper.
* 3. Suddenly becomes tense or anxious.
* 4. Has bursts of being overly affectionate for little
reason, hugging or kissing more than you would expect.
* 5. Suddenly loses interest in what he/she is doing.
* 6. It is hard to tell what mood he/she will be in.
* 7. Suddenly loses his/her temper (may yell, curse, or
throw something) when you would not expect it.
* 8. Has bursts of increased talking.
*
9. Complains of short periods when he/she feels shaky
or his/her heart is pounding, or he/she has difficulty
breathing (not due to asthma or another medical
problem).
* 10. It is hard to tell what will set him/her off crying.
* 11. Has bursts of silliness for little or no apparent
reason.
* 12. Does an activity and then suddenly stops and says
he/she is tired.
* 13. You never know when he/she is going to blow up.
* 14. Has periods of time when he/she talks about the
same thing over and over.
* 15. Suddenly starts to laugh about something that most
people do not think is funny.
* 16. Suddenly appears sad, depressed, and down in the
dumps for no apparent reason.
* 17. Has bursts of being nervous or fidgety.
* 18. Has bursts of crabbiness or irritability.
* 19. Suddenly is overly familiar with people he/she barely
know.
* 20. Appears very angry (yells, uses abusive language) in
response to a simple request.
Please click on "Submit"
Self-Report for Childhood Anxiety Related Disorders - Parent Report (SCARED-P)
SCARED-P: 11-Apr-2006
Instructions
On the next pages are a list of statements that describe how people feel. Read each statement carefully and decide if it is"Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for yourchild. Then for each statement, choose the circle that corresponds to the response that seems to describe your child'sfeelings now or for the last 3 months. Please respond to all statements as well as you can, even if some do not seem toconcern your child.
Please select one choice per statement.
0. Not True or
Hardly Ever True
1. Somewhat True or
Sometimes True
2. Very True or
Often True
* 1. When my child feels frightened, it is hard forhim/her to breathe.
*2. My child get headaches when he/she is atschool.
* 3. My child doesn't like to be with people he/shedoesn't know well.
*4. My child gets scared if he/she sleeps awayfrom home.
* 5. My child worries about other people likinghim/her.
*6. When my child gets frightened, he/she feelslike passing out.
* 7. My child is nervous.
*8. My child follows me wherever I go (he/she islike my shadow).
* 9. People tell my child that he/she looksnervous.
*10. My child feels nervous with people he/shedoesn't know well.
* 11. My child gets stomach aches at school.
*12. When my child feels frightened, he/she feelslike he/she is going crazy.
* 13. My child worries about sleeping alone.
* 14. My child worries about being as good asother kids.
*15. When my child gets frightened, he/she feelslike things are not real.
* 16. My child has nightmares about somethingbad happening to his/her parents.
* 17. My child worries about going to school.
* 18. When my child gets frightened, his/herheart beats fast.
* 20. My child has nightmares about somethingbad happening to him/herself.
Please select one choice per statement.0. Not True or
Hardly Ever
True
1. Somewhat True
or Sometimes True
2. Very
True or
Often True
* 21. My child worries about things working out for him/herself.
* 22. When my child gets frightened, he/she sweats a lot.
* 23. My child is a worrier.
* 24. My child gets really frightened for no reason at all.
* 25. My child is afraid to be alone in the house.
* 26. It is hard for my child to talk with people he/she doesn't knowwell.
* 27. When my child gets frightened, he/she feel like he/she ischoking.
* 28. People tell my child that he/she worries too much.
* 29. My child doesn't like to be away from his/her family.
* 30. My child is afraid of having anxiety (or panic) attacks.
* 31. My child worries that something bad might happen to his/herparents.
* 32. My child feels shy with people he/she doesn't know well.
* 33. My child worries about what is going to happen in the future.
* 34. When my child gets frightened, he/she feels like throwing up.
* 35. My child worries about how well he/she does things.
* 36. My child is scared to go to school.
* 37. My child worries about things that have already happened.
* 38. When my child gets frightened, he/she feels dizzy.
*39. My child feels nervous when he/she is with other children oradults and he/she has to do something while they watch him/her(for example: read aloud, speak, play a game, play a sport.)
*40. My child feels nervous when he/she is going to parties, dances,or any place where there will be people that he/she does not knowwell.
* 41. My child is shy.
19. My child gets shaky.*
SCARED-P: Page 2
DBD Rating Scale
DBD: 11-Apr-2006
INSTRUCTIONS: Read each item below carefully and fill in the circle in the column that represents your choice; do not mark between two choices. Please be sure to answer every item. In the PAST 4 WEEKS have you noticed that your child...
Not
at all
Just a
little
Pretty
much
Very
much
* 1. Fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
* 2. Has difficulty sustaining attention in taks or play activities
* 3. Does not seem to listen to what is being said to him or her
*
4. Does not follow through on instructions and fails to finish schoolwork, chores,
or duties in the workplace (not due to oppositional behavior or failure to
understand
* directions)
* 5. Has difficulty organizing tasks and activities
* 6. Avoids, expresses reluctance about, or has difficulties engaging in tasks that
require sustained mental effort (such as schoolwork or homework)
* 7. Loses things necessary for tasks or activities (e.g., school assignments, pencils,
books, tools, or toys)
* 8. Is easily distracted by extraneous stimuli
* 9. Is forgetful in daily activities
* 10. Fidgets with hands or feet or squirms in seat
* 11. Leaves seat in classroom or in other situations in which remaining seated is
expected
* 12. Runs about or climbs excessively in situations where it is inappropriate
* 13. Has difficulty playing or engaging in leisure activities quietly
* 14. Is always "on the go" or acts as if "driven by a motor"
* 15. Talks excessively
* 16. Blurts out answers to questions before the questions have been completed
* 17. Has difficulty waiting in lines or awaiting turn in games or group situations
* 18. Interrupts or intrudes on others
* 19. Loses temper
* 20. Argues with adults
--------------------------------------Page Break--------------------------------------
Continue to mark whether in the PAST 4 WEEKS have you noticed that your child...
Not at
all
Just a
little
Pretty
much
Very
much
* 21. Actively defies or refuses adult requests or rules
* 22. Does things that deliberately annoy people
* 23. Blames others for his or her mistakes or misbehavior
* 24. Is touchy or easily annoyed by others
* 25. Is angry and resentful
* 26. Is spiteful or vindictive
* 27. Often bullies or intimidates others
* 28. Often initiates physical fights
* 29. Used a weapon that can cause serious physical harm to others (e.g., a bat,
brick, broken bottle, knife, gun)
* 30. Been physically cruel to people
* 31. Been physically cruel to animals
* 32. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion,
armed robbery)
* 33. Forced someone into sexual activity
* 34. Deliberately engaged in firesetting with intention of causing serious damage
* 35. Deliberately destroyed others' property (other than by firesetting)
* 36. Broken into someone else's house, building, or car
* 37. Lies to obtain goods or favors or to avoid obligations (i.e. "cons" others)
* 38. Stolen items of nontrivial value without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery)
* 39. Stays out at night despite parental prohibitions, beginning before age 13
* 40. Run away from home overnight at least twice while living in parental home or
parental surrogate home (or once without returning for a lengthy period)
* 41. Often truant from school, beginning before age 13
Please click on "Submit"
Submit
CHI - Parent
CHI-P: 11-Apr-2006
Please mark the choice next to each item which describes something your child does/ Fill in FALSE beside each item whichdoes not apply to your child's behavior, or TRUE if it does apply to your child's behavior. Please check one answer, eitherTrue or False, for every item.
True False
* 1. He/she only hits back once in a while, even if someone hits him/her first.
* 2. He/she sometimes says bad things about people he/she doesn't like.
* 3. He/she thinks that people often say bad things about him/her behind his/her back.
* 4. Once in a while he/she cannot control his/her wanting to harm others.
* 5. He/she never gets mad enough to throw things.
* 6. He/she thinks other people always seem to have good things happening to them.
* 7. Sometimes people bug him/her just by being around.
* 8. When someone makes a rule my child doesn't like, he/she would often like to break it.
* 9. At times he/she feels as if more bad things happen to him/her than other people.
* 10. He/she sometimes has bad thoughts which make him/her feel bad about him/herself.
* 11. He/she cannot think of a good reason for ever hitting anyone.
* 12. When someone is bossy, he/she doesn't do what that person asks.
* 13. He/she is usually madder than most people realize.
* 14. He/she doesn't know anyone that he/she really hates.
* 15. He/she can't help getting into arguments when others don't agree with him/her.
* 16. He/she thinks people who don't do their work must feel very guilty.
* 17. When he/she is mad, he/she sometimes slams doors.
* 18. He/she can always wait for others.
* 19. Occasionally, when he/she is mad at someone, he/she will not talk to them.
* 20. He/she would feel that anyone making fun of him/her or his/her family is asking for a fight.
* 21. It makes him/her very upset to have someone make fun of him/her.
* 22. Almost every week he/she see someone he/she dislikes.
* 23. He/she thinks that people who are always bugging others are asking for a punch in the nose.
* 24. He/she often feels like a bomb ready to explode.
* 25. When people yell at him/her, he/she yells back.
* 26. He/she does many things that make him/her feel bad afterwards.
* 27. When he/she really gets mad, he/she is able to hit someone.
* 28. He/she has never had a temper tantrum.
* 29. He/she often thinks about what reasons another person may have for doing something nice for him/her.
* 30. He/she could not yell at someone, even if they needed it.
* 31. He/she can remember being so mad that he/she picked up the nearest thing and broke it.
* 32. He/she often says things he/she doesn't really mean to say.
* 33. He/she doesn't know anyone who really would wish to harm him/her.
* 34. He/she used to think that most people told the truth, but he/she doesn't anymore.
* 35. He/she usually hides his/her bad thoughts about others.
* 36. When he/she does something wrong, he/she thinks he/she is a really bad person.
* 37. If someone doesn't treat him/her right, he/she doesn't let it bug him/her.
* 38. He/she would rather agree with someone than get into an argument about it.
True False
CHI-P: Page 2
Thank you for participating!
Just another couple of simple questions. First, approximately how long in minutes did it take you to complete these
surveys?
How much work was it to fill out these surveys?
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Did you find the process of filling out these questionnaires upsetting at all?
No, not upsetting at all
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A moderate number of the questions were upsetting
Many of the questions were upsetting
Very upsetting through most of the questions
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