THE CHILD AND ADOLESCENT

PSYCHIATRIC ASSESSMENT

(CAPA)

Child Interview
Version 5.0
ADRIAN ANGOLD, MRCPsych

Developmental Epidemiology Program

Department of Psychiatry and Behavioral Sciences, Duke University
Durham, North Carolina 27710-3454

ANTHONY COX, FRCPsych

MICHAEL PRENDERGAST, MRCPsych
MICHAEL RUTTER, MD, FRS
EMILY SIMONOFF, MRCPsych
MRC Child Psychiatry Unit
Institute of Psychiatry
London SE5 8AF England

Revised CAPA Mania Section Module Contributors

Joan Luby & Melissa Meade Stalets

October 2008
A Angold, A Cox, M Prendergast, M Rutter, E Simonoff
Copyright (1987,1990,1992,1994,1996,1998)
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

INTERVIEW #

CAA3X01
INTERVIEWER PVIEWER

LY
N
CAP0X01
PINTLOC
FIRST DAY OF PRIMARY PERIOD

O
/ /
CAQ1D01

TIME AT BEGINNING OF INTERVIEW

EW
VI

TIME AT END OF INTERVIEW :

RE
R
FO

1
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

QUALITY OF INTERVIEW
CQA9X01
Code your subjective impression as to the quality of the Quality of interview
information collected during the interview. The subject
may have refused to provide adequate descriptions of Adequacy of Interview
symptoms or been deliberately misleading on occasion.
CQA9X02

Misleading Answers or Lies

0= Adequate

LY
2= The interview is inadequate, in relation to the specified area,
CQA9X03
only in certain parts of the interview. Note the section where data Did Not Answer Many Questions
is probably inadequate. Verbally

N
3= The whole interview is inadequate.
CQA9X04
Guarded Informant

O
EW Refused to Continue CQA9X05

Impaired Consciousness CQA9X06

VI

Intoxicated with Alcohol or Drugs

RE

CQA9X07

Unsuitable Interview Environment

CQA9X08
R
FO

Interviewer Comments
________________________________
________________________________
________________________________
________________________________

2
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

SUBJECT

CAA0X01
PSEX
GENDER
M=Male
F= Female

LY
CAA1O01
DATE OF BIRTH DOB

N
ETHNIC ORIGIN
1=African American
2= American Indian or Alaskan Native

O
3= Asian or Pacific Islander
4= Hispanic
5= Other
6= White (European or Middle Eastern)
EW CEE4X01

BIRTH WEIGHT ( pounds/ounces)

/
CEE4D01
VI

GESTATIONAL AGE (Weeks)

RE

CURRENT WEIGHT

CURRENT HEIGHT
R
FO

CAP7I01
LANGUAGE SPOKEN AT HOME
1= English
2= Spanish
3= Other
CAP9X01

AGE AT ADOPTION (Years and Months) :

3
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

v PARENTAL FIGURES

CAB2X01
BIOLOGICAL PARENTS MARITAL STATUS
1= Married
2= Widowed
3= Separated
4= Divorced
5= Cohabited>6 months

LY
6= Cohabited<6 months
7= Never cohabited CAB3F01

YEARS BIOLOGICAL PARENTS LIVED TOGETHER

N
CAB5X01

O
PARENT #1: Name___________________________
1= Biological parent
2= Adoptive parent
3= Step parent
4= Live-in partner of one parent (> 6 months)
5= Live-in partner of one parent (<6 months)
EW
6= Grandparent
7= Other relative
10= Foster parent
11= Unrelated adult serving as parent
12= Deceased biological parent
VI

13= Deceased non-biological parent CAB5X02

Gender
M= Male
RE

F= Female
CAB5X03
AGE

EDUCATION
1= 0-8 years completed
R

CSA0X01
2= Some high school
3= GED or high school equivalency
4= High school degree
FO

5= Post high-school training (vocational, technical, job

training)
6= Some college (0-2 years)
7= 2 year associate degree
8= Some college (2-4 years)
9= 4 year college degree
10= Some graduate or professional school training
11= Completed graduate or professional degree

4
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

Parental Employment and Occupation

Parent #1
CSA1X01
Current Employment Status
1= Employed full-time
2= Employed full-time and part-time
3= Employed part-time (1 or more jobs)

LY
4= Not employed outside of the home
5= Student
6= Retired
7= Disabled
8= Unemployed

N
CSA1X02
Type of Employment (Current or most recent)

O
1= Employee of private business
2= Government employee
3= Self-employed
4= Working without pay
EW CSA1X03

Occupation (Current or most recent)

Enter code from Census Index of Occupations

CSA1X04
VI

Industry (Current or most recent)

Enter code from Census Index of Occupations
RE

CSA2O01
Date Last Employed
Code if not employed at the time of the interview
/ /
R
FO

5
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

v PARENTAL FIGURES

CAB6X01
PARENT #2: Name___________________________
1= Biological parent
2= Adoptive parent
3= Step parent
4= Live-in partner of one parent (> 6 months)
5= Live-in partner of one parent (<6 months)

LY
6= Grandparent
7= Other relative
10= Foster parent
11= Unrelated adult serving as parent CAB6X02
12= Deceased biological parent

N
13= Deceased non-biological parent

Gender

O
M= Male
F= Female

AGE
EW CAB6X03

EDUCATION
1= 0-8 years completed
2= Some high school CSA0X02
3= GED or high school equivalency
4= High school degree
VI

5= Post high-school training (vocational, technical, job

training)
6= Some college (0-2 years)
7= 2 year associate degree
RE

8= Some college (2-4 years)

9= 4 year college degree
10= Some graduate or professional school training
11= Completed graduate or professional degree
R
FO

6
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

Parental Employment and Occupation

Parent #2
CSA3X01
Current Employment Status
1= Employed full-time
2= Employed full-time and part-time
3= Employed part-time (1 or more jobs)

LY
4= Not employed outside of the home
5= Student
6= Retired
7= Disabled
8= Unemployed

N
CSA3X02
Type of Employment (Current or most recent)

O
1= Employee of private business
2= Government employee
3= Self-employed
4= Working without pay
EW CSA3X03

Occupation (Current or most recent)

Enter code from Census Index of Occupations

CSA3X04
VI

Industry (Current or most recent)

Enter code from Census Index of Occupations
RE

CSA4O01
Date Last Employed
Code if not employed at the time of the interview / /
R
FO

7
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

v PARENTAL FIGURES

CAB7X01
OTHER PARENT #1: Name___________________________
1= Biological parent
2= Adoptive parent
3= Step parent
4= Live-in partner of one parent (> 6 months)
5= Live-in partner of one parent (<6 months)

LY
6= Grandparent
7= Other relative
10= Foster parent
11= Unrelated adult serving as parent CAB7X02
12= Deceased biological parent

N
13= Deceased non-biological parent

Gender

O
M= Male
F= Female CAB7X03

AGE
EW
EDUCATION CSA0X03
1= 0-8 years completed
2= Some high school
3= GED or high school equivalency
4= High school degree
VI

5= Post high-school training (vocational, technical, job

training)
6= Some college (0-2 years)
7= 2 year associate degree
RE

8= Some college (2-4 years)

9= 4 year college degree
10= Some graduate or professional school training
11= Completed graduate or professional degree
R
FO

8
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

Parental Employment and Occupation

Other Parent #1
CSA5X01
Current Employment Status
1= Employed full-time
2= Employed full-time and part-time
3= Employed part-time (1 or more jobs)

LY
4= Not employed outside of the home
5= Student
6= Retired
7= Disabled
8= Unemployed

N
CSA5X02
Type of Employment (Current or most recent)

O
1= Employee of private business
2= Government employee
3= Self-employed
4= Working without pay
EW CSA5X03

Occupation (Current or most recent)

Enter code from Census Index of Occupations

CSA5X04
VI

Industry (Current or most recent)

Enter code from Census Index of Occupations
RE

CSA6O01
Date Last Employed
Code if not employed at the time of the interview / /
R
FO

9
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

v PARENTAL FIGURES

CAB8X01
OTHER PARENT #2: Name___________________________
1= Biological parent
2= Adoptive parent
3= Step parent
4= Live-in partner of one parent (> 6 months)
5= Live-in partner of one parent (<6 months)

LY
6= Grandparent
7= Other relative
10= Foster parent
11= Unrelated adult serving as parent
12= Deceased biological parent

N
13= Deceased non-biological parent CAB8X02

Gender

O
M= Male
F= Female

AGE
EW CAB8X03

EDUCATION
1= 0-8 years completed CSA0X04
2= Some high school
3= GED or high school equivalency
4= High school degree
VI

5= Post high-school training (vocational, technical, job

training)
6= Some college (0-2 years)
7= 2 year associate degree
RE

8= Some college (2-4 years)

9= 4 year college degree
10= Some graduate or professional school training
11= Completed graduate or professional degree
R
FO

10
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

Parental Employment and Occupation

Other Parent #2
CSA7X01
Current Employment Status
1= Employed full-time
2= Employed full-time and part-time
3= Employed part-time (1 or more jobs)

LY
4= Not employed outside of the home
5= Student
6= Retired
7= Disabled
8= Unemployed

N
CSA7X02
Type of Employment (Current or most recent)

O
1= Employee of private business
2= Government employee
3= Self-employed
4= Working without pay
EW CSA7X03

Occupation (Current or most recent)

Enter code from Census Index of Occupations

CSA7X04
VI

Industry (Current or most recent)

Enter code from Census Index of Occupations
RE

CSA8O01
Date Last Employed
Code if not employed at the time of the interview
/ /
R
FO

11
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

SIBLINGS CAA6X01

Siblings 1.______________________________
1= Full Sib CAA6X02
2= Half Sib
3= Step Sib
4= Adopted Sib
5= Unrelated Child CAA6X03
6= Other related child (e.g. cousin, aunt)

LY
7= Biological parent living in the home but non-
functional in the parental role
CAA6X04
Sex of Sibling
M= Male

N
F= Female
CAA6X05
Age

O
Sibling Living In the Home 2.______________________________
0= Live at home at least 1 month
CAA6X06
2= Live away from home
EW
CAA6X07
VI

CAA6X08
RE

CAA6X09
3.______________________________

CAA6X10
R
FO

CAA6X11

CAA6X12

12
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

SIBLINGS CAA6X13

Siblings 4.______________________________
1= Full Sib CAA6X14
2= Half Sib
3= Step Sib
4= Adopted Sib
5= Unrelated Child CAA6X15
6= Other related child (e.g. cousin, aunt)

LY
7= Biological parent living in the home but non-
functional in the parental role
CAA6X16
Sex of Sibling
M= Male

N
F= Female
CAA6X17
Age

O
Sibling Living In the Home 5.______________________________
0= Live at home at least 1 month
CAA6X18
2= Live away from home
EW
CAA6X19
VI

CAA6X20
RE

CAA6X21
6.______________________________

CAA6X22
R
FO

CAA6X23

CAA6X24

13
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

SIBLINGS CAA6X25

Siblings 7.______________________________
1= Full Sib CAA6X26
2= Half Sib
3= Step Sib
4= Adopted Sib CAA6X27
5= Unrelated Child
6= Other related child (e.g. cousin, aunt)

LY
7= Biological parent living in the home but non-
functional in the parental role CAA6X28

Sex of Sibling
M= Male

N
F= Female

Age CAA6X29

O
Sibling Living In the Home 8.______________________________
0= Live at home at least 1 month
CAA6X30
2= Live away from home
EW
CAA6X31
VI

CAA6X32
RE

9.______________________________ CAA6X33

CAA6X34
R
FO

CAA6X35

CAA6X36

14
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

MULTIPLE BIRTH
CAA7X01
Twin
IDENTICAL/NON-IDENTICAL
1= Identical
2= Non-identical (fraternal)
CAA7X02
3= other multiple
Triplet

LY
CAA7X04
Other Multiple

N
O
CAA7X03
BIRTH ORDER IN MULTIPLE BIRTH
1= First born
2= Second born
EW Birth Order

3= Third born
VI
RE
R
FO

15
Child and Adolescent Psychiatric Assessment

Definitions and questions Codes

OTHERS IN HOUSE List respondent first
CAA8X01

1.______________________________
Status
CAA8X02
1= Biological parent
2= Adoptive parent
3= Step parent 2.______________________________
4= Live-in partner of one parent (> 6 months)
5= Live-in partner of one parent (<6 months)

LY
CAA8X03
6= Grandparent
7= Other relative
8= Paying boarder 3.______________________________
9= Other
10= Foster Parent

N
CAA8X04

4.______________________________

O
CAA8X05

EW 5.______________________________

CAA8X06

6.______________________________
VI

CAA8X07
RE

7.______________________________

CAA8X08

8.______________________________
R

CAA8X09
FO

9.______________________________

CAA8X10

10._____________________________

16
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PRESENTING PROBLEMS

The initial section of the interview is designed

to set the subject at ease, to obtain "scene-
setting" information, and to allow the subject to
express his/her concerns. The interviewer
should follow the subject's leads and should
avoid premature intrusive cross-questioning.

LY
WHETHER DIFFICULTIES (CHILD'S
PERCEPTION)
How come you're here at the clinic? WHETHER DIFFICULTIES (PARENT'S CAP0I01
PERCEPTION) Intensity

N
Do you know why you're goin to the clinic? 0 = None

Who's idea was it that you go to the clinic? 1 = Yes, but not more than most children

O
2 = Yes, but vague or indefinite
specification

3 = Yes, definite

TYPE OF PROBLEM (CHILD'S PERCEPTION)

EW
Do you think you've got any difficulties or problems for TYPE OF PROBLEM (PARENT'S CAP0X02
which you need help or advice? PERCEPTION) Intensity
0 = No
What are they?
MAKE A BRIEF LIST OF DIFFICULTIES/PROBLEMS 2 = Emotional Problems
VI

3 = Conduct Problems

4 = Drug/Alcohol Problems

5 = Overactivity/inattention Problems
RE

6 = School Non-Attendance

7 = Learning Problem

8 = Family Relationships Problem

9 = Other
R
FO

Presenting Problems 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FAMILY SECTION
FAMILY STRUCTURE AND FUNCTION

This section has five major functions;

(1) ESTABLISHING RAPPORT BETWEEN THE

INTERVIEWER AND THE INTERVIEWEE. The
better the rapport between the interviewer and

LY
the interviewee, the better the material
collected by the interview is likely to be. Good
rapport also makes the interview much more
pleasant for both parties and improves the flow
of information. The interviewer should appear
friendly, alert, and interested, but without being

N
too obviously intrusive. The interviewee should
be allowed to talk, and not over-energetically
harried with questions. As far as possible the

O
child's interests and activities should be
positively connoted, and a non-censorious
attitude to his/her limitations and attitudes
should be adopted. Attention should be paid to
the maintenance of rapport throughout the
EW
interview, but the early stages are especially
important in setting the tone for the rest of the
session.

(2) ESTABLISHING THE STYLE OF THE

INTERVIEW. At the start of the interview, the
VI

interviewee does not know what to expect of it,

or what sort of information s/he is being asked
to provide. The early stages of the interview are
therefore important in providing an opportunity
for the interviewee to learn what is required.
RE

(3) COLLECTING INFORMATION ABOUT

FAMILY STRUCTURE, LIFE AND
RELATIONSHIPS. This section represents an
extension of the original family life and
relationship section for use when more detailed
information is required. A number of ratings are
R

made of dimensions of family function and

dysfunction that have been found to be related
to child psychopathology in many studies.
FO

Many of these items are modified versions of

material contained in the Child Life Events and
Long-term Environment Adversity (CLELEA)
interview, developed at the Institute of
Psychiatry by Seija Sandberg and Micheal
Rutter.

(4) FINDING ENTERIES TO OTHER SECTIONS

OF THE INTERVIEW. This section is likely to
throw up indications of areas of pathology,
which may then be followed up.

Family Section 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

(5) COLLECTING INFORMATION RELEVANT TO

THE INCAPACITY RATINGS. Many of the
questions in these sections are directly
relevant to the ratings of Incapacity. It is
important, right from the start of the interview,
that the interviewer should be thinking about
disturbance at the level both of symptoms and
incapacity.

LY
ORGANIZATION OF THE SECTION

The section is organized into 4 sub-areas:

N
(1) Family structure

(2) Family life and relationships

O
(3) Relationships with parents

(4) Relationships with siblings EW

VI
RE
R
FO

Family Section 2
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FAMILY STRUCTURE

SIBLINGS

In this context, "siblings" include all children

(or adults 18 or older) of the parents or parent
substitutes who are responsible for the child,
whether they are related by blood or not, and

LY
are listed in order of age (oldest first).
Therefore, half-siblings and other children by
previous marriages who may not be
biologically related to the index child are
included, as are "adoptive siblings" (which can
mean that either the sibling or the child is

N
adopted). This item includes siblings who
either live or do not live at home with the index
child. At this stage in the interview, the focus is

O
on forming a picture of the current home
environment of the child, with some
understanding of the complications of the
wider family group. EW
For each sibling, note name, relationship to
child, sex, age, and whether the sibling has
been in the home for one month of the primary
period.

Newborns need not have lived in the home one

VI

month to be recorded as living in the home.

For siblings less than 1 year old, mark 0 for

age.
RE

A half sibling is one who shares one common

parent with the child. For example, a mother
who remarries and has another child with her
new husband; the half-siblings would both
have the same mother.
R

A step sibling, is related to the child by

marriage only, and shares no biological parent
with the child
FO

MULTIPLE BIRTH

Note whether the target child is the product of a

multiple birth. Code whether the parent
believes the child to be an identical or non
identical twin (or triplet, etc.). The child's
position in that birth is then coded. A first born
twin is coded as 1, even if s/he has older
siblings.

Family Section 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

Make a note of the evidence for identical/non

identical status.

Code the details of the birth order here only if

the child is the result of a multiple birth.

OTHERS IN THE HOUSE

LY
Note here the name and status of any adult
(other than adult siblings) who has lived in the
house for at least 1 month during the previous
three months.

N
Some families have very complicated patterns
of relationships, and some children may have
lived in various places during the three month
primary period. The basis for these codings

O
should be the site where the child has lived for
the greatest proportion of the primary period,
provided that there was at least one parental
figure (that is, one who assumed some EW
responsibility for attempting to control the
behavior and discipline of the child) in the
household during that time.

If the child has not lived at home for at least 1

month during the primary period, complete the
Family Section on the last one-month period
VI

that s/he did live at home. If two different family

placements of at least one month's duration
have occurred during the primary period, the
codings are made for the longest lasting of
these. If there have been two placements of
RE

equal duration, the more recent is the basis for

coding.

If there are more than ten others in the house,

omit those who are the least closely related to
the child. If further discrimination is required,
R

omit those who have been there for the least

time.
FO

AGE AT ADOPTION

Enter the age (in years and months) at which

the child was adopted by the current family, or
the age at which a child is legally adopted by a
step-parent.

FOSTER CARE

Family Section 4
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

If child has ever been in foster care, code the

number of foster homes and the earliest date of
placement.

If child is currently in foster care, code the date

of placement in that home.

BIOLOGICAL PARENTS' MARITAL STATUS

LY
This item refers to the biological parents' latest
marital status. Thus, if a couple lived together
for a year, were then married for 5 years before
being divorced, they would be coded 4

N
(Divorced).

If biological parents have a common law

marriage (i.e. have cohabited for a period that

O
the state determines is common law marriage)
then code marital status as cohabited > 6
months.

Biological parents who prefer to live apart or

are legally separated are coded as separated.
EW
Note that this item refers only to the biological
parents, and so does not necessarily refer to
those who now "parent" the child.
VI

NUMBER OF YEARS BIOLOGICAL PARENTS

LIVED TOGETHER

The number of years that the biological parents

RE

lived together, regardless of marital status.

Include the years that the child's biological
parents lived together unwed, or the time
biological parents lived together before getting
married.

PARENTAL FIGURES
R

The term Parent refers to any adult who has

lived in the child's home for at least 1 month,
FO

who assumes some responsibility for

attempting to control the behavior and
discipline of the child. Thus, a parent's live-in
partner is regarded as a parent if s/he is
involved in any way in providing discipline or
care for the child.

Family Section 5
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

For the entire Family Functioning Section,

Parent #1 and Parent #2 refer to parental
figures in the home who have lived with the
child for at least 1 month in the 3 months being
used in the family section. These are coded
here as parental figures in the home.

Other Parent #1 and Other Parent #2 refer to

parents who no longer live in the home. These

LY
may include biological parents, adoptive
parents, step parents, or other "parents" who
have had an impact on the child's upbringing.
These are coded here as parental figures living
elsewhere.

N
This section clarifies who are coded throughout
the interview as Parent #1, Parent #2, Other

O
Parent #1, and Other Parent #2. #1 and #2 are
used in order to allow coding of atypical
combinations of parents (two of the same sex
as in having had two previous step-fathers, gay
or lesbian parental relationships, or people who
EW
are not married as in mother and grandfather).

For the entire Family Functioning Section the

mother and father refer to parental figures in
the home, except as noted below. Information
on who lives in the family home is coded
VI

separately under Others in Family Home. The

relationship between the "parents" in the home
is coded separately under Parental
Relationships. The Marital Status of the
Biological Parents is coded separately as well.
RE

Examples of Codings of Parental Figures:

CHILD IN HOME WITH BOTH BIOLOGICAL

PARENTS
R

If the child lives with both biological parents,

code them throughout the section as Parent #1
and Parent #2.
FO

If the biological parents have separated or

divorced within the primary period and the
parent now living elsewhere was in the family
home for at least 1 month, code the biological
parents as Parent #1 and Parent #2.

Family Section 6
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CHILD IN HOME WITH ONE BIOLOGICAL

PARENT: If the child lives with one biological
parent and a new partner who serves as a
parent, and the other biological parent lives
elsewhere, code the parent and the new partner
as Parent #1 and Parent #2 respectively. Code
the other biological parent living elsewhere as
Other Parent #1.

LY
If the child lives with one biological parent who
does not have a new partner who serves as
parent, code that parent at Parent #1, and the
absent biological parent as Other Parent #1. As
the child may have had very little contact with

N
the biological parent living elsewhere, some of
the questions may not be applicable and
should be coded 'structurally missing'.

O
If the biological parents are separated or
divorced and share custody of the child exactly
50/50. The mother counts as Parent #1 and her
home is the home used for the section. If the
mother is unavailable to interview, and the
EW
father is available, the father is coded as Parent
#1 with his home being used for the home
section, and the mother becomes other Parent
#1.
VI

CHILD IN HOME WITH NO BIOLOGICAL

PARENT: If the child lives with
adoptive/foster/step parents, both of whom are
involved in parenting the child, code them as
Parent #1 and Parent #2. If the child has any
RE

knowledge of or contact with the biological

parents, code them as Other Parent #1 and
Other Parent #2.

If only one adoptive/foster/step parent is in the

home, with no current partner who parents,
code him/her as Parent #1. Code the absent
R

biological parents as Other Parents #1 and #2.

If Parent #1's previous partner (who is not
biological parent) served as a parent and is still
FO

involved in the child's life, you may choose to

code him/her as an Other Parent, instead of a
biological parent with whom the child has no
contact.

If the child lives with another adult (e.g.,

grandmother, aunt, non-related person) who
has a partner who serves as a parent, code
them as Parent #1 and Parent #2. Code the
absent biological parents as Other Parents #1
and 2.

Family Section 7
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Definitions and questions Coding rules Codes

If the child lives with another adult (e.g.

grandmother, aunt, non-related person) who
has no partner, code that adult as Parent #1.
Code the absent biological parents as Other
Parent #1 and #2.

Code aunts/grandparent/adult siblings as

parents ONLY if they are acting as parent,
instead of the mother or father. For instance, if

LY
the child lives with his/her biological mother
and grandmother, but the latter does not act as
a parent, as defined above, the grandmother
would not count as Parent #2.

N
CHILD WITH DECEASED PARENT(S): If the
child's parent(s) died during the primary period,
code the parent as deceased. However,

O
because the parent(s) was alive for at least part
of the primary period, code information relevant
to the child's relationship with that parent
wherever possible throughout the Family
Section.
EW
If the child's parent(s) died prior to the primary
period, code as deceased and complete the
following items on the deceased parent: ethnic
origin/race of biological parent, parental
psychological problems, parental substance
VI

abuse problems, and parental arrests and

prosecutions. For the age of deceased parents,
code the age at time of death.
RE
R
FO

Family Section 8
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Definitions and questions Coding rules Codes

ETHNIC ORIGIN/RACE

This refers to the ethnic origin of each

biological parent and the child. These
categories have been established by the
Federal Government for all Federal Grants.

AI= American Indian or Alaskan Native. A

LY
person having origins in any of the original
peoples of North America, and who maintains a
cultural identification through tribal affiliation
or community recognition.

N
AS= Asian or Pacific Islander. A person having
origins in any of the original peoples of the Far
East, Southeast Asia, the Indian subcontinent,
or the Pacific Islands. This area included China,

O
India, Japan, Korea, the Philippine Island and
Samoa.

BL= African-American/Black African. A person EW

having origins in any of the black racial groups
of Africa.

HI= Hispanic. A person of Mexican, Puerto

Rican, Cuban, Central or South American, or
other Spanish culture or origin, regardless of
race.
VI

WH= White (European or Middle Eastern). A

person having origins in any of the original
peoples of Europe, North Africa, or the Middle
RE

East.

OT= Other. A person of a previously

unspecified origin or a person insisting of a
cultural indentification of mixed origins.

ETHNIC ORIGIN/RACE: BIOLOGICAL MOTHER

R

NOTE: RACE ALWAYS PRESENT. ETHNIC ORIGIN/RACE CUB3I01

Intensity
0 = Absent
FO

2 = Present

Is your biological mother Spanish, Hispanic, or Latino? SPANISH, HISPANIC, OR LATINO: CUB3X01
BIOLOGICAL MOTHER

0 = Absent

2 = Present

Family Section 9
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What race is your biological mother, the mother who ETHNIC ORIGIN/RACE: BIOLOGICAL CUB3X02
gave birth to you? You can choose more than one race. MOTHER

1 = American Indian or Alaska Native

Is she American Indian or Alaskan Native?
2 = Asian CUB3X03
Is she Asian?
3 = Native Hawaiian or Other Pacific
Islander
African-American or Black African? CUB3X04
4 = Black or African American

LY
White, that is, of European, Middle Eastern, or North
5 = White
African origin?
6 = Some Other Race CUB3X05
Native Hawaiian or other Pacific Islander?

Some other race that I have not mentioned?

N
CUB3X06

O
CUB3X07

ETHNIC ORIGIN/RACE: BIOLOGICAL FATHER

EW
NOTE: RACE ALWAYS PRESENT. ETHNIC ORIGIN/RACE CUB4I01
Intensity
0 = Absent

2 = Present

Is your biological father Spanish, Hispanic, or Latino? SPANISH, HISPANIC, OR LATINO: CUB4X01
VI

BIOLOGICAL FATHER

0 = Absent

2 = Present
RE
R
FO

Family Section 10
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Definitions and questions Coding rules Codes

What race is your biological father of you? You can ETHNIC ORIGIN/RACE: BIOLOGICAL CUB4X02
choose more than one. FATHER

1 = American Indian or Alaska Native

Is he American Indian or Alaskan Native?
2 = Asian CUB4X03
Is he Asian?
3 = Native Hawaiian or Other Pacific
Islander
African-American or Black African? CUB4X04
4 = Black or African American

LY
White, that is, of European, Middle Eastern, or North
5 = White
African origin?
6 = Some Other Race CUB4X05
Native Hawaiian or other Pacific Islander?

Is he some other race that I have not mentioned?

N
CUB4X06

O
CUB4X07

ETHNIC ORIGIN/RACE: CHILD

EW
NOTE: RACE ALWAYS PRESENT. ETHNIC ORIGIN/RACE CUB5I01
Intensity
0 = Absent

2 = Present

Are you Spanish, Hispanic, or Latino? SPANISH, HISPANIC, OR LATINO: CUB5X01

VI

CHILD

0 = Absent

2 = Present
RE
R
FO

Family Section 11
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What race are you. You can choose more than one. ETHNIC ORIGIN/RACE: CHILD CUB5X02
1 = American Indian or Alaska Native
Are you American Indian or Alaskan Native?
2 = Asian
Or Asian? CUB5X03
3 = Native Hawaiian or Other Pacific
Islander
African-American or Black American?
4 = Black or African American CUB5X04
White, that is, of European, Middle Eastern, or North

LY
African origin? 5 = White

6 = Some Other Race

Native Hawaiian or other Pacific Islander? CUB5X05

Some other race that I have not mentioned?

N
CUB5X06

O
CUB5X07

ADOPTION
EW
Were you ever adopted? ADOPTION CAA9X99
Intensity
0 = No
What age were you when you were adopted?
2 = Yes

MONTHS CAA9X01
VI

Duration
RE
R
FO

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FOSTER CARE
Have you ever been in foster care? FOSTER CARE Ever:CAB1I01
Intensity
0 = No
How long have you been in this foster home?
2 = Yes
How many foster homes have you been in?
FOSTER CARE CAB1E01
When did you first go into a foster home? Intensity
0 = No

LY
How long have you been with your current foster parent(s)? 2 = Yes

What is the total amount of time spent in all foster care? NUMBER OF FOSTER HOMES Ever:CAB1F01

N
DATE OF FOSTER PLACEMENT Ever:CAB1O01

/ /

O
DATE OF CURRENT FOSTER CAB0O01
PLACEMENT
/ /
YEARS CAB1D01
EW
MARITAL RELATIONSHIP
A Marital Relationship is either a legal marriage or any LIVING AT HOME PAB9I01
continuing relationship that has lasted at least six months. Intensity
VI

0 = Absent
In both cases, the relationship must have been ongoing
during the last 3 months, with the partners living together in 2 = Present
the same home for at least one month of that period.
RE

N.B. Include homosexual partnerships if they fulfill the

above criteria.

In the absence of a Marital Relationship, complete the

ratings for an Exclusive Partnership, if appropriate.
R
FO

Family Section 13
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RELATIONSHIP BETWEEN PARENT 1 AND

OTHER(S)
EXCLUSIVE PARTNERSHIP
Any exclusive relationship that has been ongoing for at EXCLUSIVE PARTNERSHIP PAC0I01
least 3 months and has continued for some period during Intensity
0 = Absent
the preceding 3 months; and that has involved the partner
in visiting the child's home for at least 10 hours per week. 2 = Present

LY
DATING
A relationship that fulfills the criteria for an Exclusive DATING PAC1I01
Partnership, except that it does not meet the 10 hr. time Intensity
0 = Absent
criterion.

N
2 = Present

O
FAMILY LIFE AND RELATIONSHIPS
GET A GENERAL PICTURE OF LIFE IN THE HOME, LIVING AT HOME CAC2I01
FOLLOWING ANY LEADS PROVIDED BY THE SUBJECT Intensity
0 = Present
IN GIVING INFORMATION ON THE HOUSEHOLD. EW 2 = Absent
REMEMBER THIS INFORMATION MAY BE IMPORTANT NUMBER OF WEEKS LIVING AT HOME CAC2F01
FOR INCAPACITY RATINGS; AVOID A PATHOLOGY IN THE LAST THREE MONTHS
FOCUS AT THIS STAGE, BUT ENSURE THAT THE
AREAS IMPLICIT IN THE QUESTIONS BELOW ARE
COVERED SYSTEMATICALLY.
VI

IF NOT LIVING AT HOME, CODE THE SECTION FOR

PERIOD OF AT LEAST ONE MONTH WHEN LIVING AT
HOME.
RE

NOW I WANT TO ASK YOU SOME QUESTIONS ABOUT

HOW YOU GET ALONG WITH YOUR FAMILY.

How do you usually spend the weekends?

Who do you do that with?
What sort of things do you do with your Mom and Dad?
With both of them, or just one?
R

What do you like doing best?

Who do you get on best with in the family?
Do you go out as a family at all?
What sort of things do you do together?
FO

What do you generally do when you get home from school?

Do you have any homework?
Or do you do any reading?
Do your parents help you at all with that?
Who do you find is the most help?
How much do you play/do things with "siblings"?
How do you get on together?
How much do you squabble?
Or get in fights?
Do your parents get fed up with anything you do?

Family Section 14
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Definitions and questions Coding rules Codes

If child did not live in home at least 4 weeks in last 3 SECONDARY PERIOD: BEGINNING CAC3O01
months, code beginning date of last 4 weeks when was DATE OF LAST MONTH LIVING AT
living in home.
HOME / /
REASON(S) NOT LIVING AT HOME 4 CAC3X01
WEEKS

1 = Time spent away from home and

parental figures while attending special
program or camp, traveling, vacationing,
CAC3X02

LY
visiting relatives or friends.

2 = In hospital.
CAC3X03
3 = In treatment facility(ies)

4 = Living with other parent.

N
5 = Foster care

6 = Other

O
Specify

EW
VI
RE
R
FO

Family Section 15
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Definitions and questions Coding rules Codes

RELATIONSHIPS WITH AND BETWEEN

PARENTS

There are two basic dimensions of

relationships with parents: a qualitative aspect,
that is the quality of the relationship during that
time; and a quantitative aspect, that is, time
actually spent incvoved with parents.

LY
ACTIVITES WITH PARENT #1
Activities with parental involvement are coded here. ACTIVITIES WITH PARENT CAC4I01
Intensity
0 = All or most (atleast 75%) shared
What sort of things do you do with "Parent #1"? activities said to be a source of enjoyment

N
to child
Do you go out together? 2 = At least some (25-74%) shared
What about shopping? activities are a souce of tension, worry, or

O
Do they help you with homework? disinterest to the child.
Or with your hobbies?
3 = All mor most (at least 75%) shared
Do you go fishing/hunting etc. with them? activities are a souce of tension, worry, or
Do you have meals together? disinterest to the child.
Or watch T.V. togther?
Do you all go out together as a family?
Do you enjoy it?
EW
Does s/he drive you to outside activities?

Does s/he enjoy having you around?

VI

Do you enjoy doing things with him/her?

Is that all the time or...

Why not?
What happens?
RE

Can you tell me about the last time something like that
happend?

ACTIVITIES WITH PARENT #2

Activities with parental involvement are coded here. ACTIVITIES WITH PARENT PAC4I02
Intensity
R

0 = All or most (atleast 75%) shared

What about "Parent #2"? activities said to be a source of enjoyment
to child
Do you enjoy doing things with him/her?
FO

2 = At least some (25-74%) shared

activities are a souce of tension, worry, or
disinterest to the child.

3 = All mor most (at least 75%) shared

activities are a souce of tension, worry, or
disinterest to the child.

Family Section 16
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Definitions and questions Coding rules Codes

CHILD-PARENT COMMUNICATION
Frequency of conversations between child and each CHILD-PARENT COMMUNICATION CAC5X01
parent, regardless of who initiates the conversations, and Intensity
0 = Absent
regardless of whether the child enjoys the conversation. An
exchange must last at least 5 minutes to be regarded as a 2 = Present
conversation.
PARENT #1 - CHILD CONVERSATIONS CAC5F01

Differentiate form Arguments and Criticism. A conversation

LY
is a verbal exchange that does not involve shouting, or
aggressive exchanges, and is not explicitly focused on PARENT #2 - CHILD CONVERSATIONS CAC5F02
disciplinary matters or criticism.

Do you have conversations with your parents?

N
Who do you talk to most?

What sort of things do you talk about?

O
Do you enjoy the conversations?
Does your parent enjoy them?
What about your "Other Parent"?

How often do you talk to "Parent #1"?

How long do conversations last?
EW
How often do you talk to "Parent #2"?
How long do conversations last?

PARENT USES CHILD AS CONFIDANT(E)

VI

The parent talks over his/her own problems with child, or PARENT USES CHILD AS CAC6X01
looks to the child for emotional support. For instance, CONFIDANT(E) Intensity
expecting comfort from the child when upset. 0 = Absent
RE

2 = Present
Do they talk to you about their own problems?
CHILD USED AS CONFIDANT(E) CAC6I01
Who does that most?
How often 0 = Child not used as confidant(e)
What do you do? 2 = Child is sometimes used as
Does s/he have anyone else to talk to about them? confidant(e), but not the only person who
Waht about your "Other Parent"? fulfills role
R

3 = Child is the paren'ts only confidant(e)

CHILD USED AS PARENT'S CAC6I02

FO

CONFIDANT(E)

0 = Absent

2 = Child sometimes used as confidant(e),

but not the only person who fulfills this role.

3 = Child is the parent's only confidant(e).

Family Section 17
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TIME SPENT WITH PARENTS

Include time spent with parents in any activity in which both TIME SPENT WITH PARENTS CAC7X01
child and parent(s) are actively involved (e.g. hobbies, Intensity
0 = Absent
games, time spent driving child to outside activities).
2 = Present
IF NOT ALREADY DONE, GO THROUGH TYPICAL HOURS CAC7D01
SCHOOL DAY AND WEEKEND DAY TO DETERMINE
HOW MUCH TIME SPENT.

LY
HOURS CAC7D02
How much time do you spend with your parent(s)?

INTERVIEWER: Determine how much time spent before

school, driving places, dinner, after dinner, homework, tv,

N
etc.

How much time do you spend with "Parent #1"

O
How much time do you spend with "Parent #2"?

EW
VI
RE
R
FO

Family Section 18
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INADEQUATE SUPERVISION BY PARENT #1

Parent fails to provide sufficient supervision. as shown by INADEQUATE SUPERVISION BY PAC8I01
frequent lack of knowledge of the child's whereabouts, PARENT Intensity
activities, or company; and/or fails to maintain effective 0 = Appropriate supervision/control for age
control/ or discilpinary strategies; and/or is not concerned, and circumstances.
or does not attempt to interveve, when the chid's behavior
2 = Whereabouts of child not known at least
is deviant, or likely to lead him/her into trouble. once per week; or parent unable to exercise
effective control at leat once per week.

LY
If parents have given up trying to maintain discipline, Code 3 = Whereabouts of child unknown at least
as 3. 5 times per week; or parent usually (>50%
of the time) unable to exercise effective
control.
Do you do any chores?

N
What do you do?
Do you do a good job?
Do you help around the "house" in any other way?
Is it easy for "Parent #1" to get you to do what s/he

O
wants?

What happens when you don't want to do what s/he

says? EW
Have there been times in the last three months when
you didn't do what was asked?

What does "Parent #1" do about it?

Does it bother him/her?
Does it lead to arguments?
Does s/he ever just give up?
VI

What happens then?

How often had that heppend in the last three months?
Does "Parent #1" always know where you are when
you are not at home?
RE

Does "Parent #1" expect you to let them know where

you are?

Over the last three months, how often have you been out
without "Parent #1" knowing where you were?
R
FO

Family Section 19
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Definitions and questions Coding rules Codes

INADEQUATE SUPERVISION BY PARENT #2

Parent fails to provide sufficient supervision. as shown by INADEQUATE SUPERVISION BY PAC8I02
frequent lack of knowledge of the child's whereabouts, PARENT Intensity
activities, or company; and/or fails to maintain effective 0 = Appropriate supervision/control for age
control/ or discilpinary strategies; and/or is not concerned, and circumstances.
or does not attempt to interveve, when the chid's behavior
2 = Whereabouts of child not known at least
is deviant, or likely to lead him/her into trouble. once per week; or parent unable to exercise
effective control at leat once per week.

LY
If parents have given up trying to maintain discipline, Code 3 = Whereabouts of child unknown at least
as 3. 5 times per week; or parent usually (>50%
of the time) unable to exercise effective
control.
What about with parent #2?

N
OVERINVOLVEMENT BY PARENT #1
Parent is unusually intrusive into, and controlling of, the OVERINVOLVMENT BY PARENT PAC9I01

O
child's life, to a degree that involves infantilazation of the Intensity
0 = Appropriate level of involvement for the
child. For instance, by exessive checking of the child's child's age and situation
ativities, preventing age-appropriate independent behavior
or decision-making (such as selecting friends or clothes). 2 = Definite infantilazation (e.g. dressing of
washing chold above age where this is

Do you think Parent #1 gives you enough

EW normal); and prevention of age-appropriate
behavior or decision -making
independence? 3 = As 2, but reaching extreme proportions

Does you still need help choosing clothes?

Does you want Parent #1 to help?

What about washing your hair?
VI

Can Parent #1 trust you to get clean at bath time?

Does Parent #1 let you go out alone?

Can you ride your bicycle or walk to places you want to go?
RE

Does Parent #1 exercise control over who your friends

are?

How much does Parent #1 like you to make decisions

on your own?

Does Parent #1 ever go through your belongings?

R

Or look in your closets?

FO

Are there things you would like to be able to do that

Parent #1 won't let you do?

Family Section 20
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OVERINVOLVEMENT BY PARENT #2
Parent is unusually intrusive into, and controlling of, the 0 = Appropriate level of involvement for the PAC9I02
child's life, to a degree that involves infantilazation of the child's age and situation Intensity
child. For instance, by exessive checking of the child's 2 = Definite infantilazation (e.g. dressing of
ativities, preventing age-appropriate independent behavior washing chold above age where this is
or decision-making (such as selecting friends or clothes). normal); and prevention of age-appropriate
behavior or decision -making

What about Parent #2? 3 = As 2, but reaching extreme proportions

LY
HARSH DISCIPLINE BY PARENT #1
One or both parents uses a harsh, restrictive or phsyical HARSH DISCIPLINE BY PARENT PAD0I01
disciplinary style, leading to punishments that are more Intensity

N
0 = Absent
severe than would usually be thought appropriate.
2 = A disciplineary stlye thta is more severe
than most parents would use, but delivered
How often do they punish you altogether?

O
in a basically nurturant setting.
Do you feel that they love you?
What do they do to discipline you? 3 = Severe discipline, delievered coldlt, or
frequently in anger, unaccompanied by a
generally nuturant atmosphere.
Do they have to punish you often? EW
Tell me about the last time they had to punish you.
Was that fairly typical of what happens?
How often do you get grounded for doing something
wrong?

What other sorts of punishment do you get?

VI

Does your father/mother ever hit you?

How often?
What happens then?
Are you frightened of your mom or dad?
RE

HARSH DISCIPLINE BY PARENT #2

One or both parents uses a harsh, restrictive or phsyical HARSH DISCIPLINE BY PARENT CAD0I02
disciplinary style, leading to punishments that are more Intensity
0 = Absent
severe than would usually be thought appropriate.
R

2 = A disciplineary stlye thta is more severe

than most parents would use, but delivered
What about your "parent #2"? in a basically nurturant setting.
FO

3 = Severe discipline, delievered coldlt, or

frequently in anger, unaccompanied by a
generally nuturant atmosphere.

Family Section 21
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Definitions and questions Coding rules Codes

NUMBER OF ARGUMENTS WITH PARENT #1

An argument is defined as as disagreement, lasting at least NUMBER OF ARGUMENTS A1B2C03
5 minutes, that results in a dispute involving raised voices, Intensity
0 = Absent
shouting, verbal abuse, or phsyical aggression or fights.
2 = Present
Does you have arguments with parent #1? CAD1F01
Frequency
Tell me about the last time.

LY
How long do these arguments last?
How many arguments have you had with parent #1 in the
last three months? CAD1O01
Did the arguments ever get phsyical? Onset
What happened?
/ /

N
Have you "hit" your "parent #1" over the last three months?
ARGUMENTS WITH PHSYICAL CAD2I01
VIOLENCE BY CHILD

O
0 = Absent

2 = Present

ARGUMENTS WITH PHYSICAL CAD2F01

VIOLENCE BY CHILD (P1)
EW
ARGUMENTS WITH PHYSICAL CAD2O01
VIOLENCE BY CHILD (P1) FREQUENCY
/ /
OTHER PHSYICAL VIOLENCE BY CHILD CAD3I01
(WITHOUT ARGUMENTS)
VI

0 = Absent

2 = Present

OTHER PHYSICAL VIOLENCE BY CHILD CAD3F01

RE

(P1) FREQUENCY

OTHER PHYSICAL VIOLENCE BY CHILD CAD3O01

(P1) ONSET
/ /
R
FO

Family Section 22
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

NUMBER OF ARGUMENTS WITH PARENT #2

An argument is defined as a disagreement, lasting at least NUMBER OF ARGUMENTS abc1112
5 minutes, that results in a dispute involving raised vioces, Intensity
0 = Absent
shouting, verbal abuse, or phsyical aggression or fights.
2 = Present
Do you have arguments with parent #2? CAD4F01
Frequency
Tell me about the last time.

LY
How long do these arguments last?
How many arguments have you had with parent #2 over
the last three months? CAD4O01
Did the arguments ever get phsyical? Onset
What happened?
/ /

N
Has you"hit" your "parent #2" over the last three
months? ARGUMENTS WITH PHYSICAL CAD5I01
VIOLENCE BY CHILD

O
0 = Absent

2 = Present

ARGUMENTS WITH PHYSICAL CAD5F01

VIOLENCE BY CHILD (P2) FREQUENCY
EW
ARGUMENTS WITH PHYSICAL CAD5O01
VIOLENCE BY CHILD (P2) ONSET
/ /
OTHER PHYSICAL VIOLENCE BY CHILD CAD6I01
(WITHOUT ARGUMENTS)
VI

0 = Absent

2 = Present

OTHER PHYSICAL VIOLENCE BY CHILD CAD6F01

RE

(WITHOUT ARGUMENTS P2)

FREQUENCY

OTHER PHYSICAL VIOLENCE BY CHILD CAD6O01

(P2) ONSET
/ /
R

IF THERE IS MORE THAN ONE CHILD

FO

IN THE HOME COMPLETE "SELECTIVE

NEGATIVE VIEW". OTHERWISE, SKIP
TO "OTHER PARENTING - OTHER
PARENT #1", (PAGE 26).

Family Section 23
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Definitions and questions Coding rules Codes

SELECTIVE NEGATIVE VIEW BY PARENT #1

The target child is regarded more negatively by his/her CHILD HAS SIBLINGS CAD7I90
parents than the other child(ren) in the home. Just because Intensity
0 = Absent
one child has more problems, it doesn't mean that s/he will
be the subject of a selective negative view. To be rated 2 = Present
here, the child must actually receive different treatment
SELECTIVE NEGATIVE VIEW BY CAD7I01
from the other child(ren) for equivalent misdemeanors. PARENT #1

LY
0 = Target child treated in same way as rest
Do you have siblings in the home? of children.

Do you think your parents treat you the same as your 2 = Target child consistently treated
brother(s) and sister(s)? differently from other children in a negative
manner, in some areas.
Do you think they treat you unfairly?

N
3 = Target child is regarded as being
markedly different from other children in
Has it always been like that? family, and subjected to markedly different
In what ways do they treat you differently? rules or restrictions.

O
Can you give me an example?
When things go wrong, is it usually your fault?

Do your parents have any difficulties with your

"brothers and sisters"?
EW
What sort of problems do you have?

SELECTIVE NEGATIVE VIEW BY PARENT #2

The target child is regarded more negatively by his/her SELECTIVE NEGATIVE VIEW BY CAD7I02
VI

parents than the other child(ren) in the home. Just because PARENT #2 Intensity
one child has more problems, it doesn't mean that s/he will 0 = Target child treated in same way as rest
be the subject of a selective negative view. To be rated of children.
here, the child must actually receive different treatment
2 = Target child consistently treated
RE

from the other child(ren) for equivalent misdemeanors. differently from other children in a negative
manner, in some areas.
Does your "parent 2" feel the same way? 3 = Target child is regarded as being
markedly different from other children in
When things go wrong, is it usually your fault? family, and subjected to markedly different
rules or restrictions.
Does your "parent 2" have difficulties with the other
R

children?

What sort of problems?

FO

IF CHILD HAS "OTHER PARENT #1"

AND/OR "OTHER PARENT #2",
COMPLETE "OTHER PARENTING".
OTHERWISE, SKIP TO
"RELATIONSHIPS WITH SIBLINGS",
(PAGE 52).

Family Section 24
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LY
N
O
EW
VI
RE
R
FO

Family Section 25
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OTHER PARENTING - OTHER PARENT #1

Code here any relationship that the child has with Other CHILD HAS "OTHER PARENT #1" CAD8I01
Parent #1 who no longer lives in the home. Intensity
0 = Absent

CODE QUALITY OF RELATIONSHIPS EVEN IF NO 2 = Present

CONTACT IN THE LAST 3 MONTHS. OTHER PARENT #1: NUMBER OF VISITS CAD8F01

Child has "Other Parent #1."

LY
Do you see or have any contact with your "other parent?' OTHER PARENT #1: DURATION OF CAD8D01
VISITS
Do you want to?
0 = >1 week
How do you get along with your "other parent"?
1 = 1 day- 1 week

N
Are there any problems? 2 = < 1 day
What sort of problems?
Do you like visiting "other parent"? 3 = < 5 hours

O
What types of things do you do with him/her? NUMBER OF PHONE CALLS/LETTERS CAD9F01
Do you enjoy that? TO OR FROM OTHER PARENT #1 IN
Would you rather not see him/her? LAST 3 MONTHS

OTHER PARENT #1: QUALITY OF CAE0I01

EW RELATIONSHIP

0 = No evidence of relationship problems

with absent parent.

1 = No relationship and child grieves or is

angry over this.

2 = Relationship has negative aspects (e.g.

VI

child argues with absent parent, or resents

that parent's new partner).

3 = Relationship with absent parent almost

completely negative (e.g. child very
unhappy until visit ends, or persistently
RE

difficult during visits to or from absent

parent).
R
FO

Family Section 26
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Definitions and questions Coding rules Codes

OTHER PARENTING - OTHER PARENT #2

Code here any relationship that the child has with Other CHILD HAS "OTHER PARENT #2" CAE1I01
Parent #2 who no longer lives in the home. Intensity
0 = Absent

CODE QUALITY OF RELATIONSHIPS EVEN IF NO 2 = Present

CONTACT IN THE LAST 3 MONTHS. OTHER PARENT #2: NUMBER OF VISITS CAE1F01

Child has "Other Parent #2."

LY
Do you see or have any contact with your "other parent?" DURATION OF VISITS: OTHER PARENT CAE1D01
#2
Do you want to?
0 = >1 week
How do you get along with your "other parent"?
1 = 1 day- 1 week

N
Are there any problems? 2 = < 1 day
What sort of problems?
Do you like visiting your "other parent"? 3 = < 5 hours

O
What sort of things do you do together? NUMBER OF PHONE CALLS/LETTERS CAE2F01
Do you enjoy that? TO OR FROM OTHER PARENT #2 IN
Would you rather not see him/her? LAST 3 MONTHS

OTHER PARENT #2: QUALITY OF CAE3I01

EW RELATIONSHIP

0 = No evidence of relationship problems

with absent parent.

1 = No relationship and child grieves or is

angry over this.

2 = Relationship has negative aspects (e.g.

VI

child argues with absent parent, or resents

that parent's new partner).

3 = Relationship with absent parent almost

completely negative (e.g. child very
unhappy until visit ends, or persistently
RE

difficult during visits to or from absent

parent).
R
FO

Family Section 27
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Definitions and questions Coding rules Codes

NUMBER OF ARGUMENTS WITH OTHER

PARENT #1
An argument is defined as a disagreement, lasting at least ARGUMENTS WTIH OTHER PARENT INTBF38
5 minutes, that results in a dispute involving raised voices, Intensity
0 = Absent
shouting, verbal abuse, or physical aggression or fights.
2 = Present
Do you have arguments with "other parent #1"? CAE4F01
Frequency

LY
Tell me about the last time.
How long do these argumetns last?
How many arguments have you had wtih him/her in the last
three months? CAE4O01
Did the arguments ever get physical? Onset

N
What happened?
Have you"hit" your "other parent #1" over the last
/ /
three months? ARGUMENTS WTIH PHYSICAL CAE5I01
VIOLENCE BY CHILD

O
0 = No

2 = Yes

3 = No Contact
EW ARGUMENTS WITH PHSYICAL
VIOLENCE BY CHILD
CAE5F01

ARGUMENTS WITH PHYSICAL CAE5O01

VIOLENCE BY CHILD - ONSET
/ /
VI

OTHER PHYSICAL VIOLENCE BY CHILD CAE6I01

0 = No

2 = Yes
RE

3 = No Contact

OTHER PHYSICAL VIOLENCE BY CHILD CAE6F01

(WITHOUT ARGUMENTS)

PAE6O01 CAE6O01
R

/ /
FO

Family Section 28
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

NUMBER OF ARGUMENTS WITH OTHER

PARENT #2
Do you have arguments with "other parent #2"? NUMBER OF ARGUMENTS INTBF13
Intensity
0 = Absent
Tell me about the last time.
How long do these arguments last? 2 = Present
How many arguments have you had with "other parent #2"
in the last three months? CAE7F01
Frequency

LY
Did the arguments ever get physical?
What happened?
Have you "hit" your "other parent #2" over the last
three months? CAE7O01
Onset

N
/ /
ARGUMENTS WITH PHYSICAL CAE8I01
VIOLENCE BY CHILD

O
0 = No

2 = Yes

ARGUMENTS WITH PHYSICAL CAE8F01

EW VIOLENCE BY CHILD - FREQUENCY

ARGUMENTS WITH PHYSICAL CAE8O01

VIOLENCE BY CHILD - ONSET
/ /
OTHER PHYSICAL VIOLENCE BY CHILD CAE9I01
VI

(WITHOUT ARGUMENTS)

0 = No

2 = Yes
RE

OTHER PHYSICAL VIOLENCE BY CHILD CAE9F01

(WITHOUT ARGUMENTS) - FREQUENCY

OTHER PHYSICAL VIOLENCE BY CHILD CAE9O01

(WITHOUT ARGUMENTS) - ONSET
/ /
R
FO

Family Section 29
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL ARGUMENTS
Arguments are disagreements between parents in the PARENTAL ARGUMENTS CAF0I01
home, lasting at least 5 minutes, that result in a dispute Intensity
0 = Absent
involving raised voices, shouting, verbal abuse, physical
aggression, or fights. Only one parent need to be involved 2 = Present
in shouting, etc.
CAF0F01
Frequency
Nearly all couples argue sometimes. How often do your

LY
parents argue with each other?

What are the arguments like?

Can you tell me about the last time?
How long do they last?

N
How often do they happen?

INTER-PARENTAL PHYSICAL VIOLENCE

O
(PARENTAL ARGUMENTS)
Any form of physical aggression from either partner. INTER-PARENTAL PHYSICAL Ever:CAF1E01
VIOLENCE Intensity
Do they ever hit each other? 0 = Absent
EW
Have they in the last three months hit eachother? 2 = Present

LAST 3 MONTHS: INTER-PARENTAL CAF1I01

PHYSICAL VIOLENCE Intensity
0 = Absent

2 = Present
VI

CAF1F01
Frequency
RE

ONSET OF INTER-PARENTAL Ever:CAF1O01

PHYSICAL VIOLENCE
/ /
R

IF "PARENTAL ARGUMENTS" AND

"INTER-PARENTAL PHYSICAL
VIOLENCE" ABSENT, SKIP TO
FO

"RELATIONSHIP BETWEEN OTHER

PARENT #1 AND ONE OF CHILD'S
CURRENT PARENTS", (PAGE 32).

Family Section 30
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

INVOLVEMENT OF CHILD IN ARGUMENTS OR

VIOLENCE (PARENTAL ARGUMENTS)
The child is involved in arguments, whether directly taking INVOLVEMENT OF CHILD IN CAF2I01
part, or used by one or both parents as an ally in the ARGUMENTS/VIOLENCE Intensity
argument. For instance a parent may attempt to persuade, 0 = Child is not involved in arguments.
or demand, that the child join in condemnation of his/her
partner. 2 = Child is upset by arguments/violence at
least sometimes, as manifested by
protesting about them to parents, or

LY
Do you get involved in these "arguments" or "fights" at becoming withdrawn.
all? 3 = Child is actively involved in
argument/violence by one or both parents.
In what way?
Do either of them try to get you on their side?

N
What do you do?
What happens then?
Do you get upset when they "argue" or "fight?"

O
What happens then?
Do they do anything to keep you out of their
arguments?

What do you do?

EW
VI
RE
R
FO

Family Section 31
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL RELATIONSHIP(S) WITH PARENTS

OUTSIDE THE HOME
RELATIONSHIP BETWEEN OTHER PARENT #1
AND ONE OF CHILD'S CURRENT PARENTS
The relationship between one of the child's current parents CHILD'S CURRENT PARENT CAF3X01
(either Parent #1 or #2) and Other Parent #1. Intensity
1 = Parent #1.

2 = Parent #2.

LY
Do "your parents" have any contact with "Other Parent
#1?" NUMBER OF CONTACTS: NUMBER OF CAF4F01
CALLS, VISITS, LETTERS, ETC IN LAST
How do they get on? 3 MONTHS BETWEEN "CURRENT
PARENT" AND "OTHER PARENT #1"
How much contact has there been in the last 3 months?
CAF5I01

N
QUALITY OF RELATIONSHIP BETWEEN
CURRENT PARENT AND OTHER
PARENT #1

0 = No evidence of relationship problems.

O
2 = Relationship has some negative
aspects.

3 = Relationship almost completely

negative.
EW
ARGUMENTS BETWEEN PARENT AND OTHER
PARENT
Arguments are disagreements lasting at least 5 minutes, ARGUMENTS BETWEEN CURRENT CAF6I01
which result in a dispute involving raised voices, shouting, PARENT AND OTHER PARENT #1 Intensity
verbal abuse, physical aggression, or fights. Only one
VI

0 = Absent
parent need be involved in shouting, etc.
2 = Present

Do they argue with each other? CAF6F01

Frequency
RE

What are the arguments like?

Can you tell me about the last time?
ONSET: ARGUMENTS BETWEEN CAF6O01
PARENT AND OTHER PARENT
/ /
R
FO

Family Section 32
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

INTER-PARENTAL PHYSICAL VIOLENCE

Any form of physical Aggression from either parent. PHYSICAL VIOLENCE BETWEEN Ever:CAF7E01
CURRENT PARENT AND OTHER Intensity
PARENT #1
Have they ever hit each other?
0 = Absent
What about in the last 3 months? 2 = Present

PHYSICAL VIOLENCE BETWEEN CAF7I01

LY
CURRENT PARENT AND OTHER Intensity
PARENT #1 IN LAST 3 MONTHS

0 = Absent

2 = Present

N
ONSET: INTER-PARENTAL VIOLENCE Ever:CAF7O01

/ /

O
CAF7F01
Frequency

EW
IF "ARGUMENTS BETWEEN PARENT
AND OTHER PARENT #1" AND
"PHYSICAL VIOLENCE BETWEEN
CURRENT PARENT AND OTHER
VI

PARENT #1" ABSENT, SKIP TO

"RELATIONSHIP BETWEEN OTHER
PARENT #2 AND ONE OF CHILD'S
CURRENT PARENTS", (PAGE 35).
RE
R
FO

Family Section 33
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

INVOLVEMENT OF CHILD IN ARGUMENTS OR

VIOLENCE
Do you get involved in these "arguments" or "fights" at INVOLVEMENT OF CHILD IN CAF8I01
all? ARGUMENT/VIOLENCE Intensity
0 = Child is not involved in arguments.
In what way?
Do either of them try to get you on their side? 2 = Child is upset by arguments/violence at
least sometimes, as manifested by
protesting about them to parents, or

LY
What do you do? becoming withdrawn.
What happens then?
Do you get upset when they "argue" or "fight?" 3 = Child is actively involved in
argument/violence by one or both parents.
What happens then?

N
IF CHILD HAS OTHER PARENT #2

O
LIVING OUTSIDE OF THE HOME,
COMPLETE SECTION. OTHERWISE,
SKIP TO "PARENTAL
PSYCHOLOGICAL PROBLEMS-
DISRUPTION OF LIFE ROLE", (PAGE
38).
EW
VI
RE
R
FO

Family Section 34
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

RELATIONSHIP BETWEEN OTHER PARENT #2

AND ONE OF CHILD'S CURRENT PARENTS
The relationship between one of the child's current parents CHILD'S CURRENT PARENT CAF9X01
(either Parent #1 or #2) and Other Parent #2. Intensity
1 = Parent #1.

Do "your parent" have any contact with "Other Parent 2 = Parent #2.
#2? CAG0F01
Frequency

LY
How do they get along?

How much contact has there been in the last 3 months?

QUALITY OF RELATIONSHIP BETWEEN CAG1I01
CURRENT PARENT AND OTHER
PARENT #2

N
0 = No evidence of relationship problems.

2 = Relationship has some negative

O
aspects.

3 = Relationship almost completely

negative.

ARGUMENTS BETWEEN PARENT AND OTHER

PARENT #2
EW
Arguments are disagreements lasting at least 5 minutes, ARGUMENTS BETWEEN CURRENT CAG2I01
which result in a dispute involving raised voices, shouting, PARENT AND OTHER PARENT #2 Intensity
verbal abuse, physical aggression, or fights. Only one 0 = Absent
parent need be involved in shouting, etc.
2 = Present
VI

Do they argue with each other? CAG2F01

Frequency
What are the arguments like?
Can you tell me about the last time?
RE

ONSET: ARGUMENTS BETWEEN CAG2O01

PARENT AND OTHER PARENT #2
/ /
R
FO

Family Section 35
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

INTER-PARENTAL PHYSICAL VIOLENCE

(OTHER PARENT #2)
Any form of physical aggression from either parent. PHYSICAL VIOLENCE BETWEEN Ever:CAG3E01
CURRENT PARENT AND OTHER Intensity
PARENT #2
Have they ever hit each other?
0 = Absent
What about in the last 3 months? 2 = Present

LY
PARENTAL VIOLENCE BETWEEN CAG3I01
CURRENT PARENT AND OTHER Intensity
PARENT #2 IN LAST 3 MONTHS

0 = Absent

2 = Present

N
Ever:CAG3F01
Frequency

O
ONSET: INTER-PARENTAL PHYSICAL Ever:CAG3O01
VIOLENCE (OTHER PARENT #2)
EW / /

IF "ARGUMENTS BETWEEN PARENT

AND OTHER PARENT #2" AND
"PHYSICAL VIOLENCE BETWEEN
VI

PARENT AND OTHER PARENT #2"

ABSENT, SKIP TO "PARENTAL
PSYCHOLOGICAL PROBLEMS-
DISRUPTION OF LIFE ROLE", (PAGE
RE

38).
R
FO

Family Section 36
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

INVOLVEMENT OF CHILD IN ARGUMENTS OR

VIOLENCE (OTHER PARENT #2)
Do you get involved in these "arguments" or "fights" at INVOLVEMENT OF CHILD IN CAG4I01
all? ARGUMENTS/VIOLENCE Intensity
0 = Child is not involved in arguments.
In what way?
Do either of them try to get you on his/her side? 2 = Child is upset by arguments/violence at
least sometimes, as manifested by
protesting about them to parents, or

LY
What do they do? becoming withdrawn.
What happens then?
Do you get upset when they "argue" or "fight?" 3 = Child is actively involved in
argument/violence by one or both parents.
What happens then?
Do they try to keep you out of the arguments?

N
What do they do?

O
EW
VI
RE
R
FO

Family Section 37
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL PSYCHOPATHOLOGY

Psychological, nervous, or psychiatric

problems, which have either caused a parent to
seek treatment, or led to family or social
disruption or impaired performance in a major
life role (e.g. inability to care adequately for
children, loss of job, etc.).

LY
PARENTAL PSYCHOLOGICAL PROBLEMS-
DISRUPTION OF LIFE ROLE
Psychological, nervous, or psychiatric problems, which DISRUPTION OF LIFE ROLE - PARENT Ever:CAG5E01
have either caused a parent to seek treatment, or led to #1 Intensity

N
family or social disruption or impaired performance in a 0 = Absent
major life role (e.g. inability to care adequately for children,
loss of job, etc.). 2 = Present

O
Does your parent have any "emotional" or "nervous"
problems like "depression" or "nerves?"

Has your parent ever had any problem which has

EW
affected their ability to work or their ability to look after
you (or other children)?

PARENTAL PSYCHOLOGICAL PROBLEMS-

SOUGHT TREATMENT
Ever:CAG6E01
VI

Has your parent ever had any treatment for any SOUGHT TREATMENT FROM MENTAL
"emotional," "nervous," or "depression" problems? HEALTH PROFESSIONAL Intensity
0 = Absent
Who from?
2 = Present
RE

What sort of treatment?

PARENTAL PSYCHOLOGICAL PROBLEMS-

RECEIVED MEDICATION
Has your parent ever received medication for any RECEIVED MEDICATION Ever:CAG7E01
"emotional," "nervous," or "depression" problems? Intensity
R

0 = Absent

What sort of medication? 2 = Present

FO

PARENTAL PSYCHOLOGICAL PROBLEMS-

HOSPITALIZED FOR MENTAL HEALTH
PROBLEM
Has your parent ever been hospitalized for mental HOSPITALIZED FOR MENTAL HEALTH Ever:CAG8E01
health problems? PROBLEM Intensity
0 = Absent

2 = Present

Family Section 38
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IF CHILD HAS OTHER PARENT LIVING

IN HOME CONTINUE, OTHERWISE,
SKIP TO "PARENTAL
PSYCHOLOGICAL PROBLEMS BY
OTHER PARENT #1- DISRUPTION OF
LIFE ROLE", (PAGE 41).

LY
N
O
EW
VI
RE
R
FO

Family Section 39
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL PSYCHOLOGICAL PROBLEMS BY

PARENT #2- DISRUPTION OF LIFE ROLE
Has your "parent" ever had any problems which have DISRUPTION OF LIFE ROLE Ever:CAG9E01
affected his/her ability to work or his/her ability to look Intensity
0 = Absent
after you or other children?
2 = Present

LY
PARENTAL PSYCHOLOGICAL PROBLEMS BY
PARENT #2- SOUGHT TREATMENT
Has your "parent" ever sought treatment from a mental SOUGHT TREATMENT FROM MENTAL Ever:CAH0E01
health profession? HEALTH PROFESSIONAL Intensity
0 = Absent

N
Who from?
2 = Present
What sort of treatment?

O
PARENTAL PSYCHOLOGICAL PROBLEMS BY
PARENT #2- RECEIVED MEDICATION
Has your "parent" ever received medication for any RECEIVED MEDICATION Ever:CAH1E01
EW
"emotional," "nervous," or "depression" problems? 0 = Absent
Intensity

2 = Present

PARENTAL PSYCHOLOGICAL PROBLEMS BY

PARENT #2- HOSPITALIZED FOR MENTAL
VI

HEALTH PROBLEMS
Has your "parent" ever been hospitalized for mental HOSPITALIZED FOR MENTAL HEALTH Ever:CAH2E01
health problems? PROBLEM Intensity
0 = Absent
RE

2 = Present

IF CHILD DOES NOT HAVE OTHER

PARENT(S) LIVING OUTSIDE OF
R

HOME, SKIP TO "PARENTAL

SUBSTANCE USE PROBLEMS-
PROBLEMS RELATED TO ALCOHOL",
FO

(PAGE 43).

Family Section 40
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL PSYCHOLOGICAL PROBLEMS BY

OTHER PARENT #1- DISRUPTION OF LIFE
ROLE
What about your "Other Parent(s)"? DISRUPTION OF LIFE ROLE - OTHER Ever:CAH3E01
PARENT #1 Intensity
Does s/he have any "emotional" or "nervous" 0 = Absent
problems like "depression" or "nerves"?
2 = Present

LY
Has s/he ever?

Have they affected "parent's" life much?

How about work?
Or his/her ability to adequately look after you?

N
PARENTAL PSYCHOLOGICAL PROBLEMS BY
OTHER PARENT #1- SOUGHT TREATMENT

O
Has s/he ever sought treatment from a mental health SOUGHT TREATMENT FROM MENTAL Ever:CAH4E01
professional? HEALTH PROFESSIONAL-OP1 Intensity
0 = Absent
Who from?
2 = Present
What sort of treatment?
EW
PARENTAL PSYCHOLOGICAL PROBLEMS BY
OTHER PARENT #1- RECEIVED MEDICATION
Has s/he ever received medication for any "emotional," RECEIVED MEDICATION- OP1 Ever:CAH5E01
VI

"nervous," or "depression" problems? Intensity

0 = Absent

2 = Present
RE

PARENTAL PSYCHOLOGICAL PROBLEMS BY

OTHER PARENT #1- HOSPITALIZED FOR
MENTAL HEALTH PROBLEMS
Has s/he ever been hospitalized for mental health HOSPITALIZED FOR MENTAL HEALTH Ever:CAH6E01
problems? PROBLEMS- OP1 Intensity
0 = Absent
R

2 = Present
FO

PARENTAL PSYCHOLOGICAL PROBLEMS BY

OTHER PARENT #2-DISRUPTION OF LIFE
ROLE
Has s/he ever had any problems which affected his/her DISRUPTION OF LIFE ROLE Ever:CAH7E01
ability to work or look after you or other children? Intensity
0 = Absent

2 = Present

Family Section 41
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL PSYCHOLOGICAL PROBLEMS BY

OTHER PARENT #2- SOUGHT TREATMENT
Has s/he ever sought treatment from a mental health SOUGHT TREATMENT FROM MENTAL Ever:CAH8E01
professional? HEALTH PROFESSIONAL (OP2) Intensity
0 = Absent
Who from?
2 = Present
What sort of treatment?

LY
PARENTAL PSYCHOLOGICAL PROBLEMS BY
OTHER PARENT #2- RECEIVED MEDICATION
Has s/he ever received medication for any "emotional," RECEIVED MEDICATION (OP2) Ever:CAH9E01

N
"nervous," or "depression" problems? Intensity
0 = Absent

2 = Present

O
PARENTAL PSYCHOLOGICAL PROBLEMS BY
OTHER PARENT #2- HOSPITALIZED FOR
MENTAL HEALTH PROBLEM EW
Has s/he ever been hospitalized for mental health HOSPITALIZED FOR MENTAL HEALTH Ever:CAI0E01
problems? PROBLEMS Intensity
0 = Absent

2 = Present
VI
RE
R
FO

Family Section 42
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL SUBSTANCE USE PROBLEMS-

PROBLEMS RELATED TO ALCOHOL
A level of alcohol or drug use that has caused a parent to CURRENTLY USES DRUGS/HAS CAI1I01
seek treatment, led to family or social disruption, or ALCOHOL PROBLEM - PARENT #1 Intensity
impaired performance in a major life role (e.g. inability to 0 = Absent
care adequately for children, loss of job, loss of driver's
license, etc.). 2 = Present

PROBLEMS RELATED TO Ever:CAI2E01

LY
Tell me about how much your parents drink? ALCOHOL/DRUGS - PARENT #1 Intensity
0 = Absent
Do they use any drugs?
2 = Problem with alcohol.
Have they ever had a problem with drinking?
3 = Problem with drugs.

N
How much do they drink? 4 = Problem with both.
How often do they drink?
Does that lead to any problems?

O
What sort of problems?
Does it cause arguments?
Do you ever get violent?
What happens?
Has drinking alcohol caused any problems outside the
home?
What sort of problem?
EW
Have they ever been arrested for DWI?
Have they ever had a problem with drug use?

What do you use?

How much?
VI

Has that caused him/her any problems?

Has s/he ever had a problem with drinking?

How much do they drink?

RE

How often do they drink?

Does that lead to any problems?
What sort of problems?
Does it cause arguments?
Does s/he ever get violent?
What happens?
Has drinking alcohol caused any problems outside the
R

home?
What sort of problems?
Has s/he ever been arrested for DWI?
FO

Has s/he ever had a problem with drug use?

What do you use?

How much?
Has that caused him/her any problems?
What sort of problems?

Family Section 43
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL SUBSTANCE USE PROBLEMS-

SOUGHT TREATMENT FOR ALCOHOL/DRUG
PROBLEM
Has s/he ever had any treatment for his/her drinking? SOUGHT TREATMENT FOR Ever:CAI3E01
ALCOHOL/DRUG PROBLEM Intensity
0 = Absent

2 = Treatment for alcohol.

LY
3 = Treatment for drugs.

4 = Treatment for both.

PARENTAL SUBSTANCE USE PROBLEMS-

N
HOSPITALIZED FOR ALCOHOL/DRUG
PROBLEM
Has s/he ever been hospitalized for alcohol or drug HOSPITALIZED FOR ALCOHOL/DRUG Ever:CAI4E01

O
use? PROBLEM Intensity
0 = Absent

EW 2 = Hospitalized for alcohol.

3 = Hospitalized for drugs.

4 = Hospitalized for both.

PARENTAL SUBSTANCE USE PROBLEMS BY

PARENT #2- PROBLEMS RELATED TO
ALCOHOL/DRUGS
VI

Tell me about how much your parents drinks. CURRENTLY USED DRUGS/ HAS CAI5I01
ALCOHOL PROBLEM (P2) Intensity
Does s/he use any drugs? 0 = Absent
RE

Has s/he ever had any problems with drinking? 2 = Present

How much does s/he drink? PROBLEMS RELATED TO Ever:CAI6E01

ALCOHOL/DRUGS (P2) Intensity
How often does s/he drink?
Does that lead to any problems? 0 = Absent
What sort of problems?
2 = Problem with alcohol.
Does it cause arguments?
R

Does s/he ever get violent? 3 = Problem with drugs.

What happens?
4 = Problem with both.
Has drinking alcohol caused any problems outside the
FO

home?
What sort of problems?
Has s/he been arrested for DWI?
Has s/he ever had a problem with drug use?

What does s/he use?

How much?
Has that caused him/her any problems?
What sort of problems?

Family Section 44
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL SUBSTANCE USE PROBLEMS BY

PARENT #2- SOUGHT TREATMENT FOR
ALCOHOL/DRUG PROBLEM
Has s/he ever had any treatment for his/her drinking? SOUGHT TREATMENT FOR Ever:CAI7E01
ALCOHOL/DRUG PROBLEM (P2) Intensity
Or treatment for using drugs? 0 = Absent

2 = Treatment for alcohol.

LY
3 = Treatment for drugs.

4 = Treatment for both.

PARENTAL SUBSTANCE USE PROBLEMS BY

N
PARENT #2- HOSPITALIZED FOR
ALCOHOL/DRUG PROBLEM
Has s/he ever been hospitalized for alcohol or drug HOSPITALIZED FOR ALCOHOL/DRUG Ever:CAI8E01

O
use? PROBLEM Intensity
0 = Absent

EW 2 = Hospitalized for alcohol.

3 = Hospitalized for drugs.

4 = Hospitalized for both.

PARENTAL SUBSTANCE USE PROBLEMS BY

OTHER PARENT #1- PROBLEMS RELATED TO
ALCOHOL/DRUGS
VI

Tell me about how much your "Other Parent #1" drinks. CURRENTLY USES DRUGS/HAS CAI9I01
ALCOHOL PROBLEM - OTHER PARENT Intensity
#1
Does your "other parent" use any drugs?
0 = Absent
RE

Has s/he ever had a problem with drinking?

2 = Present
How much does s/he drink?
PROBLEMS RELATED TO Ever:CAJ0E01
How often does s/he drink? ALCOHOL/DRUGS - OTHER PARENT #1 Intensity
Does that lead to any problems?
What sort of problems? 0 = Absent
Does it cause arguments? 2 = Problem with alcohol.
R

Does "parent" ever get violent?

What happens? 3 = Problem with drugs.
Has drinking alcohol caused any problems outside the 4 = Problem with both.
FO

home?
What sort of problems?
Has s/he been arrested for DWI?
Has s/he ever had a problem with drug use?

What does s/he use?

How much?
Has that caused him/her any problems?
What sort of problems?

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PARENTAL SUBSTANCE USE PROBLEMS BY

OTHER PARENT #1- SOUGHT TREATMENT
FOR ALCOHOL/DRUGS
Has "Other Parent" ever had any treatment for his/her SOUGHT TREATMENT FOR Ever:CAJ1E01
drinking? ALCOHOL/DRUG PROBLEM (OP1) Intensity
0 = Absent
Or treatment for using drugs?
2 = Treatment for alcohol.

LY
3 = Treatment for drugs.

4 = Treatment for both.

PARENTAL SUBSTANCE USE PROBLEMS BY

N
OTHER PARENT #1- HOSPITALIZED FOR
ALCOHOL/DRUG PROBLEM
Has s/he ever been hospitalized for alcohol or drug HOSPITALIZED FOR ALCOHOL/DRUG Ever:CAJ2E01

O
use? PROBLEM Intensity
0 = Absent

EW 2 = Hospitalized for alcohol.

3 = Hospitalized for drugs.

4 = Hospitalized for both.

PARENTAL SUBSTANCE USE PROBLEMS BY

OTHER PARENT #2- PROBLEMS RELATED TO
ALCOHOL/DRUGS
VI

Tell me about how much your "Other Parent #2 drinks. CURRENTLY USING DRUGS/ HAS CAJ3I01
ALCOHOL PROBLEM (OP2) Intensity
Does "Other Parent" use any drugs? 0 = Absent
RE

2 = Present
R
FO

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Has s/he ever had a problem with drinking? PROBLEM RELATED TO Ever:CAJ4E01
ALCOHOL/DRUGS (OP2) Intensity
How much dos s/he drink? 0 = Absent
How often does s/he drink?
Does that lead to any problems? 2 = Problem with alcohol.
What sort of problems? 3 = Problem with drugs.
Does it cause arguments?
Does s/he ever get violent? 4 = Problem with both.
What happens?

LY
Has drinking alcohol caused any problems outside the
home?
What sort of problems?
Has s/he been arrested for DWI?
Has s/he ever had a problem with drug use?

N
What does s/he use?
How much?
Has that caused him/her any problems?

O
What sort of problems?

PARENTAL SUBSTANCE USE PROBLEMS BY EW

OTHER PARENT #2- SOUGHT TREATMENT
FOR ALCOHOL/DRUG PROBLEM
Has "Other Parent" ever had any treatment for his/her SOUGHT TREATMENT FOR Ever:CAJ5E01
drinking? ALCOHOL/DRUG PROBLEM (OP2) Intensity
0 = Absent
Or treatment for using drugs?
2 = Treatment for alcohol.
VI

3 = Treatment for drugs.

4 = Treatment for both.

RE

PARENTAL SUBSTANCE USE PROBLEMS BY

OTHER PARENT #2- HOSPITALIZED FOR
ALCOHOL/DRUG PROBLEM
Has s/he ever been hospitalized for alcohol or drug HOSPITALIZED FOR ALCOHOL/DRUG Ever:CAJ6E01
use? PROBLEM Intensity
0 = Absent
R

2 = Hospitalized for alcohol.

3 = Hospitalized for drugs.

FO

4 = Hospitalized for both.

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PARENTAL ADULT ARRESTS AND

PROSECUTIONS
Arrest and/or prosecution of parent(s) since age 18. ARRESTED - PARENT #1 Ever:CAJ7E01
Intensity
0 = Absent
Have either of your parents ever been arrested?
2 = Present
What happened? ACTION TAKEN BY POLICE - PARENT Ever:PAJ8E01
Were charges brought against him/her? #1

LY
What was the result of the prosecution? 0 = Not charged.

2 = Charged

DATE OF FIRST CHARGE - PARENT #1 Ever:CAJ8O01

N
/ /
WORST RESULT OF CHARGE Ever:PAJ8E02

O
0 = Not guilty.

2 = Probation and/or community service.

EW 3 = Treatment order.

9 = Fine

10 = Prison/house arrest.

Has Parent #1 been in prison or jail in the last 3 CURRENTLY IN JAIL/PRISON - PARENT CAJ9I01
months? #1 Intensity
0 = Absent
VI

2 = Present

What is the total amount of time spent in prison or jail? MONTHS Ever:PAJ9V01
RE
R
FO

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PARENTAL ADULT ARRESTS AND

PROSECUTIONS (PARENT #2)
Arrest and/or prosecution of parent(s) since age 18. ARESSTED - PARENT #2 Ever:CAK0E01
Intensity
0 = Absent
Has parent # 2 ever been arrested?
2 = Present
What happened? ACTION TAKEN BY POLICE - PARENT Ever:CAK1E01
Were charges brought against him/her? #2

LY
What was the result of the prosecution? 0 = Not charged.
When was the first time s/he were arrested? 2 = Charged

DATE OF FIRST CHARGE - PARENT #2 Ever:CAK1O01

N
/ /
WORST RESULT OF CHARGE - PARENT Ever:CAK1E02
#2

O
0 = Not guilty.

2 = Probation and/or community service.

3 = Treatment order.
EW 9 = Fine

10 = Prison/house arrest.

Has parent #2 been in prison or jail in the last 3 CURRENTLY IN JAIL/PRISON - CAK2I01
months? PARENT#2 Intensity
0 = Absent
VI

2 = Present

What is the total amount of time spent in prison or jail? MONTHS Ever:CAK2V01
RE
R
FO

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PARENTAL ADULT ARRESTS AND

PROSECUTIONS (OTHER PARENT #1)
Arrest and/or prosecution of parent(s) since age 18. ARRESTED - OTHER PARENT #1 Ever:CAK3E01
Intensity
0 = Absent
Has your "other parent #1" ever been arrested?
2 = Present
What happened? ACTION TAKEN BY POLICE - OTHER Ever:PAK4E01
Were charges brought against him/her? PARENT #1

LY
What was the result of the prosecution? 0 = Not charged.

2 = Charged

DATE OF FIRST CHARGE - OTHER Ever:CAK4O01

PARENT #1

N
/ /
WORST RESULT OF CHARGE - OTHER Ever:CAK4E02
PARENT #1

O
0 = Not guilty.

2 = Probation and/or community service.

3 = Treatment order.
EW 9 = Fine

10 = Prison/house arrest.

Has other parent #1 been in prison or jail in the last 3 CURRENTLY IN JAIL/PRISON - OTHER CAK5I01
months? PARENT #1 Intensity
0 = Absent
VI

What is the total amount of time spent in prison or jail?

2 = Present

MONTHS Ever:CAK5V01
RE
R
FO

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PARENTAL ADULT ARRESTS AND

PROSECUTIONS (OTHER PARENT #2)
Arrest and/or prosecution of parent(s) since age 18. ARRESTED - OTHER PARENT #2 Ever:CAK6E01
Intensity
0 = Absent
Has your "other parent #2" ever been arrested?
2 = Present
What happened? ACTION TAKEN BY POLICE - OTHER Ever:CAK7E01
Were charges brought against him/her? PARENT #2

LY
What was the result of the prosecution? 0 = Not charged.

2 = Charged

DATE OF FIRST CHARGE - OTHER Ever:CAK7O01

PARENT #2

N
/ /
WORST RESULT OF CHARGE - OTHER Ever:CAK7E02
PARENT #2

O
0 = Not guilty.

2 = Probation and/or community service.

3 = Treatment order.
EW 9 = Fine

10 = Prison/house arrest.

Has other parent #2 been in prison or jail in the last 3 CURRENTLY IN JAIL/PRISON - OTHER CAK8I01
months? PARENT #2 Intensity
0 = Absent
VI

2 = Present

What is the total amount of time spent in prison or jail? MONTHS Ever:CAK8V01
RE
R
FO

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RELATIONSHIPS WITH SIBLINGS

DETERMINE THE QUALITY OF THE CHILD'S CHILD HAS SIBLINGS CAK9I90
RELATIONSHIP WITH EACH SIBLING, REGARDLESS Intensity
0 = Absent
OF PLACE OF RESIDENCE.
2 = Present
Check that siblings are coded in the same order. RELATIONSHIPS WITH SIBLING #1 CAK9X01
0 = The child has a relationship with the
Child has siblings.

LY
sibling that is characterized by a generally
positive tone. Interactions are more likely to
How do you get along with your "brothers and be harmonious than conflictual; joint
sisters?" activities are usually pleasurable; and it is
uncommon for either to try to avoid the
other.
Are you especially close to any of them?

N
1 = "Neutral" relationship
Who is that? (Note Age and Sex).
In what way are you close? 2 = The child has a relationship with the
sibling that is characterized by a generally
Do you do things together?

O
negative tone. Interactions are more likely
What sort of things? to be conflictual than harmonious; joint
Can you share secrets or talk about your activities are usually either avoided, or
problems/worries with "sibling?" unpleasurable.

RELATIONSHIPS WITH SIBLING #2 CAK9X02

What sort of things?
EW
Does "sibling" talk to you about his/her worries?
Are there any of your brothers/sisters that you don't
0 = The child has a relationship with the
sibling that is characterized by a generally
positive tone. Interactions are more likely to
get along with? be harmonious than conflictual; joint
activities are usually pleasurable; and it is
Do any of your brothers/sisters pick on you in uncommon for either to try to avoid the
particular? other.
VI

1 = "Neutral" relationship
Or are there any of your brothers/sisters that you avoid
because you don't get along? 2 = The child has a relationship with the
sibling that is characterized by a generally
Who is that? negative tone. Interactions are more likely
to be conflictual than harmonious; joint
What happens?
RE

activities are usually either avoided, or

Do you argue a lot? unpleasurable.
Or get into physical fights - I mean real fights?
How often does that happen? RELATIONSHIPS WITH SIBLING #3 CAK9X03
Are there times when you do get along? 0 = The child has a relationship with the
How long do you stay angry at each other afterwards? sibling that is characterized by a generally
Is it ever as long as a day? positive tone. Interactions are more likely to
be harmonious than conflictual; joint
Would you say you get along most of the time, or that you
R

activities are usually pleasurable; and it is

don't get along? uncommon for either to try to avoid the
When did you start not getting along? other.
Can you remember a time when you did get along?
FO

1 = "Neutral" relationship
When did you start to get along badly?
What about the others? 2 = The child has a relationship with the
sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint
activities are usually either avoided, or
unpleasurable.

RELATIONSHIPS WITH SIBLING #4 CAK9X04

0 = The child has a relationship with the
sibling that is characterized by a generally
positive tone. Interactions are more likely to

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be harmonious than conflictual; joint

activities are usually pleasurable; and it is
uncommon for either to try to avoid the
other.

1 = "Neutral" relationship

2 = The child has a relationship with the

sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint

LY
activities are usually either avoided, or
unpleasurable.

RELATIONSHIPS WITH SIBLING #5 CAK9X05

0 = The child has a relationship with the
sibling that is characterized by a generally

N
positive tone. Interactions are more likely to
be harmonious than conflictual; joint
activities are usually pleasurable; and it is
uncommon for either to try to avoid the

O
other.

1 = "Neutral" relationship

2 = The child has a relationship with the

EW sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint
activities are usually either avoided, or
unpleasurable.

RELATIONSHIPS WITH SIBLING #6 CAK9X06

0 = The child has a relationship with the
sibling that is characterized by a generally
VI

positive tone. Interactions are more likely to

be harmonious than conflictual; joint
activities are usually pleasurable; and it is
uncommon for either to try to avoid the
other.
RE

1 = "Neutral" relationship

2 = The child has a relationship with the

sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint
activities are usually either avoided, or
unpleasurable.
R

RELATIONSHIPS WITH SIBLING #7 CAK9X07

0 = The child has a relationship with the
sibling that is characterized by a generally
FO

positive tone. Interactions are more likely to

be harmonious than conflictual; joint
activities are usually pleasurable; and it is
uncommon for either to try to avoid the
other.

1 = "Neutral" relationship

2 = The child has a relationship with the

sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint
activities are usually either avoided, or

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unpleasurable.

RELATIONSHIPS WITH SIBLING #8 CAK9X08

0 = The child has a relationship with the
sibling that is characterized by a generally
positive tone. Interactions are more likely to
be harmonious than conflictual; joint
activities are usually pleasurable; and it is
uncommon for either to try to avoid the
other.

LY
1 = "Neutral" relationship

2 = The child has a relationship with the

sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint

N
activities are usually either avoided, or
unpleasurable.

RELATIONSHIPS WITH SIBLING #9 CAK9X09

O
0 = The child has a relationship with the
sibling that is characterized by a generally
positive tone. Interactions are more likely to
be harmonious than conflictual; joint
activities are usually pleasurable; and it is
EW uncommon for either to try to avoid the
other.

1 = "Neutral" relationship

2 = The child has a relationship with the

sibling that is characterized by a generally
negative tone. Interactions are more likely
to be conflictual than harmonious; joint
VI

activities are usually either avoided, or

unpleasurable.
RE
R
FO

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OUT OF SCHOOL ACTIVITIES AND PEER

RELATIONSHIPS
OUT OF SCHOOL ACTIVITIES AND PEER
RELATIONSHIPS

GET A GENERAL PICTURE OF THE CHILD'S

ACTIVITIES. GET EXAMPLES OF FEELINGS
AND BEHAVIOR. NOTE NAMES. OBTAIN
PICTURE OF PATTERN AND FREQUENCY OF

LY
PEER CONTACTS, AND DURATION OF
FRIENDSHIPS

REMEMBER THIS INFORMATION MAY BE

IMPORTANT FOR INCAPACITY RATINGS. DO

N
NOT FOCUS ON PATHOLOGY AT THIS STAGE,
BUT ENSURE THAT THE AREAS IMPLICIT IN
THE QUESTIONS ARE COVERED

O
SYSTEMATICALLY.

SAFETY OF NEIGHBORHOOD
What kinds of things do you like to do in your spare SAFETY OF NEIGHBORHOOD CAL0I01
time?
EW 0 = Subject feels neighborhood is safe.
Intensity

What do you like doing best out of school? 2 = Subject feels neighborhood is unsafe.
Do you do that on your own or with others?
3 = Subject's activities in neighborhood are
Do you enjoy any sport? restricted because of perceived lack of
What about games like pool? safety.
How much are you interested in music?
VI

Do you play an instrument at all?

Does your family worship together?
What about you?
Do you have a job outside school?
Are you in any clubs (outside school)?
RE

How do you get along with other kids around here?

How do you get along with other kids at school?
Do you ever see friends on the weekends?
What do you tend to do together?
What about in the evenings after school?
Who are your particular friends? How often do you see
them outside of school?
R

Do you feel safe around where you live?

What is it like?
FO

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NUMBER OF ARGUMENTS WITH OTHER

ADULTS
An argument is defined as a disagreement, lasting at least NUMBER OF ARGUMENTS WITH OTHER abc1101
5 minutes, that results in a dispute involving raised voices, ADULTS Intensity
shouting, verbal abuse, or physical aggression or fights. 0 = Absent

2 = Present
Do you have arguments with other adults whom you
see outside of school? CAL1F01

LY
Frequency
Who do you argue with?
Tell me about the last time.
How long do these argument last?
CAL1O01
Onset

N
/ /

O
IF ARGUMENTS WITH ADULTS
PRESENT, CONTINUE. OTHERWISE,
SKIP TO "AGE APPROPRIATENESS OF
FRIENDS", (PAGE 3).
EW
VI
RE
R
FO

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ARGUMENTS WITH PHYSICAL VIOLENCE BY

CHILD
An argument is defined as a disagreement, lasting at least ARGUMENTS WITH PHYSICAL CAL2I01
5 minutes, that results in a dispute involving raised voices, VIOLENCE BY CHILD Intensity
shouting, verbal abuse, or physical aggression or fights. 0 = No

2 = Yes
How many arguments do you have with other adults over
the last three months? CAL2F01

LY
Did the arguments ever get physical? Frequency
What happened?

CAL2O01
Onset

N
/ /

O
OTHER PHYSICAL VIOLENCE BY CHILD
Have you "hit" an "other adult" over the last three OTHER PHYSICAL VIOLENCE BY CHILD CAL3I01
months? Intensity
EW 0 = No

2 = Yes

CAL3F01
Frequency

CAL3O01
VI

Onset

/ /
RE

AGE APPROPRIATENESS OF FRIENDS

The degree to which the child's friends are within two years AGE APPROPRIATENESS OF FRIENDS CAL4I01
of his/her own age. Friends, in this context, refer to those Intensity
0 = Majority of friends within 2 years of age
with whom the child spends leisure time, and who are not of child.
family members.
2 = Majority of friends 2 or more years older
R

than child.
Are most of your friends about your age?
3 = Majority of friends 2 or more years
Are they mostly younger than you? younger than child.
FO

Or older?

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FREQUENCY OF CONTACT WITH PEERS

The frequency with which the child meets with others, who FREQUENCY OF CONTACT WITH CAL5I01
are not family members, during his/her leisure time. Peers PEERS Intensity
can be child's friends, acquaintances, or peers in 0 = Sees at least 1 peer outside of
neighborhood. college/work more than once per week.

2 = Sees at least 1 peer outside of

Now I want to ask a few questions about your college/work between once per week and
friendships with other children. once every two weeks.

LY
3 = Sees less than 1 peer outside of
How often do you play with other children you know, college/work in 2 weeks.
outside of daycare/school?

Do you have "play dates" with any friends?

Or play with children in your neighborhood?

N
BEST FRIEND

O
An intensive, selective, and exclusive or semi-exclusive BEST FRIEND CAL6I01
friendship with another person, in which there is an Intensity
0 = Definite best friend in last year.
expectation that the dyad does things together, and in
which there is a preferential sharing of confidences. There 1 = Uncertain (including 3 or more close
EW
may be 1 or 2 "best friends" at any one time, but if the
friendship involves 3 or more peers this would not ordinarily
friendships described as "best").

2 = No best friend in last year.

be included as a "best friend" relationship.

Do you have a best friend? (NOTE NAME)

Does s/he ever come to your house?

VI

Or do you go to his/hers?
How long has s/he been your best friend?
What about your other friends?
Is that different from your other friendships?
Do you tell "best friend" things you wouldn't tell other
RE

people?
IF NO "BEST FRIEND" CURRENTLY, ASK:

Have you had a best friend in the past?

R
FO

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CONFIDANT(E) AMONG PEERS

The presence of a confidante is demonstrated by a CONFIDANT(E) AMONG PEERS OR CAL7I01
personal sharing of intimate feelings with one or more other OTHER ADULTS Intensity
people in a fashion that is selective to that relationship. The 0 = Definite confidant(e) with whom shared
sharing may consist of hopes, worries, personal "secrets," feelings in last year.
ambitions, problems, fantasies, feelings of love or rejection,
1 = Uncertain (including sharing of feelings
etc., but the sharing must be private to the relationship and to wider non-exclusive group).
it must involve some self-disclosure.

LY
2 = No confidant(e).

Do not include sibling relationships here.

Do you talk with anyone about your feelings? I mean

about your worries or hopes...... or about whom you

N
want to make friends wtih?

O
CONFIDANT(E) IN FAMILY
Do you share "secrets" with anyone? CONFIDANT(E) IN FAMILY CAL8I01
Who is that? Intensity
0 = Definite confidant(e) with whom shared
Do you have a friend you have talked to about worries or feelings in last year.
problems?
EW 1 = Uncertain (including sharing of feelings
to wider non-exclusive group).

2 = No confidant(e)

OTHER ADULT CONFIDANT(E)

VI

Do you share her thoughts or personal problems with OTHER ADULT CONFIDANT(E) CAL9I01
adults outside of the family? Intensity
0 = Definite confidant(e) with whom shared
feelings in last year.

1 = Uncertain (including sharing of feelings

RE

to wider non-exclusive group).

2 = No confidant(e)

NUMBER OF ARGUMENTS WITH PEERS

An argument is defined as a disagreement, lasting at least NUMBER OF ARGUMENTS CAM1XYZ 00
Intensity
R

5 minutes, that results in a dispute involving raised voices, 0 = Absent

shouting, verbal abuse, or physical aggression or fights.
2 = Present
FO

Do you have arguments with other kids when you is CAM1F01

not at school? Frequency

Who do you argue with?

Tell me about the last time.
How long do these arguments last? CAM1O01
How many arguments have you had with other kids away Onset
from school over the last three months?
/ /

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DIFFICULTY MAKING OR KEEPING FRIENDS

Child has difficulty either forming or maintaining DIFFICULTY MAKING FRIENDS CAM0I03
friendships, which is evidence by having no or few friends. Intensity
0 = Absent
The difficulty may be due to failure to approach other
children (withdrawl) or aggressive relationships with other 2 = Present
children (discord) or both.
WITHDRAWAL CAM0I01

Do not include worry or anxiety about friendships unless it 0 = Absent

LY
leads to difficulty in making or keeping friendships. 2 = Definite difficulty in making or keeping
friends, but has managed to maintain
friendship for at least 3 months since onset.
Do you have any difficulty making friends with other
children 3 = As above, but has had no friendship
lasting as long as 3 months since onset.

N
Do you have any trouble keeping friends?
DISCORD CAM0I02
Do you find other children don't want to play with you 0 = Absent
or don't choose you for games

O
2 = Definite difficulty in making or keeping
What happens? friends, but has managed to maintain
friendship for at least 3 months since onset.
Do you think you are more shy than other boys/girls the
same age? 3 = As above, but has had no friendship
Does that affect your making/keeping friends? lasting as long as 3 months since onset.
EW
Or do you get into arguments or fights with friends or other
children who might become friends?
How do you feel about that?
Does it bother you?
How long have you had difficulty making/keeping friends?
Has it always been like that, or can you remember when it
started?
VI

CONFLICTUAL RELATIONSHIP WITH FRIENDS

The child has relationships with a friend or friends that 0 = Absent CAM2I01
RE

include substantial amounts of physical or verbal Intensity

2 = Present with at least one friend.
aggression or arguments. Conflict may or may not cause
the child problems in making or keeping friends. 3 = Most or all friendships characterized by
conflictual relationships.

THIS ITEM IS GENERALLY CODABLE BASED ON

INFORMATION ALREADY GIVEN.
R

YOU HAVE TOLD ME THAT YOU DOESN'T HAVE

DIFFICULTY MAKING OR KEEPING FRIENDS.
FO

Do you have a lot of conflict with your friends?

Does it cause you difficulty in making or keeping friends?

IF CHILD DOES NOT HAVE DIFFICULTY MAKING OR
KEEPING FRIENDS DUE TO DISCORD, THEN
COMPLETE CONFLICTUAL RELATIONSHIP WITH
FRIENDS. OTHERWISE SKIP TO SHYNESS WITH
PEERS.

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SHYNESS WITH PEERS

Sensitive reluctance to approach peers who are little known SHYNESS WITH PEERS CAM3I01
to the subject. Intensity
0 = Absent

CONSIDER SOCIAL ANXIETY ESPECIALLY IF SHYNESS 2 = Shyness involving definite discomfort on

meeting new people with whom child has
IS PRESENT TO THE EXTENT THAT CONTACT IS no special reason to feel usch discomfort.
ACTIVELY AVOIDED.

LY
Do you think that you're more shy than other kids?

In what way?
How shy?
Does that stop you from doing anything?
Can you tell me about last time it did?

N
SUBJECT IS TEASED/BULLIED

O
Child is a particular object of mockery, physical attacks or CHILD TEASED OR BULLIED CAM4I01
threats by peers or siblings. Intensity
0 = Absent

Do you get teased or bullied at all by your siblings or 2 = The child is a particular and preferred
friends?
EW object for bullying or teasing. S/he is at
least somewhat singled out for this sort of
attention.
Is that more than other children?
Are other boys and girls mean to you? HOME CAM4F01
Home
How much? Frequency
Tell me about the last time.
VI

Who does it?

Why do they do it? DAYCARE/SCHOOL CAM4F02
Why do they pick on you? Daycare/School
What do you do about it? Frequency
RE

ELSEWHERE CAM4F03
Elsewhere
Frequency
R

CAM4O01
Onset

/ /
FO

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"SCHIZOID" LACK OF INTEREST IN PEOPLE

Child has pervasive lack of interest in peers that is not a "SCHIZOID" LACK OF INTEREST IN CAM5I01
consequence of anxiety; does not seek increased contact PEOPLE Intensity
with them; and lacks a sense of closeness or involvement 0 = Absent
with other people.
2 = Present

Do you prefer doing things alone or with other people?

LY
Why is that?
Do you enjoy being with people?
How well do you fit in with other kids?

Are you usually one of the group?

N
Is there anyone you feel really close to?

Do you have a special friend?

O
Do you wish you had more friends?
Why don't you have more friends?

LACK OF EMPATHY/EMOTIONAL SENSITIVITY

EW
A lack of awareness of, and sensitivity to, other people's LACK OF EMPATHY CAM6I01
Intensity
feelings. Lack of ability to detect other's feelings, not lack of 0 = Absent
willingness to respond to them. This lack is pervasive and
not specific to any particular relationship. 2 = Present

Can you usually tell when other people are upset?

VI

Or happy?

What about your family?

RE

Do your friends talk with you about their worries or

troubles?
IF NO:

Why not?
R
FO

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GIRLFRIEND/BOYFRIEND
A selective relationship with a member of the opposite sex, BOYFRIEND/GIRLFRIEND CAM7I01
that involves joint activities. The relationship need not Intensity
0 = No
include any sexual activity.
2 = Yes
IF CHILD IS AGE 11 OR ABOVE, ASK ABOUT SEXUAL INTERCOURSE Ever:CAM8E01
BOYFRIEND/GIRLFRIEND. Intensity
0 = Absent

LY
Have you had a boyfriend/girlfriend in the last 3 2 = Present
months?
ONSET - SEXUAL INTERCOURSE CAM8O01
How long have you been dating him/her?
/ /
Have you ever had sexual intercourse?

N
NUMBER OF SEXUAL PARTNERS - Ever:CAM9V01
When was the first time? CODE ACTUAL NUMBER
How many people have you had sex with in your life?

O
Have you ever been pregnant/gotten a girl pregnant? NUMER OF PREGNANCIES - CODE Ever:CAN0V01
How many times? ACTUAL NUMBER
When was the first time?
What was the outcome?
Do you have any children? CAN0O01
How many?
EW Onset

/ /
PREGNANCY OUTCOME CAN1I01
0 = Still pregnant
VI

1 = Miscarriage
CAN1I02
2 = Abortion

3 = Live birth, mother kept child

CAN1I03
4 = Live birth, father kept child
RE

5 = Child adopted or cared for by another

family member

6 = Child released for extra-familial

adoption

7 = Child in foster care

R

8 = Live birth: mother, father and child live

together

9 = Live birth: mother and father live

FO

separately, however child lives equal time

with each

NUMBER OF CHILDREN CAN2F01

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SCHOOL/WORK PERFORMANCE AND

BEHAVIOR
SCHOOL PERFORMANCE AND BEHAVIOR

LY
N
O
EW
VI
RE
R
FO

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GENERAL SCHOOL INFORMATION

GET A GENERAL PICTURE OF THE CHILD'S

LIFE IN THE SCHOOL.

TYPE OF SCHOOL
CHILD ATTENDS SCHOOL. TYPE OF SCHOOL CBA1XYZ 00
Intensity

LY
0 = Absent
Which school do you go to?
2 = Present
What grade are you in?
TYPE OF SCHOOL CBA0X01
Have you ever repeated a grade? 0 = Regular (non-treatment facility) school

N
Have you ever skipped a grade? 1 = Alternative school

2 = Treatment facility school

How many weeks were you in school in the last 3

O
months? 3 = More than 1 type of school

Did you attend each day? 4 = Home schooling

CBA1X01
Were you out for sickness? Frequency
Vacation?
Did you skip school?
EW
Or miss school because you was worried about going to
school? EVER REPEATED GRADE CBA2X01
How do you like school? 0 = No

How do you get along with the teachers? 2 = Yes

VI

Which teacher do you like best? EVER SKIPPED A GRADE CBA2X02

Are there any teachers who you really dislikes? 0 = No
How are you getting along in school?
What are your report cards like? 2 = Yes
RE

WEEKS CBA3D01
What sort of trouble do you get into at school? Duration
Have you ever been sent home from school?
Have you ever been expelled?
Or suspended? PRIMARY PERIOD: NUMBER OF DAYS CBA4F01
Had in-school suspension? PRESENT
R

How do you get along with the kids at school?

How much do you get into fights? PRIMARY PERIOD: NUMBER OF WEEKS CBA5F01
WHERE PRESENT AT LEAST 1 DAY PER
FO

Are these friendly fights or real fights? WEEK

CURRENT GRADE OR GRADE LAST COMPLETED

EVER REPEATED GRADE.

EXCLUDE WEEKS OF VACATION OR EXTENDED

ILLNESS. INCLUDE WEEKS WHEN ENROLLED BUT
MISSED SCHOOL BECAUSE OF TRUANCY OR
WORRY/ANXIETY.

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IF CHILD IS STILL IN SCHOOL,

COMPLETE. OTHERWISE , SKIP TO
"REGULAR EMPLOYMENT", (PAGE 9).

LY
N
O
EW
VI
RE
R
FO

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NUMBER OF WEEKS ENROLLED IN SCHOOL -

SECONDARY PERIOD
Beginning date of last month period when enrolled in SECONDARY PERIOD abc0001
school. Intensity
0 = No

ENROLLED DURING A SECONDARY PERIOD. 2 = Yes

CBA6O01
IF CHILD NOT ENROLLED IN SCHOOL 4 WEEKS IN Onset

LY
LAST 3 MONTHS, CODE BEGINNING DATE OF LAST 4
WEEKS WHEN WAS IN SCHOOL / /
SECONDARY PERIOD: NUMBER OF CBA6F01
DAYS PRESENT

N
SECONDARY PERIOD: NUMBER OF CBA6F02
WEEKS WHERE PRESENT AT LEAST 1
DAY PER WEEK

O
NUMBER OF WEEKS ENROLLED IN SCHOOL -
TERTIARY PERIOD EW
Beginning date of last 4 week period when child present in ENROLLED IN TERTIARY PERIOD abc0002
school 1 day per week. Intensity
0 = No

ENROLLED IN TERTIARY PERIOD. 2 = Yes

CBA7O01
IF CHILD NOT ENROLLED IN SCHOOL 4 WEEKS IN Onset
LAST 3 MONTHS, CODE BEGINNING DATE OF LAST 4
VI

WEEKS WHEN WAS IN SCHOOL 1 DAY PER WEEK / /

TERTIARY PERIOD: NUMBER OF DAYS CBA7F01
PRESENT
RE

AFTER SCHOOL WORK

Include any paid employment, including weekend and CURRENTLY WORK AFTER SCHOOL CBC1I01
vacation jobs, (apart from work required in order to qualify Intensity
0 = Absent
for an allowance from parents) in the past 3 months.
R

2 = Present
Have you had a job in the last 3 months? CBC1F01
Frequency
FO

What do you do?

How many hours a week do you work?

How long have you been working? CBC1O01
Have you ever been dismissed from a job? Onset

Why was that? / /

School/Work Performance and Behavior 4

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EVER DISMISSED FROM JOB

Include any paid employment, including weekend and CURRENTLY WORK AFTER SCHOOL CBC1I01
vacation jobs, (apart from work required in order to qualify Intensity
0 = Absent
for an allowance from parents) in the past 3 months.
2 = Present
Have you had a job in the last 3 months? CBC1F01
Frequency
What do you do?

LY
How many hours a week do you work?
How long have you been working? CBC1O01
Have you ever been dismissed from a job? Onset

Why was that? / /

N
Have you ever been dismissed from a job? EVER DISMISSED FROM JOB CBC2I01
0 = Absent

O
Why was that?
2 = Present

SAFETY OF SCHOOL EW
How safe is your school? SAFETY OF SCHOOL CBA8I01
Intensity
0 = Child feels safe.
Do you feel that it is a dangerous place to be?
2 = Child reports feeling unsafe.

3 = Child restricts activities because of lack

of safety.
VI
RE
R
FO

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NUMBER OF ARGUMENTS WITH TEACHERS

An argument is defined as a disagreement, lasting at least NUMBER OF ARGUMENTS WITH BCAYXZ5 00
5 minutes, that results in a dispute involving raised voices, TEACHERS Intensity
shouting, verbal abuse, or physical aggression or fights. 0 = Absent

2 = Present
Do you have arguments with teachers?
CBB7F01
Who do you argue with? Frequency

LY
Tell me about the last time.
How long do these arguments last?
How many arguments have you had with teachers over the
last three months? CBB7O01
Onset
Did the arguments ever get physical?
/ /

N
What happened?
Have you "hit" a teacher over the last three months?
ARGUMENTS WITH PHYSICAL CBB8I01
VIOLENCE BY CHILD

O
0 = Absent

2 = Present

ARGUMENTS WITH PHYSICAL CBB8F01

EW VIOLENCE BY CHILD (FREQUENCY)

NUMBER OF ARGUMENTS WITH CBB8O01

TEACHERS (WITH PHYSICAL
VIOLENCE) / /
VI

OTHER PHYSICAL VIOLENCE BY CHILD

(WITHOUT ARGUMENTS WITH TEACHERS)
An argument is defined as a disagreement, lasting at least OTHER PHYSICAL VIOLENCE BY CHILD CBB9I01
5 minutes, that results in a dispute involving raised voices, Intensity
RE

0 = Absent
shouting, verbal abuse, or physical aggression or fights.
2 = Present
Have you hit a teacher in the last 3 months? OTHER PHYSICAL VIOLENCE BY CHILD CBB9F01
-FREQUENCY

OTHER PHYSICAL VIOLENCE BY CBB9O01

R

CHILD- ONSET
/ /
FO

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NUMBER OF ARGUMENTS WITH PEERS AT

SCHOOL
Do you have arguments with peers at school? NUMBER OF ARGUMENTS WITH PEERS ABCM204
AT SCHOOL Intensity
Who do you argue with? 0 = Absent
Tell me about the last time.
How long do these arguments last? 2 = Present
How many arguments have you had with other kids at CBC0F01

LY
school over the last three months? Frequency
When did you first argue with friends like that?

CBC0O01
Onset

N
/ /

O
EW
VI
RE
R
FO

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WORK PERFORMANCE AND BEHAVIOR

SCHOOL INFORMATION FOR THOSE WHO
HAVE LEFT SCHOOL
Information about the school history of students who left LEFT SCHOOL OFFICIALLY CBA9I01
school before the 3 month period. Do not include students Intensity
0 = No
who are on summer break.
2 = Yes

LY
When did you leave school? CBA9O01
Onset
What was the last grade you completed?
/ /
Have you ever repeated a grade?
PBB0O01 CBB0O01

N
Did you graduate before leaving?
/ /
IF NOT GRADUATE, ASK
SECONDARY PERIOD: NUMBER OF CBB0F01

O
Have you gotten your GED? DAYS PRESENT

Or attended night school?

SECONDARY PERIOD: NUMBER OF CBB0F02
Or another alternative school? EW WEEKS WHERE PRESENT AT LEAST 1
DAY PER WEEK
IF CHILD NOT PRESENT IN SCHOOL 1 DAY A WEEK
FOR 4 WEEKS IN SECONDARY PERIOD, CODE TERTIARY PERIOD: BEGINNING DATE CBB1O01
BEGINNING DATE OF 4 WEEK PERIOD WHEN WAS IN OF LAST 4 WEEK PERIOD WHEN CHILD
SCHOOL 1 DAY PER WEEK. PRESENT IN SCHOOL 1 DAY PER WEEK / /
TERTIARY PERIOD: NUMBER OF DAYS CBB1F01
PRESENT
VI

LAST GRADE COMPLETED CBB2X01

RE

EVER REPEATED GRADE Ever:CBB3I01

Intensity
0 = No

2 = Yes

GRADUATED CBB4I01
R

0 = Yes

2 = No

CBB5I01
FO

EARNED GED

0 = Yes

2 = No

COMPLETE ALTERNATIVE SCHOOL CBB6I01

PROGRAM

0 = Yes

2 = No

School/Work Performance and Behavior 8

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REGULAR EMPLOYMENT
Paid employment for those who have left school officially. REGULAR EMPLOYMENT Ever:CCB30XX
00
0 = Absent Intensity
Have you ever had a job?
2 = Present
Have you had a job in the last 3 months?
CURRENTLY EMPLOYED CBC3I01
What do you do? Intensity

LY
0 = Absent
How many hours a week do you work? 2 = Present
Have you ever worked 20 or more hours a week?
How many weeks have you worked in the last 3 months? CURRENTLY EMPLOYED >20 HR/WEEK CBC3I02
When did you get your first job?
0 = Absent
How many jobs have you has in your life?

N
Have you ever been dismissed from a job? 2 = Present

What is the longest you have been without a job? NUMBER OF WEEKS WORKED IN PAST CBC3F01
3 MONTHS

O
CURRENTLY EMPLOYED
DATE FIRST JOB BEGAN SINCE CBC3O01
LEAVING SCHOOL
EW / /
EVER: NUMBER OF JOBS HELD Ever:CBC3V01

CODE ONLY IF OFFICIALLY LEFT SCHOOL EVER: DISMISSED FROM JOB Ever:CBC4E01
0 = Absent
CODE NUMBER OF WEEKS UNEMPLOYED
VI

2 = Present

EVER: LONGEST PERIOD OF Ever:CBC5V01

UNEMPLOYMENT
RE
R
FO

School/Work Performance and Behavior 9

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PATTERN OF NON-ATTENDANCE (TRUANCY)

MISSING TIME AT SCHOOL (TRUANCY)
The child fails to reach, or leaves school, without SKIPPED SCHOOL CBC6I01
permission of school authorities, and without a normally Intensity
0 = Absent
acceptable excuse (such as illness), for reasons not
associated with either seperation anxiety or fear of school. 2 = Present
The reason may be dislike of school or a wish to take part
in other activities, with or without friends.

LY
Non-attendance because of worry or anxiety may also
occur, in which case both are rated as being present.

Have you skipped school in the last 3 months?

N
NUMBER OF 1/2 DAYS IN SCHOOL PERIOD WHEN MISSING TIME AT SCHOOL CBC6F01
ENROLLED IN SCHOOL

O
EVER: MISSING TIME AT SCHOOL (TRUANCY)
The child fails to reach, or leaves school, without Ever:CBC6E01
EW
permission of school authorities, and without a normally
acceptable excuse (such as illness), for reasons not
EVER: SKIPPED SCHOOL (TRUANCY)

0 = Absent
Intensity

associated with either seperation anxiety or fear of school. 2 = Present

The reason may be dislike of school or a wish to take part
Ever:CBC6O01
in other activities, with or without friends. Onset

/ /
VI

Non-attendance because of worry or anxiety may also

occur, in which case both are rated as being present.

Have you ever skipped school?

RE

Have you ever skipped any classes while in school?

How often?
What about during the last 3 months?
Why was that?
Tell me about the last time.
What did you do?
R

What were up to?

Were you on your own or with other children/people?
Have you ever skipped out of school during the day?
FO

How often?
Why was that?
Have you ever pretended to be sick so that you would not
have to go to school?

School/Work Performance and Behavior 10

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IF MISSED AT LEAST 1 HALF DAY, NO

ACCEPTABLE REASON FOR SCHOOL
ABSENCE, AND ABSENCE NOT DUE
TO WORRY/ANXIETY, COMPLETE.
OTHERWISE , SKIP TO "ACTUAL
DISTRESS WHEN ATTACHMENT
FIGURE ABSENT", (PAGE 14).

LY
N
O
EW
VI
RE
R
FO

School/Work Performance and Behavior 11

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STAYS AT HOME SOME MORNINGS

(TRUANCY)
Do you ever stay at home sometimes when you should STAYS AT HOME SOME MORNINGS CBC7I01
be at school? Intensity
0 = Does not stay at home

How often? 2 = Stays at home at least one occasion in

Do your parents make you go? 3 months.
Do they try to? CBC7F01

LY
What happens then? Frequency
Tell me about the last time it happened.
Is it like that every morning?

HAS TO BE TAKEN TO SCHOOL (TRUANCY)

N
Parent or someone else has to take child to school to HAS TO BE TAKEN TO SCHOOL CBC8I01
ensure arrival, for reason other than the child's anxiety or Intensity
0 = No

O
emotional disturbance.
2 = Yes, on at least one occasion in last 3
months.
Do your parents have to take you to school sometimes
to make sure that you will go? CBC8F01
Frequency
How often?
What happens?
EW
PARENTAL COLLUSION (TRUANCY)
The child is out of school, meeting criteria for truancy PARENTAL COLLUSION CBC9I01
Intensity
VI

(above). The parents know the child is not attending 0 = Child truanted in last three months and
school, and do not take measures to get the child to school. parents have made repeated, consistent
attempts to get child to attend school
(irrespective of whether successful)
Do your parents know that you skip school?
1 = Sporadic and inconsistent parental
RE

What do your parents do when you don't want to go to attempts

school?
2 = Child truanted in last 3 months, without
parental attempts to enforce school
Do they try to make you go? attendance

Do your parents think you should be going to that school? 3 = Child taken out of school by parents
Does your not going to school bother them?
R
FO

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RUNS OUT OF SCHOOL (TRUANCY)

Child either fails to reach school, or leaves school before RUNS OUT OF SCHOOL zyxabc9 00
end of school day, without permission. Intensity
0 = Absent

Do not code here if absence is due to anxiety related to 2 = Present

going to school. CHILD FAILS TO REACH, OR LEAVES, CBD0I01
SCHOOL AND RETURNS HOME
When you skip school, where do you go? (TRUANCY)

LY
0 = No
What do you do?
Is that on your own or with someone else? 2 = Yes
Who? CBD0F01
Frequency

N
CHILD FAILS TO REACH, OR LEAVES, CBD1I01

O
SCHOOL AND GOES OFF ALONE
(TRUANCY)

0 = No

2 = Yes
EW CHILD FAILS TO REACH, OR LEAVES,
SCHOOL AND GOES OFF ALONE
CBD1F01

(TRUANCY) - FREQUENCY

CHILD FAILS TO REACH, OR LEAVES, CBD2I01

SCHOOL AND GOES OFF WITH PEERS
(TRUANCY)
VI

0 = No

2 = Yes

CHILD FAILS TO REACH, OR LEAVES, CBD2F01

RE

SCHOOL AND GOES OFF WITH PEERS

(TRUANCY)-FREQUENCY
R
FO

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SCHOOL/SEPARATION ANXIETY
WORRY/ANXIETY OVER SCHOOL
ATTENDANCE AND SEPARATION
EVER: SCHOOL NON-ATTENDANCE
(WORRYING/ANXIETY)
Have you been worried at all about going to school? EVER: SCHOOL NON-ATTENDANCE Ever:CBD7E01
(WORRY/ANXIETY) Intensity
Have you ever been unable to go to school because

LY
0 = Absent
you were worried or upset?
2 = Present
Have you ever pretended to be sick so you won't have
Ever:CBD7O01
to go to school?
Onset

/ /

N
O
SCHOOL NON-ATTENDANCE
(WORRYING/ANXIETY)
Have you missed any school due to being worried or SCHOOL NON-ATTENDANCE CBD7I01
upset or pretending to be sick in the last three (WORRY/ANXIETY) Intensity
months?

FREQUENCY CODED AS NUMBER OF 1/2 DAYS IN

EW 0 = No

2 = Yes
SCHOOL PERIOD WHEN ENROLLED IN SCHOOL.
CBD7F01
Frequency
VI
RE
R
FO

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LEGAL ACTION OR TREATMENT FOR SCHOOL

NON-ATTENDANCE
Code legal action or treatment for school non-attendance, LEGAL ACTION OR TREATMEN FOR xbayzc4200
due to truancy or separation (worry anxiety) in the last SCHOOL NON-ATTENDANCE Intensity
three months. 0 = Absent

2 = Present
IF TRUANCY OR MISSING SCHOOL DUE TO ANXIETY,
ASK FOLLOWING QUESTIONS. OTHERWISE CODE AS SCHOOL-BASED RESPONSE TO NON- CBD3I01

LY
ABSENT. ATTENDANCE

0 = None
Has anyone done anything about your missing school?
2 = Any school-based disciplinary action
Like a school counselor?
3 = Counselling or other therapeutic

N
response
Who?
PROFSSIONAL INVOLVEMENT FOR CBD4I01
What have they done? SCHOOL NON-ATTENDANCE

O
Has anyone else tried to help you get back to school? 0 = No

2 = Involvement of any professional from

What have they done? mental health services who would not
EW normally be involved with child. Include
Have they taken any legal action? psychologists, doctors, etc.

LEGAL ACTION FOR SCHOOL NON- CBD5I01

ATTENDANCE

0 = No

2 = Code here only when legal action

actually under way. Do not code threats of
VI

legal action.
RE
R
FO

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SCREEN: SCHOOL
ATTENDANCE/SEPARATION
(WORRY/ANXIETY) POSITIVE
NB: IF SCHOOL NON-ATTENDANCE IN THE LAST SCREEN: SCHOOL NON-ATTENDANCE CBD6I01
THREE MONTHS DUE TO WORRY/ANXIETY, CODE (WORRYING/ANXIETY) Intensity
SCREEN AS POSITIVE. 0 = Absent

Have you been worried at all about going to school in 2 = Present

LY
the last 3 months?

What happens when you're worried about school?

Do you get anxious or upset on school morning?

Do you worry or get upset about being away from your

N
"parents"?

Do you worry when they go out without you?

O
Or when your at school?

What about if they go away without you?

Such as because of work or on vacation? EW
Would you worry about that?

IF SCHOOL ATTENDANCE OR
SEPARATION SCREEN POSITIVE,
COMPLETE. OTHERWISE, SKIP TO
VI

"EXCESSIVE NEED FOR

REASSURANCE", (PAGE 3).
RE
R
FO

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WORRIES/ANXIETY OVER GOING TO SCHOOL

WORRIES/ANXIETY ABOUT LEAVING HOME
Worry or subjective anxious affect related to leaving home WORRIES/ANXIETY ABOUT LEAVING CBD8I01
for school. HOME Intensity
0 = Absent
Do you ever worry about leaving home to go to
2 = Anticipatory worry or anticipatory
school? anxiety intrusive into at least 2 activities that

LY
cannot be entirely controlled.
Are you frightened about having to leave home?
3 = Anticipatory worry or anticipatory
anxiety occurring, almost entirely
Why?
uncontrollable, in most activities.
What do you think might happen?
Do you ever end up staying at home? CBD8F01

N
Or leaving school early, before you should? Frequency

How long does this last?

How often does this happen?

O
HOURS : MINUTES CBD8D01
How long do you remain upset or worried?
Duration
Once you actually leave the house (for example, are in the
car), how long does it take for youto calm down?
Can you say why you're afraid or worried? EW CBD8O01
When did you start acting this way? Onset

/ /

ANTICIPATORY FEAR OF SCHOOL

VI

Anticipatory worry or subjective anxious affect related to ANTICIPATORY FEAR OF SCHOOL CBD9I01
school situation. Intensity
0 = Absent

Are you frightened or worried about anything at 2 = Anticipatory worry or anticipatory

anxiety intrusive into at least 2 activities that
RE

school? cannot be entirely controlled.

Such as particular classes, or teachers, or the behavior 3 = Anticipatory worry or anticipatory

of other children? anxiety occurring, almost entirely
uncontrollable, in most activities.
Why? CBD9F01
Do you worries about school when your're not there? Frequency
R

What do you do about it?

Can you stop being frightened?
Can anyone manage to reassure you? HOURS : MINUTES CBD9D01
FO

Duration

CBD9O01
Onset

/ /

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FEAR WHEN AWAY OF WHAT WILL HAPPEN

AT HOME
Worry or subjective anxious affect related to the possibility FEAR WHEN AWAY OF WHAT WILL CBE0I01
of bad things happening at home while the child is at HAPPEN AT HOME Intensity
school. 0 = Absent

2 = Anticipatory worry or anticipatory

Do you worry about what might happen at home when anxiety intrusive into at least 2 activities that
you're away at school? cannot be entirely controlled.

LY
What do you think might happen? 3 = Anticipatory worry or anticipatory
anxiety occurring, almost entirely
What do you do about that? uncontrollable, in most activities.
Do you worry about it even when you're at home?
What does your "parents" say about it? CBE0F01
Frequency

N
Can they manage to reassure you?

CBE0D01

O
HOURS : MINUTES
Duration

CBE0O01
EW Onset

/ /

PHYSICAL SYMPTOMS OF SEPARATION

Complaints of physical symptoms, e.g. stomachaches, CBE1I01
VI

PHYSICAL SYMPTOMS ON
headaches, nausea, vomiting, on school days, or on other SEPARATION Intensity
occasions when separation from major attachment figures 0 = No
occurs or is anticipated.
2 = Yes
RE

Do you get any aches or pains on school days?

Or at other times when you're seperated from your

parents?

Do you ever feel sick at these times?

R

Or get headaches?
Or stomachaches?
REMEMBER TO COMPLETE ANXIOUS AUTONOMIC
FO

SYMPTOMS.

NUMBER OF DAYS IN PRIMARY PERIOD CBE1F01

Frequency
When did it start?

CBE1O01
Onset

/ /

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PATTERN OF NON-ATTENDANCE
(WORRIES/ANXIETY)
STAYS AT HOME SOME MORNINGS
(WORRY/ANXIETY)
Child stays out of school because of fear/anxiety/emotional STAYS AT HOME SOME MORNINGS CBE2I01
disturbance. (WORRY/ANXIETY) Intensity
0 = Absent

LY
Do you stay at home sometimes?
2 = Without marked parental attempts to get
him/her to school.
When is that?
How often? 3 = With marked parental attempts to get
How do you feel on these mornings? him/her to school.
What do your "parents" do when you don't want to go to CBE2O01

N
school? Onset
Do they make you go?
Do they try to? / /

O
What happens then?
Tell me about the last time it happened.
Is it like that every morning?
QUESTION IN DETAIL TO DIFFERENTIATE STAYING AT
HOME BECAUSE OF ANXIETY, OR OTHER EMOTIONAL
DISTURBANCES, FROM STAYING AT HOME FOR
OTHER REASONS.
EW
When was the first time this happened?

HAS TO BE TAKEN TO SCHOOL

VI

(WORRY/ANXIETY)
Parent, or someone else, has to take child to school to HAS TO BE TAKEN TO SCHOOL CBE3I01
ensure arrival because the child is anxious about leaving (WORRY/ANXIETY) Intensity
home or going to school. 0 = No
RE

2 = Yes, on at least one occasion in last 3

Do your "parents" have to take you to school months.
sometimes?
CBE3F01
Why is that? Frequency
How often?
What happens?
R
FO

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RUNS OUT OF SCHOOL (WORRY/ANXIETY)

Child either fails to reach school because of worry/anxiety, RUNS OUT OF SCHOOL zyxabc4 00
or leaves before end of school day without permission (WORRY/ANXIETY) Intensity
because of worry/anxiety. 0 = Absent

2 = Present
Are there ever times when you just can't bear to go into
school? CHILD FAILS TO REACH OR LEAVES CBE4I01
SCHOOL AND RETURNS HOME

LY
What is it that makes it difficult for you to go into school? (WORRY/ANXIETY)
Or when you leaves school without permission? 0 = Absent

Why do you leave? 2 = Present

Where do you go?
CHILD FAILS TO REACH OR LEAVES CBE4F01
Who with?

N
SCHOOL AND RETURNS HOME
What have your "parents" done about that? (WORRY/ANXIETY) - FREQUENCY
What has the school done?
QUESTION IN DETAIL TO DIFFERENTIATE ANXIETY CHILD FAILS TO REACH OR LEAVES CBE5I01

O
OVER SCHOOL ATTENDANCE FROM TRUANCY OR SCHOOL AND GOES OFF ALONE
(WORRY/ANXIETY)
OTHER FORMS OF NON-ATTENDANCE.
0 = Absent
IF SCHOOL NON-ATTENDANCE PRESENT, REMEMBER
TO COMPLETE LEGAL ACTION OR TREATMENT 2 = Present
SECTION AND AUTONOMIC SYMPTOMS.
EW CHILD FAILS TO REACH OR LEAVES
SCHOOL AND GOES OFF ALONE
CBE5F01

(WORRY/ANXIETY) FREQUENCY

CHILD FAILS TO REACH OR LEAVES CBE6I01

SCHOOL AND GOES OFF WITH PEERS
(WORRY/ANXIETY)
VI

0 = Absent

2 = Present

CHILD FAILS TO REACH OR LEAVES CBE6F01

RE

SCHOOL AND GOES OFF WITH PEERS

(WORRY/ANXIETY)-FREQUENCY

SEPARATION ANXIETY POSITIVE

Endorsement of separation questions requires that you do SEPARATION ANXIETY POSITIVE CBD6I03
the whole section. Intensity
R

0 = No

Endorsement of worry/anxiety over school attendance 2 = Yes

questions only, allows you to skip the separation part of the
FO

section.

Separation anxiety would code "yes" if child has

worries/anxieties about being separated from parent(s). If
child has worries/anxieties about school attendance only,
code "no".

NB. INTERVIEWER USE INFORMATION ALREADY

COLLECTED TO CODE THIS ITEM.

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IF SEPARATION ANXIETY POSITIVE,

CONTINUE. OTHERWISE, SKIP TO
"EXCESSIVE NEED FOR
REASSURANCE", (PAGE 3).

LY
N
O
EW
VI
RE
R
FO

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SEPARATION ANXIETY
SEPARATION WORRIES/ANXIETY
Excessive worries or fear concerning separation from the SEPARATION WORRIES/ANXIETY CBE7I01
persons to whom the affected child is attached. Intensity
0 = Absent

There are 2 forms of Separations Worries/Anxiety: 2 = Worrying or anxiety is intrusive into at

least 2 activities and uncontrollable at least
soem of the time.

LY
Worries/Anxiety about Possible Harm, and Worries/Anxiety
3 = Worrying is intrusive into most ativities
about calamitous Separation. and nearly always uncontrollable.

Worries/Anxiety About Possible Harm: CBE7F01

Frequency

N
Unrealistic and persistent worry or fear about possible
harm befalling major attachment figures, or fear that they
will leave and will not return. HOURS : MINUTES CBE7D01
Duration

O
Worries/Anxiety About Calamitous Separation:

Unrealistic and persistent worry or fear that an unexpected CBE7O01

calamitous event will separate the child from a major Onset

killed, or be the victim of an accident.

EW
atachment figure, e.g., the child will be lost, kidnapped,
/ /
WORRIES ABOUT POSSIBLE HARM CBE8I01
Tell me how you react when you're separated from
0 = Absent
your "parents" or other household members.
2 = Worrying is intrusive into at least 2
Are you afraid of being away from them?
VI

activities and uncontrollable at least some

of the time.
Do you worry when they're away?
3 = Worry is intrusive into most activities
and nearly always uncontrollable.
Or when you have to leave them?
CBE9I01
RE

WORRIES ABOUT CALAMITOUS

When you're away from your "parents" do you worry SEPARATION
that they might come to some harm?
0 = Absent

Or that they might leave you? 2 = Worrying is intrusive into at least 2

activities and uncontrollable at least some
What do they do about it? of the time.
Can they stop your worrying?
R

3 = Worry is intrusive into most activities

What do they do? and nearly always uncontrollable.

Does s/he worry that s/he might come to some harm

FO

while s/he's away from the family?

What does s/he do about it?

What happens at school time?
What happens if a friend asks him/her to go out?
Can you stop X worrying about that?

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WORRIES/ANXIETY ABOUT POSSIBLE HARM

Unrealistic and persistent worry or fear about possible WORRIES ABOUT POSSIBLE HARM CBE8I01
harm befalling major attachment figures, or fear that they Intensity
0 = Absent
will leave and will not return.
2 = Worrying is intrusive into at least 2
activities and uncontrollable at least some
When you're away from your parents do you worry that of the time.
they might come to some harm?
3 = Worry is intrusive into most activities

LY
Or leave you? and nearly always uncontrollable.

How much do you worry about that?

What do you do about it?
Can you stop yourself worrying?
What do yo do?

N
WORRIES/ANXIETY ABOUT CALAMITOUS

O
SEPARATION
Unrealistic and persistent worry or fear that an unexpected WORRIES ABOUT CALAMITOUS CBE9I01
calamitous event will separate the child from a major SEPARATION Intensity
attachment figure, e.g., the child will be lost, kidnapped, 0 = Absent
killed, or be the victim of an accident.
EW 2 = Worrying is intrusive into at least 2
activities and uncontrollable at least some
Does you worry that youmight come to some harm of the time.
while you're away from your family?
3 = Worry is intrusive into most activities
and nearly always uncontrollable.
What do you do about it?
Can you stop yourself worrying?
VI

What do you do?

RE
R
FO

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RELUCTANCE TO SLEEP ALONE

Persistent reluctance, or refusal to go to sleep without RELUCTANCE TO GO TO SLEEP ALONE CBF0I01
being near a major attachment figure. Intensity
0 = Absent

Can you go to sleep on your own? 2 = Sometimes reluctant to go to sleep

alone.
What happens? 3 = Almost always reluctant to go to sleep
What do your "parents" do about it? alone. Protest nearly every night unless

LY
How long does that last? allowed to sleep with family member.
Could you go to sleep on your own if you had to? CBF0F01
Frequency

N
HOURS : MINUTES CBF0D01
Duration

O
CBF0O01
Onset

/ /
EW
SLEEPS WITH FAMILY MEMBER
Actually sleeps with a family member because of persistent SLEEPS WITH FAMILY MEMBER CBF8I01
refusal to sleep (through the night) without being near a Intensity
0 = Absent
major attachement figure.
VI

2 = Sometimes reluctant to go to sleep

alone.
Can you sleep the night through on your own?
3 = Almost always reluctant to go to sleep
Do you ever have to sleep with "Mom" or "Dad"? alone. Protests nearly every night unless
allowed to sleep with fmaily member.
RE

How often do you sleep with family member(s)?

CBF8F01
Frequency

CBF8O01
Onset
R

/ /
FO

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RISING TO CHECK ON FAMILY MEMBERS

Rising at night to check that attachment figures are still RISES TO CHECK ON FAMILY CBF1I01
present and/or free from harm. MEMBERS Intensity
0 = Absent
This does not include rising to check on subject's own child,
2 = Sometimes rises to check on family
if s/he has one. members but without waking them.

3 = Wakes family members up when

Do you ever get up to check that "family members" are

LY
checks on them.
OK?
CBF1F01
How often do you do that? Frequency

Does your "parents" wake up when you checks on them?

N
Are you able to go back to bed and fall asleep on your own
after getting up to check on them? CBF1O01
Onset
When did you start getting up to check on the family? / /

O
AVOIDANCE OF SLEEPING AWAY FROM
FAMILY
EW
Aviodance, or attempted aviodance, or sleeping away from
family, as a result of worrying or anxiety about separation
AVOIDANCE OF SLEEPING AWAY
FROM FAMILY
CBF2I01
Intensity
from home or family. 0 = Absent

2 = Aviodance, or attempted aviodance, in

Have you ever been on any overnight school trips? last 3 months, but has slept away from the
family at some time.
VI

Do you ever stay overnight with friends?

3 = Avoidance in last 3 months, and has
never slept away from family.
What about your grandmother's (or other relatives)?
CBF2O01
IF NO, ASK: Onset
RE

Hasve you ever been asked to sleep over? / /

Do you get worried about sleeping away from home?
R
FO

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SEPARATION DREAMS
Unpleasant dreams involving theme of separation. SEPARATION DREAMS CBF3I01
Intensity
0 = Absent
Have you had any nightmares about leaving your
"parents"? 2 = Separation dreams recalled

3 = Separation nightmares wake child.

How often?
CBF3F01

LY
How often do you have these bad dreams? Frequency
Did they wake you up from sleep?

CBF3O01
Onset

N
/ /

O
AVOIDANCE OF BEING ALONE
Persistent avoidance of being alone due to anxiety about AVOIDANCE OF BEING ALONE CBF4I01
being away from attachment figures. Intensity
EW 0 = Absent

Do you try to aviod being on your own? 2 = At least sometimes tries to avoid being
alone because of at least sometimes
uncontrollable worry or anxiety about being
Why is that? away from attachment figures.
What do you do?
What do your "parents" do? 3 = Almost always tries to avoid being alone
because of nearly always uncontrollable
worry or anxiety about being away from
When did it start? attachment figures.
VI

How do your "parents" respond?

CBF4O01
Onset

/ /
RE

ANTICIPATORY DISTRESS
Signs or complaints of excessive distress in anticipation of ANTICIPATORY DISTRESS CBF5I01
separation from major attachment figures; or crying, Intensity
0 = Absent
pleading with parents not to leave.
R

2 = At least sometimes uncontrollable

distress related to potential separation from
What do you do when you think your "parents" might attachment figures. At least sometimes
leave him/her? unresponsive to reassurance and occurring
FO

in at least 2 activities.
Or when they have to leave you?
3 = Nearly always uncontrollable distress
related to potential separation from
attachment figures. Usually unresponsive to
reassurance and occurring in most
activities.

CBF5O01
Onset

/ /

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WITHDRAWAL WHEN ATTACHMENT FIGURE

ABSENT
Social withdrawal, apathy, sadness, or difficulty WITHDRAWAL CBF6I01
concentrating on work or play when not with a major Intensity
0 = Absent
attachment figure.
2 = At least sometimes uncontrollable
withdrawal etc., in at least 2 activities, when
What happens when you're left alone (or with a sitter)? not with attachment figures.

LY
How do you feel? 3 = Nearly always uncontrollable withdrawal
Can you concentrate? etc., in most activities, when not with
attachment figures.
Does anything make you feel better?
What if you're with friends? CBF6O01
Onset

N
/ /

O
ACTUAL DISTRESS WHEN ATTACHMENT
FIGURE ABSENT
Signs or complaints of excessive distress, or extreme DISTRESS CBF7I01
homesickness, when separated from major attachment Intensity
0 = Absent
figure.
EW 2 = At least sometimes uncontrollable
distress etc., in at least 2 activities, when
Do you get very upset sometimes when your "parent" not with attachment figures.
is not with you?
3 = Nearly always uncontrollable distress
Do you get homesick? etc., in most activities, when not with
attachment figure.
What's that like?
VI

What do you do? CBF7O01

Onset

/ /
RE
R
FO

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WORRIES
GET EXAMPLES OF BEHAVIOR AND
CONSIDER CODING FOR INCAPACITY.
WORRIES
A round of painful, unpleasant, or uncomfortable thoughts WORRIES CCA0I01
that cannot be stopped voluntarily and that occurs across Intensity
0 = Absent
more than one activity, with a total daily duration of at least
1 hour. 2 = Worrying is intrusive into at least 2

LY
activities and uncontrollable at least some
of the time.
Do not include worries coded under School Non-
Attendance, Separation Anxiety, or Hypochondriasis. 3 = Worrying is intrusive into most activities
and nearly always uncontrollable.

Most people have got some worries, what do you worry CCA0F01

N
about? Frequency

O
HOURS : MINUTES CCA0D01
Duration

EW CCA0O01
Onset

/ /
Do you worry about what will happen in the future? WORRIES ABOUT FUTURE EVENTS CCA0I02
0 = Absent
Do you worry about bad things happening in the
VI

future? 2 = Present

Does you worry about things you have done? WORRIES ABOUT PAST BEHAVIOR CCA0I03
0 = Absent
RE

2 = Present

Does you worry about how well you does things? WORRIES ABOUT COMPETENCE OR CCA0I04
PERFORMANCE
Like school work? 0 = Absent
Or how good you are at sports?
2 = Present
R

Do you worry about what people think of you?

SELF-CONSCIOUSNESS CCA0I05
Does you get worried when other people are around? 0 = Absent
FO

Or worry about how you are with other people? 2 = Present

Does you get self-conscious?

Do you worry about how you look? WORRIES ABOUT APPEARANCE CCA0I06
0 = Absent

2 = Present

Worries 1
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Do you worry about whether your family will have WORRIES ABOUT MONEY CCA0I07
enough money? 0 = Absent

What is it like when you worries? 2 = Present

Can you give me an example?
When you worry about these things, how long does it last?
How often does you worry like that in a day?
Can you stop feeling like that?
Any times in the last three months you couldn't stop?

LY
What are you doing when you are worrying like that?
Does it make any difference what you are doing?
How often have she worried like that in the last three
months?
When did you start worrying like that?

N
How much do you worry?
Is it all the time or just now and then?
How worried do you get?
Can you stop worrying if you want to?

O
Does anything make the worrying better?
Make it worse?
Can you turn your mind to other things?
How do you stop worrying? EW
Are there ever times that you can't stop worrying?
What about when you are doing other things?
Or what s/he wants to do?
Like T.V. or school work?
Does worrying affect your concentration?
Does worrying change how you are with others (make you
irritable)?
VI

Does worrying keep you awake at night?

Do you have other worries? OTHER WORRIES CCA0I08

0 = Absent
What are they?
RE

What is it like when you worry? 2 = Present

Does it make you irritable?
Or agitated?
Or quiet and constricted in your play or interactions?
Does worrying keep you awake at night?
Can you give me an example?
How often do you worry?
R

Can you stop worrying if you want to?

Were there any times in the last three months you couldn't
stop worrying?
FO

How often have you worried in the last three months?

When did you start worrying like that?

Worries 2
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WORRIES ABOUT PHYSICAL ILLNESS

(HYPOCHONDRIASIS)
All characteristsics of worrying are present including a total HYPOCHONDRIASIS CCA1I01
daily duration of at least 1 hour, but the worrying is Intensity
0 = Absent
specifically concentrated on the possibility of disease or
malfunction in the subject. 2 = Worrying is intrusive into at least 2
activities and uncontrollable at least some
of the time
Do you worry at all about whether you're phsyically ill?

LY
3 = Worrying is intrusive into most activities
That there may be something seriously wrong with you? and nearly always uncontrollable
What do you worry about? CCA1F01
What do you think might happen? Frequency
How much do you worry about that?

N
Can you stop yourself worrying?
What do you do?
How long does it last? HOURS : MINUTES CCA1D01
When did those worries start? Duration

O
CCA1O01
EW Onset

/ /

EXCESSIVE NEED FOR REASSURANCE

The subject seeks reassurance from others about at least EXCESSIVE NEED FOR REASSURANCE CCA2I01
two topics of worry, but the worries continue in spite of Intensity
0 = Absent
VI

such reassurance. Include School-Related Worries/Anxiety,

Separation Anxiety, Worries and Hypochondriasis. 2 = Seeks reassurance at least weekly
(once a week for four consecutive weeks),
but not to the extent of interfering with
Do you tell people about your worries? ordinary social discourse.
RE

How often? 3 = Seeks reassurance to such an extent

that ordinary social discourse with at least
Do they ever get fed up with hearing about your one person is interfered with, as evidenced
worries? by loss of patience, or avoidance of contact
with subject, by that person.
What happens then?
Can you stop yourself from talking about your worries?
R
FO

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ANXIOUS AFFECT
NERVOUS TENSION
An unpleasant feeling of "nervousness," "nervous tension," NERVOUS TENSION CCA3I01
"being on edge," "being keyed-up." Intensity
0 = Absent

Do you feel tense, nervous, or on edge? 2 = Nervous tension is intrusive into at least
2 activities and uncontrollable at least some
of the time.
How bad is it?

LY
When does that happen? 3 = Nervous tension is intrusive into most
Does anything bring it on? activities and nearly always uncontrollable.
Do you know why? CCA3F01
What do you feel "tense" about? Frequency
If you concentrate on something, or do something you like,

N
does that feeling go away?
Or do your muscles get sore?
IF NERVOUS TENSION IS PRESENT, REMEMBER TO HOURS : MINUTES CCA3D01
COMPLETE PANIC ATTACKS AND ANXIOUS Duration

O
AUTONOMIC SYMPTOMS SECTION. DISTINGUISH
BETWEEN ANXIOUS AUTONOMIC SYMPTOMS
SPECIFIC TO PANIC ATTACK AND ANXIOUS CCA3O01
SYMPTOMS NOT ACCOMPANIED BY PANIC ATTACK. EW Onset

How long does the feeling last? / /

When did it start?
VI
RE
R
FO

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SCREEN: SUBJECTIVE ANXIOUS AFFECT

(FRIGHTENED AFFECT)
Feelings of fear and apprehension. All anxious affect SUBJECTIVE ANXIOUS AFFECT CCA5I01
situations refer to anxiety-provoking stressors that affect SCREEN POSITIVE Intensity
the subject regardless of their immediate presence. The 0 = No
subject can experience anxiety without being confronted by
the anxiety-provoking situation, by just thinking about it. 2 = Yes

LY
Do you ever get frightened without knowing why?

When did that happen?

What was it like?
Do you ever get frightened by particular things that

N
most people don't mind?

Do any animals frighten you?

O
What about crowds?

Or open spaces?

Or elevators
EW
Do you get nervous and shy when you have to meet
new people?

Are you really afraid of injections?

Or really afraid of the sight of blood?

VI

Do you ever get panicky?

RE
R
FO

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ANXIOUS FOREBODING
Subjective Anxious Affect with an unaccountable feeling of ANXIOUS FOREBODING CCA4I01
doom or that something awful may happen. It should have Intensity
0 = Absent
a total daily duration of at least 1 hour.
2 = Anxious foreboding is intrusive into at
least 2 activities and uncontrollable at least
When did it start? some of the time.
Do you ever have a feeling, for no reason, that
something awful is going to happen? 3 = Anxious foreboding is intrusive into

LY
most activities and nearly always
uncontrollable.
What?
How often does that happen? CCA4F01
How long does it last? Frequency
Is there anything you can do about it?

N
HOURS : MINUTES CCA4D01
Duration

O
CCA4O01
EW Onset

/ /
VI
RE
R
FO

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SOCIAL ANXIETY
Subjective Anxious Affect specific to social interactions. SOCIAL ANXIETY CCA6I01
There is desire for involvement with familiar people. Intensity
0 = Absent

Include fear, self-consciousness, embarrassment, and 1 = Fear is intrusive into at least one activity
and uncontrollable at least some of the
concern about appropriateness of behavior when time.
interacting with unfamiliar figures. Also include fear and
anxiety when meeting or anticipating meeting a strange 2 = Social anxiety is intrusive into at least 2

LY
activities and uncontrollable at least some
adult. of the time.

Do you ever get "nervous" or "frightened" when you 3 = Social anxiety is intrusive into most
activities and nearly always uncontrollable.
have to talk to people you don't know well?
4 = The child has not been in such a

N
Do you feel very self-conscious or emabarrassed wtih situation during the last 3 months because
people you don't know well? parent helped him/her to avoid it, but parent
reports that anxious affect would have
occurred if the child had been in situation.
Do you ever aviod meeting people because of it?

O
What about parties? CCA6F01
Do you do anything to aviod it? Frequency
Has it affected what you do?
What affect has it had? EW
Do you get upset when you have to meet new people? HOURS : MINUTES CCA6D01
Duration

CCA6O01
Onset
VI

/ /
DISTRESS CCA7I01
0 = Absent
RE

2 = New or forced social situation leads to

(or would lead to) crying, lack of
spontaneous speech, withdrawal from
social situation, or anxious silliness.

SOCIAL ANXIETY - DISTRESS ONSET CCA7O01

/ /
R

AVOIDANCE CCA8I01
0 = Absent
FO

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.

SOCIAL ANXIETY - AVOIDANCE ONSET CCA8O01

/ /

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FEAR OF ACTIVITIES IN PUBLIC

Subjective Anxious Affect specific to the public FEAR OF ACTIVITIES IN PUBLIC CCA9I01
performance of activities that do not elicit fear when Intensity
0 = Absent
performed in private. Include going to the bathroom at
daycare/school or other public places, eating in public, 1 = Fear is intrusive into at least one activity
speaking up at circle time or participating in "sharing" at and uncontrollable at least some of the
time.
daycare/school.
2 = Fear is intrusive into at least 2 activities

LY
and uncontrollable at least some of the
Do you get nervous or frightened when you have to do time.
things in front of other people?
3 = Fear is intrusive into most activities and
What about when you're called on in class? nearly always uncontrollable.

4 = The child has not been in such a

Does it embarrass you to eat when other people are

N
situation during the past 3 months because
around? of avoidance, but parent reports that
anxious affect would have occurred if the
What happens? child had been in situation.

O
How does it affect you? CCA9F01
Can you stop from feeling that way? Frequency
Do you do anything to avoid having to "do it" in front of
others?
What effect has it had on what you do?
EW
How often have you done that in the last three months?
HOURS : MINUTES CCA9D01
Duration

How long does that last?

CCA9O01
Onset
VI

/ /
DISTRESS CCB0I01
0 = Absent
RE

2 = New or forced social situation leads to

(or would lead to) crying, lack of
spontaneous speech, or withdrawal from
social situation.

FEAR PF ACTIVITIES IN PUBLIC - CCB0O01

DISTRESS ONSET
/ /
R

AVOIDANCE CCB1I01
0 = Absent
FO

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.

FEAR OF ACTIVITIES IN PUBLIC - CCB1O01

AVOIDANCE ONSET
/ /

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AGORAPHOBIA
Subjective anxious affect specific to open spaces or AGORAPHOBIA CCB2I01
crowds. Typical places and situations relevant to Intensity
0 = Absent
agoraphobia include being outside the home alone, being
in a crowd, standing in line, traveling on public transport or 1 = Fear is intrusive into at least one activity
by automobile. and uncontrollable at least some of the
time.

Distinguish from acrophobia (fear of heights) when fear of 2 = Agoraphobia is intrusive into at least 2

LY
activities and uncontrollable at least some
being on bridges, etc. is described. of the time.

Distinguish from separation-related anxieties and worries, 3 = Agoraphobia is intrusive into most
activities and nearly always uncontrollable.
where the central fears or worries concern separation from
attachment figures. When there is doubt as to the correct 4 = The child has not been in the anxiety

N
coding in such a case, code both the appropriate provoking situation during the past 3
months because of avoidance, but the
separation-related symptoms and agoraphobia and parent reports that the anxious affect would
complete the coding indicating possible overlap with have occurred if the child had been in such

O
separation-related symptoms. a situation.

CCB2F01
Are you afraid in open spaces? Frequency

Or going out in crowded places?

Or using public transportation?

EW HOURS : MINUTES CCB2D01
Duration
How does it affect you?
Can you stop yourself from being afriad?
Do you do anything to aviod it?
CCB2O01
Has it affected what you do?
Onset
VI

What affect has it had?

/ /
How often has that happened in the last three months?
AVOIDANCE CCB3I01
How long does that last?
RE

0 = Absent

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.
R

AGORAPHOBIA - AVOIDANCE ONSET CCB3O01

/ /
FO

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ANIMAL FEARS
Subjective Anxious Affect specific to animals. FEAR OF ANIMALS CCB4I01
Intensity
0 = Absent
Distinguish from Fear of Monsters, remembering the
"monsters" can include animals that really exist under 2 = Fear of animals is intrusive into at least
2 activities and uncontrollable at least some
certain circumstances. of the time.

3 = Fear of animals is intrusive into most

Do any animals frighten you?

LY
activities and nearly always uncontrollable.

Which? 4 = Subject has not been in situation in past

Why are you frightened of them? 3 months because of avoidance, but reports
that anxious affect would be present if had
What do you do about it? been in situation.
Do you try yo aviod them?

N
CCB4F01
How often has that happened in the last three months? Frequency

How long does that last?

O
HOURS : MINUTES CCB4D01
Duration
EW CCB4O01
Onset

/ /
TYPE OF ANIMAL FEARED CCB4X01
VI

1 = Dogs

2 = Cats
CCB4X02
3 = Mice/rats

4 = Other mammals (horses, lions)

RE

CCB4X03
5 = Bats

6 = Insects

7 = Spiders

8 = Snakes
R

9 = Birds

10 = Other
FO

Specify

AVOIDANCE CCB5I01
0 = Absent

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.

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ANIMAL FEARS - AVOIDANCE ONSET CCB5O01

/ /

FEAR OF INJURY
Subjective anxious affect specific to the possibility of being FEAR OF INJURY CCB6I01
hurt. Intensity
0 = Absent

LY
Do you feel "nervous" or "frightened" about getting 1 = Fear is intrusive into at least one activity
and uncontrollable at least some of the
hurt or injured? time.

What is that like? 2 = Fear is intrusive into at least 2 activities

Does it affect what you do? and uncontrollable at least some of the

N
time.
In what way?
What do you do about it? 3 = Fear is intrusive into most activities and
nearly always uncontrollable.

O
How often has that happened in the last three months?
4 = The child has not been in such a
situation during the past 3 months because
How long do you stay afraid for? of avoidance, but parent reports that
anxious affect would have occurred if the
EW child had been in situation.

CCB6F01
Frequency

HOURS : MINUTES CCB6D01

Duration
VI

CCB6O01
Onset
RE

/ /
AVOIDANCE CCB7I01
0 = Absent

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
R

lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.
FO

FEAR OF INJURY - AVOIDANCE ONSET CCB7O01

/ /

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FEAR OF BLOOD/INJECTION
Subjective Anxious Affect in relation to sight of blood, FEAR OF BLOOD/INJECTION CCE0I01
receipt or sight of injections, or anticipation of sight of blood Intensity
0 = Absent
or injections.
1 = Fear is intrusive into at least one activity
and uncontrollable at least some of the
AIDS-related fears are not coded here. time.

2 = Fear is intrusive into at least 2 activities

Distinguish from Fear of Doctor/Dentist

LY
and uncontrollable at least some of the
time.
Do you feel "nervous" about the sight of blood?
3 = Fear is intrusive into most activities and
nearly always uncontrollable.
Are you fearful of getting a shot or injection?
4 = The child has not been in such a

N
Are you afraid of seeing anyone getting an injection? situation during the past 3 months because
of avoidance, but parent reports that
anxious affect would have occurred if the
How does it affect you? child had been in situation.
Can you stop yourself from being afraid?

O
Do you do anything to avoid it? CCE0F01
Frequency
How often, in the last three months, have you been afraid
of blood/injections? EW
How long do you stay afraid for? HOURS : MINUTES CCE0D01
Duration

CCE0O01
Onset
VI

/ /
AVOIDANCE CCE1I01
0 = Absent
RE

1 = Child can be reassured about the sight

of blood or cooperate about receiving a
shot if accompanied/reassured.

2 = "Parent" has developed routines that

allow child to avoid feared situation
including postponing shots or
immunizations.
R

AVOIDANCE - ONSET CCE1O01

/ /
FO

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ANXIETY OR FEAR PROVOKING SITUATIONS

AIDE-MEMOIR
Are there any other things that you're afraid of? OTHER FEARS CCB8I01
Intensity
0 = Absent
IF YES, OR IF ONE OR MORE FEARS ALREADY
ELICITED, CHECK ITEMS ON LIST BELOW. 1 = Fear is intrusive into at least one activity
OTHERWISE, PROCEED TO SITUATIONAL ANXIOUS and uncontrollable at least some of the
time.
AFFECT.

LY
2 = Fear is intrusive into at least 2 activities
Heights and uncontrollable at least some of the
time.
Elevators
3 = Fear is intrusive into most activities and
nearly always uncontrollable.
Insects and spiders

N
4 = The child has not been in such a
Snakes situation during the past 3 months because
of avoidance, but parent reports that
anxious affect would have occurred if the
Birds

O
child had been in situation.

The dark Specify

Illness EW CCB8F01
Frightening things on TVand Movies
Frequency
War

Other HOURS : MINUTES CCB8D01

Duration
How often have you been afraid in the last three months?
VI

How long do you stay afraid for?

CCB8O01
Onset

/ /
RE

AVOIDANCE CCB9I01
0 = Absent

2 = Subject has developed routines that

allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.
R

3 = Subject lives a highly restricted life

because of feared situations.
FO

ANXIETY OR FEAR PROVOKING CCB9O01

SITUATIONS AIDE-MEMOIR -
AVOIDANCE ONSET / /

IF NO ANXIETIES, SKIP TO "FREE

FLOATING ANXIOUS AFFECT", (PAGE
13).

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LY
N
O
EW
VI
RE
R
FO

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SITUATIONAL ANXIOUS AFFECT

Anxious Affect that occurs in certain SITUATIONAL ANXIOUS AFFECT CCC0I01
situations/environments. Intensity
0 = Absent

REVIEW NOTES OF THE ANXIETY CIRCUMSTANCES 1 = Fear is intrusive into at least one activity
and uncontrollable at least some of the
AND CODE THE PROVOKING OCCURRENCES OF ANY time.
OF THE FORMS OF SPECIFIC ANXIOUS AFFECT.
2 = The child feels fear, or experiences

LY
anticipatory anxiety, that is at least
REMEMBER TO COLLECT FREQUENCIES AND sometimes uncontrollable in 2 activities or
DURATIONS. requires excessive reassurance.

3 = The child feels fear, or experiences

INTERVIEWER NOTE: IF ANY ANXIETY SYMPTOMS anticipatory anxiety, that is almost
ARE PRESENT, CHOOSE A RATING AND COMPLETE completely uncontrollable in most activities.

N
SECTION. 4 = The child has not been in the anxiety
provoking situation during the past 3
months because of avoidance, but the

O
parent reports that the anxious affect would
have occurred if the child had been in such
a situation.

CCC0F01
Frequency
EW
HOURS : MINUTES CCC0D01
Duration
VI

CCC0O01
Onset

/ /
RE
R
FO

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FREE FLOATING ANXIOUS AFFECT

Anxiety not associated with any particular situation. FREE FLOATING ANXIOUS AFFECT CCC1I01
Intensity
0 = Absent
Do you ever feel frightened without knowing why?
1 = Fear is intrusive into at least one activity
and uncontrollable at least some of the
How often does this happen? time.
How long does each episode of anxiety last?
When did it start? 2 = The child feels fear, or experiences

LY
free-floating anxiety that is at least
sometimes uncontrollable in 2 activities or
requires excessive reassurance.

3 = The child feels fear, or experiences

free-floating anxiety, that is almost
completely uncontrollable in most activities.

N
CCC1F01
Frequency

O
HOURS : MINUTES CCC1D01
Duration
EW CCC1O01
Onset

/ /
VI

IF SITUATIONAL, FREE-FLOATING
ANXIOUS AFFECT, WORRY ABOUT
SCHOOL, SEPARATION ANXIETY OR
RE

NERVOUS TENSION PRESENT, CONT.

OTHERWISE, SKIP TO "SELECTIVE
MUTISM", (PAGE 20).
R
FO

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STARTLE RESPONSE
Exaggerated startle response to minor stimuli. Do not STARTLE RESPONSE CCC2I01
include startling in response to situations that would make Intensity
0 = Absent
most people jump.
2 = Startles to an exaggerated degree on
slight provocation.
Startle response may also appear in PTSD section. If so,
code in both places.

LY
Do you startle easily?

What sort of things make you jump?

N
CONCENTRATION DIFFICULTIES
Difficulty in concentrating, or mind "going blank" when CONCENTRATION DIFFICULTIES CCC3I01
feeling anxious. Intensity

O
0 = Absent

When you feel "anxious", is it hard for you to 2 = Concentration impairment sufficient to
interfere with ongoing activities.
concentrate?
NUMBER OF DAYS IN THE LAST THREE CCC3F01
What happens?
Does your mind go blank?
EW MONTHS

EASY FATIGABILITY
Child becomes easily fatigued when anxious. EASY FATIGABILITY CCC4I01
Intensity
VI

0 = Absent
When you feel "anxious" do you get tired easily?
2 = Feels fatigued after slight exertion but
continues with tasks at hand.
What happens?
When you're "worried", "anxious," or firghtened, does 3 = Fatigue leads to reduced performance
it affect you physicallu at all? of tasks at hand.
RE

What do you notice? NUMBER OF DAYS IN THE LAST 3 CCC4F01

MONTHS

Do your muscles tense up?

Do you get jumpy?

R

Keyed up?
On edge?
Do you get restless?
FO

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ANXIOUS AUTONOMIC SYMPTOMS

Autonomic symptoms accompanied by subjective anxious AUTONOMIC SYMPTOMS CCD0I90
affect (occurs when child is frightened, worried or nervous). Intensity
0 = Absent

When you are "anxious" or frightened, does it affect 2 = Present

you physically at all? MUSCLE TENSION CCD0I14

What do you notice? 0 = Absent

LY
2 = Present
Do your muscles get tensed up?
JUMPINESS CCD0I20
Do you get jumpy?
0 = Absent
Keyed up?

N
2 = Present
Agitated?
On edge? RESTLESSNESS CCD0I21
0 = Absent

O
Do you get restless?
2 = Present
Do you become more "wild" when you are scared or
anxious?
EW
VI
RE
R
FO

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PANIC ATTACKS
Panic attacks are discrete episodes of overwhelming PANIC ATTACKS CCC5I01
subjective anxious affect and autonomic symptoms that Intensity
0 = Absent
reach a peak within 10 minutes of onset, and that the
subject usually tries to terminate by taking some definite 2 = Panic attack that is of such severity that
action, unless they are too "frozen" by panic to do so. subject stops activity engaged in at the
time.

Do you ever get panicky? FREE FLOATING CCC5I02

LY
0 = Absent
What happens then?
Does it affect you physically at all? 2 = Panic attack unassociated with any
When does it happen? particular situation.
Does it occur for no good reason? SITUATIONAL CCC5I03

N
Do you have to get out of the situation?
How long does it last? 0 = Absent
What do you do? 2 = Panic attack that occurs in certain
Do you try to avoid situations where you might get panicky?

O
situations/environments.
When did it start?
CCC5F01
Frequency
EW HOURS : MINUTES CCC5D01
Duration

CCC5O01
Onset
VI

/ /
RE

IF NO PANIC ATTACKS, SKIP TO

"COMPULSIONS", (PAGE 5).
R
FO

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DEREALIZATION DURING PANIC ATTACK

The subject experiences his/her surroundings as unreal; DEREALIZATION CCC6I01
everything may seem colorless, artificial, or dead. Intensity
0 = Absent

When you got panicky, did you feel that things around 2 = Present
you didn't seem real?

Or that it was like a stage set with people acting like

LY
robots instead of being themselves?

What was it like?

N
DEPERSONALIZATION DURING PANIC
ATTACK
The subject feels as if s/he is unreal, that s/he is acting a DEPERSONALIZATION CCC7I01
Intensity

O
part, that s/he is detached from his/her own experiences. 0 = Absent

When you got panicky, did you feel as if you weren't 2 = Present
real? EW
Did you feel like you were acting your life instead of being
natural?
Did you feel that you were outside your body looking at
yourself from outside your body?

FEAR OF LOSS OF CONTROL DURING PANIC

VI

ATTACK
Subject feels as though "going crazy" or is afraid of losing FEAR OF LOSS OF CONTROL CCC8I01
control over body or mind (e.g. urinating in public, falling Intensity
0 = Absent
down, creating a "scene").
RE

2 = Present
When you got panicky, were you afraid of what you
might do?

That you might fall down, or create a "scene"?

Did you feel like you were going crazy?
R

Or losing control of your mind?

FO

FEAR OF DYING DURING PANIC ATTACK

Subject feels as though s/he might die, or is afraid that s/he FEAR OF DYING CCC9I01
might die. Intensity
0 = Absent

When you got panicky, were you afraid that you might 2 = Present
die?

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CONCERN ABOUT ADDITIONAL PANIC

ATTACKS
Concern, worry, or anxious affect related to the possibility CONCERN ABOUT ADDITIONAL PANIC CCE2I01
that another panic attack may occur. ATTACKS Intensity
0 = Absent
Are you worried about having another "panic attack"?
2 = Present
Does it bother you much?

LY
CHANGE IN BEHAVIOR
Any change in usual behavior or routines, intended to avoid CHANGE IN BEHAVIOR CCE3I01
the possibility of a panic attack recurrence. Or changes in Intensity

N
0 = Absent
behavior or routine to avoid potential embarrassment or
humiliation that the subject fears might result from a panic 2 = Subject has developed routines that
attack. allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

O
Have you done anything to avoid having anymore 3 = Subject lives a highly restricted life
because of feared situation.
"panic attacks"?

Does that affect your life much?

EW
WORRY ABOUT IMPLICATIONS
Worry or anxious affect related to possible secondary WORRY ABOUT IMPLICATIONS CCE4I01
consequences of having another panic attack. Intensity
0 = Absent
VI

Do not include such worries or fears during a panic attack 2 = Present

which are coded under Fear of Loss of Control During
Panic Attack.
RE

Have you been worried about what might happen if you

had another "panic attack"?

What do you think might happen?

Have you been afraid that you might die?
Or go crazy?
Or lose control?
R
FO

IF PANIC NOT PRESENT, SKIP TO

"COMPULSIONS", (PAGE 5).

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ANXIOUS AUTONOMIC SYMPTOMS IN PANIC

ATTACKS
Autonomic symptoms accompanied by subjective anxious ANXIOUS AUTONOMIC SYMPTOMS IN CCE5I90
affect. PANIC ATTACKS Intensity
0 = Absent
When you're "worried," "anxious," or frightened, does
2 = Present
it affect you physically at all?
DIZZINESS/FAINTNESS CCE5I01

LY
What do you notice?
0 = No
Do you get dizzy, giddy, or faint? 2 = Yes

Does it affect your breathing? CHOKING/SMOTHERING CCE5I03

N
How? 0 = No

2 = Yes
Does it affect your heart?
CCE5I04

O
DIFFICULTY BREATHING
Do you get a pain in your chest?
0 = No
Do you get sweaty? 2 = Yes

CCE5I05
Or feel sick?
EW RAPID BREATHING

0 = No

2 = Yes

PALPITATIONS/TACHYCARDIA CCE5I06
0 = No
VI

2 = Yes

TIGHTNESS OR PAIN IN CHEST CCE5I07

0 = No
RE

2 = Yes

SWEATING CCE5I08
0 = No

2 = Yes

NAUSEA CCE5I09
R

0 = No

2 = Yes
FO

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Does it affect your stomach? BUTTERFLIES/PAIN IN THE STOMACH CCE5I11

0 = No
Do you get shaky or twitch?
2 = Yes
Do you get flushed?
TREMBLING/SHAKING/TWITCHING CCE5I13
Do you get chills? 0 = No

Do you have funny feelings in your fingers or toes? 2 = Yes

LY
Does your stomach churn? FLUSHING OR CHILLS CCE5I14
0 = No
Does it only happen in certain situations?
Or can it happen any time? 2 = Yes

N
PARAESTHESIAE CCE5I16
0 = No

2 = Yes

O
ABDOMINAL CHURNING CCE5I18
0 = No

2 = Yes
EW
SELECTIVE MUTISM
Reluctance or inability to speak to certain persons or in SELECTIVE MUTISM CCD1I01
certain situations, while able to speak adequately to other Intensity
0 = Absent
people in other situations. A change in speaking ability is
selective in certain situations.
VI

2 = Speech limited in volume or amount to

an extent that substantially interferes with
communication; marked discrepancy with
Are there some situations in which you find you can't adequate speech usage in other
talk? circumstances.
RE

3 = Almost complete absence of speech in

Or some people you can't talk to? particular settings or to particular people.

Why is that? CCD1O01

What happens then? Onset
When did it start?
What happens when you are encouraged to speak up? / /
R
FO

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RUMINATIONS, OBSESSIONS, AND

COMPULSIONS
Painful, recurrent, repetitive ideas, thoughts, or
images that the subject experiences as
intrusive and unwanted. Subject regards these
as being incompatible with his/her image of
him/herself as a person, but does not regard
these as being external implants.

LY
IF OBSESSIONAL THOUGHTS,
OBSESSIONAL RITUALS, OR
COMPULSIONS ARE PRESENT, ASK
ABOUT OBSESSIONAL SLOWNESS.

N
OTHERWISE,, SKIP TO "OBSESSIONAL
SLOWNESS", (PAGE 7).

O
EW
VI
RE
R
FO

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OBSESSIONAL THOUGHTS
Painful, recurrent, repetitive ideas, thoughts, or images that OBSESSIONAL THOUGHTS CCD3I01
the subject experiences as intrusive and unwanted. Subject Intensity
0 = Absent
regards these as being incompatible with his/her image of
him/herself as a person, but does not regard these as 2 = Obsessional thoughts are intrusive into
being external implants. at least 2 activities and uncontrollable at
least sometimes.

Do you have thoughts that get stuck in your mind that 3 = Obsessional thoughts are intrusive into

LY
most activities and almost always
you can't get rid of? uncontrollable.

Do you have any awful or ridiculous thoughts that keep HOME CCD3F01
coming back into your mind even though you don't Home
want them to? Frequency

N
What kind of thoughts are they?
Do you have any silly thoughts or words that won't go
DAYCARE/SCHOOL CCD3F02
away?
Daycare/School

O
Do you have any special things you think about to get Frequency
rid of horrible things in your mind?

What are they?

Do you have to count things over and over? ELSEWHERE CCD3F03
EW
Do you have thoughts you have to think in a certain
Elsewhere
Frequency
way?

Do you feel uncomfortable if you can't think these thoughts

just right? HOURS : MINUTES CCD3D01
Duration
What makes you do it?
VI

Do you try and make the thoughts go away?

Do they interfere with other things you want to think about? CCD3O01
Can you do anything about it? Onset
Do you try not to think about them?
/ /
RE

How long do they go on for?

When did they start?
RESISTANCE NOT MEETING CRITERIA CCD3I02
FOR OBSESSIONAL RITUALS

0 = Absent

2 = Subject tries to resist thinking the

R

obsessional thought at least sometimes.

3 = Subject usually tries to resist.

FO

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OBSESSIONAL RITUALS
Recurrent, repetitive ideas, thoughts, images, or mental OBSESSIONAL RITUALS CCD4I01
rituals engaged in to reduce or extinguish the mental Intensity
0 = Absent
discomfort generated by Obsessional Thoughts. Performed
despite being regarded as excessive, unreasonable, 2 = Obsessional rituals are intrusive and
pointless, or absurd. uncontrollable in at least 2 activities at least
sometimes.

Occasionally mental rituals may be performed but the 3 = Obsessional rituals are intrusive into

LY
most activities and almost always
subject is unable or unwilling to describe clear Obsessional uncontrollable.
Thoughts. Such mental rituals may be coded as
Obsessional Rituals provided they meet the other criteria HOME CCD4F01
for an Obsessional Ritual. Home
Frequency

N
DAYCARE/SCHOOL CCD4F02
Daycare/School

O
Frequency

ELSEWHERE CCD4F03
EW Elsewhere
Frequency

HOURS : MINUTES CCD4D01

VI

CCD4O01
Onset

/ /
RE

RESISTANCE TO OBSESSIONAL CCD5I01

RITUALS

0 = Absent

2 = Subject tries to resist thinking the

obsessional ritual at least sometimes.
R

3 = Subject usually tries to resist thinking

the obsessional ritual.
FO

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CONTENT OF OBSESSIONAL THOUGHTS

Code the theme or content of the Obsessional Thoughts. CONTENT OF OBSESSIONAL CCD6X01
More than one type may be present, in which case code THOUGHTS Intensity
both or all. 0 = Absent

2 = Present
IF OBSESSIONAL THOUGHTS ARE ASSOCIATED WITH
TRAUMATIC EVENTS, CODE THERE ALSO. TRANSMITTING DISEASE CCD6I01

LY
0 = Absent

2 = Present

MAGICAL, E.G., WARDING OFF CCD6I02

DANGER

N
0 = Absent

2 = Present

CCD6I03

O
SEX RELATED

0 = Absent

2 = Present

CONCERNS ABOUT PERFORMANCE CCD6I04

EW 0 = Absent

2 = Present

VIOLENCE CCD6I05
0 = Absent
VI

2 = Present

OTHER CCD6I06
0 = Absent
RE

2 = Present
R
FO

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COMPULSIONS
Repetitive, purposeful, and intentional acts associated with COMPULSIONS CCD7I01
a subjective feeling of compulsion arising within the subject Intensity
0 = Absent
and not forced by any external power or agency,performed
despite being regarded as excessive, unreasonable, 2 = Compulsions intrusive into at least 2
pointless, or absurd. activities and are at least sometimes
uncontrollable.

Do you have to check things more than other people? 3 = Compulsions intrusive into most

LY
activities and are almost always
uncontrollable.
Are there any things you feel you have to do?
HOME CCD7F01
Like touching things in a certain way? Home
Frequency
Or washing over and over again?

N
Do you spend a lot of time putting things in a special
order? DAYCARE/SCHOOL CCD7F02
Daycare/School

O
Or arranging things so that they are just right? Frequency

Do you have any routines or rituals that you have to

do? ELSEWHERE CCD7F03
What do you do?
EW Elsewhere
Frequency
What are you afraid will happen?
Do you feel uncomfortable if you don't "do compulsion" just
right?
Are you worried about dirt or germs? HOURS : MINUTES CCD7D01
What do you do about it? Duration
VI

Why do you do it?

What makes you do it?

CCD7O01
How long do you do it for? Onset
Does you try not to do it?
/ /
RE

When did it start?

IF A CLEAR EXTERNAL FORCE IS REPORTED AS
BEING THE MOTIVATOR OF COMPULSIVE BEHAVIOR,
CODE UNDER DELUSIONS AND DELUSIONAL
INTERPRETATIONS (PSYCHOSIS SECTION)
R
FO

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Do you try not to do it? RESISTANCE CCD7I02

What happens then? 0 = Absent

2 = Subject tries to resist performing the

compulsive act at least sometimes.

3 = Subject usually tries to resist.

CHECKING (AT LEAST 3 TIMES) CCD8I01

LY
0 = Absent

2 = Present

AVOIDING CCD8I02
0 = Absent

N
2 = Present

TOUCHING CCD8I03

O
0 = Absent

2 = Present

EW WASHING/CLEANING CCD8I04
0 = Absent

2 = Present

REPEATING CCD8I05
0 = Absent

2 = Present
VI

OTHER CCD8I09
0 = Absent

2 = Present
RE
R
FO

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OBSESSIONAL SLOWNESS
Normal actions take an unreasonable amount of time due OBSESSIONAL SLOWNESS CCD9I01
to internal concerns to do things "correctly" or due to Intensity
0 = Absent
obsessional thought patterns.
2 = Obsessional slowness intrusive into at
least 2 activities that at least sometimes
Do not include slowness by rituals themselves. Minor cannot be overcome.
degrees of slowness are not rated here.
3 = Obsessional slowness affecting most

LY
activities that can hardly ever be overcome.
Do you get slowed down by having to think certain
things? CCD9O01
Onset
Or are you very slow for other reasons?
/ /

N
Why is that?
What can you do about it?
Is it because of your having to think certain thoughts or do
certain things?

O
How long does it last?
When did you start to get slowed down like that?

EW
VI
RE
R
FO

Ruminations, Obsessions, and Compulsions 7

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Definitions and questions Coding rules Codes

DEPRESSED AFFECT
Now we are going to talk about some of X's
feelings. N.B. GET EXAMPLES OF BEHAVIOR
AND CONSIDER CODING FOR INCAPACITY
DEPRESSED MOOD
Feelings of low mood. Includes feeling unhappy, miserable, DEPRESSED MOOD CDA0I01
blue, low spirited, being down in the dumps or dejected. Intensity
0 = Absent

LY
Distinguish from other unpleasant affects e.g. Nervous 2 = The depressed mood is sometimes
intrusive but also sometimes alleviated by
Tension or Anxiety, Apathy and Anhedonia. It is also enjoyable events or activities.
important to make sure that it is the mood itself that is
being rated and not its "expected" concomitants (such as 3 = Scarcely anything is able to lift the
mood.
apathy, self depreciation or crying). Items such as these

N
are rated separately. If they are used as evidence of CDA0F01
depression as well, spurious relationships will be generated Frequency
by the interviewer.

O
Have you been feeling "down" at all? HOURS : MINUTES CDA0D01
Duration
Have you been acting very unhappy, or depressed?

Have you cried at all because of this feeling?

What was that like?
Was it serious?
EW CDA0O01
Onset
If I had seen you then would I have been able to tell?
What made you feel "miserable"? / /
How much of the time do you feel like that? EPISODE OF DEPRESSED MOOD CDA0I02
Is that on your mind all the time?
VI

0 = Absent
Or only some of the time?
2 = At least 1 week with 4 days depressed
What happens when you're doing something else? mood.

When you feel "miserable", how long does it last? 3 = Period of 2 consecutive weeks where
RE

depressed mood present on at least 8 days.

When did it start?
PERIOD OF 2 CONTINUOUS MONTHS CDA0I03
WITHOUT DEPRESSED MOOD IN LAST
IF PRESENT, ASK; YEAR?

Was there a week when you felt "miserable" most 0 = Present

days? 2 = Absent
R

Were there two weeks when you were "miserable" on

at least 8 days?
FO

IF DEPRESSED MOOD PRESENT, ASK;

Has there been a period of at least 2 months in the last

year when you didn't feel like that?

Depression 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IF "DEPRESSED MOOD" IS PRESENT,

CONTINUE. OTHERWISE, SKIP TO
"REPORTED TEARFULNESS AND
CRYING", (PAGE 6).

LY
N
O
EW
VI
RE
R
FO

Depression 2
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DISTINCT QUALITY OF DEPRESSED MOOD

Depressed mood has a subjectively different quality from DISTINCT QUALITY OF DPERESSED CDA1I01
sadness. Thus the rating should be contrasted with an MOOD Intensity
experience that caused sadness, such as loss of a pet or 0 = Absent
watching a very weepy film.
2 = Subject understands quality of sadness
and reports that periods of depressed mood
Check that the provoking situation is one that is appropriate have a different quality.
for sadness. Prompt on such situations if necessary.

LY
Is it different from the feeling you get when something
sad happens or you see a sad tv show or movie?

Is your feeling "depressed" like that or does it feel

N
different?

Can you tell me how it is different?

O
ALLEVIATION OF DEPRESSED MOOD BY
SELF-GENERATED MEANS
Alleviation of depressed mood refers to means that the ALLEVIATION BY SELF-GENERATED CDA2I01
EW
child may find effective in alleviating his/her depressed
mood.
MEANS

0 = Means of Alleviation never employed.

Intensity

2 = Means of Alleviation employed at least

Alleviation by self generated means: The child alleviates sometimes.
mood by actively involving him/herself in other thoughts or
activities.
VI

N.B.: BOTH ALLEVIATION BY SELF-GENERATED

MEANS AND EXTERNAL MEANS MAY BE PRESENT.

N.B.: ALLEVIATION NOT APPLICABLE IF SUBJECT

RE

RATED 0 OR 3 ON "DEPRESSED MOOD". IF

"DEPRESSED MOOD" IS NOT PRESENT AS DEFINED
IN THE GLOSSARY, IT CANNOT BE RELEIVED. IF THE
DEPRESSED MOOD IS PRESENT AT AN INTENSITY
LEVEL 3 THEN IT IS, BY DEFINITION, ESSENTIALLY
UNALLEVIABLE. CODE AS "NEVER EMPLOYED".
R

When you felt "miserable", could anything cheer you

up?
FO

How long would it cheer you up for?

Or make you feel better?

How much of the time would things "cheer" you up?

Could you do anything to "cheer yourself up"?

What?
How much of the time does that work?

Depression 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ALLEVIATION OF DEPRESSED MOOD BY

EXTERNAL MEANS
Alleviation of depressed mood refers to means that the ALLEVIATION BY EXTERNAL MEANS CDA2I02
child may find effective in alleviating his/her depressed Intensity
0 = Means of Alleviation never employed.
mood.
2 = Means of Alleviation employed at least
sometimes.
Alleviation by external means: The mood is alleviated by a
more passive process in which other activities or events

LY
occurring without the child's willful use of them for this
purpose alleviated depressed mood.

N.B.: BOTH ALLEVIATION BY SELF-GENERATED

MEANS AND EXTERNAL MEANS MAY BE PRESENT.

N
N.B.: ALLEVIATION NOT APPLICABLE IF SUBJECT
RATED 0 OR 3 ON "DEPRESSED MOOD". IF

O
"DEPRESSED MOOD" IS NOT PRESENT AS DEFINED
IN THE GLOSSARY, IT CANNOT BE RELEIVED. IF THE
DEPRESSED MOOD IS PRESENT AT AN INTENSITY
LEVEL 3 THEN IT IS, BY DEFINITION, ESSENTIALLY
UNALLEVIABLE. CODE AS "NEVER EMPLOYED".

When you feel "miserable," can other people do

EW
anything to cheer you up?

Do you cheer up when you take part in an activity?

Like playing with other children?

VI

Or going out for ice cream or a treat?

How much of the time would things "cheer" you up?

RE

DIURNAL VARIATION OF MOOD - AM WORST

Depressed mood is consistently worse in the first half of the AM WORST CDA3I01
day, irrespective of external events. Intensity
0 = Absent

The parent must report a difference in the intensity of the 2 = Present

R

depressed mood that is of a degree noticeable to others.

Is there any time of the day when you feel more

FO

"depressed" or "sad" than others?

Do you feel more "depressed" in the morning/evening?

How long does the worst time last?
How would anybody know that you felt like that?

Depression 4
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DIURNAL VARIATION OF MOOD - PM WORST

Depressed mood is consistently worse in the second half of P.M. WORST CDA3I02
the day, irrespective of external events. Intensity
0 = Absent

The parent must report a difference in the intensity of the 2 = Present

depressed mood that is of a degree noticeable to others.

Is there any time of the day when you feel more

LY
"depressed" than others?

Do you feel more "depressed" in the morning/evening?

How long does the worst time last?
How would anybody know that you felt like that?

N
SUBJECTIVE AGITATION

O
Markedly changed motor activity associated with SUBJECTIVE AGITATION CDA5I01
depressed mood. Account of a severe level of Intensity
0 = Absent
inappropriate, unpleasant motor restlessness during a
period of dysphoric mood, indicated by pacing, wringing of 2 = Agitation is present in at least 2
hands, or similar activities; with a total daily duration of at activities and cannot be entirely controlled,
least 1 hour.
EW but sometimes the subject can inhibit
his/her agitation with effort.

3 = Agitation almost entirely uncontrollable.

DO NOT INCLUDE SIMPLE RESTLESSNESS OR
FIDGETINESS IN THE ABSENCE OF MOOD CHANGE. CDA5F01
Frequency
Do you get very restless when you're "miserable?"
VI

Do you have difficulty keeping still when depressed?

HOURS : MINUTES CDA5D01
Duration
What is that like?
Can you keep yourself still?
RE

Do you have to move around?

What do you do? CDA5O01
Are you always like that? Onset
How about when you're not "miserable"?
How long does it last? / /
When did the "agitation" start?
R

Are you always like that?

How about when you're not "miserable?"
FO

How long does it last?

When did the "agitation" start?

Depression 5
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

REPORTED TEARFULNESS AND CRYING

Eyes filling with tears or actual shedding of tears as a REPORTED TEARFULNESS AND CDA4I01
response to an internal state of unhappiness or misery. CRYING Intensity
0 = Absent
Do not rate crying precipitated by usual precipitants (such
2 = When feeling miserable, the eyes fill
as sad situations or anger or being spanked or disciplined). with tears, or shed tears, at least
sometimes uncontrollably, in at least 2
Do you ever feel so "miserable" that you want to cry? activities.

LY
3 = When feeling miserable, the eyes nearly
What happens then? always uncontrollably fill with, or shed, tears
Do you actually cry? in most activities.

Can you stop yourself? CDA4F01

Frequency

N
What do you do?

How long does it last?

When was the last time? HOURS : MINUTES CDA4D01

O
Tell me about it. Duration
Do you cry more easily than you used to?
Do you cry more than other people?

When did you start being tearful? CDA4O01

EW Onset

/ /

TOUCHY OR EASILY ANNOYED

The child is generally more prone to FEELINGS of anger TOUCHY OR EASILY ANNOYED CDA6I01
VI

bad temper, short temper, resentment, sulking or Intensity

0 = Absent
annoyance, UNDER MINOR PROVOCATION than most
children. This pattern need not represent a change in 2 = Present
behavior.
CDA6F01
RE

Frequency
Do things get on your nerves easily?

What sorts of things?

Do you get annoyed more easily than most people, do HOURS : MINUTES CDA6D01
you think? Duration
R

What do you do?

CDA6O01
How often does that sort of thing happen?
Onset
FO

How long have you been like that? / /

Depression 6
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ANGRY OR RESENTFUL
The child is generally more prone to MANIFESTATIONS of ANGRY OR RESENTFUL CDA7I01
anger or resentment (such as snappiness, shouting, Intensity
0 = Absent
quarreling or sulking) under minor provocation, than most
children. 2 = Present

CDA7F01
This pattern need not represent a change in behavior. Frequency

LY
Do you get angry very often?

How often? HOURS : MINUTES CDA7D01

Duration
What happens?
How often does that happen?

N
Do you get "sulky" or "pout"?
CDA7O01
How often? Onset
What do you do?

O
How often does that happen? / /
How long have you been like that?
EW
VI
RE
R
FO

Depression 7
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IRRITABILITY
Increased ease of precipitation of externally directed IRRITABILITY CDA8I01
feelings of anger, bad temper, short temper, resentment, or Intensity
0 = Absent
annoyance. (Change may predate the primary period and
continue into at least part of the primary period.) 2 = Irritable mood present in at least 2
activities manifested by at least one
instance of snappiness, shouting,
Note that this rating is of a change in the child's usual quarrelsomeness and at least sometimes
liability to be precipitated into anger, it does not refer to the uncontrollable.

LY
form of the anger once it has been precipitated. 3 = Irritable mood present in most activities,
accompanied by snappiness, shouting,
N.B.: The irritable mood itself is being rated, not just its quarrelsomeness, and nearly always
uncontrollable.
manifestations; thus, frequency and duration ratings refer
to the number and length of episodes of the mood, not of CDA8F01

N
the episodes of snappiness, shouting or quarrelsomeness. Frequency

N.B. INFORMATION OBTAINED HERE MAY ALSO BE

O
RELEVANT TO LOSING TEMPER AND TEMPER HOURS : MINUTES CDA8D01
TANTRUMS. Duration

Have you been more irritable than usual in the last 3

months?

Or made angry more easily?

EW CDA8O01
Onset

What have you been "touchy" about?

/ /
Is that more than usual? EPISODE OF IRRITABLE MOOD CDA8I02
What do you do when you feel like that?
Do you keep it to yourself? 0 = Absent
VI

2 = At least 1 week with 4 days irritable

How long does it last when you feel like that? mood.
Have you been snappy with friends or family members?
Have you gotten into arguments lately? 3 = Period of 2 consecutive weeks where
irritable mood present on at least 8 days.
What has happened?
RE

What did you say? PERIOD OF 2 CONTINUOUS MONTHS CDA8I03

What did you do? WITHOUT IRRITABLE MOOD IN LAST
Have you hit or broken anything when you were angry? YEAR

0 = Present
When did you start to get "irritable" like that?
2 = Absent
IF PRESENT, ASK;
R

Was there a week when you felt "irritable" most days?

Were there two weeks when you were "irritable" on at least
FO

8 days?

IF IRRITABILITY PRESENT ASK;

Has there been a period of at least 2 months in the last

year when you didn't feel like that?
IF PRESENT, ASK;

In the last 3 months has there been a week when you were
irritable like that every day?
IF IRRITABLE PRESENT FOR A WEEK (7
CONSECUTIVE DAYS), REMEMBER TO COMPLETE

Depression 8
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

THE MANIA SECTION.

LOSS OF AFFECT
Complaint of loss of a previously existing ability to feel or LOSS OF AFFECT CDA9I01
experience emotion. Intensity
0 = Absent

Have you felt that you didn't have any feelings 2 = Loss of affect in at least 2 activities and

LY
uncontrollable at least some of the time.
(emotions) left?
3 = Affect is felt to be lost in almost all
Or that you had lost your feelings? activities.

Had your feelings gone completely? CDA9O01

Onset

N
Could you feel any emotions?
When did you start to lose your feelings? / /

O
CONATIVE PROBLEMS
BOREDOM
Activities the child is actually engaged in are felt to be dull
EW BOREDOM CDB0I01
and lacking in interest while interest in other possible Intensity
0 = Absent
potential activities is expressed.
2 = More than half the time.
Everyone gets bored sometimes, so code a child positively 3 = Almost all the time.
here only if s/he is more often bored than not. But code
positive even if the activities are truly dull. It must seem to CDB0O01
the child that other potential activities would be of interest Onset
VI

even if s/he is uncertain what those other activities might

be.
/ /

Differentiate from anhedonia and loss of interest, where

RE

nothing seems to be of potential interest or likely to give

pleasure.

Code even if the activities described are truly boring in your

opinion.

How much of the time are you bored?

R

Do you get bored more than other people?

IF PRESENT ASK;
FO

What can you do to stop yourself from being bored?

What do you do?
What would you like to be doing?

How long have you been feeling so bored?

Depression 9
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LOSS OF INTEREST
Diminution of the child's interest in usual pursuits and LOSS OF INTEREST CDB1I01
activities. Intensity
0 = Absent

Either some interests have been dropped or the intensity of 2 = Generalized diminution in interest taken
in normally interesting activities.
interest has decreased. Everyone has interests of some
sort, but the extent of the diminution must be measured in 3 = The subject is completely or almost
the context of the range and depth of the child's usual completely uninterested in everything or

LY
nearly everything.
activities. Take into account everyday daycare/school and
home activities as well as watching TV, playing games, CDB1O01
taking an interest in clothes, food, appearance, toys, etc. Onset
Inevitably, those with more intense and varied interests
initially will have more room to lose interest than those who / /

N
have never taken a great interest in things.

Distinguish from "growing out" of activities or giving up

O
certain activities to take up new ones or because of
increased pressure of work.

NOTE INFORMATION FROM THE OUT OF SCHOOL

ACTIVITIES SECTION
EW
Have things been interesting to you as much as they
used to?

Have you lost interest in anything?

IF PRESENT ASK;
VI

What kinds of things have you lost interest in?

Can you get interested in anything?

When did you start to lose interest in things?

RE
R
FO

Depression 10
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ANHEDONIA
A partial or complete loss or diminution of the ability to ANHEDONIA CDB2I01
experience pleasure, enjoy things, or have fun. It also Intensity
0 = Absent
refers to basic pleasures like those resulting from eating
favorite foods. 2 = Generalized diminution in pleasure
taken in normally pleasurable activities.

Anhedonia concerns the mood state itself. Loss of Interest, 3 = Almost nothing gives pleasure.
Loss of Initiative, Lack of Protest, inability to engage in
CDB2O01

LY
activities, or loss of the ability to concentrate on looking at
Onset
books, games, TV or school may accompany Anhedonia,
so the interviewer may code different aspects under / /
different items. Do not confuse this item with a lack of
opportunity to do things or to excessive parental restriction.

N
Comparison should be made with enjoyment when the
child is normal. This may not be accessible in episodes of
very long duration.

O
DISTINGUISH FROM BOREDOM AND LOSS OF
INTEREST OR LACK OF OPPORTUNITIES FOR
PARTICIPATION.

Can you have fun or enjoy yourself?

EW
Are there things you used to enjoy but don't anymore?

Do you feel that you can't enjoy things anymore?

What things are fun (or enjoyable) now?
VI

When did you start to feel like that?

RE
R
FO

Depression 11
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUBJECTIVE ANERGIA
The child is markedly lacking in energy compared with ANERGIA CDB3I01
usual state. The child is described as being easily fatigued Intensity
0 = Absent
and/or excessively tired. This is a general rating of child's
overall energy level. 2 = A generalized listlessness and lack of
energy.

DIFFERENTIATE FROM MOTOR SLOWING (NEXT 3 = A report of being almost completely

PAGE), AND FATIGABILITY (SLEEP SECTION), without energy.

LY
ALTHOUGH YOU MAY DOUBLE CODE IF CRITERIA CDB3O01
FOR MORE THAN ONE ARE MET. Onset

Have you been feeling energetic? / /

N
Do you have as much energy as you used to have?

Or have you lost any of your usual energy?

O
Have you been feeling a lack of energy?
Do you have enough energy to do things?
Do you put things off because you haven't got enough
energy?
How has that bothered you?

When did you start feeling less energetic?

EW
SUBJECTIVE MOTOR SLOWING
The child is slowed down in movement AND speech MOTOR SLOWING CDB4I01
VI

compared with his/her usual condition. Intensity

0 = Absent

Have you been moving more slowly than you used to? 2 = Slowing present and cannot be
overcome in at least 2 activities.
Do you do things more slowly than you used to?
RE

3 = Slowing present and cannot be

overcome in almost all activities.
Or talk more slowly?
CDB4F01
Would other people notice? Frequency
Can you give me an example?

How long does it last? CDB4D01

R

HOURS : MINUTES
Can you do anything to speed yourself up? Duration
What?
When did you start to feel slowed down?
FO

When did you start to feel slowed down? CDB4O01

Onset

/ /

Depression 12
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUBJECTIVE COMPLAINTS ABOUT THINKING

INEFFICIENT THINKING
Unpleasant difficulty with thinking clearly or efficiently, or INEFFICIENT THINKING CDB5I01
concentrating, even about simple matters; daily total Intensity
0 = Absent
duration of at least 1 hour.
2 = Sometimes uncontrollable in at least 2
activities
Do your thoughts get muddled or confused easily?

LY
3 = Almost always uncontrollable and
How long has it been like that? occuring in relation to almost all situations
Can you think clearly if you need to? where clear thinking required
Does it cause you any trouble? What? CDB5O01
When did you start to have trouble with yourr thinking? Onset
Is there any interference with your thoughts?
/ /

N
O
INDECISIVENESS
Unpleasant difficulty in reaching decisions, even about INDECISIVENESS CDB6I01
simple matters. This is a general rating of child's ability to Intensity
0 = Absent
make decisions. EW 2 = Sometimes uncontrollable in at least 2
activities.
What about decisions; are you good at making
decisions (making up your mind)? 3 = Almost always uncontrollable and
occurring in relation to almost all decisions.
Why not?
CDB6O01
Have you had any trouble making decisions? Onset

/ /
VI

Why?
When was the last time you had that sort of trouble?
What happens when you have to make up your mind?
Can you remember the last time that happened?
Have you always been like that?
RE

Does it cause you any trouble?

What?
R
FO

Depression 13
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUBJECTIVE RUSHING THOUGHTS

Subjective, unpleasant sensation of thoughts passing SUBJECTIVE RUSHING THOUGHT CDB7I01
through the mind at an abnormal speed, being too fast; Intensity
0 = Absent
lasting at least 1 hour in daily total.
2 = Rushing of thoughts intrusive in at least
2 activities and cannot be completely
Do your thought ever go too fast? controlled.

What is that like? 3 = Rushing of thoughts intrusive in nearly

LY
Is it unpleasant? all activities and almost completely
uncontrollable.

CDB7F01
Frequency

N
HOURS : MINUTES CDB7D01
Duration

O
CDB7O01
EW Onset

/ /

SUBJECTIVE SLOWED THOUGHTS

Subjective, unpleasant sensation of thoughts passing SUBJECTIVE SLOWED THOUGHT CDB8I01
through the mind at an abnormal speed, being too slow; Intensity
0 = Absent
VI

lasting at least 1 hour in daily total.

2 = Slowing of thoughts intrusive in at least
2 activities and cannot be completely
Do your thoughts ever go too slow? controlled.

What's that like? 3 = Slowing of thoughts intrusive in nearly

RE

Is it unpleasant? all activities and almost completely

uncontrollable.

CDB8F01
Frequency
R

HOURS : MINUTES CDB8D01

Duration
FO

CDB8O01
Onset

/ /

Depression 14
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DEPRESSIVE THOUGHTS

In the definitions in this section the term

"feeling" is frequently used, despite the fact
that cognitions are being referred to. For most
people, the term "feeling" carries both
cognitive and affective components. However,
these items refer not to mood states per se, but
to certain cognitions, thoughts, opinions or

LY
attitudes. In other words, it is the content of the
thought that is to be coded, not its affective
tone.

LONELINESS

N
A feeling of being alone and/or friendless, regardless of the LONELINESS CDB9I01
justification for the feeling. Intensity
0 = Absent

O
Adult contacts and peer friendships should be considered. 2 = The subject definitely feels intrusively
and uncontrollably lonely, in at least 2
Differentiate from feeling unloved. A child may be lonely but activities.
still acknowledge being loved and vice versa.
3 = S/he feels lonely almost all the time.

NOTE RELEVANT INFORMATION FROM PEER

RELATIONSHIPS.
EW CDB9O01
Onset

Do you ever feel lonely?

/ /
How often is that?
When was the last time?
VI

What did that feel like ?

Do you have friends who would help you if you needed
help?
RE

Do they care about you?

Do you feel lonely even though you've got some friends?
Would they want to help you if you needed help?
Do you get left out by others?
Do you get left out of your friends' activities?
How do you feel about that?
Do you think that's likely to change?
R

When did you start to feel lonely like that?

FO

Depression 15
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FEELS UNLOVED
A generalized feeling of being unloved and uncared for, FEELS UNLOVED CDC0I01
regardless of the justification for that feeling. Intensity
0 = Absent

DIFFERENTIATE FROM LONELINESS. 2 = The subject feels that there are others
who love him/her but that s/he is loved or
cared for less than other people.
RELEVANT INFORMATION TO CODE THIS ITEM MAY
3 = The subject feels that almost no one
HAVE EMERGED IN THE FAMILY LIFE AND

LY
loves him/her, or hardly ever believes that
RELATIONSHIPS SECTION. anyone does.

CDC0O01
Is there anyone who loves you?
Onset
Who? / /

N
How do you know?

What about your parents?

O
Has it always been like that?
Will it always be like that?
How do you know?
When did you start to feel like that? EW
VI
RE
R
FO

Depression 16
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SELF-DEPRECIATION AND SELF-HATRED

An unjustified feeling of inferiority to others (including SELF-DEPRECIATION CDC1I01
unjustified feelings of ugliness). Self-hatred involves severe Intensity
0 = Absent
hostility directed by the child against him/herself,
accompanied by expressed dislike or expressed criticism. 2 = The subject rates him/herself lower than
seems justified, but does not see
him/herself as being completely without
Do not rate delusional phenomena here. value, since in some activities s/he does not
feel inferior.

LY
How do you feel about yourself? 3 = The subject feels almost entirely
worthless and without saving graces, in
Do you like yourself? nearly all activities, or inferior to everyone.
Self-hatred is also rated here.
How do you feel about your appearance (looks)? CDC1O01

N
What are you like compared with others? Onset
If you had to choose, would you say you were good-
looking, average, or ugly? / /

O
How ugly do you think you are?
Are you much worse-looking than most people?
How much of the time do you feel like that?
Is there anything that you are good at?
What are you like compared with others?
As a person are you as good as other people?
EW
Are you good at all?
Do you think you're no good? ... at anything?
Is everyone better that you are?
Do you think you will ever be any better?
Do you think that all the time or only part of the time?
VI

What things do you do that you are proud of?

When did you start to feel like that?

RE
R
FO

Depression 17
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FEELING SORRY FOR ONESELF

A feeling that life or people have been unfairly unpleasant FEELING SORRY FOR ONESELF CDC2I01
or troubling and that the child deserves better. Child feels Intensity
0 = Absent
unlucky, victim of "bad luck".
2 = The subject feels sorry for him/herself
but thinks that some aspects of life have not
Code regardless of justification. been unfairly troubling or unpleasant.

3 = The subject thinks that nothing has

Do you think that life has been fair to you?

LY
occurred according to his/her just desserts,
and feels sorry for him/herself in nearly all
Do you think you deserve better? situations.

In what way? CDC2O01

Do you feel like that all the time or only some of the time? Onset

N
When do you feel like that?
Is everything unfair or just some things?
/ /
Do you deserve a better deal?
Will it always be like that?

O
When did you start to fee that life hasn't been fair to you?

When did you start to feel like that?

PATHOLOGICAL GUILT
EW
Excessive self-blame for minor or non-existent PATHOLOGICAL GUILT CDC3I01
wrongdoings. Child realizes that guilt is exaggerated Intensity
0 = Absent
(otherwise, code as Delusions of Guilt).
2 = At least partially unmodifiable excessive
self-blame not generalized to all negative
Do you feel bad or guilty about anything that you've
VI

events.
done?
3 = The child generalizes the feeling of self-
What? blame to almost anything that goes wrong
in his/her environment.
How often do you feel like that? CDC3O01
RE

When was the last time? Onset

Do you blame yourself at all?
/ /
Do you deserve to have bad things happen to you?

Do you think you deserve punishment?

Why?
R

Do you ever feel guilty about things that you know aren't
really your fault?
Do you feel that a lot of things that go wrong are your fault?
FO

What?
How guilty do you feel?
IF PATHOLOGICAL GUILT IS PRESENT, CONSIDER
DELUSIONS OF GUILT.

When did you start to feel that you were "to blame"?

Depression 18
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Definitions and questions Coding rules Codes

DELUSIONS OF GUILT
Delusional self-blame for minor or non-existent DELUSIONS OF GUILT CDC4I01
wrongdoings. Child DOES NOT realize that guilt is Intensity
0 = Absent
exaggerated.
2 = The subject has a delusional conviction
of having done wrong but there is a
The child may believe that s/he has brought ruin to his/her fluctuating awareness that his/her feelings
family by being in his/her present condition or that his/her are an exaggeration of normal guilt.
symptoms are a punishment for not doing better.

LY
3 = The subject has an unmodifiable
Distinguish from pathological guilt without delusional delusional conviction that s/he has sinned
elaboration, in which the child is in general aware that the greatly, etc.
guilt originates within him/herself and is exaggerated.
CDC4O01
Onset
Do you believe that you have committed a crime?

N
Or sinned greatly? / /
Do you deserve to be punished?
Do you think that you might hurt or ruin other people?

O
EW
VI
RE
R
FO

Depression 19
CAPA-Omnibus Child Version 5.0.0

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IDEAS OF REFERENCE
Subjective feeling of being noticed or commented about in IDEAS OF REFERENCE CDC5I01
public settings that are not justified by reality. Comments Intensity
0 = Absent
seem to be mocking, critical, or blaming. Do not include
situations in which the description offers evidence that 2 = Simple ideas of reference
subject actually was being noticed or commented upon. 3 = Guilty ideas of reference

IF IDEAS OF REFERENCE ARE PRESENT, CONSIDER CDC5F01

LY
WHETHER THERE ARE DELUSIONS. Frequency

IF IDEAS OF REFERENCE ARE PRESENT, CONSIDER

WHETHER THERE ARE DELUSIONS. HOURS : MINUTES CDC5D01
Duration

N
Sometimes people get the feeling that other people are
looking at them even when they know they aren't
really. Does that happen to you?
CDC5O01

O
Onset
When was the last time?
Can you tell me about that? / /
What do you think people think or say when you feel that
they're noticing you? EW
Do you ever feel that people are talking about you?

Do you ever feel they might be laughing at you or saying

rude things about you?
Do people follow you or watch you?
How do you know they are?
Are you just being sensitive?
Are you imagining it?
VI

Are people blaming you for something? What?

Are people accusing you of something? What?
How do you know they are?
What do they do?
RE

Do you think they really are or are you just being sensitive?
Are you imagining it?

When did you first notice it?

How long does it last when you feel like that?

R

When did you first start feeling like that?

FO

Depression 20
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HELPLESSNESS
The child feels that there is little or nothing s/he can do to HELPLESSNESS CDC6I01
improve his/her situation or psychological state, though Intensity
0 = Absent
such a change would be welcome. This is a generalized
feeling. 2 = The subject feels helpless and cannot
always modify his/her feelings, but can
report expectations of being able to help
Is there anything about the way things are, or the way him/herself.
you are that you would like to change?

LY
3 = The subject expresses almost no hope
of being able to help him/herself.
IF PRESENT ASK;
CDC6O01
Is there anything you could do to make things better? Onset

Or make yourself feel better? / /

N
What?
Would it work, do you think?

O
When did you start to feel you couldn't do anything to
imporve your situation?

HOPELESSNESS
EW
The child has a bleak, negative, pessimistic view of the HOPELESSNESS CDC7I01
future, and little hope that his/her situation will improve. Intensity
0 = Absent
This is a generalized feeling.
2 = The subject feels hopeless and cannot
always modify his/her feelings, but can
What do you think the future will be like? report some positive expectations of the
VI

future.
Will things get better for you? Or worse?
3 = The subject expresses almost no hope
for the future at all.
Do you think anyone can help you?
Will things be better when you're grown up? CDC7O01
RE

Do you feel hopeless about the future? Onset

In what way?
How often do you feel like that? / /
Can you do anything about it?
When did you start to feel that the future didn't hold good
things for you?
R
FO

Depression 21
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUICIDE

Purposes of the Section

This section has 1 major function:

(1) To assess the suicidal and self injurious

intentions and actions of the child.

LY
Organization of the Section

The section is organized in 2 sub areas:

N
(1) Suicidal ideation and behavior.

(2) Non suicidal deliberate self harm.

O
SUICIDE AND SELF-INJURIOUS BEHAVIOR
Do you ever think about death or dying? EVER: SUICIDE SCREEN POSITIVE CDC8I01
Intensity
EW
Have you ever thought you couldn't go on any longer?
0 = Absent

2 = Present
Have you ever thought life was not worth living?
SUICIDE SCREEN POSITIVE CDC8I02
Have you ever wished you were dead? 0 = Absent
Have you though of hurting yourself?
Have you ever thought about ending it all? 2 = Present
VI

When was that?

Have you felt like that in the past 3 months?
Have you ever tried to hurt or kill yourself?

When?
RE

Why was that?

What happened?
Have you tried more than once?
Have you ever done anything that made people think
you wanted to die?

What?
R

When was that?

What happened?
FO

Depression 22
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

THINKING ABOUT DEATH

Thoughts about death and dying, whether referred to self or THINKING ABOUT DEATH CDC9I01
others. Intensity
0 = Absent

Include thoughts about not being able to go on any longer 2 = Present but not including thoughts
about wanting to die. The thoughts should
and life not being worth living. Include discussion about a be intrusive into at least 2 activities and at
grandparent who has died ("Do they go to heaven?" "What least sometimes uncontrollable.
will happen when I die?") To code, thoughts must be

LY
3 = Including thoughts about wanting to die.
intrusive into at least two activities. The thoughts should be intrusive into at
least 2 activities and at least sometimes
CODE THOUGHTS ABOUT TAKING ONE'S OWN LIFE uncontrollable.
UNDER SUICIDAL THOUGHTS (NEXT PAGE). CDC9F01
Frequency

N
What do you think about?

How much do you think about it?

CDC9O01

O
Do you sometimes wish you were dead?
Do you want to die? Onset
Why do you feel like that? / /
How long have you been thinking like that? EW
SUICIDAL THOUGHTS
Thoughts specifically about killing oneself, by whatever SUICIDAL THOUGHTS CDD0I01
means, with some intention to carry them out. Intensity
0 = Absent

2 = At least sometimes uncontrollable

VI

This may accompany thinking about death in general, or

suicidal thoughts, recurring in at least 2
may be present if a child has reported a suicidal plan or activities.
past attempt.
3 = Usually uncontrollable suicidal thoughts
intruding into most activities.
Do not include suicidal plans.
RE

CDD0F01
Do you ever think about ending it all? Frequency

When was the last time?

What do you think about? CDD0O01
Are you actually going to do that? Onset
R

/ /
FO

IF SUICIDAL THOUGHTS NOT

PRESENT, SKIP TO "SUICIDAL
ATTEMPTS", (PAGE 24).

Depression 23
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUICIDAL PLANS
Suicidal thoughts that contain plans of a suicidal act and SUICIDAL PLANS CDD1I01
some intent to carry them out. Intensity
0 = Absent

If suicidal attempt has been made, determine whether a 2 = A specific plan, considered on more
than 1 occasion, over which no action was
plan was present prior to the attempt. taken.

3 = A specific plan, considered on more

Have you thought about actually killing yourself?

LY
than 1 occasion, with preparatory action
taken, for example storing up pills.
Have you thought what you might do?
Are you going to do this? CDD1F01
Have you done anything to prepare for killing yourself? Frequency
What?

N
CDD1O01
Onset

O
/ /

SUICIDAL ATTEMPTS EW
Episodes of deliberately self-harmful behavior involving SUICIDAL BEHAVIOR Ever:CDD2E01
some intention to die at the time of the attempt. Rate here, Intensity
0 = Absent
no matter how unlikely the attempt was to cause death, so
long as the child's intention was to die. If parent unsure 2 = Present
about intention to die, code if the parent can describe a
DATE OF FIRST ATTEMPT Ever:CDD2O01
clear self-harmful event.
/ /
VI

Have you ever actually tried to kill yourself?

DATE OF LAST ATTEMPT Ever:CDD2O02
What happened?
Where did you do it? / /
RE

Were there any people around at the time?

Ever:CDD2V01
how were you feeling? Frequency
Did you really want to die?
Who found you?
Did you go to the hospital?
SUICIDAL BEHAVIOR IN LAST 3 CDD2I01
When did you first try to kill yourself? MONTHS Intensity
R

0 = Absent
When did you last try to kill yourself?
2 = Present
How many times have you tried?
FO

CDD2F01
What do you think about it now? Frequency
Would you do it again if you had the chance?
Do you wish you were dead now?

Depression 24
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IF A SUICIDE ATTEMPT HAS (EVER)

BEEN MADE COMPLETE EVER:
METHOD, EVER: INTENT, AND EVER:
LETHALITY. IF ATTEMPT MADE IN THE
PAST 3 MONTHS, ALSO COMPLETE
ITEMS ABOUT THE RECENT
ATTEMPT(S): METHOD, INTENT, AND

LY
LETHALITY.
IF NO SUICIDE ATTEMPTS MADE, SKIP
TO "NON-SUICIDAL PHYSICAL SELF-
DAMAGING ACTS", (PAGE 30).

N
O
EW
VI
RE
R
FO

Depression 25
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

EVER: METHODS OF SUICIDE ATTEMPT(S)

Methods of self harm used with the intention of ending life. SUICIDE ATTEMPTS PRESENT Ever:CDD3E90
Rate here, no matter how unlikely to cause death the Intensity
0 = Absent
attempt was, so long as the child's intention was to die.
2 = Present

EVER: OVERDOSE OF PRESCRIPTION Ever:CDD3E01

OR OVER-THE-COUNTER MEDICATION

LY
0 = Absent

2 = Present

EVER: ILLICIT DRUG OVERDOSE Ever:CDD3E02

0 = Absent

N
2 = Present

EVER: HANGING Ever:CDD3E03

O
0 = Absent

2 = Present

EW EVER: STABBING/CUTTING Ever:CDD3E04

0 = Absent

2 = Present

EVER: SHOOTING Ever:CDD3E05

0 = Absent

2 = Present
VI

EVER: RUNNING INTO TRAFFIC Ever:CDD3E06

0 = Absent

2 = Present
RE

OTHER Ever:CDD3E07
0 = Absent

2 = Present

Specify
R
FO

IF SUICIDE ATTEMPT(S) MADE IN THE

LAS 3 MONTHS, COMPLETE METHODS
OF SUICIDE ATTEMPT(S) (NEXT
PAGE). OTHERWISE, SKIP TO
"SUICIDAL INTENT", (PAGE 28).

Depression 26
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

METHODS OF SUICIDE ATTEMPT(S)

Methods of self harm used in the last 3 months with the SUICIDE ATTEMPT(S) PRESENT IN THE CDD4I90
intention of ending life. Rate here, no matter how unlikely to LAST 3 MONTHS Intensity
cause death the attempt was, so long as the child's 0 = Absent
intention was to die.
2 = Present

OVERDOSE OF PRESCRIPTION OR CDD4I01

OVER-THE-COUNTER MEDICATION

LY
0 = Absent

2 = Present

ILLICIT DRUG OVERDOSE CDD4I02

N
0 = Absent

2 = Present

CDD4I03

O
HANGING

0 = Absent

2 = Present

STABBING/CUTTING CDD4I04
EW 0 = Absent

2 = Present

SHOOTING CDD4I05
0 = Absent
VI

2 = Present

RUNNING INTO TRAFFIC CDD4I06

0 = Absent
RE

2 = Present

OTHER CDD4I07
0 = Absent

2 = Present

Specify
R
FO

Depression 27
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SUICIDAL INTENT
Code the highest level of suicidal intent manifested in an EVER: SUICIDAL INTENT Ever:CDD5E01
attempt. Do not include potentially self-injurious behavior Intensity
1 = Subject reports minimal intention to
without suicidal intent here. actually kill him/herself, but either revealed
the attempt to others, or otherwise ensured
that there was little risk to take his/her life.
Which time were you the most serious about killing
yourself? 2 = Substantial intent to kill self, but
associated with ambivalence to a sufficient

LY
What did you do? degree that the intention was not absolute.
Did you really want to die? 3 = Absolute (or almost absolute) intention
IF ATTEMPT IN THE PAST 3 MONTHS, ASK; to commit suicide, expressed with little or
no ambivalence or uncertainty. If uncertain
Was you serious about killing yourself when you tried in the whether to code 2 or 3, code 2.
last 3 months?

N
SUICIDAL INTENT CDD5I01
Intensity
1 = Subject reports minimal intention to
actually kill him/herself, but either revealed

O
the attempt to others, or otherwise ensured
that there was little risk to take his/her life.

2 = Substantial intent to kill self, but

associated with ambivalence to a sufficient
EW degree that the intention was not absolute.

3 = Absolute (or almost absolute) intention

to commit suicide, expressed with little or
no ambivalence or uncertainty. If uncertain
whether to code 2 or 3, code 2.

LETHALITY OF SUICIDAL ATTEMPT

VI

Code here the degree of threat to life resulting from the EVER: LETHALITY OF SUICIDAL Ever:CDD7E01
most serious suicidal attempt. ATTEMPT Intensity
1 = Mild: No Medical attention needed or
sought.
RE

2 = Moderate: Some medical attention

sought or required (e.g., sewing up cuts,
stomach lavage).

3 = Serious: The attempt resulted in

unconsciousness, the need for
resuscitation, assisted respiration, blood
transfusion, or operative intervention.
R

LETHALITY OF SUICIDAL ATTEMPT CDD7I01

Intensity
1 = Mild: No Medical attention needed or
sought.
FO

2 = Moderate: Some medical attention

sought or required (e.g., sewing up cuts,
stomach lavage).

3 = Serious: The attempt resulted in

unconsciousness, the need for
resuscitation, assisted respiration, blood
transfusion, or operative intervention.

Depression 28
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ALCOHOL OR DRUG INTOXICATION AT TIME

OF SUICIDE ATTEMPT
Alcohol or drug consumption prior to attempt sufficient for EVER: INTOXICATION AT TIME OF Ever:CDD8E01
subject to be experiencing effects at time of attempt. ATTEMPT Intensity
0 = Absent
When you tried to kill yourself, had you had anything to
2 = The subject had drunk alcohol or used
drink? drugs but was not showing marked effect at
the time of the attempt.

LY
Had you used any drugs?
3 = Definitely intoxicated, drunk or high at
time of attempt.
Had you been sniffing glue?
INTOXICATION AT TIME OF ATTEMPT CDD8I01
How long was that before you tried to kill yourself? Intensity
Were you drunk? 0 = Absent

N
Were you high? 2 = The subject had drunk alcohol or used
Was the alcohol (drug) having any effect on you at the time drugs but was not showing marked effect at
you tried to kill yourself? the time of the attempt.

O
3 = Definitely intoxicated, drunk or high at
Were you drunk or high when you tried in the last 3 time of attempt.
months?

"SUICIDAL" BEHAVIOR WITHOUT INTENT

EW
Actions threatening suicide, without intention of ending life, EVER: "SUICIDAL" BEHAVIOR Ever:CDD6E01
e.g., taking a gun and threatening to shoot oneself, in order WITHOUT INTENT Intensity
to control others' behavior. 0 = Absent

2 = Present
Have you done anything that made people think you
VI

wanted to die? Ever:CDD6V01

Frequency
Why did you do it?

How many times have you done that in the last 3 months?
RE

Ever:CDD6O01
When was the first time? Onset

Have you done anything that made people think you / /

wanted to die in the last three months?
"SUICIDAL" BEHAVIOR WITHOUT CCD6X99
INTENT (LAST 3 MONTHS) Intensity
R

0 = Absent

2 = Present

CDD6F01
FO

Frequency

Depression 29
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

NON-SUICIDAL PHYSICAL SELF-DAMAGING

ACTS
Self-mutilation, etc., not accompanied by any wish or NON-SUICIDAL PHYSICAL SELF- Ever:CDE0E01
intention to die (e.g., cutting on skin with a knife, buring DAMAGING ACTS Intensity
self, deliberately putting finger in door jam and closing 0 = Absent
door, wrist-slashing or cigarette burns).
2 = Acts not receiving medical treatment.

Have you ever hurt yourself on purpose (apart from 3 = Acts receiving medical treatment

LY
when you wanted to die)? (simple attending hospital counts as
treatment).
Or cut yourself on purpose? Ever:CDE0V01
Frequency
Why did you do it?
What did you feel like before you did it?

N
Did it make you feel better?
Did you want to kill yourself? Ever:CDE0O01
Onset

O
How about in the last three months?
/ /
NON-SUICIDAL PHYSICAL SELF- CDD9I01
EW DAMAGING ACTS Intensity
0 = Absent

2 = Acts not receiving medical treatment.

3 = Acts receiving medical treatment

(simple attending hospital counts as
treatment).

CDD9F01
VI

Frequency

CDD9O01
RE

Onset

/ /

IF NON-SUICIDAL PHYSICAL SELF-

R

DAMAGING ACTS ARE PRESENT,

COMPLETE DYSPHORIA OF SELF-
MUTILATORY TYPE. OTHERWISE ,
FO

SKIP TO "BRAGGING", (PAGE 12).

Depression 30
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DYSPHORIA OF SELF-MUTILATORY TYPE

Highly unpleasant mounting feeling of inner tension, DYSPHORIA OF SELF-MUTILATORY CDE1I01
released by a self-mutilatory act. TYPE Intensity
0 = Absent
Questions as under non-suicidal physical self-damaging
2 = Present
acts.
CDE1F01
How did you feel when you hurt or cut yourself? Frequency

LY
How many times have you hurt/cut yourself (in the last 3
months)? HOURS : MINUTES CDE1D01
Duration
How long does that feeling last?

N
When did you first get it (the tension)?
CDE1O01
Onset

O
/ /
EW
VI
RE
R
FO

Depression 31
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

HYPOMANIA AND MANIA

The symptoms in this section includes the
contribution of Dr. Joan Luby of Washington
University in St. Louis.
MANIC MOOD DISTURBANCE

REMEMBER TO GET EXAMPLES AND

BEHAVIORAL DESCRIPTIONS.

LY
EXPANSIVE MOOD
Feelings of euphoria or elation which represents a EXPANSIVE MOOD CDE2I01
substantial change from the child's usual mood and which Intensity
0 = Absent
are not a response to specific situations.

N
2 = The expansive mood is intrusive into
non-elating situations, but can sometimes
Do not include responses to happy events (such as be controlled when inappropriate.
birthdays, holidays, etc.).

O
3 = Expansive mood is intrusive and
uncontrollable in almost all activities and
IF EXPANSIVE MOOD IS PRESENT BE PREPARED TO often inappropriate.
RECONSIDER PREVIOUS RATINGS OF IRRITABILITY.
CDE2F01
Frequency
EW
Have you felt really high for no special reason?

What was that like?

HOURS : MINUTES CDE2D01
Have you felt unusually good in yourself? Duration

Did anyone comment on your behavior?

VI

What did they say? CDE2O01

Did they think you were over the top? Onset
What did you do?
When you were "high", had you had anything to drink?
/ /
Were you drunk?
RE

Had you taken any drugs?

Had you been sniffing glue?
Had anything happened to make you feel happy?

How long did that feeling last?

When did you first have it?

R
FO

IF EXPANSIVE MOOD PRESENT,

COMPLETE. OTHERWISE, SKIP TO
"ABDOMINAL PAIN", (PAGE 21).

Hypomania and Mania 1

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EXPANSIVE MOOD -
SPONTANEITY/REACTIVITY
Degree to which expansive mood is related to or EXPANSIVE MOOD - CDAL151
independent of external events. SPONTANEITY/REACTIVITY Intensity
0 = Absent
Are you super happy only when something very
2 = Expansive mood at times in the
exciting is happening (e.g., birthday party, trip to absence of positive events.
Disneyland, etc.)?

LY
CDAL152
Are you ever super happy for no reason? Frequency

How often are you super happy 'out of the blue' or for no
reason?
HOURS : MINUTES CDAL153

N
How long does this super happy mood for no reason last? Duration

When did you first notice that you would get super happy

O
for no reason? CDAL154
Onset

EW / /

EXPANSIVE MOOD - CONCERN TO ADULT

Do you think it is a problem? ADULT CONCERN CDAL155
Are you concerned about your super happy moods? Intensity
0 = Absent

Is anyone else concerned about your super happy 2 = Present

moods? Who?
VI

WHO IS CONCERNED (CODE ALL THAT CDAL156

APPLY)
Has anyone commented that you seem to be too happy at
times? Who? 1 = Parent 1.

2 = Parent 2. CDAL157
RE

3 = Other Parent 1.

4 = Other Parent 2. CDAL158

5 = Teacher/childcare provider.

6 = Other adult.
CDAL159
R

CDAL160
FO

CDAL161

Hypomania and Mania 2

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EXPANSIVE MOOD - ALLEVIATION

When you feel 'super happy,' can anyone do anything EXPANSIVE MOOD - ALLEVIATION CDAL157
to settle you down? Intensity
0 = Child's mood is always and easily
brought to baseline by attempts to "settle"
What? or calm.
How long would it keep you settled?
2 = Child's mood is brought to baseline at
How much of the time would things settle you down?
least sometimes by attempts to "settle" or
Can anyone do anything to settle you down? calm.

LY
Can you do anything to settle yourself down?
3 = Means of alleviation never effective.

4 = Means of alleviation never employed.

N
IF EVIDENCE OF EXPANSIVE MOOD
OR IF IRRITABILITY PRESENT 4

O
HOURS A DAY FOR A WEEK, THEM
COMPLETE THIS SECTION.
OTHERWISE, SKIP TO "ABDOMINAL
PAIN", (PAGE 21). EW
VI
RE
R
FO

Hypomania and Mania 3

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IRRITABILITY WITH EXPANSIVE MOOD

If both Irritability and Expansive Mood have been present IRRITABILITY WITH EXPANSIVE MOOD CDE4I01
together, or within the same 24 hour period, then code Intensity
0 = Expansive Mood not accompanied by
here. Irritability.

2 = Expansive Mood accompanied by

Irritability.

LY
DEPRESSED MOOD WITH EXPANSIVE MOOD
Both Depressed Mood and Expansive Mood present within DEPRESSED MOOD WITH EXPANSIVE CDE6I01
same 24 hour period. Either the two moods must both MOOD Intensity
separately meet the criteria for each, or if the two rapidly 0 = Absent
alternate, the two taken together must last at least one

N
continuous hour at a level that meets the other minimum 2 = Present, with both moods, either
separately or together, meeting the intensity
criteria. level '2' criteria.

O
Were there times when you were both "really happy" CDE6O01
Onset
and "depressed" on the same day?

Tell me about that.

/ /
Were you usually like that?
Or were you usually either one or the other?
How long did it last?
EW PERIOD OF 2 MONTHS WITHOUT
EITHER DEPRESSED MOOD OR
EXPANSIVE MOOD IN LAST YEAR
CDE6I02

0 = Absent
When did you start to get the "depression" and "feeling
really happy" so close together? 2 = Present

Has there been a period of at least 2 months during the

VI

last year when you didn't have either "depressed

mood" or "expansive mood?"
RE

MORE TALKATIVE THAN USUAL

Child is more talkative than usual. Speech may be loud, MORE TALKATIVE THAN USUAL CDF4I01
rapid, nonstop, or difficult to interrupt during periods of Intensity
0 = Absent
Expansive, Expansive/Irritable, or Irritable Mood.
2 = More talkative than usual, intrusive into
at least two activities but retains some
Distinguish from chattiness. regard for others’ wishes to communicate.
R

3 = More talkative in most activities with

Have you had times when you were more talkative than little regard for others’ wishes to
usual? communicate.
FO

What was that like? CDF4O01

Could others get a word in edgewise? Onset

/ /

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RACING THOUGHTS
A description of many images and ideas flashing through RACING THOUGHTS CDAL402
the mind or many ideas arising quickly. Intensity
0 = Absent

Have you had times when lots of thoughts flashed 2 = Child describes periods of racing
thoughts. These thoughts are intrusive into
through your head one after the other very fast? at least 2 activities.

What was that like? 3 = Racing thoughts occur regularly and

LY
Did your mind keep jumping from one things to frequently.
another when you were "high"? CDAL403
Frequency
Did your thoughts come so fast that you could hardly keep
up with them?
Were they faster than you could get into words?

N
Were they so fast that you got confused? HOURS : MINUTES CDAL404
What did other people think of your ideas at the time? Duration
How long does it last?

O
When did it start?
CDAL405
Onset

/ /
EW
VI
RE
R
FO

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OTHER MANIC SYMPTOMS

SUBJECTIVE FLIGHT OF IDEAS
A description of images and ideas flashing through the FLIGHT OF IDEAS CDE7I01
mind, when in Expansive or Expansive/Irritable Mood, or Intensity
0 = Flight of ideas absent.
Irritable Mood.
2 = Flight of ideas intrusive into normal
thinking, involving at least 2 activities, but
Have you had times when lots of thoughts flashed some coherent thought processes possible,

LY
through your head one after the other very fast? even if with effort to maintain control.

What was that like? 3 = Flight of ideas so intrusive as to be

almost completely disruptive of normal
Did your mind keep jumping from one thing to another thought.
when you were "high"?
CDE7O01

N
Did your thoughts come so fast that you could hardly keep Onset
up with them?
Were you faster than you could get into words? / /

O
Were they so fast that you got confused?
What did other people think of your ideas at the time?
How long does it last?

When did it start? EW

SUBJECTIVE PRESSURE OF SPEECH
A description of periods of talking fast, with a sensation of PRESSURE OF SPEECH CDE8I01
pressure to get words and ideas out, when in Expansive or Intensity
0 = Pressure of speech absent.
Expansive/Irritable Mood, or Irritable Mood.
2 = Pressure of speech intrusive into
VI

normal communication in at least 2

Were you talking very fast? activities; but some coherent
communication possible, even if with an
What was that like? effort to maintain control.
How long did that last?
3 = Pressure of speech so intrusive and
RE

uncontrollable as essentially to prevent

When did you first notice it? normal communication.

CDE8O01
Onset

/ /
R
FO

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SUBJECTIVE MOTOR PRESSURE

Feeling of increased physical energy or capacity expressed MOTOR PRESSURE CDE9I01
in motor behavior, when in Expansive or Expansive/Irritable Intensity
0 = Absent
Mood, or Irritable Mood.
2 = Motor pressure leads to increased
activity only within the child's usual range of
Have you had times when you felt really energetic? activities involving at least 2 activities.

What did you do? 3 = Child actually takes up new physical

LY
When you were feeling "high", did you do any physical activities as a result of increased motor
activity.
activities that you wouldn't normally?
CDE9F01
Had you developed any new interests? Frequency
How did you become interested in that?
What did other people think of your activities?

N
Were you moving faster than usual?
HOURS : MINUTES CDE9D01
When did this first happen to you? Duration

O
CDE9O01
EW Onset

/ /

SUBJECTIVE AGITATION
Markedly changed motor activity associated with Expansive AGITATION CDF5I01
or Expansive/Irritable or Irritable Mood. Account of a severe Intensity
0 = Absent
VI

level of inappropriate, unpleasant motor restlessness

during the mood state, indicated by pacing, wringing of 2 = Agitation is present in at least 2
hands, or similar activities. activities and cannot be entirely controlled,
but sometimes the subject can inhibit
his/her agitation with effort.
Do not include simple restlessness or fidgetiness in the
RE

3 = Agitation almost entirely uncontrollable.

absence of mood change.
CDF5F01
Do you get very restless when you're "miserable"? Frequency

Do you have difficulty keeping still?

What is that like? HOURS : MINUTES CDF5D01

R

Duration
Can you keep yourself still?
Do you have to move around?
What do you do?
FO

Are you always like that? CDF5O01

How about when you're not "miserable"? Onset

/ /

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UNUSUALLY ENERGETIC
During waking hours, subject is more active that usual UNUSUALLY ENERGETIC CDAL607
without expected fatigue. Or subject demonstrates little Intensity
0 = Absent
fatigue in spite of maintenance of normal activities.
2 = Child has persistent daily periods of
increased energy.
Have you had more energy than usual to do things
without getting tired? CDAL608
Frequency

LY
Do you go 'non-stop' without getting worn out?

Did it ever seem that you had too much energy?

HOURS : MINUTES CDAL609
What were you like then? Duration

N
CDAL700
Onset

O
/ /

DISTRACTIBILITY
EW
Inability to screen out irrelevant external stimuli during the DISTRACTIBILITY CDF6I01
period of mood disturbance. May have difficulty keeping Intensity
0 = Absent
thoughts on themes relevant to the topic.
2 = Present in a least 2 activities and at
least sometimes uncontrollable by the child.
Do you have difficulty paying attention when you can
look out of the window or hear other people talking in 3 = Present in most activities and at least
VI

the next room? sometimes uncontrollable by the child or by

admonition.
Do you find yourself easily distracted by things going CDF6O01
on around you? Onset
RE

Can you give me an example? / /

Is it like that in all activities or just some?
Can you stop yourself from getting distracted?
Is that all the time or just some times?
R
FO

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DECREASED NEED FOR SLEEP

During the period of mood disturbance, child feels DECREASED NEED FOR SLEEP CDF0I01
adequately rested with at least 1 hour less sleep than usual Intensity
0 = Absent
per night, for at least 1 week.
2 = 1-2 hours less sleep than usual per
night.
Differentiate from Insomnia, where reduced sleep is
associated with a feeling of being inadequately rested. 3 = More than 2 hours less sleep than usual
per night.

LY
When you were "high", did you need as much sleep as CDF0F01
usual? Frequency

How much sleep were you getting?

CDF0O01

N
Did you feel as if you needed more sleep?
When you woke did you feel properly rested? Onset

When did that start? / /

O
GRANDIOSE IDEAS AND ACTIONS
An unusually increased level of self-esteem or self- GRANDIOSE IDEAS AND ACTIONS CDF1I01
EW
appraisal of worth, such as the feeling of being superbly
strong, or exceptionally able, or intelligent, when in
0 = Absent
Intensity

Expansive or Expansive/Irritable Mood or Irritable Mood. 2 = Ideas present but not translated into
action.

Distinguish from fantasy play unrelated to mood changes. 3 = Ideas translated into action.

HOURS : MINUTES CDAL162

Have you felt specially healthy?
VI

Duration
Did you think you had (have) special powers or talents?
Have you been buying any interesting things lately?
What did you think of yourself when you felt "high"?
HOME CDAL159
Home
RE

Were there any times when you felt that you were a really
great or marvelous person? Frequency
Or a super-hero?
Did you think you were very important when you were
"high"? DAYCARE/SCHOOL CDAL160
Who/what did (do) you think you were (are)? Daycare/School
What did you do when you felt like that? Frequency
R

Did you feel super efficient?

Do you get this way at home/school/elsewhere? ELSEWHERE CDAL161

FO

Elsewhere
When did you start to feel like that about yourself? Frequency

CDF1O01
Onset

/ /

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IF GRANDIOSE IDEAS AND ACTIONS

PRESENT, COMPLETE. OTHERWISE,
SKIP TO "BRAGGING", (PAGE 12).

LY
N
O
EW
VI
RE
R
FO

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GRANDIOSE IDEAS AND ACTIONS - IDEAS

TRANSLATED INTO ACTION
Degree to which ideas result in action. TRANSLATED INTO ACTION CDAL165
Intensity
0 = No
Do you do anything because of these beliefs (e.g., child
believes s/he can fly and jumps from heights. Or child 2 = Yes
believes s/he is in charge and tells the teacher how to
manage the classroom)?

LY
What have you done?

GRANDIOSE IDEAS AND ACTIONS - CONCERN

N
TO ADULTS
Is your Parent 1 or Parent 2 concerned about your CONCERN TO ADULTS CDAL166
beliefs that you have special powers/abilities or think Intensity
0 = Absent

O
you're in charge?
2 = Present
Do they think it is a problem?
WHO IS CONCERNED (CODE ALL THAT CDAL167
APPLY)
Is anyone else concerned about your beliefs that you
EW
have special powers/abilities or think you're in charge? 1 = Parent 1.
Who? CDAL168
2 = Parent 2.
Has anyone commented that about your beliefs that 3 = Other Parent 1.
you have special powers/abilities or think you're in
charge? Who? 4 = Other Parent 2. CDAL169
5 = Teacher/childcare provider.
VI

6 = Other adult.
CDAL170
RE

CDAL171

CDAL172
R
FO

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GRANDIOSE IDEAS AND ACTIONS -

ALLEVIATION
When you think you're in charge, think your especially GRANDIOSITY - ALLEVIATION CDAL168
talented, etc., can you do anything to bring yourself Intensity
0 = Child will give up these ideas easily with
"back to reality?" adult redirection.

How much of the time does it work? 2 = Child's appraisal of self-worth is

restored to baseline at least sometimes with
adult re-direction.

LY
3 = Means of alleviation never effective.

4 = Means of alleviation never employed.

N
BRAGGING
Boastful talking about his/her real or perceived talents, BRAGGING CDAL170
accomplishments, etc. Intensity
0 = Absent

O
Do you brag about anything? 2 = Child brags about abilities in activities in
which s/he is not especially talented (e.g.,
child brags about soccer skills and is of
What kinds of things? average ability or less.)
Is this something you really are good at?
Have others commented that you brag?
EW HOME CDAL180
Home
Do you brag at home/school/elsewhere? Frequency

How often do you brag at home/school/elsewhere?

DAYCARE/SCHOOL CDAL181
When did you first notice that you bragged a lot?
Daycare/School
VI

Frequency

ELSEWHERE CDAL182
RE

Elsewhere
Frequency

CDAL185
Onset
R

/ /
FO

IF BRAGGING IS PRESENT, CONTINUE.

OTHERWISE, SKIP TO "SEXUAL
LANGUAGE", (PAGE 14).

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BRAGGING - CONCERN TO ADULT

Is your Parent 1 or Parent 2 concerned about how CONCERN TO ADULT CDAL187
much you brag? Intensity
0 = Absent

Do they think it is a problem? 2 = Present

Is anyone else concerned about how much you brag? WHO IS CONCERNED (CODE ALL THAT CDAL188
APPLY)
Who?

LY
1 = Parent 1.

2 = Parent 2. CDAL189

3 = Other Parent 1.

4 = Other Parent 2. CDAL190

N
5 = Teacher/childcare provider.

6 = Other adult.
CDAL191

O
CDAL192
EW CDAL193

BRAGGING - ALLEVIATION
VI

When you thinks you're in charge, think you're BRAGGING - ALLEVIATION CDAL189
especially talented, etc., can your Parent 1 or Parent 2 Intensity
0 = Child will give up these ideas easily with
do anything to bring you 'back to reality? adult re-direction.
RE

How much of the time does it work? 2 = Child's appraisal of self-worth is

restored to baseling at least sometimes with
adult re-direction.

3 = Means of alleviation never effective.

4 = Means of alleviation never employed.

R
FO

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SEXUAL LANGUAGE
Do you talk about body parts? SEXUAL LANGUAGE CDAL507
Intensity
0 = Absent
Do you use dirty or sexual language?
2 = Child makes inappropriate sexual
comments on more than one occasion.

3 = Child exhibits overt sexual language

several times a week or at inappropriate

LY
times.

CDAL508
Frequency

N
CDAL509
Onset

/ /

O
SEXUALLY ABUSED
Have you been sexually abused in any way? CDAL603
EW SEXUALLY ABUSED

0 = No
Intensity

2 = Yes

POOR JUDGMENT (HYPOMANIA AND MANIA)

VI

Uncharacteristic behaviors performed with disregard for POOR JUDGMENT CDF2I01

possible negative consequences during Expansive or Intensity
0 = Absent
Expansive/Irritable Mood state or Irritable Mood.
2 = Behavior that involved definitely poor
judgment but which was within the range of
Did you do anything that you regret when you were
RE

socially acceptable irresponsible behavior

"high"? (e.g. speaking rudely/impertinently to other
people, being physically reckless or
What did you do? aggressive).
Did you spend a lot of money then? 3 = Behavior that is outside the range of
socially acceptable irresponsible behavior
What did you spend it on? (e.g. being overtly insulting to figures of
Did you behave in ways that seem embarassing or silly authority, undressing in a public place), or
R

dangerous behavior (e.g., jumping off a roof

now?
because child believed s/he could fly) and
Did you get into any trouble when you were "high"? hence likely to result in some negative
consequences.
FO

What happened?
Have you been left with any problems by ...? CDF2O01
When did you first do something like that? Onset

When did you first do something like that?

/ /

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INAPPROPRIATE LAUGHING, JOKING,

GRINNING
Subject demonstrates laughing, joking, grinning in a INAPPRORIATE LAUGHING, JOKING, CDAL500
manner incongruent to context. GRINNING Intensity
0 = Absent
Do you just laugh for no reason when nothing funny
2 = Present in at least two activities and at
happened? least sometimes uncontrollable.

LY
Do you laugh uncontrollably? 3 = Present in most activities and
uncontrollable most of the time.
Do you laugh out when it's inappropriate (e.g., church,
CDAL501
preschool during lesson)? Frequency

N
HOURS : MINUTES CDAL502
Duration

O
CDAL503
EW Onset

/ /

UNINHIBITED/GREGARIOUSNESS
The subject is willing to be friendly toward almost any adult UNINHIBITED/GREGARIOUSNESS CDAL504
or child, to a degree unusual for his/her developmental age, Intensity
0 = Absent
VI

social group, and familiarity with the person. The subject

demonstrates reduced or absent reticence around 2 = Inappropriate gregariousness is
unfamiliar people. occasionally present and does not pose a
social problem.

Do you start a conversation with anyone - adult or 3 = Present and poses a significant social
RE

problem.
child?
CDAL505
Are you the type of child who has no hesitation to Frequency
engage in conversation with a stranger?

Are you concerned that you would talk inappropriately

to strangers? CDAL506
R

Onset
Would you run off with a stranger without any
hesitation or reserve? / /
FO

Do you seem to know everyone in your school or child

care?

Are you concerned you would say inappropriately

friendly or bossy things to unfamiliar adults, even
those in a position of authority?

Do you think this is a problem?

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MOOD CYCLING
Subject exhibits significant and abrupt mood changes. MOOD CYCLING CDAL701
Intensity
0 = Absent
Does it seem like your mood can change 'on a dime?'
For example, going from being very happy to very 2 = Child displays abrupt changes in mood.
These occur spontaneously (for no
irritable or sad in a short time? apparent reason) or in response to minor
disappointments or most limit-setting.
Does your mood change often and quickly?

LY
3 = Child frequently and continuously
displays spontaneous and abrupt changes
in mood or child displays abrupt mood
changes to nearly all disappointments or
limit-setting.

CDAL702

N
Frequency

O
CDAL703
Onset

EW / /

INCREASE IN ADAPTIVE ACTIVITY AS

COMPARED WITH USUAL LEVEL
increased appropriate involvement or activity during INCREASE IN ADAPTIVE ACTIVITY CDF3I01
periods of Expansive or Expansive/Irritable Mood or Intensity
0 = Absent
Irritable Mood.
VI

2 = Increase in adaptive activity in at least 2

activities.
Do not include responses to there being a sudden need to
meet deadlines or to avoid punishment. 3 = Increase in adaptive activity in almost
all activities.

When you felt "so good" how did it affect your work? CDF3O01
RE

Onset
Were you abel to work better or more efficiently than
usual? / /
How did you get along with your parents or friends
when you were "high"?

Did you get more involved in things than you normally

R

do?

Did you take more interest in things than you normally like
FO

to do?
Did you get more done?
When did that first happen to you?

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SOMATIZATION
NOTE THAT THIS SECTION SERVES TO
EXCLUDE BRIQUET'S SYNDROME, BUT THAT
THE MOST COMMON CAUSE OF MULTIPLE
PHYSICAL SYMPTOMS IS PHYSICAL ILLNESS.
SOMATIZATION

How have you felt physically over the last 3

months?

LY
Have you had any illness?

How did the illness affect you?

N
Does your body work normally?

O
EW
VI
RE
R
FO

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HEADACHES
Do you get any headaches? HEADACHES CEA0I01
Intensity
0 = Absent
How long do the symptoms last?
How often over the last 3 months have you had a 2 = Headaches lasting at least one hour at
headache like that? least once per week for each week of the
primary period.
How ill are you?
Have you missed any school/work because of "sympotms"? CEA0F01

LY
When did the symptoms start? Frequency
What have you done about them?
What have your parents done about them?
How much do they affect your life?
What does your soctor say is wrong? HOURS : MINUTES CEA0D01
Duration
When was that?

N
What did you do about it?
What did your parents do?
Did you contact a doctor? MISSED SCHOOL OR WORK CEA0I02

O
What did s/he do?
0 = No school or work missed on account of
symptom.

EW 2 = At least 1 day of school or work missed.

PHYSICIAN CEA0I03
0 = No contact.

2 = Any medical contact related to

symptoms.

MEDICATION CEA0I04
VI

0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.

3 = Any prescribed medical/surgical

RE

treatment related to symptoms.

ALTERED LIFE PATTERN CEA0I05

0 = No effect on functioning.

2 = Some reduction in functioning.

CEA0O01
R

Onset

/ /
FO

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ABDOMINAL PAINS
Exclude menstrual cramps. ABDOMINAL PAINS (AT LEAST 1 HOUR) CEA1I01
Intensity
0 = Absent
Do you get any stomach aches?
2 = Abdominal pains lasting at least one
hour at least once per week for each week
How long do the symptoms last? of the primary period.
How often over the last 3 months have you had a stomach
ache like that? CEA1F01

LY
When did they start? Frequency

Have you missed any school/work because of "sympotms"?

How ill are you? HOURS : MINUTES CEA1D01

When did the symptoms start? Duration

N
What have you done about them?
How much do they affect your life?
What does your doctor say is wrong? MISSED SCHOOL OR WORK CEA1I02

O
When was that?
0 = No school or work missed on account of
What did you do about it? symptom.
What did your parents do?
Did you contact a doctor? 2 = At least 1 day of school or work missed.
What did s/he do?
EW PHYSICIAN

0 = No contact.
CEA1I03

2 = Any medical contact related to

symptoms.

MEDICATION CEA1I04
VI

0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.

3 = Any prescribed medical/surgical

RE

treatment related to symptoms.

ALTERED LIFE PATTERN CEA1I05

0 = No effect on functioning.

2 = Some reduction in functioning.

CEA1O01
R

Onset

/ /
FO

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ACHES AND PAINS

Aches and pains in muscles. ACHES AND PAINS CEE0I01
Intensity
0 = Absent
Do not include headaches or stomach aches, which are
coded separately, or aches and pains resulting only from 2 = Describes aches and pains as occurring
at least three times per week for each week
involvement in sports. of the primary period.

3 = Aches and pains almost constantly

Do you get a lot of aches and pains in your muscles or

LY
present.
joints?
CEE0O01
How often does this happen? Onset

Have you given up any activities because of aches and / /

N
pains?
AVOIDANCE CEE1I01
0 = Absent

O
2 = Subject has developed routines that
allow him/her to adopt a relatively normal
lifestyle while avoiding feared situation.

3 = Subject lives a highly restricted life

because of feared situations.
EW ACHES AND PAINS - AVOIDANCE
ONSET
CEE1O01

/ /

FEELS UNWELL
VI

A generalized feeling of illness or unwellness. FEELS UNWELL CEE2I01

Intensity
0 = Absent
Have you felt physically unwell at all during the last 3
months? 2 = Feeling physically less well than usual.
RE

3 = Feels physically unwell almost all of the

Less well than usual? time.

How much of the time? CEE2O01

Onset

/ /
R

SICKLY
The subject states that s/he has been sickly for a good part SICKLY CEA2I01
FO

of their life, including the last 3 months. Intensity

0 = Absent

How would you describe your health in general? 2 = Present

How long have you been ill?

Have you been "ill" for most of your life?
What has your health been like in the last 3 months?

Have you had frequent health problems?

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SOMATIZATION SCREEN POSITIVE

ASSOCIATED PHYSICAL COMPLAINTS FROM ONE SOMATIZATION SCREEN POSITIVE CEA3I01
BOUT OF ONE ILLNESS (I.E., COUGH, FEVER, CHILLS, Intensity
0 = No
RUNNY NOSE, SCRATCHY THROAT OCCURRING IN
ONE BOUT OF COLD OR FLU) COUNT AS ONE 2 = Yes
SYMPTOM FOR SCREEN. COUNT MULTIPLE
EPISODES OF COLD AND FLU AS ONE SYMPTOM.

LY
IF 3 OR MORE SYMPTOMS ARE MENTIONED BY THE
SUBJECT AS BEING PRESENT IN THE LAST 3 MONTHS
OR IF RATED AS SICKLY OR FEELS UNWELL,
COMPLETE THIS SECTION.

N
MENSTRUATION
IF CHILD IS FEMALE, ASK MENSTRUATION. SEX OF CHILD CEE1203
Intensity

O
0 = Male
Have you ever had a period?
2 = Female
When was her first period?
MENSTRUATION Ever:CEE3E01
Intensity
0 = No
EW 2 = Yes

Ever:CEE3O01
Onset

/ /
VI

Do you have regular periods every month? REGULAR ESTABLISHED CYCLE Ever:CEE3E02
0 = No
Have you had at least three monthly periods in a row?
2 = At least three months in a row.
What was the date of your last period?
RE

FIRST DAY OF LAST PERIOD Ever:CEE3O02

/ /
R
FO

5
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SOMATIZATION CHECK LIST

ALL CODINGS IN CHECK LIST ARE "EVER"

RATINGS FOR SUBJECT'S LIFETIME.

ONSET SHOULD BE RATED IF SYMPTOM

PRESENT, EVEN IF SYMPTOM DID NOT
RESULT IN MISSED SCHOOL/WORK,

LY
CONTACT WITH PHYSICIAN, MEDICATION, OR
ALTERED LIFE PATTERN.

N
O
EW
VI
RE
R
FO

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SYMPTOMS REFERRED TO THE NERVOUS

SYSTEM
DIFFICULTY SWALLOWING
Have you had any difficulty swallowing? DIFFICULTY SWALLOWING CEA4X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?

LY
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA4I01
When did it start? 0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

N
PHYSICIAN CEA4I02
0 = No contact.

O
2 = Any medical contact related to
symptoms.

MEDICATION CEA4I03
EW 0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA4I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEA4O01
Onset
RE

/ /
R
FO

7
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LOSS OF VOICE
Have you lost your voice? LOSS OF VOICE CEA5X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA5I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEA5I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEA5I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA5I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEA5O01
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DEAFNESS
Have you suffered from deafness? DEAFNESS CEA6X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA6I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEA6I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEA6I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA6I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEA6O01
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Definitions and questions Coding rules Codes

DOUBLE VISION
Have you suffered from double vision? DOUBLE VISION CEA7X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA7I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEA7I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEA7I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA7I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEA7O01
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Definitions and questions Coding rules Codes

BLURRED VISION
Have you suffered from blurred vision? BLURRED VISION CEA8X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA8I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEA8I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEA8I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA8I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEA8O01
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BLINDNESS
Have you gone blind? BLINDNESS CEA9X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEA9I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEA9I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEA9I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEA9I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEA9O01
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FAINTING OR LOSS OF CONSCIOUSNESS

Have you ever fainted? FAINTING OR LOSS OF CEB0X01
CONSCIOUSNESS Intensity
Or had any blackouts or loss of consciousness? 0 = Absent

Did you miss any school/work? 2 = Present

What happened about that?
MISSED SCHOOL OR WORK CEB0I01
Did you take anything for it?

LY
Dit it affect your life at all? 0 = No school or work missed on account of
When did it start? symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB0I02

N
0 = No contact.

2 = Any medical contact related to

symptoms.

O
MEDICATION CEB0I03
0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.
EW 3 = Any prescribed medical/surgical
treatment related to symptoms.

ALTERED LIFE PATTERN CEB0I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB0O01
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Definitions and questions Coding rules Codes

MEMORY LOSS
Have you ever lost your memory? MEMORY LOSS CEB1X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB1I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB1I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB1I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB1I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB1O01
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SEIZURES OR CONVULSIONS
Have you ever had any fits or convulsions? SEIZURES OR CONVULSIONS CEB2X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB2I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB2I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB2I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB2I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB2O01
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TROUBLE WALKING
Have you ever had trouble walking? TROUBLE WALKING CEB3X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB3I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB3I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB3I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB3I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB3O01
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PARALYSIS OR MUSCLE WEAKNESS

Have you ever had any muscle weakness or paralysis? PARALYSIS OR MUSCLE WEAKNESS CEB4X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB4I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB4I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB4I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB4I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB4O01
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URINARY RETENTION OR DIFFICULTY

URINATING
Have you ever had any trouble passing water? URINARY RETENTION OR DIFFICULTY CEB5X01
URINATING Intensity
Did you miss any school/work? 0 = Absent
What happened about that?
Did you take anything for it? 2 = Present
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB5I01

LY
When did it start?
0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB5I02

N
0 = No contact.

2 = Any medical contact related to

O
symptoms.

MEDICATION CEB5I03
0 = No treatment.
EW 2 = Any non-prescribed medical/surgical
treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB5I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEB5O01
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OTHER UNEXPLAINED "NEUROLOGICAL

SYMPTOMS"
Have you ever had any other symptoms affecting your OTHER UNEXPLAINED CEB6X01
nerves or brain? "NEUROLOGICAL SYMPTOMS" Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it? MISSED SCHOOL OR WORK CEB6I01

LY
Dit it affect your life at all?
When did it start? 0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB6I02

N
0 = No contact.

2 = Any medical contact related to

O
symptoms.

MEDICATION CEB6I03
0 = No treatment.
EW 2 = Any non-prescribed medical/surgical
treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB6I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEB6O01
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SYMPTOMS REFERRED TO THE

GASTROINTESTINAL TRACT
SENSATION OF A LUMP IN THE THROAT
Have you ever had a feeling of a lump in your throat? OTHER UNEXPLAINED CEB7X01
"NEUROLOGICAL SYMPTOMS" Intensity
Did you miss any school/work? 0 = Absent
What happened about that?
Did you take anything for it? 2 = Present

LY
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB7I01
When did it start?
0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

N
PHYSICIAN CEB7I02
0 = No contact.

O
2 = Any medical contact related to
symptoms.

MEDICATION CEB7I03
EW 0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB7I04

VI

0 = No effect on functioning.

2 = Some reduction in functioning.

CEB7O01
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ABDOMINAL PAIN
Have you had any stomach pains? ABDOMINAL PAIN CEB8X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB8I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB8I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB8I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB8I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB8O01
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NAUSEA
Have you ever felt sick? NAUSEA CEB9X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Dit it affect your life at all? MISSED SCHOOL OR WORK CEB9I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEB9I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEB9I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEB9I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEB9O01
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VOMITING SPELLS (OTHER THAN DURING

PREGNANCY)
Have you vomited at all? VOMITING SPELLS (OTHER THAN CEC0X01
DURING PREGNANCY) Intensity
Did you miss any school/work? 0 = Absent
What happened about that?
Did you take anything for it? 2 = Present
Dit it affect your life at all? MISSED SCHOOL OR WORK CEC0I01

LY
When did it start?
0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC0I02

N
0 = No contact.

2 = Any medical contact related to

O
symptoms.

MEDICATION CEC0I03
0 = No treatment.
EW 2 = Any non-prescribed medical/surgical
treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC0I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEC0O01
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Definitions and questions Coding rules Codes

BLOATING (GASSY)
Have you vomited at all? BLOATING (GASSY) CEC1X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC1I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC1I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEC1I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC1I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC1O01
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INTOLERANCE OF A VARIETY OF FOODS

Are you sensitive to certain foods? INTOLERANCE TO A VARIETY OF CEC2X01
FOODS Intensity
Did you miss any school/work? 0 = Absent
What happened about that?
Did you take anything for it? 2 = Present
Did it affect your life at all? MISSED SCHOOL OR WORK CEC2I01
When did it start?

LY
0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC2I02

N
0 = No contact.

2 = Any medical contact related to

symptoms.

O
MEDICATION CEC2I03
0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.
EW 3 = Any prescribed medical/surgical
treatment related to symptoms.

ALTERED LIFE PATTERN CEC2I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC2O01
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Definitions and questions Coding rules Codes

DIARRHEA
Have you had diarrhea? DIARRHEA CEC3X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC3I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC3I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEC3I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC3I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC3O01
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Definitions and questions Coding rules Codes

FEMALE REPRODUCTIVE SYSTEM

PAINFUL MENSTRUATION
Have your periods started? PAINFUL MENSTRUATION CEC4X01
Intensity
0 = Absent
Are they painful?
2 = Present
Did you miss any school/work?
What happened about that? MISSED SCHOOL OR WORK CEC4I01

LY
Did you take anything for it? 0 = No school or work missed on account of
Did it affect your life at all? symptom.
When did it start?
2 = At least 1 day of school or work missed.

PHYSICIAN CEC4I02

N
0 = No contact.

2 = Any medical contact related to

symptoms.

O
MEDICATION CEC4I03
0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC4I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEC4O01
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EXCESSIVE BLEEDING
Have your periods very heavy? EXCESSIVE BLEEDING CEC5X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC5I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC5I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEC5I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC5I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC5O01
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PAIN
BACK
Do you get any pains in any part of your body? BACK CEC6X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC6I01

LY
When did it start? 0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC6I02

N
0 = No contact.

2 = Any medical contact related to

symptoms.

O
MEDICATION CEC6I03
0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC6I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEC6O01
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JOINTS OR EXTREMITIES
Do you get any pains in your joints? JOINTS OR EXTREMITIES CEC7X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC7I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC7I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEC7I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC7I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC7O01
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GENITAL AREA (OTHER THAN DURING

INTERCOURSE)
Do you get any pains in your genital area? GENITAL AREA (OTHER THAN DURING CEC8X01
INTERCOURSE) Intensity
Did you miss any school/work? 0 = Absent
What happened about that?
Did you take anything for it? 2 = Present
Did it affect your life at all? MISSED SCHOOL OR WORK CEC8I01

LY
When did it start?
0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC8I02

N
0 = No contact.

2 = Any medical contact related to

O
symptoms.

MEDICATION CEC8I03
0 = No treatment.
EW 2 = Any non-prescribed medical/surgical
treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC8I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CEC8O01
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PAIN ON URINATION
Do you get any pains upon urination? PAIN ON URINATION CEC9X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CEC9I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CEC9I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CEC9I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CEC9I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CEC9O01
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HEADACHE
Do you get any headaches? HEADACHE CED0X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CED0I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CED0I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CED0I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED0I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CED0O01
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OTHER PAIN
Do you get any other pains? OTHER PAIN CED1X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CED1I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CED1I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CED1I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED1I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CED1O01
Onset

/ /
RE
R
FO

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SYMPTOMS REFERRED TO
CARDIOPULMONARY SYSTEM
SHORTNESS OF BREATH
Has your breathing been a problem? SHORTNESS OF BREATH CED2X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?

LY
Did it affect your life at all? MISSED SCHOOL OR WORK CED2I01
When did it start? 0 = No school or work missed on account of
symptom.

2 = At least 1 day of school or work missed.

N
PHYSICIAN CED2I02
0 = No contact.

O
2 = Any medical contact related to
symptoms.

MEDICATION CED2I03
EW 0 = No treatment.

2 = Any non-prescribed medical/surgical

treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED2I04

0 = No effect on functioning.
VI

2 = Some reduction in functioning.

CED2O01
Onset
RE

/ /
R
FO

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PALPITATIONS
Has your heart been a problem? PALPITATIONS CED3X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CED3I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CED3I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CED3I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED3I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CED3O01
Onset

/ /
RE
R
FO

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CHEST PAIN
Do you get any chest pain? CHEST PAINS CED4X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CED4I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CED4I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CED4I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED4I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CED4O01
Onset

/ /
RE
R
FO

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DIZZINESS
Do you get dizzy? DIZZINESS CED5X01
Intensity
0 = Absent
Did you miss any school/work?
What happened about that? 2 = Present
Did you take anything for it?
Did it affect your life at all? MISSED SCHOOL OR WORK CED5I01
When did it start? 0 = No school or work missed on account of

LY
symptom.

2 = At least 1 day of school or work missed.

PHYSICIAN CED5I02
0 = No contact.

N
2 = Any medical contact related to
symptoms.

CED5I03

O
MEDICATION

0 = No treatment.

2 = Any non-prescribed medical/surgical

EW treatment related to symptoms.

3 = Any prescribed medical/surgical

treatment related to symptoms.

ALTERED LIFE PATTERN CED5I04

0 = No effect on functioning.

2 = Some reduction in functioning.

VI

CED5O01
Onset

/ /
RE
R
FO

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FOOD RELATED BEHAVIOR

REDUCED APPETITE
Reduction of normal appetite, or reduced interest in, or REDUCED APPETITE CFA0I01
enthusiasm for, food. Include change in appetite due to Intensity
0 = Absent
substance use or side effects of medication.
2 = Food intake has been definitely reduced
below normal level because of lack of
How has your appetite been in the last 3 months? appetite for at least 1 week.

LY
Has it been less than usual? 3 = Subject can only be induced to eat by
marked parental or other persuasion.
Has the amount you eat changed at all?
CFA0O01
Have you been eating as much as usual? Onset
Why not?
How much have you been eating? / /

N
Have you lost any weight?
When did your appetite start to fall off?

O
WEIGHT LOSS
Have you lost an unusual amount of weight during the WEIGHT LOSS CFA1I01
last 3 months?
EW Intensity
0 = Absent

How much? 2 = Present

When did you start losing weight?
WEIGHT LOSS IN POUNDS CFA1X01

CFA1O01
VI

Onset

/ /
RE

EXCESSIVE APPETITE
An increase in appetite outside the normal range of the EXCESSIVE APPETITE CFA2I01
subject, including eating for comfort. Include change in Intensity
0 = Absent
appetite due to substance sue or side effects of medication.
2 = Food consumption has been definitely
increased above the subject's usual level
Have you had a bigger appetite than usual? for at least 1 week.
R

Why? CFA2O01
Have you actually eaten more than usual? Onset
FO

How much more? / /

When did you start eating more?

Food Related Behavior 1

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WEIGHT GAIN
Do not include normal developmental weight gain, WEIGHT GAIN CFA3I01
premenstrual weight gain, or weight gain because of Intensity
0 = Absent
pregnancy.
2 = Present
Have you put on an unusual amount of weight in the WEIGHT GAIN IN POUNDS CFA3X01
last 3 months?

LY
How much?
How long have you been putting on weight? CFA3O01
Onset

/ /

N
FOOD FADS
Child will consume only a restricted range of foods not FOOD FADS CFA4I01

O
typical of others of his/her developmental stage or social Intensity
0 = Absent
group.
2 = The subject eats only within the range
of his/her fads.
Do not include simple dislike of cabbage etc. EW 3 = Eating with others difficult because of
extreme fads.
Are you choosy about the foods you will eat?
CFA4O01
What sort of things won't you eat? Onset
Why is that?
What do you do about it? / /
Will you eat these things if you're pushed?
VI

When did you start to get choosy about the food you will
eat?
RE
R
FO

Food Related Behavior 2

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ANOREXIA/BULIMIA SCREEN
IF THERE IS EVIDENCE OF DIETING LASTING AT ANOREXIA/BULIMIA SCREEN POSITIVE CFA5I01
LEAST ONE WEEK, FEAR OF GETTING FAT, Intensity
0 = No
EXERCISING TO LOSE WEIGHT LASTING AT LEAST
ONE WEEK, OR PRIVATE BINGES, THEN COMPLETE 2 = Yes
SECTION.

Have you been on a diet in the last 3 months?

LY
How long did you stick to it?
Are you afraid of getting fat?

Do you ever have really severe eating binges on your

own?

N
Do you avoid foods that might make you fat?

O
Have you done any exercise to lose weight?

Have you done anything else to lose weight?

Do you think you need to lose weight? EW

Does your weight bother you at all?

IF ANOREXIA/BULIMIA SCREEN
POSITIVE CONTINUE, OTHERWISE,
VI

SKIP TO "SELF EVALUATION

DEPENDS ON SHAPE AND WEIGHT",
(PAGE 9).
RE
R
FO

Food Related Behavior 3

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DELIBERATE REDUCTION OF BODY WEIGHT

Deliberate attempts to reduce body weight by dieting or any DELIBERATE REDUCTION ATTEMPTS CFA6X01
other method, for any reason. PRESENT Intensity
0 = No
A "diet" refers to any attempt to reduce body weight by the
2 = Yes
deliberate restriction of caloric intake (no matter how feebly
adhered to), lasting at least 1 week. DIETING CFA6I01

LY
0 = No
"Exercise" refers to any physical activity undertaken for at
least 1 week with the specific intention of reducing body 2 = Yes
weight. Do not include items such as jogging for general
CFA6O01
health purposes, unless the subject also states that a Onset
supplementary aim is weight reduction.
/ /

N
Do not include diets or exercise regimens prescribed by
physician or other medical advisor, or parent. VOMITING CFA7I01

O
0 = No
How do you try to keep your weight down? 2 = Yes

Are you on a diet? VOMITING ONSET CFA7O01

/ /
What sort of diet?
Do you exercise to lose weight?
EW
EXERCISE CFA8I01
Do you ever vomit? 0 = No

Do you take any medicines or pills for your weight? 2 = Yes

EXERCISE ONSET CFA8O01

VI

When did you start doing that?

/ /
DRUGS USED TO REDUCE BODY CFA9I01
WEIGHT: PURGATIVES
RE

0 = No

2 = Yes

APPETITE SUPPRESSANTS CFA9I02

0 = No
R

2 = Yes

DIURETICS CFA9I03
FO

0 = No

2 = Yes

OTHER CFA9I04
0 = No

2 = Yes

CODE DATE OF FIRST DRUG USED CFA9O01

/ /

Food Related Behavior 4

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PREOCCUPATION WITH FOOD AND EATING

Unusual and excessive amount of time spent thinking or PREOCCUPATION WITH FOOD AND CFB0I01
worrying about food and eating; total daily duration of at EATING Intensity
least 1 hour. 0 = Absent

2 = Thoughts or worries about food or

How much do you think about food and eating? eating intrusive into at least 2 activities and
uncontrollable at least some of the time.

LY
What do you know about how fattening foods are?
3 = Thoughts or worries about food or
eating intrusive into most activities and
Do you worry about food?
nearly always uncontrollable.

How much? CFB0F01

Frequency

N
Why do you think (worry) about it?
How much time do you spend thinking about food or
eating?
How long have you been bothered about food and eating?

O
HOURS : MINUTES CFB0D01
Duration

CFB0O01
EW Onset

/ /

WORRY ABOUT BECOMING FAT

CFB1I01
VI

A round of painful, unpleasant or uncomfortable thoughts WORRY ABOUT BECOMING/BEING FAT

about becoming (or being) fat or obese; total daily duration Intensity
0 = Absent
of at least 1 hour.
2 = Worries about becoming fat are
intrusive into at least 2 activities and at
Do you think you are the right weight?
RE

least sometimes uncontrollable.

How much do you think you should weigh? 3 = Worries about becoming fat are
intrusive into most all activities and almost
always uncontrollable.
Do you worry about getting fat?
CFB1F01
How much do you worry about it? Frequency
Does worrying interfere with whatever else you're doing?
R

How long do you spend worrying about it?

When did you start worrying about it?
HOURS : MINUTES CFB1D01
Duration
FO

CFB1O01
Onset

/ /

Food Related Behavior 5

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BODY IMAGE DISTURBANCE

Child has unrealistic conviction that s/he is fatter than is the BODY IMAGE DISTURBANCE CFB2I01
case. Intensity
0 = Absent

Do not code fat people, who realistically report that they are 2 = The subject has a persistent unrealistic
view that s/he is fat but sometimes can be
fat, here. induced to agree that s/he may not be
overweight.
How do you see your body size?

LY
3 = The subject's belief in his/her fatness is
unshakeable.
Are you fatter than average?
CFB2O01
What do you think if I tell you that I think that you're actually Onset
thinner than average (really just right)?
/ /

N
When did you start to feel fat?
IF BODY IMAGE DISTURBANCE PRESENT OR IF CHILD
DENIES SERIOUSNESS OF LOW BODY CFB2I02
IS OBVIOUSLY THIN ASK THE FOLLOWING ITEM. WEIGHT

O
Do you think it is dangerous to be so thin? 0 = Absent

2 = Subject denies seriousness of current

low body weight.
EW
VI
RE
R
FO

Food Related Behavior 6

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BULIMIA (EATING BINGES)

Recurrent, discrete, secret, episodes of excessive, rapid EATING BINGES CFB3I01
eating of easily ingested food. Do not include snack Intensity
0 = Absent
"binges" (for instance on return from workout or sports)
where there is no attempt at secrecy, even though there 2 = Binges at least sometimes
may be no one else around. Do not include public displays uncontrollable.
of greed, or individuals who normally have large appetites. 3 = Binges almost always uncontrollable.

CFB3F01

LY
Does you have eating "binges" or attacks?
Frequency
What are they like?
What do you eat?
Do you go off on your own to eat? HOURS : MINUTES CFB3D01

N
Does anything trigger them? Duration
Do you try to resist them?
What ends a "binge"?
How do you feel afterwards?

O
CFB3O01
Do you feel miserable?
Onset
Do you feel bad about yourself?
Or guilty? / /
Or ashamed?
CFB4I01
How long do these "binges" last?
When did you start having "binges"?
EW EPISODE TERMINATED BY

0 = None

2 = Abdominal Pain.
CFB4I02
3 = Self-Induced Vomiting.

4 = Sleep
CFB4I03
VI

5 = Social Interruption.

CFB4I04
RE

DEPRESSED FOLLOWING BINGE CFB5I01

0 = No

2 = Yes
R

GUILT, SHAME AND/OR LOW SELF CFB5I02

ESTEEM

0 = No
FO

2 = Yes

IF SUBJECT IS A GIRL COMPLETE.

OTHERWISE, SKIP TO "SELF
EVALUATION DEPENDS ON SHAPE
AND WEIGHT", (PAGE 9).

Food Related Behavior 7

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LY
N
O
EW
VI
RE
R
FO

Food Related Behavior 8

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AMENORRHEA
Absence of periods for at least 3 months in a row after AMENORRHEA CFB6I01
onset of regular periods. Onset of regular periods means Intensity
0 = Absent (or female subject has not
that subject has had a period three times in a row, no more begun regular periods).
than 36 days apart.
2 = Present

Have your periods started? CFB6O01

Onset

LY
IF PERIODS HAVE STARTED, ASK ABOUT
AMENORRHEA. / /
Have they stopped again?

When did they stop?

N
SELF EVALUATION DEPENDS ON SHAPE AND

O
WEIGHT
The subject's evaluation of him/herself is reported to be SELF EVALUATION DEPENDS ON CFD0I01
strongly dependent on his/her shape or weight. Thus s/he SHAPE AND WEIGHT Intensity
regards his/her value as a person, evaluation by peers or
EW 0 = Absent
others as being heavily influenced by his/her shape or
weight. Do not include being underweight or 2 = The subject's self evaluation includes
body shape and/or weight as an important
underdeveloped. component.

3 = The subject's self evaluation is

Does your weight make a difference to how you feel overwhelmingly influenced by
about yourself? considerations of body shape or weight.
VI

How important is your weight or shape in affecting how CFD0O01

your feel about yourself? Onset
Is it the most important factor in the way you think about
yourself?
/ /
Do you think it affects how other people see you and
RE

what they think of you?

Would you feel better about yourself if you were

thinner?

Would it make a really big difference?

When did you start to feel like that about your weight or
R

shape?
FO

Food Related Behavior 9

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SLEEP PROBLEMS
Now I want to talk with you about X's sleep. I
want to understand what usually happens when
you put X to bed, what happens during the
night, and what it is like waking him/her up in
the morning. Tell me about what kind of sleeper
X is. Has s/he always been like that?
SLEEP PROBLEMS

LY
INSOMNIA
Disturbance of usual sleep pattern involving a reduction in INSOMNIA CFB7I01
actual sleep time during the subject's sleep period that is Intensity
0 = Absent
accompanied by a subjective feeling of a need for more
sleep. Do NOT include externally imposed changes in 2 = If the insomnia covers a period between

N
overall sleep pattern (e.g., change in job hours, arrival of 1 and 2 hours.
new baby), or insomnia during first 2 weeks following such 3 = If its duration is greater than or equal to
changes. Sleep problems are scored irrespective of taking 2 hours per night.

O
medication for them, but note whether medication is being
taken. Also include changes attributed to side effects of
medication or substance use.

How has your sleep been in the last 3 months?

What time do you go to bed?

EW
Is it hard to fall asleep when you want to?

How long does it take?

Is that every night? How often?
VI

Is there any reason for it (e.g. fear of the dark)?

Once you're off to sleep, do you wake up again in the
night?

Why is that?
RE

Can you get back to sleep again easily?

Do you wake up early in the morning and can't go back
to sleep?

Is that earlier than you need to?

Do you need more sleep?
How long have you been having sleep problems?
R

CODE FREQUENCY (NUMBER OF DAYS) AND ONSET CFB7F01

OF SYMPTOMS FOR INSOMNIA OVERALL (I.E. FOR Frequency
FO

INITIAL, MIDDLE, AND TERMINAL INSOMNIA

COMBINED).
CFB7O01
Onset

/ /

1
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DIFFICULTY GETTING TO SLEEP AT NIGHT LASTING INITIAL INSOMNIA CFB7I02

AT LEAST ONE HOUR. 0 = Absent

AT LEAST ONE HOUR AND UNABLE TO RETURN TO 2 = Present

SLEEP.
MIDDLE INSOMNIA (WAKING AT NIGHT CFB7I03
OTHER THAN FOR MICTURITION)

1 = Any middle insomnia under 1 hour

LY
2 = 1-2 hours of middle insomnia

3 = More than 2 hours of middle insomnia

EARLY MORNING WAKENING CFB7I04

(TERMINAL INSOMNIA)

N
0 = Absent

2 = Present

O
MEDICATION FOR INSOMNIA
NOTE HERE ANY MEDICATION (PRESCRIPTION OR MEDICATION FOR INSOMNIA CFB7I05
OVER THE COUNTER) SPECIFICALLY USED IN AN Intensity
0 = Absent
ATTEMPT TO IMPROVE SLEEP PATTERN. NOTE NAME
EW
OF DRUG. CODE PRESCRIPTIONS IN INCAPACITIES. 2 = Present

Do you take anything to help you sleep?

What?
Does it work?
VI
RE
R
FO

2
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HYPERSOMNIA - INCREASED NEED FOR

SLEEP
Total hours sleep exceed usual amount by at least one INCREASED NEED FOR SLEEP CFB8I01
hour, unless subject prevented from sleeping. Intensity
0 = Absent

Do you feel sleepy during the day? 2 = Hypersomnia occurs in at least 2

activities and is at least sometimes
uncontrollable.
More sleepy than usual?

LY
More than most other people? 3 = Hypersomnia occurs in nearly all
Do you sleep in the day? activities and is nearly always
uncontrollable.
For how long? CFB8F01
Frequency
How long have you been more sleepy than usual?

N
HOURS : MINUTES CFB8D01

O
Duration

CFB8O01
Onset
EW / /

RESTLESS SLEEP
Sleep is described as restless. RESTLESS SLEEP CFD1I01
Intensity
VI

0 = Absent
How would you describe an average night's sleep?
2 = Present
Do you sleep soundly? CFD1O01
Do you toss and turn? Onset
RE

Are you restless?

/ /

INADEQUATELY RESTED BY SLEEP

Sleep disturbance does not meet criteria for insomnia, but INADEQUATELY RESTED BY SLEEP CFD2I01
R

subject describes being inadequately rested by sleep upon Intensity

0 = Absent
waking.
2 = Present
FO

Do you usually get a good night's sleep? CFD2O01

Onset
Are you fairly well rested when you get up?
/ /
Or after sleeping during the day?

How do you feel?

When did that start?

3
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NIGHTMARES
Frightening dreams that waken the child with a markedly NIGHTMARES CFB9I01
unpleasant affect on wakening (which may be followed Intensity
0 = Absent
rapidly by feelings of relief).
2 = Bad dreams have woken the subject in
the last 3 months.
IF NIGHTMARES ARE ASSOCIATED WITH
SEPARATION ANXIETY, CODE THEM MORE CFB9F01
SPECIFICALLY AS SEPARATION DREAMS. Frequency

LY
IF NIGHTMARES ARE ASSOCIATED WITH TRAUMATIC
EVENTS, AND MEET CRITERIA FOR CODINGS, CODE CFB9O01
THEM HERE AND THERE ALSO. Onset

/ /

N
Do you have any bad dreams or nightmares?

Do they wake you up?

O
What are they about?
What are they like?
How often?
When did the nightmares start?

TIREDNESS
EW
A feeling of being tired or weary at least half the time. TIREDNESS CFD3I01
Intensity
0 = Absent
Have you been feeling especially tired or weary?
2 = Feels tired at least half of the time.
VI

How much of the time have you felt tired like that? 3 = Feels tired almost all of the time.

CFD3O01
Onset

/ /
RE

FATIGABILITY
Child becomes tired or "worn out" more easily than usual. FATIGABILITY CFD4I01
Intensity
0 = Absent
Have you become tired or "worn out" more easily than
R

usual? 2 = Increased fatigability not meeting

criteria for 3.
Do you feel exhausted even by things that would have 3 = Even minimal physical activity rapidly
FO

been no problem before? results in subject feeling exhausted, and

recovery from that exhaustion is slow.
When you get tired like that, does it take a long time to get
CFD4O01
over it? Onset
Is that more than usual for you?
/ /

4
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ELIMINATION DISORDERS
ELIMINATION DISORDERS
NOCTURNAL ENURESIS
Urine passed involuntarily in bed or underwear. NOCTURNAL ENURESIS Ever:CFC0I01
Intensity
0 = Absent
Do not include episodes of wetting directly and exclusively
associated with marked physical illness, or wetting that is 2 = Any episode of nocturnal enuresis that
involves the involuntary passage of a

LY
directly and exclusively associated with lack of toilet substantial amount of urine (i.e. excluding
facilities. minor dampness associated with careless
hygiene or with sever sneezing/laughing).
Have you ever wet your bed? PREVIOUS PERIOD OF ONE YEAR'S CFC0I02
NOCTURNAL CONTINENCE Intensity
Has this happened recently?

N
When was the last time that it happened? 0 = Absent

2 = Present

O
MONTHS OF AGE WHEN LAST WET PRECEDING 1 AGE OF FIRST NOCTURNAL CFC0I03
YEAR'S CONTINENCE CONTINENCE

EW NOCTURNAL ENURESIS CFC0F01

CFC0O01
Onset

/ /
VI

DIURNAL ENURESIS
How about wetting your pants in the daytime? DIURNAL ENURESIS CFC1I01
Intensity
0 = Absent
What happens?
RE

How often does that happen? 2 = Any episode of diurnal enuresis meeting
IF WET IN THE LAST THREE MONTHS, ASK: criteria as for nocturnal enuresis.

PREVIOUS PERIOD OF ONE YEAR'S CFC1I02

When you were younger, were you ever dry for as long as DIURNAL CONTINENCE
a year?
When did you start wetting again? 0 = Absent
R

2 = Present
FO

Elimination Disorders 1
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MONTHS OF AGE WHEN LAST WET PRECEDING 1 AGE OF FIRST DIURNAL CONTINENCE CFC1I03
YEAR'S CONTINENCE

CFC1F01
Frequency

CFC1O01

LY
Onset

/ /

N
ENCOPRESIS
The passage of stool in inappropriate places. ENCOPRESIS CFC2I01
Intensity
0 = Absent

O
Have you ever messed your pants?
1 = Underwear is occasionally severely
stained with feces but no actual lumps of
What happens? motion
ESTABLISH THAT BOWEL, NOT URINARY, FUNCTION
IS BEING ASKED ABOUT. 3 = Stools selectively deposited, with

How did that happen?

EW apparent control, in clearly inappropriate
places (such as in the piano or a drawer)
How many times has that happened? CFC2F01
Where does it happen? Frequency
What are your "motions" like?
Formed or loose?
Can you control your "motions"?
CFC2O01
VI

Have you ever made a mess somewhere that wasn't in a

Onset
toilet?
Where? / /
What happened?
Have you ever smeared your "motions"? MEDICAL REASON FOR SYMPTOM CFC2I02
RE

QUESTION TO DETERMINE WHETHER THE CHILD

0 = Absent
HAS, OR HAS EVER HAD, VOLUNTARY CONTROL
OVER DEFECATION 2 = Present

When did you start to mess your pants again? CONSISTENCY OF STOOL CFC2I03
2 = Loose/slimy/unformed
R

3 = Formed

PRIMARY/SECONDARY CFC2I04
FO

2 = Previous period of bowel control lasting

6 months or longer

3 = No previous periods of bowel control

SMEARING CFC2I05
2 = No smearing

3 = Stools deliberately smeared on self or

walls or other objects (include anal
masturbation here)

Elimination Disorders 2
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CONSTIPATION
Frequency of passage of motion reduced by at least one CONSTIPATION CFC3I01
third, compared with subject's usual state, lasting for at Intensity
0 = No constipation
least 1 week.
2 = Reduced frequency but normal
consistency
Do you have any problems with constipation - I mean
not being able to pass a motion? 3 = Reduced frequency of motions
unusually hard in consistency

LY
MAKE SURE THE SUBJECT IS CLEAR THAT YOU ARE
CFC3O01
ASKING ABOUT BOWEL HABITS, NOT MICTURITION. Onset
How often do you "pass a motion"? / /
Has that changed?
Is it hard to go when you do? CFC3I02

N
MEDICAL REASON FOR SYMPTOM
Is it painful?
0 = Absent
When did you start to get "constipated?"
2 = Present

O
EW
VI
RE
R
FO

Elimination Disorders 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

TICS AND TRICHOTILLOMANIA

Tics are sudden, rapid, stereotyped, repetitive,
non-rhythmic, predictable, purposeless,
coordinated contractions of functionally related
muscle groups. They can usually be
suppressed voluntarily for a time and can
usually be imitated. To be coded at all, tics
should have occurred at least 10 times each
day for at least a week during the past three

LY
months.
TRICOTILLOMANIA
Recurrent pulling out of one's own hair, resulting in 0 = Absent CFC4I01
noticeable hair loss from scalp, eyebrows, eyelashes, Intensity
1 = No obvious hair loss.
and/or beard.

N
2 = Noticeable but partial hair loss.

Do not include hair loss because of radiation therapy. 3 = Most or all hair on scalp is missing.

O
CFC4O01
Do you ever pull your hair out? Onset
Do you pull out hair from your head, face, eyebrows, or / /
eyelashes? EW TENSION BEFORE PULLING HAIR OUT CFC4I02
What do you feel like when you do it?
0 = Absent
Do you feel tense just before you do that?
Do you feel better after you do it? 2 = Subject experiences a building sense of
Can you stop yourself from doing it? tension prior to hair pulling
Have you pulled out so much that other people have
RELIEF AFTER PULLING HAIR OUT CFC4I03
noticed
VI

Have you done it in the past 3 months? 0 = Absent

When did you first start doing it?
2 = Subject experiences a relief of tension
as a result of hair pulling
RE
R
FO

Tics 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

REPORTED MOTOR TICS

Tics are sudden, rapid, stereotyped, repetitive, non- REPORTED MOTOR TICS CFC5I01
rhythmic, predictable, purposeless, coordinated Intensity
0 = Absent
contractions of functionally related muscle groups. They
can usually be suppressed voluntarily for a time and can 2 = Single motor tics.
usually be imitated. 3 = More than one type of tic.

To be coded at all, tics should have occurred at least 10 FREQUENCY PER HOUR CFC5F01

LY
times each day for at least a week during the past three 1 = Less than 10 per hour.
months.
2 = More than 10 per hour.

Do you have any twitches, like winking, that people 3 = More than 100 per hour.
notice?
CFC5D01

N
What do you do? Frequency
Can you show me?
How often does that happen?

O
Can you stop yourself? CFC5O01
When did that start? Onset

EW / /

REPORTED PHONIC TICS

Phonic tics are sudden, rapid, stereotyped, repetitive, REPORTED PHONIC TICS CFC6I01
predictable, purposeless, phonic productions. Intensity
0 = Absent

To be coded at all, tics should have occurred at least 10 2 = Single phonic tic type.
VI

times each day for at least a week during the past three 3 = More than one type of tic (includes
months. coprolalia)

FREQUENCY PER HOUR CFC6F01

Do you often make strange noises like grunting or
RE

screeching? 1 = Less than 10 per hour.

2 = More than 10 per hour.

How often?
What sort of noises? 3 = More than 100 per hour.
When did that start?
CFC6D01
Frequency
R

CFC6O01
FO

Onset

/ /

Tics 2
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

COPROLALIA
A complex phonic tic resulting in the uttering of obscenities. COPROLALIA CFC7I01
Intensity
0 = Absent
Do you sometimes utter swear words, or dirty words in
that way? 2 = Present

CFC7O01
Can you show me what you do? Onset
When did that start?
/ /

LY
N
O
EW
VI
RE
R
FO

Tics 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OPPOSITIONAL/CONDUCT DISORDER
SECTION
OPPOSITIONAL BEHAVIOR

REMEMBER TO GET EXAMPLES AND

BEHAVIORAL DESCRIPTIONS

RULE BREAKING

LY
Violation of standing rules at school/college/university or RULE BREAKING CGA0I01
elsewhere but NOT at home. Intensity
0 = Absent

N.B. "Rule-breaking" at home is rated as disobedience 2 = The child breaks rules relating to at
least 2 activities, and at least sometimes
since families do not have formal rules.

N
responds to admonition by public failure to
comply.
Do not include breaking laws or violating parole. 3 = If rule breaking occurs in most activities
and the child sometimes responds to

O
How good are you at obeying the rules at school? admonition by disputing or challenging the
authority of the person admonishing
him/her
What happens if you don't?
CGA0F01
What sort of rules do you break? Frequency

Do you break the rules anywhere else?

EW
Tell me about the last time it happened. PGA0F02 CGA0F02
Do you get into trouble?

How often do you break the rules?

CGA0X01
VI

SOLITARY/ACCOMPANIED
When did you start breaking rules?
Do you do it on your own or with other people? 0 = Solitary

2 = Often accompanied (25-49% of the

time).
RE

3 = Accompanied 50% or more of the time.

CGA0O01
Onset

/ /
R
FO

Conduct Problems 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DISOBEDIENCE
Failure to carry out specific instructions when directly given. DISOBEDIENCE CGA1I01
Intensity
0 = Absent
What happens when you're told to do things by your
parents and you don't want to do them? 2 = Disobedience occurs in at least 2
activities, and child is at least sometimes
unresponsive to admonition.
What about with teachers?
3 = Disobedience may occur in most

LY
Are you disobedient anywhere (else)? activities and the child sometimes responds
to admonition by disputing or challenging
the authority of the person admonishing
When was the last time? him/her.
What happened?
Can they usually get you to do what they want in the end? HOME CGA1F01
How do they do it? Home

N
How long have you been like that? Frequency
How often do you disobey?
When did you start doing that?

O
DAYCARE/SCHOOL CGA1F02
Daycare/School
Frequency
EW ELSEWHERE CGA1F03
Elsewhere
Frequency

SOLITARY/ACCOMPANIED CGA1X01
VI

0 = Solitary

2 = Often accompanied (25-49% of the

time).
RE

3 = Accompanied 50% or more of the time.

CGA1O01
Onset

/ /
R
FO

Conduct Problems 2
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BREAKING CURFEW
Staying out late despite parental prohibitions. Do not BREAKING CURFEW CGJ1I01
include accidental lateness caused by circumstances over Intensity
0 = No
which the subject had little or no control.
2 = Yes
Do not include breaking curfew imposed by CGJ1F01
probation/parole, which is coded as probation/parole Frequency
violation.

LY
Do you have a curfew?
CGJ1O01
Onset
How good are you at keeping it?
/ /

N
Do you ever get in later than you are supposed to?

What happens then?

When did you start staying out late?

O
Did you get into trouble over it?

EW
VI
RE
R
FO

Conduct Problems 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ANNOYING BEHAVIOR
Indulgence in active behaviors that annoy or anger peers, ANNOYING BEHAVIOR CGA2I01
siblings, or other adults. The child's intention need not be to Intensity
0 = Absent
annoy, but the behaviors would obviously annoy their
recipient. 2 = Annoying behavior occurs in at least 2
activities and subject is at least sometimes
unresponsive to admonition.
Do not include annoying behaviors that are the result of
unintentional acts, for instance, annoyance caused by 3 = Annoying behavior occurs in most

LY
activities and the subject sometimes
clumsiness, or failure to understand the rules of games. responds to admonition by disputing or
challenging the authority of the person
Do not include behaviors that conform to the definitions of admonishing him/her.
Rule Breaking and Disobedience. HOME CGA2F01
Home

N
Do you find that other people get annoyed by things Frequency
you do?

O
Like what?
D you ever do things deliberately to annoy other DAYCARE/SCHOOL CGA2F02
Daycare/School
people? Frequency
Or do you find that other people get annoyed because
EW
of the things you do for fun?
ELSEWHERE CGA2F03
What happens? Elsewhere
Can you tell me about the last time? Frequency
Where do you do those sorts of things?
How often does something like that happen?
When did it start?
SOLITARY/ACCOMPANIED CGA2X01
VI

0 = Solitary

2 = Often accompanied (25-49% of the

time).
RE

3 = Accompanied 50% or more of the time.

CGA2O01
Onset

/ /
R
FO

Conduct Problems 4
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SPITEFUL OR VINDICTIVE
Spiteful: The child engages in deliberate actions aimed at SPITEFUL OR VINDICTIVE CGA3I01
causing distress to another person. Intensity
0 = Absent

Vindictive: The child responds to failure to get his/her own 2 = Present

way, disappointment, or interpersonal disagreement with HOME CGA3F01
adults or peers with deliberate attempts to hurt the other or Home
gain revenge. For instance, by pinching, pushing or Frequency

LY
attempting to get the other person into trouble.

Do not include behaviors coded under Assault, Cruelty, DAYCARE/SCHOOL CGA3F02

Bullying, Lying, or Malicious Rumors. Daycare/School
Frequency

N
Do you ever do things to upset other people on
purpose?
ELSEWHERE CGA3F03

O
Or try to hurt them on purpose?
Elsewhere
Do you ever try to get other people into trouble on Frequency
purpose?

What do you do?

What about during the last 3 months?
EW CGA3O01
Onset
Why do you do it?
How often has that happened? / /
Where does that sort of thing happen?
Who have you done it to? DIRECTED AGAINST SIBLINGS CGA3X01
What about with adults? 0 = Absent
VI

When did you start doing that sort of thing?

2 = Present

DIRECTED AGAINST PEERS CGA3X02

0 = Absent
RE

2 = Present

DIRECTED AGAINST ADULTS CGA3X03

0 = Absent

2 = Present
R
FO

Conduct Problems 5
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SWEARING
The use of swear words or obscene language not approved SWEARING CGA4I01
or countenanced by adults in whose presence they are Intensity
0 = Absent
spoken.
2 = Swears in presence of adults, but
usually (>50% of time) stops when
Do not include swearing among peers when adults are not admonished.
present, or with adults who are tolerant of swearing (i.e., do
not object to their child's swearing). 3 = Swearing in the presence of adults, that

LY
is not controlled by admonition.

Do you ever swear when adults are around?

When does that happen?

Where do you do it?

N
How often?
Do they tell not to?
What do you do then?
When did you start swearing in front of adults?

O
CODE NUMBER OF EPISODES OF SWEARING (NOT HOME CGA4F01
NUMBER OF INDIVIDUAL OBSCENE WORDS) Home
EW Frequency

DAYCARE/SCHOOL CGA4F02
Daycare/School
Frequency
VI

ELSEWHERE CGA4F03
Elsewhere
Frequency
RE

CGA4O01
Onset

/ /
R
FO

Conduct Problems 6
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

STEALING

Taking something belonging to another with

the intention of depriving the owner of its use.

Do not include items intended eventually for

general distribution that will include the subject
(such as general food from the refrigerator or

LY
school erasers).

STEALING - HIGHEST VALUE OF ITEMS

STOLEN IN SINGLE EPISODE
Taking something belonging to another with the intention of HIGHEST VALUE OF ITEMS STOLEN IN Ever:CGA5E01

N
depriving the owner of its use. SINGLE EPISODE Intensity
0 = Has not stolen anything.
Do not include items intended eventually for general

O
1 = less than $5.
distribution that will include the subject (such as general
food from the refrigerator or school eraser.) 2 = $5 - $99.

3 = Equal to or greater than $100.

Have you ever stolen anything?
Ever:CGA5V01
Have you stolen anything in the last 3 months?
EW Frequency

Have you ever broken into anywhere?

Have you ever taken a car or motorbike?

How often?
VI

What did you steal?

Who did you steal it from?
Did you steal on your own or wtih anyone else?
Why did you do it?
How often have you stolen anything in the last 3 months?
RE

When was the frist time you stole anything?

What is the most you have ever stolen at one time?

How much is that worth?

How many times have you ever stolen something?

R

IF THERE IS EVIDENCE OF STEALING

FO

IN THE PAST 3 MONTHS, COMPLETE.

OTHERWISE, SKIP TO "BREAKING
PROMISES", (PAGE 16).

Conduct Problems 7
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

STEALING AT HOME OR FROM FAMILY

Have you stolen anything at home or from family? STEALING AT HOME OR FROM FAMILY CGA6X01
Intensity
0 = No
Who did you steal it from?
What did you steal? 2 = Yes
Did you steal on your own or with anyone else?
STEALING ITEMS NOT AVAILABLE FOR CGA6I01
GENERAL USE BUT NOT AIMED
How often have you stolen anything from home or family in AGAINST A PARTICULAR PERSON

LY
the last 3 months?
0 = No
When was the first time you stole anything form home or
2 = Yes
from family?
STEALING DIRECTED SPECIFICALLY CGA6I02
AGAINST A PARTICULAR PERSON OR

N
PERSONS

0 = No

O
2 = Yes

CGA6F01
Frequency
EW CGA6O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 8
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

STEALING AT SCHOOL
Have you stolen anything from school in the last 3 STEALING AT SCHOOL CGA7X01
months? Intensity
0 = No

What did you steal? 2 = Yes

Who did you steal it from?
Did you steal on your own or with anyone else? STEALING ITEMS NOT AVAILABLE FOR CGA7I01
A GENERAL USE BUT NOT AIMED
Why did you do it? AGAINST A PARTICULAR PERSON

LY
How often have you stolen anything in the last 3 months? 0 = No

2 = Yes
When was the first time you stole anything from
school/work? STEALING DIRECTED SPECIFICALLY CGA7I02
AGAINST A PARTICULAR PERSON OR

N
PERSON

0 = No

O
2 = Yes

CGA7F01
Frequency
EW CGA7O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 9
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

STEALING ELSEWHERE
Have you stolen anything elsewhere in the last 3 months? STEALING ELSEWHERE CGA8X01
What did you steal? Intensity
0 = No
Who did you steal it from?
Did you steal on your own or with anyone else? 2 = Yes
Why did you do it?
STEALING ITEMS NOT AVAILABLE FOR CGA8I01
GENERAL USE BUT NOT AIMED
How often have you stolen anything in the last 3 months AGAINST A PARTICULAR PERSON

LY
besides at home, school, or work?
0 = No
When was the first time you stole anything outside home, 2 = Yes
school or work?
STEALING DIRECTED SPECIFICALLY CGA8I02
AGAINST A PARTICULAR PERSON OR

N
PERSONS

0 = No

O
2 = Yes

CGA8F01
Frequency
EW CGA8O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 10
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PATTERNS OF STEALING
Note: Shoplifting- Stealing, alone or in company, from a STEALING IN PRIMARY PERIOD CGA9X01
shop that is open for business. The act is covert and does Intensity
0 = Absent
not involve confrontation with the shop staff or members of
the public. Detection may provoke a confrontation, but the 2 = Present
intention is to avoid it.
STEALING ALONE CGA9I01

Were you on your own or with anybody else? 0 = Absent

LY
2 = Present
Did anyone find out?
STEALING WITH ONE OTHER CGA9I02
What did they do?
0 = Absent
What happened as a result?

N
2 = Present
Have you stolen anything else?
STEALING IN A GROUP CGA9I03
Or taken anything from a store?
0 = Absent

O
What did you do? 2 = Less than 50% of the time.

3 = More than 50% of the time.

SHOPLIFTING CGA9I04
EW 0 = Absent

2 = Present

PATTERNS OF STEALING - BREAKING AND

ENTERING
VI

Breaking and entering: Includes breaking into a house, BREAKING AND ENTERING CGB0I01
building, store to steal. Code breaking into a car separately. Intensity
0 = Absent

Have you broken into anywhere in the last three 2 = Present

RE

months? EVER: BREAKING AND ENTERING Ever:CGB0E01

Intensity
Have you ever broken into anywhere? 0 = Absent

2 = Present
What about breaking into a car?
Ever:CGB1V01
How many times have you ever broken into anywhere? Frequency
R

When was the first time you broke into anywhere?

CGB1O01
FO

Onset

/ /

Conduct Problems 11
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PATTERNS OF STEALING - BREAKING INTO A

CAR
Breaking into a car to steal. BREAKING INTO A CAR CGB2I01
Intensity
0 = Absent
Have you broken into a car to steal something?
2 = Present
Have you ever broken into a car to steal something? EVER: BREAKING INTO A CAR Ever:CGB2E01
Intensity

LY
How many times have you ever broken into a car? 0 = No

When was the first time you broke into a car to steal? 2 = Yes

Ever:CGB3V01
Frequency

N
CGB3O01
Onset

O
/ /

PATTERNS OF STEALING - STEALING MOTOR

VEHICLE OR TAKING AND DRIVING AWAY
EW
Includes attempts to steal a motor vehicle; also occasions STEALING MOTOR VEHICLE OR CGB4I01
when subject takes and drives away a car/motorcycle, even TAKING AND DRIVING AWAY Intensity
if s/he does not intend to steal it but rather to use it for 0 = Absent
his/her own purposes in an unauthorized way (e.g. joy
rides). 2 = Present
VI

EVER: STEALING MOTOR VEHICLE OR Ever:CGB4E01

Have you broken into a car to steal something? TAKING AND DRIVING AWAY Intensity
0 = Absent
Have you ever taken a car or motor-bike?
RE

2 = Present
What did you do?
Did anyone find out? Ever:CGB5V01
What did they do? Frequency

CGB5O01
R

Onset

/ /
FO

Conduct Problems 12
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PATTERNS OF STEALING - STEALING

INVOLVING CONFRONTATION OF THE VICTIM,
BUT WITHOUT ACTUAL VIOLENCE
The victim is directly confronted and money or goods are STEALING INVOLVING CGB6I01
demanded, threats may be made directly or implicitly (e.g. CONFRONTATION OF THE VICTIM, BUT Intensity
WITHOUT ACTUAL VIOLENCE
by the presence of a weapon), but no actual violence is
done. 0 = Absent

2 = Present

LY
Have you threatened anyone to make them give you
something? EVER: STEALING INVOLVING Ever:CGB6E01
CONFRONTATION OF THE VICTIM Intensity
WITHOUT ACTUAL VIOLENCE
Have you ever threatend anyone to make them give
you something? 0 = Absent

N
How many times have you ever threatened anyone to 2 = Present
make them give you something? Ever:CGJ0V01
Frequency

O
PATTERNS OF STEALING - STEALING
INVOLVING ACTUAL VIOLENCE
EW
The victim is directly confronted or set upon in some way STEALING INVOLVING ACTUAL CGB6I02
and some violent action actually takes place. For instance, VIOLENCE Intensity
the victim might be kicked or punched. 0 = Absent

2 = No physical injury to the victim.

Have you mugged anyone?
VI

3 = Some physical injury (e.g. black eye,

Did you hurt him/her? cuts)
How much?
EVER: STEALING INVOLVING ACTUAL Ever:CGB6E02
VIOLENCE Intensity
Have you ever mugged anyone?
RE

0 = Absent
How many times have you ever mugged someone?
2 = Present
When was the first time? Ever:CGB7V01
Frequency
R

CGB7O01
Onset
FO

/ /

Conduct Problems 13
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PATTERN OF STEALING - STEALING

INVOLVING VIOLENCE RESULTING IN
SERIOUS INJURY
As a result of violence committed during stealing, the victim STEALING INVOLVING VIOLENCE CGB8I01
sustained broken limbs, or required hospitalization, or was RESULTING IN SERIOUS INJURY Intensity
unconscious for any period. 0 = Absent

2 = Present
Have you mugged anyone and caused serious injury?

LY
EVER: STEALING INVOLVING Ever:CGB8E01
Have you ever mugged anyone and caused serious VIOLENCE RESULTING IN SERIOUS Intensity
injury? INJURY

0 = Absent
How often have you mugged someone and caused serious
injury? 2 = Present

N
When was the first time you seriously injured someone in a Ever:CGB9V01
Frequency
mugging situation?

O
CGB9O01
Onset

/ /
EW
PATTERNS OF STEALING - USE OF WEAPON
Use of any item that could be used to threaten or intimidate USE OF WEAPON CGC0I01
a victim. Include carrying a weapon even if it is concealed Intensity
0 = Absent
VI

and not used.

2 = Carried weapon while stealing.
Have you carried a weapon when you stole something? 3 = Used weapon to threaten victim.

What? EVER: USE OF WEAPON Ever:CGC0E01

RE

Did you use it? Intensity

0 = Absent

Have you ever carried a weapon when you stole 2 = Carried weapon while stealing.
something?
3 = Used weapon to threaten victim.
How many times have you ever carried a weapon when Ever:CGC1V01
you stole something? Frequency
R

When was the first time you carried a weapon to steal?

CGC1O01
FO

Onset

/ /

Conduct Problems 14
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OUTCOME OF STEALING
IF SUSPENDED OR EXPELLED FROM SCHOOL OUTCOME OF STEALING CGC2X01
BECAUSE OF STEALING, CODE HERE AND UNDER Intensity
0 = Absent
SCHOOL SUSPENSION, IN -SCHOOL SUSPENSION OR
SCHOOL EXPULSION. 2 = Present

ACTIVITIES WITH PEERS RESTRICTED CGC2I01

CODE POLICE INVOLVEMENT UNDER POLICE
CONTACT. 0 = Absent

LY
2 = Present
Did you get caught at all in the last 3 months?
ACTIVITIES WITH ADULTS RESTRICTED CGC2I02
What happened? 0 = Absent
Did you get punished?

N
Were the police involved? 2 = Present

OTHER PUNISHMENT BY FAMILY OR CGC2I03

What happened? OTHERS

O
0 = Absent

2 = Present

BANNED FROM PREMISES OR CGC2I04

ORGANIZATIONS/SUSPENDED OR
EW EXPELLED FROM
SCHOOL/COLLEGE/UNIVERSITY

0 = Absent

2 = Present
VI
RE
R
FO

Conduct Problems 15
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BREAKING PROMISES
Failure to carry out actions for which a direct commitment BREAKING PROMISES CGJ2I01
has been given to another person. Do not include behavior Intensity
0 = No
that meets criteria for lying.
2 = Yes
How good are you at keeping promises? HOME CGJ2F01
Home
Have you broken any promises in the last 3 months? Frequency

LY
What happened?
What did you do?
Have you broken any promises to "parental figures" or DAYCARE/SCHOOL CGJ2F02
"siblings"? Daycare/School
What about at school? Frequency

N
Have you broken any promises to anyone else?

ELSEWHERE CGJ2F03

O
Elsewhere
Frequency

EW CGJ2O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 16
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DECEPTION
LYING
Distortion of the truth with intent to deceive others. LYING CGC3I01
Intensity
0 = Absent
Most people tell lies sometimes. What sort of lies have
you told in the last 3 months? 2 = Lies told for gain, or to get out of school
attendance etc., or to escape school
punishment, in at least 2 activities that do
What about?

LY
not result in others getting into trouble.
Who to?
Where? HOME CGC3F01
Why did you do it? Home
Was it to get out of trouble? Frequency
Where do you tell lies?

N
How often do you tell lies?
When did you start telling lies? DAYCARE/SCHOOL CGC3F02
Did you ever tell lies to get out of things you don't want Daycare/School

O
to do? Frequency

What happens when your caught doing something

wrong?
ELSEWHERE CGC3F03
Elsewhere
admit it?
EW
When something goes wrong that's your fault, do you
Frequency

CGC3O01
Onset

/ /
VI

SOLITARY/ACCOMPANIED CGC3X01
0 = Solitary
RE

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

R
FO

Conduct Problems 17
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BLAMING
Do you lie if you think you can get out of trouble by BLAMING CGJ3I01
blaming someone else? Intensity
0 = Absent

Do your lies get others into trouble? 2 = Lies in at least 2 activities, that result in
others being blamed for subject's
Could they? misdemeanors or otherwise getting into
trouble or lies which, if believed, would
What do you do? have the same result.

LY
What is the result?
How often do you do this? HOME CGJ3F01
When did you start doing it? Home
Frequency

N
DAYCARE/SCHOOL CGJ3F02
Daycare/School
Frequency

O
ELSEWHERE CGJ3F03
EW Elsewhere
Frequency

CGJ3O01
Onset

/ /
VI

SOLITARY/ACCOMPANIED CGJ3X01
0 = Solitary

2 = Often accompanied (25-49% of the

RE

time).

3 = Accompanied 50% or more of the time.

R
FO

Conduct Problems 18
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PSEUDOLOGIA
Distortion of truth with intent to deceive others, with a PSEUDOLOGIA CGJ4I01
fantastical quality in which no immediate gain is apparent Intensity
0 = Absent
beyond self aggrandizement.
2 = Fantastic lies told in at least 2 settings
and at least sometimes uncontrollable.
Do you ever make up stories about yourself?
3 = Fantastic lies told in most settings and
Or pretend to be someone you're not? nearly always uncontrollable.

LY
Or something you're not? HOME CGJ4F01
Home
Frequency
What do you say?
How often do you do that?
Who do you do it with?

N
Has that happened in the last 3 months? DAYCARE/SCHOOL CGJ4F02
When did you start doing it? Daycare/School
Frequency

O
ELSEWHERE CGJ4F03
Elsewhere
Frequency
EW
CGJ4O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 19
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CON-ARTISTRY
Lying in order to obtain goods or favors with a monetary CON-ARTISTRY CGC4I01
value of at least $10. Intensity
0 = Absent

Have you ever tried to con anyone to get them to give 2 = Simple lies.
you something? 3 = "Scam" involving at least some planning
to develop and implement scheme.
Or to do you a favor?
CGC4F01

LY
Or tried to trick them to get money or something else? Frequency
What happened?

CGC4O01

N
Onset

/ /

O
SOLITARY/ACCOMPANIED CGC4X01
0 = Solitary

2 = Often accompanied (25-49% of the

time).
EW 3 = Accompanied 50% or more of the time.
VI
RE
R
FO

Conduct Problems 20
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CHEATING
Attempts to gain increased marks at school or increased CHEATING CGC5I01
success in other settings by unfair means. Intensity
0 = Absent

Do you ever cheat? 2 = Cheating in at least 2 activities and at

least sometimes not responsive to
admonition if caught.
In tests or exams?
Or games? 3 = Cheating may occur in many or most

LY
activities and is hardly ever responsive to
admonition if caught.
What about copying homework?
HOME CGC5F01
Anywhere else? Home
What about during the last 3 months? Frequency
How often does you cheat?

N
When did you start cheating?
Have you ever been caught?
What happened? DAYCARE/SCHOOL CGC5F02
Daycare/School

O
What did the school do?
Frequency
What did your parents do?

ELSEWHERE CGC5F03
EW Elsewhere
Frequency

CGC5O01
Onset
VI

/ /
RE
R
FO

Conduct Problems 21
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

MINOR FORGERY
Deliberate non-illegal imitation of documents, letters or EVER: MINOR FORGERY Ever:CGC6V01
signatures for the subject's own ends. Intensity
0 = No

Includes getting others to forge documents for the subject's 2 = Behaviors that are neither illegal nor
likely to result in police action, such as
purposes, but do not include illegal acts. faking school reports or sick notes.

Have you ever faked sick notes for school? CGC6O01

LY
Onset
Or faked your signature on report cards? / /
When? MINOR FORGERY CGC6I01
Why? Intensity

N
0 = No
What was the restult?
2 = Behaviors that are neither illegal nor
How often have you done it? likely to result in police action, such as
When was the first time? faking school reports or sick notes.

O
HOME CGC6F01
Home
Frequency
EW DAYCARE/SCHOOL CGC6F02
Daycare/School
Frequency
VI

ELSEWHERE CGC6F03
Elsewhere
Frequency
RE

SOLITARY/ACCOMPANIED CGC6X01
0 = Solitary

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

R
FO

Conduct Problems 22
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

MAJOR FORGERY
Deliberate illegal imitation of documents, letters or EVER: MAJOR FORGERY Ever:CGJ5E01
signatures for the subject's own ends. Intensity
0 = No

Include getting others to forge documents for the subject's 2 = Illegal acts such as credit card fraud,
forging a fake ID, etc.
purposes.
Ever:CGJ5V01
Include only illegal acts. Frequency

LY
Have you ever forged a fake ID?
Ever:CGJ5O01
Or anything else? Onset
Have you gotten anyone else to forge anything for
/ /

N
you?

When? MAJOR FORGERY CGJ5I01

Intensity

O
Why? 0 = No
What was the result?
2 = Illegal acts such as credit card fraud,
How often have you done it? forging a fake ID, etc.
When was the first time? EW HOME CGJ5F01
Home
Frequency

DAYCARE/SCHOOL CGJ5F02
Daycare/School
Frequency
VI

ELSEWHERE CGJ5F03
Elsewhere
RE

Frequency

SOLITARY/ACCOMPANIED CGJ5X01
0 = Solitary
R

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

FO

Conduct Problems 23
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

RUNNING AWAY FROM HOME

Leaving the home with the deliberate intention of staying RUNNING AWAY FROM HOME CGC7I01
away temporarily or permanently. Intensity
0 = Absent

N.B. "EVER" CODED IF SUBJECT HAS RUN AWAY BUT 2 = Intending to stay away at time of
leaving, but returning or returned before
NOT IN LAST 3 MONTHS. away overnight. Some preparations to allow
the subject to have stayed away should
Hasve you ever run away from home? have occurred such as packing a bag,

LY
taking some treasured possessions, or
buying a one way tick
When was that?
Have you run away from home in the last 3 months? 3 = As 2, and away at least overnight.
How long for?
CGC7F01
Why did you run away? Frequency

N
How often have you run away?
What did you do?
Did they contact the police?
What happened?

O
Why did you come back?
What did your family (caretakers) do then?
When was the first time you ran away?

CGC7D01
EW DAYS
Duration

CGC7O01
Onset

/ /
VI

SOLITARY/ACCOMPANIED CGC7X01
0 = Absent
RE

2 = Treatment for alcohol.

3 = Treatment for drugs.

4 = Treatment for both.

Enter only if at intensity level "3" RUNNING AWAY FROM HOME Ever:CGC8E01
OVERNIGHT Intensity
R

0 = Absent

2 = Present
FO

RUNNING AWAY FROM HOME Ever:CGC8V01

OVERNIGHT - FREQUENCY

DAYS Ever:CGC8D01

ONSET - RUNNING AWAY Ever:CGC8O01

/ /

Conduct Problems 24
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ACCESS TO WEAPONS

Access to weapons, such as handguns,

shotguns, semi-automatics, machine guns.

GUNS
Does anyone in your household keep a gun in the ACCESS TO GUN CGC9I01
house or car? Intensity

LY
0 = Absent

Do you have your own gun? 1 = Family member has gun, but subject
does not have access because gun is
Do you have other acceess to a gun? locked up.

2 = Subject has access to gun belonging to

N
Who does it belong to? family member or friend, but does not have
What kind of gun? own gun.
A handgun?
3 = Subject has own gun(s) and may have
A rifle or shotgun?

O
access to other guns as well.
Some other kind?
HANDGUN CGC9I02
0 = Absent

2 = Present
EW SHOTGUN OR RIFLE CGC9I03
0 = Absent

2 = Present

OTHER GUN (SEMI-AUTOMATIC, CGC9I04

MACHINE GUN, ETCETERA)
VI

0 = Absent

2 = Present
RE

IF NO ACCESS TO/POSSESSION OF
GUN , SKIP TO "KNIVES", (PAGE 27).
R
FO

Conduct Problems 25
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CURRENTLY CARRIES A GUN

Do you carry a gun when you go out? CURRENTLY CARRIES A GUN CGC9I05
Why? Intensity
0 = Has not carried a gun in last 3 months
Where do you go with it?
How often have you carried a gun in the past 3 months? 2 = Sometimes has carried a gun

3 = Usually carries a gun

LY
TAKES GUN TO SCHOOL
TAKES GUN TO CGC9I06
SCHOOL/COLLEGE/UNIVERSITY Intensity
0 = No

N
2 = Sometimes

3 = Usually

O
GUNS - ACCOMPLICE TO SHOOTING
Have you ever been there when someone else shot at EVER: ACCOMPLICE TO SHOOTING Ever:CGD0E01
someone? Intensity
0 = No

Have you ever shot another person?

EW 2 = Yes

ACCOMPLICE TO SHOOTING CGD0I01

Intensity
0 = No

2 = Yes
VI

GUNS - SHOT AT ANOTHER PERSON

Have you ever shot at anybody? EVER: SHOT AT ANOTHER PERSON Ever:CGD1E01
Intensity
RE

0 = No
IF HAS SHOT AT ANOTHER PERSON, ASK NEXT SET
OF QUESTIONS. 2 = Yes

Did you hit them? EVER: INJURED ANOTHER WITH A GUN Ever:CGD1E02
What happened to them? 0 = No
What happened to you?
2 = Yes
R
FO

Conduct Problems 26
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

KNIVES
Have you ever carried a knife as a weapon or for CURRENTLY CARRIES KNIFE CGD2I01
protection? Intensity
0 = Has not carried a knife in this 3 months

How often have you carried it in the past 3 months? 2 = Sometimes has carried a knife
Where do you carry it?
3 = Usually carries a knife
Have you taken it to school?
Have you ever used it in a fight or to threaten somebody? TAKES KNIFE TO SCHOOL CGD3I01

LY
0 = No

2 = Sometimes

3 = Usually

Ever:CGD4E01

N
EVER: USED KNIFE IN FIGHT OR TO
THREATEN Intensity
0 = No

O
2 = Yes

EVER: INJURED ANOTHER WITH A Ever:CGD5E01

KNIFE

0 = No
EW 2 = Yes

OTHER WEAPONS
Have you ever carried anything else as a weapon or for CURRENTLY CARRIES OTHER CGD6I01
protection? WEAPON Intensity
VI

0 = Has not carried other weapon in this 3

Like brass knuckles? months
Or chains?
2 = Sometimes has carried other weapon
Or a BB gun?
Or a pellet gun? 3 = Usually carries other weapon
RE

FOR BOYS, ASK,

TAKES OTHER WEAPON TO SCHOOL CGD7I01
Or a bat? 0 = No
How often have you carried it in the past 3 months?
Where do you carry it? 2 = Sometimes
Have you taken it to school? 3 = Usually
R
FO

Conduct Problems 27
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OTHER SELF DEFENSE EQUIPMENT

Have you carried anything like mace or a stun gun? CURRENTLY CARRIES SELF-DEFENSE CGD8I01
EQUIPMENT Intensity
IF GIRL, ASK, 0 = Has not carried self-defense equipment
this 3 months
Or bat to defend yourself?
2 = Sometimes has carried other self
defense equipment

LY
3 = Usually carries other self defense
equipment

TAKES SELF DEFENSE EQUIPMENT TO CGD9I01

SCHOOL

0 = No

N
2 = Sometimes

3 = Usually

O
EW
VI
RE
R
FO

Conduct Problems 28
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CONDUCT PROBLEMS INVOLVING VIOLENCE

LOSING TEMPER
Discrete episodes of temper manifested by shouting or LOSING TEMPER CGE0I01
name calling but without violence and not meeting criteria Intensity
0 = Absent
for a temper tantrum.
2 = Present
What sort of temper have you got? HOME CGE0F02

LY
Home
What happens when you lose your temper? Frequency

How often do you lose your temper?

When did that start?
DAYCARE/SCHOOL CGE0F03

N
Daycare/School
Frequency

O
ELSEWHERE CGE0F04
Elsewhere
Frequency
EW CGE0O01
Onset

/ /
VI
RE
R
FO

Conduct Problems 29
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

TEMPER TANTRUMS
Discrete episodes of excessive temper, frustration or upset, TEMPER TANTRUMS CGE1I01
manifested by shouting, crying or stamping, and involving Intensity
0 = Absent
violence or attempts at damage directed against people or
property. 2 = Non destructive violence directed only
against, property, (e.g. slamming doors,
stamping, etc.).
Violence or damage done here does not constitute
Vandalism or Assault. 3 = With destructive violence (e.g.

LY
smashing window) or violence against
persons.
Do you ever get into a tantrum?
HOME CGE1F01
What do you do? Home
Tell me about the last time. Frequency

N
What do your parents (caretakers) do about it?
How long does it go on for?
How often does it happen? DAYCARE/SCHOOL CGE1F02
When did it start? Daycare/School

O
N.B. INFORMATION OBTAINED HERE MAY ALSO BE Frequency
RELEVANT TO TOUGHY OR EASILY ANNOYED, ANGRY
OR RESENTFUL AND IRRITABILITY
ELSEWHERE CGE1F03
EW Elsewhere
Frequency

HOURS : MINUTES CGE1D01

Duration
VI

CGE1O01
Onset

/ /
RE
R
FO

Conduct Problems 30
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

VANDALISM
Damage to, or destruction of, property without the intention VANDALISM CGE2I01
of gain. Intensity
0 = Absent

DO NOT INCLUDE WRITING ON SCHOOL DESKS. 2 = Writing graffiti, carving on trees or

similar actions that are not actually
destructive of the functions of that object.
Have you ever written on walls?
3 = Other acts involving damage to, or

LY
destruction of, property.
Where?
What? HOME CGE2F01
Have you damaged or broken or smashed up Home
anything? Frequency

N
What about public telephones?

What about school books or property? DAYCARE/SCHOOL CGE2F02

Daycare/School

O
When was that? Frequency
Did you know the people whose stuff you "smashed"?
How often do you do that sort of thing?
When did you first do something like that? ELSEWHERE CGE2F03
Elsewhere
EW Frequency

DIRECTED AGAINST COMMUNAL CGE2I02

PROPERTY (E.G. PUBLIC
TELEPHONES)
VI

0 = Absent

2 = Present

DIRECTED AGAINST UNKNOWN CGE2I03

INDIVIDUAL'S PROPERTY
RE

0 = Absent

2 = Present

DIRECTED AGAINST KNOWN CGE2I04

INDIVIDUAL'S PROPERTY

0 = Absent
R

2 = Present

SOLITARY/ACCOMPANIED CGE2X01
FO

0 = Solitary

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

CGE2O01
Onset

/ /

Conduct Problems 31
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FIRESETTING
Setting of unsanctioned fires. FIRESETTING CGE3I01
Intensity
0 = Absent
Do not include burning individual matches or pieces of
paper. 2 = Deliberate setting of unsanctioned fires,
but without intent to cause damage.

N.B. "EVER" CODED IF FIRE SETTING HAS OCCURRED 3 = Deliberate setting of unsanctioned fires
with deliberate intent to cause damage.
BUT NOT IN LAST 3 MONTHS.

LY
HOME CGE3F01
Do you like playing with fire? Home
Frequency
Or burning things?

N
Have you ever started any fires in places where you're
DAYCARE/SCHOOL CGE3F02
not supposed to?
Daycare/School
Frequency
Why did you do it?

O
Where did you do it?
When did you do it?
Have you done it in the last 3 months? ELSEWHERE CGE3F03
Did anyone find out? Elsewhere
Frequency
What happened?
How often have you done that sort of thing?
EW
Do you start fires with other people or one your own?
How often do you start fires? DIRECTED AGAINST COMMUNAL CGE3I02
When was the first time you started a fire? PROPERTY (E.G. PUBLISH
Have you ever done any damage with fire? TELEPHONES)

0 = No
VI

2 = Yes

DIRECTED AGAINST UNKNOWN CGE3I03

INDIVIDUAL'S PROPERTY
RE

0 = No

2 = Yes

DIRECTED AGAINST KNOWN CGE3I04

INDIVIDUAL'S PROPERTY

0 = No
R

2 = Yes

SOLITARY/ACCOMPANIED CGE3X01
FO

0 = Solitary

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

CGE3O01
Onset

/ /

Conduct Problems 32
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FIRESETTING Ever:CGE4E01
Intensity
0 = Absent

2 = Deliberate setting of unsanctioned fires,

but without intent to cause damage.

3 = Deliberate setting of unsanctioned fires

with deliberate intent to cause damage.

Ever:CGE4V01

LY
Frequency

Ever:CGE4O01
Onset

N
/ /

O
EW
VI
RE
R
FO

Conduct Problems 33
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

VIOLENCE AGAINST PERSONS

FIGHTS
Physical fights in which both (or all) combatants are FIGHTS CGE5I01
actively initiating. Otherwise code as assault. Intensity
0 = Fights absent.

If subject is a victim of an attack and fights back only to 2 = Fights do not result in any physical
injury to either party.
protect him/herself, do not rate here or under Assault.

LY
3 = Either combatant has sustained some
physical injury as a result (e.g. black eye or
Do you get into fights at all? cuts).

Have you gotten into any fights in the last 3 months? HOME CGE5F01
Home
Who with? Frequency

N
How often?
Tell me about the last fight you were in.
Was it a friendly fight?
CGE5F02

O
DAYCARE/SCHOOL
Think of the worst fight you were in.
Daycare/School
Did either (any) of you get hurt? Frequency
What happened?
Have you been in any fights that someone else broke up?
Who?
Why?
When did you start fighting?
EW ELSEWHERE CGE5F03
Elsewhere
Frequency

SOLITARY/ACCOMPANIED CGE5X01
VI

0 = Solitary

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

RE

CGE5O01
Onset

/ /
R
FO

Conduct Problems 34
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FIGHTS- RESULTING IN SERIOUS INJURY

As the result of a fight, either combatant sustained broken FIGHTS RESULTING IN SERIOUS CGE6I01
limbs, required hospitalization, or was unconscious for any INJURY Intensity
period. 0 = None

2 = As a result of a fight either combatant

NOTE WHETHER ANY FURTHER ACTION WAS TAKEN sustained broken limbs, required
BY YHE AUTHORITIES hospitalization, or was unconscious for any
period.

LY
Have you been in a fight where someone was badly EVER: FIGHTS RESULTING IN SERIOUS Ever:CGE6E01
hurt in the last three months? INJURY Intensity

Have you ever been in a fight were someone was badly 0 = None
hurt? 2 = As a result of a fight either combatant

N
sustained broken limbs, required
hospitalization, or was unconscious for any
period.

O
Ever:CGE7V01
Frequency

Ever:CGE7O01
EW Onset

/ /
EVER: USE OF WEAPON Ever:CGE8E01
0 = No
VI

2 = Yes

USE OF WEAPON - FREQUENCY Ever:CGE8V01

RE

USE OF WEAPON - ONSET Ever:CGE8O01

/ /
R
FO

Conduct Problems 35
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ASSAULT
Attack upon or attempt to hurt another without the other's ASSAULT CGE9I01
willful involvement in the contact. Intensity
0 = No assault

If subject is the victim of an attack and fights back only to 2 = Assaults did not result in any physical
injury to either party
protect him/herself, do not rate here or under Fight.
3 = The victim sustained some physical
injury as a result (e.g.black eye or cuts)
N.B. "EVER" CODED IF ASSULTED HAS NOT OCCURED

LY
IN LAST 3 MONTHS. HOME CGE9F01
Home
Have you hurt or attacked anyone who didn't want to Frequency
fight you?

N
What was that? DAYCARE/SCHOOL CGE9F02
When was that? Daycare/School
Whose fault was it? Frequency

O
How did it happen?
Did you hurt him/her? How much?
Why?
ELSEWHERE CGE9F03
Elsewhere
Frequency
EW
SOLITARY/ACCOMPANIED CGE9X01
0 = Solitary

2 = Often accompanied (25-49% of the

VI

time).

3 = Accompanied 50% or more of the time.

CGE9O01
Onset
RE

/ /

ASSAULT RESULTING IN SERIOUS INJURY

ASSAULT RESULTING IN SERIOUS Ever:CGF0E01
INJURY Intensity
R

0 = Absent

2 = Present
FO

ASSAULTS RESULTING IN SERIOUS CGF0I01

INJURY Intensity
0 = None

2 = As a result, either combatant sustained

broken limbs, required hospitalization, or
was unconcious for any period

Conduct Problems 36
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

Ever:CGF1V01
Frequency

Ever:CGF1O01
Onset

/ /

LY
ASSAULT WITH A WEAPON
Physical aggression, attack upon, or attempt to hurt USE OF WEAPON Ever:CGF2E01
another without the other's willful involvement in the contact Intensity
0 = No

N
using a weapon.
2 = Yes
Have you ever used a weapon in an assault? Ever:CGF2V01

O
Frequency
Like a knife or stone?
Were the police involved?
How often have you done anything like that?
Where have you done that sort of thing? Ever:CGF2O01
Onset
Tell me about it.
EW
When was the first time you did anything like that?
/ /
When was the first time you used a weapon in an attack?
VI

IF ASSAULT OCCURRED, ASK ABOUT

CRUELTY. OTHERWISE, SKIP TO
"BULLYING", (PAGE 40).
RE
R
FO

Conduct Problems 37
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CRUELTY TO PEOPLE
An assault involving the deliberate inflicting of pain or fear CRUELTY TO PEOPLE CGF3I01
on the victim beyond the "heat of the moment". Include Intensity
0 = Absent
beating, cutting or burning a restrianed person, ritualized
infliction of pain, and sadistic violence or terrorization. 2 = Cruelty did not result in any physical
injury to either party.

CODE ASSAULTS INVOLVING CRULITY HERE, NOT 3 = The victim sustained some physical
UNDER ASSULTS, iF NOT CERTAIN WHICH TO CODE, injury as a result (e.g. black eye or cuts).

LY
CODE UNDER ASSAULT. HOME CGF3F01
Home
Frequency

N
DAYCARE/SCHOOL CGF3F02
Daycare/School
Frequency

O
ELSEWHERE CGF3F03
Elsewhere
Frequency
EW
SOLITARY/ACCOMPANIED CGF3X01
0 = Solitary

2 = Often accompanied (25-49% of the

VI

time).

3 = Accompanied 50% or more of the time.

CGF3O01
Onset
RE

/ /

CRUELTY RESULTING IN SERIOUS INJURY

EVER: CRUELTY RESULTING IN Ever:CGF4E01
SERIOUS INJURY Intensity
R

0 = None

2 = As a result of cruelty either combatant

FO

sustained broken limbs, required

hospitalization, or was unconcious for any
period.

CRUELTY RESULTING IN SERIOUS CGF4I01

INJURY Intensity
0 = None

2 = As a result of cruelty either combatant

sustained broken limbs, required
hospitalization, or was unconcious for any
period.

Conduct Problems 38
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

Ever:CGF5V01
Frequency

Ever:CGF5O01
Onset

/ /

LY
USE OF WEAPON Ever:CGF6E01
0 = No

2 = Yes

CRUELTY RESULING IN SERIOUS Ever:CGF6V01

N
INJURY - USE OF WEAPON -
FREQUENCY

Ever:CGF6O01

O
CRUELTY RESULTING IN SERIOUS
INJURY - USE OF WEAPON - ONSET
/ /
EW
VI
RE
R
FO

Conduct Problems 39
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BULLYING
Attempts to force another to do something against his/her BULLYING CGF7I01
will by using threats or violence, or intimidation. Intensity
0 = Absent

Do not include episodes that meet the criteria for stealing 2 = Using threats only.
involving confrontation. 3 = With actual violence.

HOME CGF7F01
Differentiate from spiteful and vindictive which does not

LY
Home
include attempts to force someone to do something against Frequency
their wishes.

Have you ever forced someone to do something s/he

didn't want to do by threatening or hurting him/her? DAYCARE/SCHOOL CGF7F02

N
Daycare/School
Do you ever pick on anyone? Frequency

O
Who was it?
Why did you do it? ELSEWHERE CGF7F03
How often? Elsewhere
Where? Frequency
When was the first time? EW
Did you use a weapon of any sort?
Where have you done that sort of thing?
Where the police involved? SOLIRATY/ACCOMPANIED CGF7X01
0 = Solitary
CODE FORCED SEXUAL ACTIVITY ON NEXT
SYMPTOM 2 = Often accompanied (25-49% of the
time).
VI

3 = Accompanied 50% or more of the time.

CGF7O01
Onset

/ /
RE

USE OF WEAPON Ever:CGF8E01

Intensity
0 = No

2 = Yes

Ever:CGF8V01
R

Frequency
FO

Ever:CGF8O01
Onset

/ /

Conduct Problems 40
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FORCED SEXUAL ACTIVITY

Have you ever made someone have sex with you when FORCED SEXUAL ACTIVITY Ever:CGF9E01
s/he didn't want to? Intensity
0 = Absent

Or have you kissed or fondled anyone who didn't want 2 = Using threats only.
you to?
3 = With actual violence.
Did you use a weapon of any sort? Ever:CGF9V01

LY
Frequency

Ever:CGF9O01
Onset

N
/ /
USE OF WEAPON FOR FORCED Ever:CGH0E01

O
SEXUAL ACTIVITY

0 = No

2 = Yes
EW USE OF WEAPON FOR FORCED
SEXUAL ACTIVITY - FREQUENCY
Ever:CGH0V01

USE OF A WEAPON FOR FORCED Ever:CGH0O01

SEXUAL ACTIVITY - ONSET
/ /
VI

SEXUAL ACTIVITY FOR GAIN

Engagement in sexual activity in order to obtain money, SEXUAL ACTIVITY FOR GAIN Ever:CGH1E01
goods, or drugs. Intensity
0 = Absent
RE

IF DRUG RELATED, ALSO CODE UNDER SUBSTANCE- 2 = Present

RELATED CRIME. Ever:CGH1V01
Frequency
Have you ever had sex with someone to get something
that you wanted?
R

How many times? Ever:CGH1O01

Onset
When did you first do that?
/ /
FO

Conduct Problems 41
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CRUELTY TO ANIMALS
Deliberate activities involving hurting animals. CRUELTY TO ANIMALS (CODE ONLY IF Ever:ABC1123
AT INTENSITY LEVEL 3) Intensity
Do not include hunting. 0 = Absent

2 = Definite cruelty not resulting in obvious

N.B. "EVER" CODED IF NO CRUELTY TO ANIMALS IN or permanent injury to the animal.
LAST 3 MONTHS.
3 = Acts resulting in obvious or permanent

LY
injury.
Have you ever hurt an animal?
FREQUENCY Ever:CGH3V01
When?
What happened? (Determine way of hurting)
Have you ever killed an animal? Ever:CGH3O01

N
Were the police brought in? Onset
Where did you do it?
Why did you do it? / /

O
How often have you done that?
When was the first time? CRUELTY TO ANIMALS CGH2I01
CODE ONLY IF ACTS RESULTING IN OBVIOUS OR Intensity
0 = Absent
PERMANENT INJURY.
EW 2 = Definite cruelty not resulting in obvious
Have you hurt an animal in the last 3 months or permanent injury to the animal.

3 = Acts resulting in obvious or permanent

injury.

HOME CGH2F01
Home
Frequency
VI

DAYCARE/SCHOOL CGH2F02
Daycare/School
Frequency
RE

ELSEWHERE CGH2F03
Elsewhere
Frequency
R

SOLITARY/ACCOMPANIED CGH2X01
0 = Solitary
FO

2 = Often accompanied (25-49% of the

time).

3 = Accompanied 50% or more of the time.

CGH2O01
Onset

/ /

Conduct Problems 42
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LETTER WRITING, TELEPHONE CALLS,

MALICIOUS RUMORS
Sending nasty, obscene, cruel, or otherwise unpleasant LETTER WRITING, PHONE CALLS, OR CGH4I01
anonymous letters to a person or persons; or making such MALICIOUS RUMORS Intensity
telephone calls; or starting malicious rumors. 0 = Absent

2 = Letters or phone calls to, or spreading

N.B. "EVER" CODED IF NO LETTER WRITING OR rumors about, unknown person(s).
TELEPHONE CALLS IN LAST 3 MONTHS.

LY
3 = Letters or phone calls to, or spreading
rumors about, person with whom the
Have you sent an anonymous letter to anyone in the subject has personal contact.
last 3 months?
CGH4F01
Or made an anonymous telephone call? Frequency

N
In the last 3 months, have you started rumors about
anybody that weren't true?
CGH4O01

O
Onset
Who?
When was that? / /
Why did you do it?
Were the police brought in?
How often have you done it?
When was the first time?
EW
EVER: LETTER WRITING, PHONE CALLS, OR
MALICIOUS RUMORS
Sending nasty, obscene, cruel, or otherwise unpleasant LETTER WRITING, PHONE CALLS, OR Ever:CGH5I01
VI

anonymous letters to a person or persons; or making such MALICIOUS RUMORS Intensity

telephone calls; or starting malicious rumors. 0 = Absent

2 = Letters or phone calls to, or spreading

N.B. "EVER" CODED IF NO LETTER WRITING OR rumors about, unknown person(s).
RE

TELEPHONE CALLS IN LAST 3 MONTHS.

3 = Letters or phone calls to, or spreading
rumors about, person with whom the
Have you ever sent an anonymous letter to anyone ? subject has personal contact.

Or made an anonymous telephone call? Ever:CGH5F01

Frequency
Have you ever started rumors about anybody that
R

weren't true?
Ever:CGH5O01
Who?
Onset
When was that?
FO

Why did you do it? / /

Were the police brought in?
How often have you done it?
When was the first time?

Conduct Problems 43
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

POLICE CONTACT
Any involvement with police resulting from items recorded POLICE CONTACT Ever:CGH6E01
in Conduct Disorder section or any other behavior or Intensity
0 = Absent
suspected behavior for which a complaint could have been
filed. 2 = Police Contact Present

Ever:CGH6O01
Do not include simple questioning such as being Onset
questioned about something the youth saw.
/ /

LY
Do not include speeding tickets, unless they are associated
POLICE CONTACT CGH6I01
with driving under the influence or reckless driving. Intensity
0 = Absent
Have you ever been involved with the police?

N
2 = Present in last 3 months

What about in the last 3 months?

O
IF POLICE CONTACT HAS OCCURRED,
COMPLETE DELINQUENCY SECTION.
OTHERWISE, SKIP TO
"PROBATION/PAROLE", (PAGE 46).
EW
VI
RE
R
FO

Conduct Problems 44
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DELINQUENCY
ACTION TAKEN BY POLICE
IF SUBJECT EVER HAS BEEN CHARGED, CODE ACTION TAKEN BY POLICE Ever:CGH7E01
EVER:RESULT OF PRESECUTION Intensity
0 = No further action

CODE EVER:TOTAL NUMBER OF DWI'S SEPARTELY 1 = Adjustment by police

FROM EVER: TOTAL NUMBER OF CHARGES. THEN 2 = Adjustment by juvenile coujnselor

LY
CODE HIGHEST RESULT OF PRESECUTION FROM
EITHER TYPE OF CHARGE. 3 = Charged

Ever:CGH8O01
Onset

/ /

N
TOTAL NUMBER OF CHARGES Ever:CGH8V01

O
Ever:CGH8V02
Frequency
EW RESULT OF PROSECUTION Ever:CGH9E01
0 = Charges dropped.

1 = Not guilty.

2 = Unsupervised probation/restitution.
VI

3 = Community service.

4 = Supervised probation only.

5 = Supervised probation with treatment

order.
RE

6 = Treatment order without probation.

7 = Detention

8 = Wilderness camp.

9 = Suspended training school commitment.

R

10 = Training school commitment.

11 = Bound over to superior court.

FO

12 = Fine in superior court.

13 = Prison commitment by superior court.

Conduct Problems 45
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PROBATION/PAROLE
Have you ever been placed on probation? PROBATION Ever:CGI0E01
Intensity
0 = No
Or been paroled?
Have you done anything that was against the terms of 2 = Juvenile probation.
your probation/parole?
3 = Adult probation.
N.B. REMEMBER TO RECONSIDER THIS ISSUE OF 4 = Parole

LY
SUBSTANCE USE PRESENT.
CURRENTLY ON PROBATION/PAROLE CGIOI01
Intensity
0 = No

2 = Yes

Ever:CGI0V01

N
Frequency

O
EW
VI
RE
R
FO

Conduct Problems 46
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

ANTI-SOCIAL
ANTI-SOCIAL BEHAVIOR
FAILURE TO HONOR FINANCIAL OBLIGATION
Subject has not paid money s/he owes, or has not repaid FAILURE TO HONOR FINANCIAL CGK0I01
money s/he has borrowed. The debt may have arisen prior OBLIGATIONS Intensity
to the last three months, but the failure to pay has been 0 = Does not owe money or has not failed
ongoing in the last three months. If two or more weeks to pay.
have passed since the debt was incurred (or bill was due)

LY
1 = Has made partial payment.
and payment has not been made, code failure to honor the
commitment despite assurance the subject plans to pay in 2 = Has not paid/repaid an amount less
the future. Code failure to pay child support more than $50.00.
specifically below. 3 = Has not paid/repaid an amount greater
than or equal to $50.00.

N
Over the last three months, have you owed anyone any
HOME CGK0F01
money? Home
Frequency

O
Or borrowed any money?

Did you pay the money back?

Were there any times in the last three months when you DAYCARE/SCHOOL CGK0F02
didn't pay someone the money you owed or borrowed? Daycare/School
EW
Did you have any financial obligations that you did not
honor?
Frequency

Are you behind on credit card payments?

ELSEWHERE CGK0F03
Or behind on car payments?
Elsewhere
What about cell phone or utility bills? Frequency
Do you owe the IRS or the State for any taxes you
VI

haven't paid?

How many times over the last three months have you owed CGK0O01
someone money but didn't pay them? Onset
Or you have missed a payment for your car, phone,
/ /
RE

utilities, or credit cards?

When was the first time you didn't pay money you owed for
a bill or to someone?

CHILD LIVING ELSEWHERE

R

Do you have any children who don't live with you? CHILD LIVING ELSEWHERE CGK1I00
Intensity
0 = No
FO

2 = Yes

IF SUBJECT HAS A CHILD THAT LIVES

ELSEWHERE, COMPLETE.
OTHERWISE, SKIP TO "FINANCIAL
CONSEQUENCES", (PAGE 3).

Conduct Problems 1
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LY
N
O
EW
VI
RE
R
FO

Conduct Problems 2
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FAILS TO PAY CHILD SUPPORT

Is there a court order that requires you to pay child FAILS TO PAY CHILD SUPPORT CGK1I01
support? Intensity
0 = Pays either court-ordered child support
or voluntarily contributes more than $20 per
Do you pay child support? month to child's upbringing.

Have you missed any payments in the last three months? 1 = Does not contribute financially, or less
than $20 per month.
NOTE: IF NO COURT ORDER ASK

LY
2 = Has missed at least one court-ordered
Do you contribute money for the child's upbringing child support payment in the last three
even though it is not court-ordered? months.

FINANCIAL CONSEQUENCES

N
Have you ever had a car or other possessions EVER: FINANCIAL CONSEQUENCES Ever:CGL1E01
repossessed? Intensity
0 = Absent

O
Have you had debts turned over to a collection 2 = Present
agency?
Ever:CGL1V01
Have you been unable to pay your rent or mortgage? Frequency

credit?
EW
Have you been unable to make a purchase due to bad
Ever:CGL1O01
Onset
Have you been turned down for a loan?
/ /
How many times have you experienced the negative
consequences of not honoring prior financial obligations?
VI

When was the first time?

RE
R
FO

Conduct Problems 3
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LACK OF REMORSE
Lack of remorse, as indicated by being indifferent to or LACK OF REMORSE CGK2I01
rationazling having hurt, mistreated, or stolen form another. Intensity
0 = Has not committed any wrongdoing or
Subject steals, cheats, maltreats people or otherwise feels remorse for transgressions.
breaks clear societal boundaries without guilt. Taking
inexpensive items or small amounts of money are 2 = Expresses no remorse for obvious
transgressions.
considered stealing if the owner was not informed and is
deprived of the use of the item. Do not code for white lies HOME CGK2F01

LY
told to spare the feelings of others. Home
Frequency
Do you feel badly when you do something wrong?

Or when you do something that really hurts someone's DAYCARE/SCHOOL CGK2F02

N
feelings? Daycare/School
Frequency
Or when you cause someone to be upset or stressed
out?

O
Do you feel guilty if you lie? ELSEWHERE CGK2F03
Elsewhere
Or if you mislead your girl/boyfriend, spouse, or Frequency
partner?

Or cheat?
EW CGK2O01
Onset
Or steal?

Or break laws that cause harm to others or society in

/ /
general?
VI

Have you hurt anyone over the last three months?

Do you feel like you should be able to do whatever you

want regardless of what affect it might have on others?
RE

Can you give me an example?

How many times have you done something like that over
the last three months without feeling badly about it?
How many of those times were at home?
School or work?
R

Other places?

When did you start doing things like that and not feeling
bad about it?
FO

Conduct Problems 4
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

HARASSMENT
Repeated or persistent infringement that causes HARASSMENT CGL2I01
annoyance or torment to another person. Intensity
0 = Absent

Over the last three months, have you called someone 2 = Present
on the phone, just to make them feel annoyed? CGL2F01
Frequency
Or to make them feel frightened?

LY
Can you tell me a little about that?
Have you just shown up at someone's house or CGL2O01
property? Onset

Why did you go there? / /

N
What happened?

How many times have you done that?

O
When did you start doing that?

IMPULSIVITY OR FAILURE TO PLAN AHEAD

Subject acts on impulse without making plans or
EW
considering the end result (i.e., quitting a job before having
IMPULSIVITY OR FAILURE TO PLAN
AHEAD
Ever:CGK3E01
Intensity
a new job, severing relationships without considering the 0 = Absent
consequences, taking on responsibilities without any "game
plan" for follow through). 2 = Impulsiveness or change of plans
occurs in at least two activities and results
in minor negative consequences.
VI

Do you sometimes do things on impulse?

3 = Impulsiveness or change of plans
occurs in most activities or more than once
Or just decide to do things without planning ahead? has resulted in major negative
consequences.
Does it cause problems when you do this?
RE

Can you give me an example? IMPULSIVITY OR FAILURE TO PLAN CGK3I01

Do you change your plans frequently? AHEAD Intensity
0 = Absent
Does that make it difficult for you or others?
Have you moved without any specific place to go? 2 = Impulsiveness or change of plans
occurs in at least two activities and results
in minor negative consequences.
Have you left a long term relationship without really
R

thinking it through? 3 = Impulsiveness or change of plans

occurs in most activities or more than once
What about in the last 3 months? has resulted in major negative
consequences.
FO

How many times have you done something like that in the CGK3F01
last 3 months? Frequency

When was the first time you acted impulsively like that?

CGK3O01
Onset

/ /

Conduct Problems 5
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

NO PERMANENT ADDRESS
Subject has spent at least a month without a home, moving NO PERMANENT ADDRESS Ever:CGL3E01
in with one acquaintance or another, living on the streets or Intensity
0 = Retained a permanent address.
in shelters. Do not include camps, hospital stays, visits with
friends, and situations where the expectation is that they 2 = No permanent address for a month or
can and will return home. more.

NO PERMANENT ADDRESS IN PP CGL3I01

Have you ever spent a month or more with no fixed Intensity

LY
0 = Retained a permanent address.
address?
2 = No permanent address for a month or
Did you move around from place to place? more.
Or live on the street?
HOURS : MINUTES Ever:CGL3D01
Or in shelters?

N
What about the last three months?
Ever:CGL3O01
What is the longest period of time that you lived like that? Onset

O
When was the first time you spent at least a month with no / /
fixed address?

USE OF AN ALIAS
EW
Subject uses another name to fool authority, or gain entree' USE OF AN ALIAS Ever:CKG4E01
to an opportunity that would not be granted under the Intensity
0 = Absent
subject's own name, or to avoid responsibilities. Do not
code literary (authorial) pseudonyms or simple nicknames. 2 = Uses another name to avoid recognition
or responsibility.
VI

Have you ever used an alias? 3 = Uses another name for illegal purposes
or to avoid legal pursuit.
Or used another name to either get something or avoid
USE OF AN ALIAS CKG4I01
something? Intensity
0 = Absent
RE

Why was that?

2 = Uses another name to avoid recognition
or responsibility.
Have you used an alias over the last three months?
3 = Uses another name for illegal purposes
How many times? or to avoid legal pursuit.

When was the first time you used another name for those CKG4F01
Frequency
R

kinds of reasons?
FO

CKG4O01
Onset

/ /

Conduct Problems 6
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

GAMBLING
Subject makes wagers on card games, sporting events, GAMBLING CKG5I11
etc. There is some intimation that this behavior goes Intensity
0 = Absent
beyond playing poker or football pools for minimal amounts
with family and friends. 2 = Gambling is present in at least two
activities and is at least sometimes
uncontrollable, but amount wagered is less
Do you gamble? than $50.00 at a time.

LY
Do you bet at cards? 3 = Gambling is present in most activities
and is usually uncontrollable or has
wagered $50.00 (or more) at a time at least
Do you bet on football or basketball games? once in the primary period.

Or horse races or animal fights? CKG5F11

Frequency

N
Do you play betting games at Casinos?

Do you play the lottery?

CKG5O11

O
Do you do any other type of gambling? Onset

Do you risk more than $50.00 at a time?

/ /
APPROXIMATE AMOUNT LOST OVER CKG6I01
last 3 months?
EW
How many times would you say you have gambled in the THE LAST THREE MONTHS

0 = Came out even or made money.

When did you first start gambling or taking bets? 1 = Less than $50.

How much have you lost over the last three months? 2 = $100 or less.

3 = $200 or less.
About how much have you ever lost?
VI

4 = $300 or less.

5 = $400 or more.

APPROXIMATE AMOUNT EVER LOST CKG6E01

RE

0 = Came out even or made money.

1 = Less than $50.

2 = $100 or less.

3 = $200 or less.
R

4 = $300 or less.

5 = $400 or more.
FO

IF SUBJECT HAS LOST MONEY BY

GAMBLING OVER THE LAST THREE
MONTHS, COMPLETE. OTHERWISE,
SKIP TO "RECKLESS DISREGARD FOR
SAFETY OF SELF OR OTHERS", (PAGE
10).

Conduct Problems 7
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LY
N
O
EW
VI
RE
R
FO

Conduct Problems 8
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DIFFICULTIES RESULTING FROM NEED TO

COVER GAMBLING LOSSES
Subject is unable to cover gambling debts and this has RESULTANT DIFFICULTIES CGK7I01
resulted in further difficulties. If the information conforms to Intensity
0 = Absent
the definitions of other items (Failure to Honor Financial
Obligations, Neglect or Failure to Care For a Child, 2 = Present
Stealing, etc.), code there as well.
FORM OF DIFFICULTY CAUSED BY CGK7I02
GAMBLING LOSSES

LY
Over the last three months, have you had any trouble
1 = Using savings.
covering your gambling losses?
2 = Working extra. CGK7I03
Where do you get the money to pay for your gambling
debts? 3 = Borrowing from others to cover losses.

N
4 = Unable to pay other expenses. CGK7I04
Have you had to use your savings?
Have you had to work extra hours, or an extra job, to raise 5 = Unable to pay child support.
the money?

O
7 = Fear of physical harassement.
Have you had to borrow from someone else to cover your
gambling losses? 8 = Has been physically harassed over non-
payment.
Have you paid them back?
Has your gambling affected your ability to cover other 9 = Stealing, selling drugs or other illegal
expenses? act to cover gamling losses.

losses?
EW
Were you unable to support your child because of gambling 10 = Other

Have you resorted to stealing to cover gambling losses? CGK7O01

Or dealt drugs to raise the money? Onset
Has anyone been calling you, or harassing you for
payment? / /
Are you in physical danger because you haven't paid your
VI

gambling debts?

When was the first time your losses caused these other
problems?
RE
R
FO

Conduct Problems 9
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

RECKLESS DISREGARD FOR SAFETY OF

SELF OR OTHERS
Subject enters into or causes dangerous situations without DISREGARD FOR SAFETY Ever:CGK8E01
considering the consequences to self or others. Do not Intensity
0 = Absent
code car accidents that clearly were not the subject's fault.
2 = Present
Have you ever been the driver when an auto accident 3 = Present, and subject or other needed
occurred? medical attention.

LY
What happened? DISREGARD FOR SAFETY IN PP CGK8I01
Have you driven a car or motor bike after using alcohol Intensity
0 = Absent
or drugs?
2 = Present
Do you like taking risks?

N
3 = Present, and subject or other needed
medical attention.
Do you consider yourself a reckless person or a risk-
taker? Ever:CGK8F01

O
Frequency
Do you do dangerous things?

Can you give me an example?

CGK8O01 Ever:CGK8O01
Why did you do that?
EW
Do you usually speed when driving a car or motorcycle
or 4-wheeler?
/ /

How much over the speed limit do you usually go?

When was the first time you put yourself or others into a
dangerous situation like that?
VI

How often have you done dangerous or risky things like

that, in the last 3 months?
RE

SUBJECT HAS CHILD OR TAKES CARE OF

CHILD
Do you babysit? SUBJECT HAS CHILD OR TAKES CARE Ever:ywn0300
OF CHILD Intensity
Do you watch your brothers or sisters? 0 = No

Or other children? 2 = Yes

R

Do you work in a situation where you are responsible PRIMARY PERIOD CARES FOR ywn3303
CHILD(REN) Intensity
for children?
FO

0 = No

2 = Yes

IF SUBJECT HAS A CHILD,

'STEPCHILD' OR TAKES CARE OF A
CHILD, CONTINUE. OTHERWISE, SKIP
TO "", (PAGE ERROR! BOOKMARK NOT
DEFINED.).

Conduct Problems 10
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LY
N
O
EW
VI
RE
R
FO

Conduct Problems 11
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

NEGLECT OR FAILURE TO CARE FOR A CHILD

Due to the subject's lack of responsibility, a child has NEGLECT OR FAILURE TO CARE FOR A CGK9I01
suffered or been put into danger. CHILD Intensity
0 = Absent
Do you take good care of your child/ the child you
2 = Neglect or failure to adequately care for
babysit? a child in at least two activities.

Have you left him/her alone for a long time? 3 = Neglect or failure to adequately care for

LY
a child in most activities.
Or not fed him/her?
CGK9F01
Frequency
Have you had the child in a car without being properly
placed in a car seat?

N
Have you put him/her in danger? CGK9O01
Onset
Have you left the child in the care of someone too
/ /

O
young to responsibly look after the child?

Or with a stranger?

What happened? EW
When was the first time that happened?

How many times in the last 3 months?

CHILD ABUSE
Have you ever spanked or hit a child so hard that it left CHILD ABUSE Ever:CGL0E01
VI

bruises? Intensity
0 = Absent

Have you ever shaken a child real hard? 2 = Present

What happened? 3 = Present and child required medical

RE

care.
Have you hurt a child in any other way?
CHILD ABUSE CGL0I01
Has anyone ever reported you to social services? Intensity
When was the first time you did something like that? 0 = Absent

2 = Present
Has that happened in the last 3 months?
3 = Present and child required medical
R

How many times? care.

CGL0F01
Frequency
FO

CGL0O01
Onset

/ /

Conduct Problems 12
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

TOBACCO, ALCOHOL, AND DRUGS

TOBACCO USE

Include use of any tobacco products.

SMOKING
Have you ever smoked tobacco? EVER SMOKED Ever:CHA0E01
Intensity

LY
0 = No
When was the first time you smoked tobacco?
Have you ever smoked regularly? (One or more per day?) 2 = Yes
When did you start smoking regularly?
DATE FIRST SMOKED Ever:CHA0O02
Have you ever regularly smoked 1 or more a day?
/ /

N
What is the most you have smoked per day on a regular
basis? DATE BEGAN SMOKING REGULARLY Ever:CHA0O01
When did you start smoking at that level? (CODE ONLY IF > 1 PER DAY)
Have you smoked on a regular basis over the last three / /

O
months?
How many cigarettes a day? EVER: MOST SMOKED PER DAY ON A Ever:CHA0V01
REGULAR BASIS (CODE ONLY IF > 1
PER DAY)
Have you smoked on a regular basis in the last 3 months?
EW DATE BEGAN MOST SMOKED PER DAY Ever:CHA0O03
ON A REGULAR BASIS (CODE ONLY IT
> 1 PER DAY) / /
USE IN PP CHA0I01
Intensity
0 = Absent
VI

2 = Present

CURRENTLY SMOKING: # PER DAY ON CHA0F01

A REGULAR BASIS (CODE ONLY IF >1
PER DAY)
RE
R
FO

Tobacco, Alcohol, and Drugs 1

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SNUFF
Have you ever used snuff? EVER USED SNUFF Ever:CHA1E01
Intensity
0 = No
Anything like Skoal, Copenhagen, or Red Wolf?
2 = Yes
When did you have your first pinch of snuff?
Have you ever used snuff on a regular basis? DATE OF FIRST PINCH OF SNUFF Ever:CHA1O02
At least 5 times a week?
/ /

LY
When did you start using snuff on a regular basis?
Have you used it at least 5 times a week? DATE BEGAN USING SNUFF Ever:CHA1O01
When did you start using at that level? REGULARLY
Do you use it now? / /
How many tins/cans do you use a week?
EVER: MOST SNUFF USED ON A Ever:CHA1V01

N
REGULAR BASIS (CODE NUMBER OF
1/2 TINS/CANS PER WEEK) (1/2
TINS/CANS = 1/2 OZ = ABOUT 5
DIPS/CHEWS

O
DATE STARTED USING SNUFF AT THAT Ever:CHA1O03
LEVEL
/ /
USE IN PP CHA1I01
EW 0 = Absent
Intensity

2 = Present

CURRENTLY USING SNUFF (CODE CHA1F01

NUMBER OF 1/2 TINS/CANS PER WEEK)
(1/2 TIN/CAN = 1/2 OZ = 5 DIPS/CHEWS)
VI
RE
R
FO

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CHEWING TOBACCO
Have you ever chewed tobacco? EVER CHEWED TOBACCO Ever:CHA2E01
Intensity
0 = No
Such as Redman, Levi Garrett, Beechnut?
When was the first time you chewed tobacco? 2 = Yes
Have you ever chewed tobacco regularly?
At least 5 times a week? DATE OF FIRST CHEW OF TOBACCO CHA2O02
What is the most you have used per week on a regular / /

LY
basis?
When did you start using tobacco at that level? DATE BEGAN CHEWING TOBACCO CHA2O01
How many pouches do you use a week? REGULARLY
/ /
Have you chewed tobacco in the last 3 months?
CHEWS TOBACCO IN LAST 3 MONTHS CHA2I01

N
Intensity
0 = Absent

2 = Present

O
EVER: MOST TOBACCO CHEWED ON A CHA2VO1 00
REGULAR BASIS (CODE NUMBER OF
1/2 POUCHES PER WEEK) (1/2 POUCH
=1 1/2 OZ = 3 WADS/CHEWS)

CHA2F01
EW CURRENTLY USING CHEWING
TOBACCO (CODE NUMBER OF 1/2
POUCHES PER WEEK) (1/2 POUCH =1
1/2 OZ = 3 WADS/CHEWS)

DATE STARTED USING AT THAT LEVEL CHA2O03

/ /
VI

TOBACCO SCREEN
Determine if subject has tried or been forced to give up ATTEMPT TO ABSTAIN FROM tob1I00
smoking, dipping, or chewing in the last 3 months. TOBACCO Intensity
RE

0 = No
Have you tried to or been forced to give up tobacco in the
2 = Yes
last 3 months?
R

IF SUBJECT HAS NOT TRIED TO GIVE

UP SMOKING AT LEAST 5
CIGARETTES DAILY, USING SNUFF OR
FO

CHEWING TOBACCO > 5X/WEEK, SKIP

TO "ALCOHOL USE", (PAGE 7).

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ABSTAINING FROM USE OF TOBACCO

Actual effort at abstaining from tobacco use, lasting at least EVER: ATTEMPTED TO ABSTAIN Ever:CHL5E01
8 hours, but which proved to be unsuccessful. Intensity
0 = No

How often have you tried to quit? 2 = Yes

For how long? Ever:CHL5V01
Frequency
Have you tried to quit or had to quit in the last 3 months?

LY
In the last 3 months, what is the longest amount of time you
went without tobacco? Ever:CHL5O01
Onset

/ /

N
ATTEMPTED TO ABSTAIN CHL5I01
Intensity
0 = Has not tried to abstain during last 3

O
months

2 = Has tried to abstain during last 3

months

DAYS CHL5D01
EW Duration
VI
RE
R
FO

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NICOTINE WITHDRAWAL

Code any of the following symptoms if they

occurred during a period of attempted
abstinence from nicotine during the last 3
months.

CRAVING

LY
How did you feel? CRAVING CHL6I01
Intensity
0 = Absent
Did you feel that you really needed a "cigarette"?
2 = Present
How long did that last?

N
IRRITABILITY

O
Did it put you in a bad mood? IRRITABILITY CHL6I02
Intensity
0 = Absent
How long did that last?
Were you bad-tempered? Or irritable? EW 2 = Present

ANXIETY
Did you feel nervous? ANXIETY CHL6I03
Intensity
0 = Absent
Or anxious?
2 = Present
VI

POOR CONCENTRATION
How was your concentration? POOR CONCENTRATION CHL6I04
Intensity
RE

0 = Absent
Did you have difficulty concentrating?
Was that different from usual? 2 = Present

RESTLESSNESS
Did you feel restless? RESTLESSNESS CHL6I05
R

Intensity
0 = Absent
Did you have trouble keeping still?
2 = Present
FO

INCREASED APPETITE
How was your appetite? INCREASED APPETITE CHL6I06
Intensity
0 = No
Did you eat more than usual?
Did you put on any weight? 2 = Increase in appetite so that more
actually is eaten than usual.

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BRADYCARDIA
Did you notice your heart rate? BRADYCARDIA CHL6I07
Intensity
0 = No
Was it any different from usual?
Was it slowed down? 2 = Subject noticed slowing of pulse.

LY
N
O
EW
VI
RE
R
FO

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ALCOHOL
ALCOHOL USE
Include any use of alcohol (beer, wine, hard liquor), even EVER: ALCOHOL USE Ever:CHA3E01
with parental permission. Intensity
0 = Never drunk alcohol

Have you ever tried drinking alcohol? 2 = Has drunk alcohol at some time

CHA3O01 Ever:CHA3O01
What about hard liquor?

LY
/ /
What do you prefer to drink (beer, wine, liquor)?
When did you first try? ALCOHOL USE IN PP JJJ0I05
Intensity
Have you had any in the last 3 months? 0 = Absent

N
2 = Present
How many drinks per week have you had, on average, in
the last 3 months? NUMBER OF DRINKS (CODE AVG # OF CHA3I01
DRINKS/WEEK DURING LAST 3 MOS; 1

O
DRINK = 1 BOTTLE OF BEER; 1 GLASS
How often have you drank in the last 3 months? OF WINE; 1 SHOT OF SPIRITS
For example, how many times per week or month do you
drink? FREQUENCY OF DRINKING EPISODES CHA3F01

Do you usually drink alone or with others?

EW
Are you with others >50% of the time when you drink?
SOLITARY/ACCOMPANIED CHA3X01
0 = Solitary

2 = Often accompanied, but < 50% of the

time

3 = Accompained 50% or more of the time

VI

IF THE SUBJECT HAS DRUNK

RE

ALCOHOL, CONTINUE, OTHERWISE,

SKIP TO "DRUGS", (PAGE 18).
R
FO

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USE OF ALCOHOL WITHOUT PERMISSION

FROM A RESPONSIBLE ADULT
Drinking alcohol without permission from a responsible EVER: USE WITHOUT PERMISSION Ever:CHA4E01
adult, whether alcohol obtained legally or illegally. Intensity
0 = Has never drunk without permission

Have you ever drank alcohol without permission? 2 = Has drunk alcohol without permission at
some time
When was the first time you drank alcohol without USE WITHOUT PERMISSION CHA4I01

LY
permission? Intensity
0 = Has not drunk alcohol without
permission during last 3 months
What about in the last 3 months?
2 = Has drunk alcohol without permission
How many times in the last 3 months? during the last three months

N
CHA4F01
Frequency

O
Ever:CHA4O01
Onset
EW / /

DRINKING WEEKLY
Once a week for a month. EVER: USED WEEKLY Ever:CHA5E01
Intensity
0 = No
Has there ever been a period when you drank every
VI

week for a month or more? 2 = Yes

CHA5O01 Ever:CHA5O01
When did that start?
/ /
Have you drank at least once a week for a month or more
RE

in the last 3 months? USED WEEKLY IN LAST 3 MONTHS CHA5I01

Intensity
0 = No

2 = Yes

DRINKING DAILY
R

5 days per week for a month EVER: USED DAILY Ever:CHA6E01

Intensity
0 = No
FO

Has there ever been a period when you drank 5 or more

days per week for a month? 2 = Yes
When did that start? CHA6O01 Ever:CHA6O01

How about in the last 3 months? / /

USED DAILY IN LAST 3 MONTHS CHA6I01
Intensity
0 = No

2 = Yes

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BINGE DRINKING
Subject has during the last 3 months drank an amount of EVER: BINGE DRINKING Ever:alc0100
alcohol that was, in their opinion or in fact, in excess of Intensity
0 = No
what they could physically handle. The focus here is on the
amount drank, not the frequency of drinking. Binge drinking 2 = Yes
leading to physical illness (i.e. vomiting, blackouts) and/or
BINGE DRINKING IN LAST 3 MONTHS alc0105
negative social consequences (i.e. loss of judgement, Intensity
violence, sexually inappropriate behavior, driving under the 0 = No

LY
influence, etc.) The subject may or may not drink often, but
2 = Yes
at times drinks to a level that interferes with functioning.
alc0110
Have you ever drank alcohol to excess? Frequency

N
Do you have drinking "binges"?
ALC0115 Ever:alc0115
Do you, at times, drink more than you intended?
Has that caused you any problems? / /

O
Tell me about the last time that happened.
Have you done anything that you really regretted or felt bad
or embarrassed about as a result?
Have you vomited or passed out as a result?
Where does that happen?
When was the first time?
EW
Has that happened in the last 3 months?

How many times in the last 3 months?

VI

DRUNK
Subject's self-report of being "drunk". EVER DRUNK Ever:CHA8E01
Intensity
0 = No
Have you ever been "drunk"?
RE

2 = Yes
Have you been "drunk" in the last 3 months? DRUNK IN PP CHA8I01
Intensity
0 = No

2 = Yes
R
FO

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ALCOHOL INTOXICATION
Alcohol ingestion associated with any of the following INTOXICATION SCREEN CHA8I02
behavioral or psychological changes: slurred speech, Intensity
0 = No
incoordination, unsteady gait, nystagmus, flushed face.
2 = Yes
In the last 3 months, have you experienced any physical NUMBER OF TIMES DRUNK; CODE CHA8F01
effects from alcohol use? NUMBER OF TIMES DRUNK IN THE
PAST 3 MONTHS

LY
How many times?
NAUSEA; CODE NUMBER OF TIMES CHA8F02
How many times have you vomited because of drinking in VOMITED WHILE DRUNK IN THE PAST 3
the last 3 months? MONTHS

How many times have you passed out because of drinking PASSED OUT; CODE NUMBER OF CHA8F03

N
TIMES PASSED OUT WHILE DRUNK IN
in the last 3 months? PAST 3 MONTHS

Was your speech slurred? SLURRED SPEECH CHA9X01

O
How was your coordination? 0 = Absent

2 = Present
Did you have trouble walking straight?
Did you fall down at all? EW INCOORDINATION CHA9X02
Or bump into things?
Or knock anything over? 0 = Absent
Could you move your arms and hands properly? 2 = Present

Could you fix your eyes on things properly? UNSTEADY GAIT CHA9X03
0 = Absent
Or were they jerking about?
VI

2 = Present
Do you know if your face was red?
NYSTAGMUS CHA9X04
How many times in the last 3 months have you had any of 0 = Absent
these symptoms associated with drinking (signs of
RE

intoxication)? 2 = Present

FLUSHED FACE CHA9X05

When was the first time you had any of these symptoms
associated with drinking? 0 = Absent

Did you start to believe any strange or unusual things? 2 = Present

INTOXICATED IN LAST 3 MONTHS CHA9F01

R

CHA8O01 CHA8O01
FO

/ /
DELUSIONS CHL7I01
0 = Absent

2 = Present

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IF SUBJECT HAS BEEN INTOXICATED,

COMPLETE THIS SECTION,
OTHERWISE , SKIP TO "DRUGS",
(PAGE 18).

LY
N
O
EW
VI
RE
R
FO

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ALCOHOL INTOXICATON CONSEQUENCES

IF IN LAST 3 MOS. ALCOHOL WAS

USED FOR ANY 5 DAY PERIOD OR AT
LEAST 10 DAYS, OR INTOXICATED 2X
OR MORE; COMPLETE SECTION,
OTHERWISE, SKIP TO "DRUGS",
(PAGE 18).

LY
N
O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHL8E01
reduce his/her alcohol intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Do you want to cut down on how much alcohol you CHL8O01 Ever:CHL8O01
drink?
/ /

LY
Have you ever wanted to?
When was the first time?

ADVISED TO CUT DOWN

N
Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHL9E01
told or advised the subject to reduce his/her alcohol intake, Intensity
0 = Never advised by parents or others to
on at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
CHL9O01 Ever:CHL9O01
Who?
When was the first time? / /
EW
What do your parents, friends, and other loved ones think?

ATTEMPTS TO CUT DOWN

Actual efforts at reduced alcohol intake or abstention made, EVER: TRIED TO CUT DOWN Ever:CHM0E01
lasting at least 8 hours, but which proved unsuccessful at Intensity
0 = Has never made attempt to cut down.
VI

permanently reducing intake.

2 = Has made unsuccessful attempt at
some time to cut down.
Have you ever actually tried to cut down on how much
alcohol you drink? Ever:CHM0V01
Frequency
RE

Why was that?

How many times have you tried?
When was the first time?
What about in the last 3 months? CHM0O01 Ever:CHM0O01
For how long? / /
Did you substitute other substances while you were cutting
down on alcohol? CHM0I01
R

TRIED TO CUT DOWN

Intensity
0 = No attempt in last 3 months to cut
down.
FO

2 = Made attempt in last 3 months to cut

down.

DAYS CHM0D01
Duration

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ALCOHOL WITHDRAWAL
To be considered symptoms of withdrawal, symptoms must DRINKS OR USES ANOTHER Ever:CHM1I01
have occured within 5 days of ending (or reducing alcohol SUBSTANCE TO AVOID WITHDRAWAL Intensity
SYMPTOMS
intake during) a period of heavy ingestion of alcohol (that
lasted at least 3 days). 0 = No

2 = Yes
What happens if you cut down on how much alcohol
you drink?

LY
Tell me about the last time you cut down?
If you drink less than usual, what happens?

Do you notice any physical symptoms?

N
If yes, Do you drink any alcohol or use other drugs to
make "symptoms" go away?

O
Does it work?
What happens then?

IF WITHIN THE LAST 3 MONTHS THE

SUBJECT HAS HAD PERIODS OF
EW
REDUCED ALCOHOL INTAKE
ASSOCIATED WITH PHYSICAL
SYMPTOMS, SKIP TO "DRUGS", (PAGE
18).
VI
RE
R
FO

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TREMOR
Coarse peripheral tremor, occuring during periods of TREMOR CHM2I01
reduced alcohol intake (such as on rising in the morning) Intensity
0 = No
and relieved by alcohol or use of other substances.
2 = Yes
Did your hands (tongue, eyelids) shake?

Can you show me what it was like?

LY
When did that start?

NAUSEA/VOMITING
Nausea or vomiting, occuring during periods of reduced NAUSEA/VOMITING CHM2I02

N
alcohol intake (such as on rising in the morning) and Intensity
0 = No
relieved by alcohol or use of other substances (unless such
substances either not avaliable or withheld). 2 = Yes

O
Did you feel nauseous?

Did you vomit?

When did that start?
EW
AUTONOMIC HYPERACTIVITY
Signs of autonomic hyperactivity, such as sweating, AUTONOMIC HYPERACTIVITY CHM2I03
tachycardia, palpitations, increased respiratory rate, or Intensity
0 = No
flushing, associated with reduced alcohol intake (such as
VI

on rising in the morning) and relieved by alcohol or other 2 = Yes

substances (unless such substances either not available or
withheld).

Did you notice any other physical symptoms?

RE

Did you get sweaty?

Or notice your heart beating fast?
When did that start?

HEADACHE
R

Headache of any sort associated with reduced alcohol HEADACHE CHM2I04

intake (such as on rising in the morning) and relieved by Intensity
0 = No
FO

alcohol or other substances (unless such substances either

not available or withheld). 2 = Yes

Did you get a headache?

How long did it last?

When did it start?

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INSOMNIA
Initial, middle or terminal insomnia, of at least 1 hour INSOMNIA CHM2I05
duration, associated with reduced alcohol intake, and Intensity
0 = No
relieved by alcohol or other substances (unless such
substances either not available or withheld). 2 = Yes

Was your sleep affected?

LY
What happened?
When did that start?

ANXIETY ASSOCIATED WITH REDUCED

N
ALCOHOL INTAKE
Anxious affect associated with reduced alcohol intake ANXIETY CHM2I06
(such as on rising in the morning) and relieved by alcohol Intensity
0 = No

O
or other substances (unless such substances either not
available or withheld). 2 = Yes

Did you feel scared or anxious? EW

What was that like?
When did that start?

DEPRESSION ASSOCIATED WITH REDUCED

ALCOHOL INTAKE
VI

Low mood associated with reduced alcohol intake (such as DEPRESSION CHM2I07
on rising in the morning) and relieved by alcohol or other Intensity
0 = No
substances (unless such substances either not available or
withheld). 2 = Yes
RE

Did you feel depressed?

What was that like?

When did that start?

IRRITABILITY ASSOCIATED WITH REDUCED

R

ALCOHOL INTAKE
Irritability associated with reduced alcohol intake (such as IRRITABILITY CHM2I08
FO

on rising in the morning) and relieved by alcohol or other Intensity

0 = No
substances (unless such substances either not available or
withheld). 2 = Yes

Did you get irritable?

What was the like?

When did that start?

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PERCEPTUAL DISTORTIONS ASSOCIATED

WITH REDUCED ALCOHOL INTAKE
Transient hallucinations or illusions,associated with PERCEPTUAL DISTORTIONS CHM2I09
reduced alcohol intake (such as on rising in the morning) Intensity
0 = No
and relieved by alcohol or other substances (unless such
substances either not available or withheld). 2 = Yes

Did you see or hear any strange things?

LY
Did your imagination play any tricks on you?

Tell me about them.

N
SEIZURES
Grand mal seizures. SEIZURES CHM2I10
Intensity

O
0 = No
Did you have a seizure or fit?
2 = Yes
Did you have spasms?
Or lose consciousness?
EW
VI
RE
R
FO

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DRUG USE

Code all drugs (since the last interview) used

by the subject

DRUGS
Have you ever experimented with any drugs? DRUG USE Ever:CHBXXX 00
Intensity

LY
0 = No
What about with your friends?
Has anyone ever given you any drugs? 2 = Yes

What did you do?

I have a list of drugs here that you might have come

N
across. Is it OK if I ask you about them?

CANNABIS USE

O
Marijuana, weed, pot, grass, hash, Thai stick. CANNABIS USE Ever:CHB0E01
Intensity
0 = No
Have you ever tried smoking pot?
2 = Yes
Have you used marijuana in the last 3 months?
EW CANNABIS USE IN LAST 3 MONTHS CHB0I01
Intensity
When was the first time you ever used marijuana? 0 = No

2 = Yes

Ever:CHB0O01
Onset
VI

/ /

COCAINE USE
RE

Coke COCAINE USE Ever:CHB1E01

Intensity
0 = No
Have you ever tried cocaine?
2 = Yes
When did you first try? COCAINE USE CHB1I01
Intensity
R

Have you used it in the last 3 months? 0 = No

2 = Yes
FO

Ever:CHB1O01
Onset

/ /

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CRACK USE
Have you ever used Crack? CRACK USE Ever:CHB2E01
Intensity
0 = No
When did you first try it?
2 = Yes
Have you used crack in the last 3 months?
CRACK USE IN THE LAST 3 MONTHS CHB2I01
Intensity
0 = No

LY
2 = Yes

Ever:CHB2O01
Onset

/ /

N
O
IF CRACK USE ABSENT, SKIP TO
"AMPHETAMINE USE", (PAGE 20).
EW
VI
RE
R
FO

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AMPHETAMINE USE
Uppers, speed. AMPHETAMINE USE Ever:CHB3E01
Intensity
0 = No
Have you ever used amphetamines (speed, uppers)?
2 = Yes
When did you first try? AMPHETAMINE USE IN THE LAST 3 CHB3I01
MONTHS Intensity
Have you had any in the last 3 months?

LY
0 = No

2 = Yes

Ever:CHB3O01
Onset

/ /

N
O
ICE USE
Have you ever tried Ice? ICE USE Ever:CHB4E01
Intensity
0 = No
When did you first start? EW 2 = Yes
Have you had any in the last 3 months?
ICE USE IN THE LAST 3 MONTHS CHB4I01
Intensity
0 = No

2 = Yes

Ever:CHB4O01
Onset
VI

/ /
RE

METHAMPHETAMINE USE
Crystal Meth, Meth, Methamphetamine EVER: METHAMPHETAMINE USE Ever:ywn9000
Intensity
0 = No
Have you ever used crystal meth?
2 = Yes
Or any methamphetamine substance? METH USE IN PP ywn9001
When did you first try it?
R

Intensity
0 = No
Have you had any in the last 3 months?
2 = Yes
FO

Ever:ywn9002
Onset

/ /

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INHALANT USE
Glue, lighter fluid, petrol, paint sniffing. INHALANT USE Ever:CHB5E01
Intensity
0 = No
Have you ever tried inhalants?
2 = Yes
When did you first try it? INHALANT USE IN THE LAST 3 MONTHS CHB5I01
Intensity
How about in the last 3 months? 0 = No

LY
2 = Yes

Ever:CHB5O01
Onset

/ /

N
NITRITE INHALANT USE

O
Poppers NITRITE INHALANTS Ever:CHM4E01
Intensity
0 = No
Have you ever used nitrite inhalants or poppers?
EW 2 = Yes
When did it first start? NITRITE INHALANT USE IN THE LAST 3 CHM4I01
MONTHS Intensity
How about in the last 3 months?
0 = No

2 = Yes

Ever:CHM4O01
Onset
VI

/ /
RE

HEROIN USE
Heroin, smack HEROIN USE Ever:CHB6E01
Intensity
0 = No
Have you ever tried heroin?
2 = Yes
When did you first try it? HEROIN USE IN THE LAST 3 MONTHS CHB6I01
R

Intensity
Have you used it in the last 3 months? 0 = No

2 = Yes
FO

Ever:CHB6O01
Onset

/ /

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ECSTASY USE
Have you ever used ecstasy? EVER: ECSTASY USE Ever:ywn9100
Intensity
0 = No
When did you first try it?
2 = Yes
In the last 3 months?
ECSTASY USE IN PP ywn9102
Intensity
0 = No

LY
2 = Yes

Ever:ywn9101
Onset

/ /

N
OTHER OPIOID USE

O
Morphine,opium, codeine, other opioid pain killers. OTHER OPIOIDS USE Ever:CHB7E01
Intensity
0 = No
Have you tried any other opiods like morphine,
codeine, or other pain killers?
EW 2 = Yes

OTHER OPIOID USE IN LAST 3 MONTHS CHB7I01

When did you first try it? Intensity
0 = No
Have you had any in the last 3 months?
2 = Yes

Ever:CHB7O01
Onset
VI

/ /

OXYCODONE USE
RE

Oxy, Oxycotin, Oxycodone EVER: OXYCODONE USE Ever:ywn9105

Intensity
0 = No
Have you ever used Oxycodone (oxycotin, oxy)?
2 = Yes
When did you first try it? OXYCODONE USE IN PP ywn9106
Intensity
Have you had it in the last 3 months?
R

0 = No

2 = Yes

Ever:ywn9107
FO

Onset

/ /

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LSD USE
Have you ever used LSD? LSD USE Ever:CHB8E01
Intensity
0 = No
When did you first try it?
2 = Yes
Have you used it in the last 3 months?
LSD USE IN THE LAST 3 MONTHS CHB8I01
Intensity
0 = No

LY
2 = Yes

Ever:CHB8O01
Onset

/ /

N
PCP USE

O
Angel Dust PCP USE Ever:CHB9E01
Intensity
0 = No
Have you ever tried PCP or Angel Dust?
EW 2 = Yes
When did you first try? PCP USE IN THE LAST 3 MONTHS CHB9IO0100
Intensity
Have you had any in the last 3 months? 0 = No

2 = Yes

Ever:CHB9O01
Onset
VI

/ /

PSILOCYBIN USE
RE

Magic mushrooms PSILOCYBIN USE Ever:CHC0E01

Intensity
0 = No
Have you ever done shrooms?
2 = Yes
When did you first try it? PSILOCYBIN USE IN THE LAST 3 CHC0I01
MONTHS Intensity
Have you had any in the last 3 months?
R

0 = No

2 = Yes
FO

Ever:CHC0O01
Onset

/ /

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SEDATIVE USE
Downers, sleepers, barbs, Valium, Librium, Xanax, SEDATIVE USE Ever:CHC1E01
Klonopin Intensity
0 = No

Have you ever used sedatives like Xanex, Klonopin, or 2 = Yes

Valium? SEDATIVE USE IN THE LAST 3 MONTHS CHC1I01
Intensity
When did you first try it? 0 = No

LY
2 = Yes
Have you had any in the last 3 months?
Ever:CHC1O01
Onset

/ /

N
OTHER DRUG USE

O
Have you used anything else? OTHER DRUG USE Ever:CHC2E01
What was it? Intensity
0 = No
When did you first try it?
EW 2 = Yes
Have you had any "other drugs" in the last 3 months?
OTHER DRUG USE IN THE LAST 3 CHC2I01
MONTHS Intensity
0 = No

2 = Yes

Ever:CHC2O01
Onset
VI

/ /
RE
R
FO

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Definitions and questions Coding rules Codes

STERIOD USE
Have you ever used steroids? STERIOD USE Ever:CHC3E01
Intensity
0 = No
When did you first try it?
2 = Yes
Have you used them in the last 3 months?
STERIOD USE IN THE LAST 3 MONTHS CHC3I01
What is the longest period of time you used steroids? Intensity
0 = No

LY
How about in the last 3 months? 2 = Yes

Ever:CHC3O01
Onset

/ /

N
WEEKS Ever:CHC3D01

O
WEEKS CHC3D02

EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

DEALING DRUGS
The subject sells illegal drugs to others, gets others to sell EVER SOLD DRUGS Ever:CHC4I90
drugs for him/her, or gives drugs to others in exchange for Intensity
0 = No
goods(including weapons) and services (including sexual
favors). 2 = Yes

EVER: DEALT CANNABIS Ever:CHC4E01

ALSO CODE UNDER SUBSTANCE RELATED CRIME IN
THE MALADAPTIVE BEHAVIOR SECTION 2 = 1-5 occasions only

LY
3 = 6 or more occasions.
Have you ever sold/dealt drugs to anyone?
4 = As 3, but value of drugs> $1,000 over
last 12 mos.
Have you sold/dealt drugs in the last 3 months?
EVER: DEALT COCAINE, CRACK Ever:CHC4E02

N
Or gotten anyone else to sell drugs for you?
2 = 1-5 occasions only
Or given anyone drugs in exchange for something you 3 = 6 or more occasions.
wanted?

O
4 = As 3, but value of drugs> $1,000 over
What kind of drugs? last 12 mos.
How many times? EVER: AMPHETAMINES, ICE, METH Ever:CHC4E03
What were the drugs worth?
2 = 1-5 occasions only
Cannabis (Marijuana, weed, pot, grass)?
EW 3 = 6 or more occasions.

Cocaine or crack? 4 = As 3, but value of drugs> $1,000 over

last 12 mos.
Amphetamines (uppers, speed), Ice, or Meth?
EVER: DEALT HEROIN/OTHER Ever:CHC4E04
OPIODS/ECSTASY/OXYCODONE
Heroin, morphine, opium, other opioids?
VI

What about ecstasy or oxycodone? 2 = 1-5 occasions only

3 = 6 or more occasions.
LSD, PCP, or Magic Mushrooms?
4 = As 3, but value of drugs> $1,000 over
Sedatives (barbiturates) such as Xanex, Klonopin, or last 12 mos.
RE

Valium?
EVER: DEALT HALLUCINOGENS Ever:CHC4E05
When was the first time you ever sold any type of drug? 2 = 1-5 occasions only

What about in the last 3 months? 3 = 6 or more occasions.

4 = As 3, but value of drugs> $1,000 over

How much were the drugs worth that you sold in the last 3 last 12 mos.
R

months?
EVER: SEDATIVES Ever:CHC4E06
2 = 1-5 occasions only
FO

3 = 6 or more occasions.

4 = As 3, but value of drugs> $1,000 over

last 12 mos.

Ever:CHC4O01
Onset

/ /

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DEALT IN PP CHC4X02
Intensity
0 = No

2 = Yes

DEALT CANNABIS CHC4I01

2 = 1-5 occasions only

3 = 6 or more occasions.

LY
4 = As 3, but value of drugs> $1,000 over
last 12 mos.

DEALT COCAINE, CRACK CHC4I02

2 = 1-5 occasions only

N
3 = 6 or more occasions.

4 = As 3, but value of drugs> $1,000 over

last 12 mos.

O
DEALT AMPHETAMINES, ICE, METH CHC4I03
2 = 1-5 occasions only

3 = 6 or more occasions.
EW 4 = As 3, but value of drugs> $1,000 over
last 12 mos.

DEALT HEROIN/OTHER CHC4I04

OPIOIDS/ECSTASY/OXYCODONE

2 = 1-5 occasions only

VI

3 = 6 or more occasions.

4 = As 3, but value of drugs> $1,000 over

last 12 mos.

DEALT HALLUCINOGENS CHC4I05

RE

2 = 1-5 occasions only

3 = 6 or more occasions.

4 = As 3, but value of drugs> $1,000 over

last 12 mos.

DEALT SEDATIVES CHC4I06

R

2 = 1-5 occasions only

3 = 6 or more occasions.
FO

4 = As 3, but value of drugs> $1,000 over

last 12 mos.

VALUE OF DRUGS SOLD IN LAST 3 Ever:CHC4X01

MONTHS

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Definitions and questions Coding rules Codes

IF FOR ANY DRUG EVER USED,

COMPLETE SPECIFIC DRUG SECTION
ON THAT DRUG, OTHERWISE, SKIP TO
"SUBJECTIVE NEED FOR
"SUBSTANCE"", (PAGE 114).

LY
IF CANNABIS USE ABSENT, SKIP TO
"EVER: COCAINE USE WEEKLY",

N
(PAGE 35).

O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

CANNABIS SECTION

When questioning about drugs, substitute the

name the subject uses for them.

CANNABIS USE WEEKLY

Earlier you said that you have smoked marijuana... EVER: USED WEEKLY (AT LEAST 1 DAY Ever:CHC5E01
PER WEEK FOR A MONTH) Intensity

LY
Have you smoked pot as often as once a week? 0 = No

For as much as a straight month? 2 = Yes

Have you smoked pot weekly in the last 3 months?
Ever:CHC5O01
When did that start?
Onset

N
/ /
USED WEEKLY (AT LEAST 1 DAY PER CHC5I01

O
WEEK FOR A MONTH) IN THE LAST 3 Intensity
MONTHS

0 = No

2 = Yes
EW
CANNABIS USE DAILY
Have you ever used "marijuana" daily; at least 5 days a EVER: CANNABIS USE DAILY Ever:CHC6E01
week for a month or more? Intensity
0 = Absent

When did you start using at that level?

VI

2 = Present

Have you used "marijuana" daily in the last 3 months? Ever:CHC6O01

Onset

/ /
RE

CANNABIS USE DAILY IN PP CHC6I01

Intensity
0 = Absent

2 = Present
R
FO

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CANNABIS USE IN COMBINATION

Did you use alcohol with "marijuana" in the last 3 USED IN COMBINATION WITH CHC7I01
months? ALCOHOL Intensity
0 = No
How often was that?
2 = < 50% of the time
Did you use any other "drugs" with marijuana in the last 3
3 = > 50% of the time
months?
CHC7I02

LY
What other drugs? USED IN COMBINATION WITH DRUGS

1 = Cannabis

2 = Cocaine/Crack
CHC7I03
3 = Amphetamines/Ice/Meth

N
4 = Inhalants
CHC7I04
5 = Heroin/Ecstasy

O
6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin CHC7I05

EW 8 = Sedatives

9 = With more than one of the above

groups CHC7I06

CHC7I07
VI

CHC7I08

CHC7I09
RE

CHC7I10
R

EVER: CANNABIS INTOXICATION

Did/Do you get high when you used "marijuana"? EVER: CANNABIS INTOXICATION Ever:CHC8E01
FO

Intensity
0 = Absent
Did/Do you notice any physical effects?
2 = Present
What did you notice?
Ever:CHC8O01
When was the first time you got "high" or noticed physical Onset
effects from "marijuana"?
/ /

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CANNABIS INTOXICATION IN PP
Any of the following signs within 2 hours of using cannabis: INTOXICATED IN LAST 3 MONTHS CHC8I01
conjunctival injection, increased appetite, dry mouth, Intensity
0 = No
tachycardia.
2 = Has been intoxicated during the last 3
months
Have you had any physical effects in the last 3 months?
CHC8F01
How many times in the last 3 months have you been Frequency

LY
intoxicated from marijuana?

Did your eyes get bloodshot?

SIGNS OF INTOXICATION CHC8X01
Did you get a dry mouth? 1 = BloodShot Eyes

N
Did you notice your heart beating fast? 2 = Dry Mouth
CHC8X02
3 = Tachycardia
Did your appetite change at all? Was it bigger?

O
4 = Increased Appetite
How did you feel? CHC8X03

EW CHC8X04
VI
RE
R
FO

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CANNABIS INDUCED BEHAVIORAL CHANGES

This item applies to Cannabis use in the last 3 months. BEHAVIORAL CHANGES: CANNABIS JJJ0I07
Intensity
0 = Absent
Do/Did you feel really happy when you smoke(d) pot?
2 = Present
Do/Did you feel suspicious of people? ADDITIONAL BEHAVIORAL CHANGES CHC8X05
Does/Did time seem to be slowed down? 1 = Euphoria

LY
2 = Suspiciousness/Paranoid Ideation
Do/Did you feel anxious? CHC8X06
3 = Sensation of Slowed Time
Did you want to be with other people or did you get
withdrawn? 4 = Anxiety
CHC8X07

N
5 = Social Withdrawal
What was that like?
Did you seem to see, hear or feel strange things that 6 = Auditory, Tactile, or Visual Illusions
weren't really happening? 7 = Auditory, Tactile or Visual Hallicinations CHC8X08

O
Did you start to believe any strange or unusual things? 8 = Delusions

CHC8X09
EW CHC8X10

CHC8X11
VI

CHC8X12
RE

CANNABIS - DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHC9E01
reduce his/her cannabis intake. There is no requirement Intensity
0 = No desire to cut down
that s/he should have actually done so.
2 = Wishes to cut down
R

Do you want to cut down on how much "marijuana" Ever:CHC9O01

you smoke? Onset
FO

When was the first time you thought you wanted to cut / /
down?

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Definitions and questions Coding rules Codes

CANNABIS- ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHD0E01
told or advised the subject to reduce his/her cannabis Intensity
0 = Never advised by parents or others to
intake, on at least one occasion. cut down

2 = Advised to cut down

Has anyone ever told you that you should cut down?
Ever:CHD0O01
Who? Onset

LY
When was the first time?
What do those close to you think? / /

CANNABIS - ATTEMPTS TO CUT DOWN

N
Actual effort at reduced cannabis intake or abstention have EVER: TRIED TO CUT DOWN Ever:CHD1E01
been made, lasting, at least 8 hours, but which proved Intensity
0 = Has never made attempt to cut down.
unsuccessful at permanently reducing intake.

O
2 = Has made unsuccessful attempt at
some time to cut down.
Have you tried to cut down?
Ever:CHD1VO1
What happened? 00
How many times have you tried? Frequency
When did that start?
EW
How long did it last?
DAYS Ever:CHD1D01
Have you tried in the last 3 months? Duration

How long did that last?

VI

Ever:CHD1O01
Onset

/ /
RE

TRIED TO CUT DOWN CHD2I01

Intensity
0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHD2D01
R

Duration
FO

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CANNABIS TOLERANCE
The need for an increased intake of "marijuana" (by at least CANNABIS TOLERANCE ywn0111
50%) to produce previously experienced psychological or Intensity
0 = Does not show tolerance.
behavioral changes associated with marijuana use.
2 = Needs to use "substance" at least 50%
more than previously to obtain desired
***CODE ONLY IF IN THE LAST 3 MONTHS effect or can tolerate at least 50% more
than previously.
Do you need to use more "marijuana" than you used

LY
ywn0112
to, to have the same effect? Onset
Are you able to tolerate larger amounts than you used / /
to?

N
How much more does it take now?
When did you start needing more to get the effect you
wanted?

O
CANNABIS WITHDRAWAL
To be considered symptoms of withdrawal, symptoms must CANNABIS WITHDRAWAL ywn0113
have occurred within 5 days of ending (or reducing Intensity
EW
marijuana intake during) a period of heavy ingestion of
marijuana (lasting at least 3 days). Include symptoms such
0 = Withdrawal symptoms absent

2 = Withdrawal symptoms present

as tremor, nausea, vomiting, autonomic hyperactivity,
ywn0114
headache, stomach ache, and insomnia. Onset

What happens if you cut down on how much marijuana / /

you use?
VI

Tell me about the last time you cut down.

Do you notice any physical symptoms when you cut
down?
RE

Did your hands shake?

Did you have nausea or vomiting?
Were you sweating more or having a rapid heartbeat?
Did you have headache, stomachache, or trouble sleeping?
Do you smoke pot or use some other substance to
make those "symptoms" go away?
R

When was the first time you noticed these "symptoms"

when you tried to cut down?
FO

IF COCAINE/CRACK USE ABSENT,

SKIP TO "AMPHETAMINE", (PAGE 46).

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Definitions and questions Coding rules Codes

COCAINE SECTION

When questioning about drugs substitute the

subject's name for them.

EVER: COCAINE USE WEEKLY

You said you have used cocaine before... EVER: USED WEEKLY Ever:CHD3E01
Intensity

LY
0 = No
How often have you used it?
Have there been times when you have used it more than 2 = Yes
that?
Have you ever used it as often as once a week? Ever:CHD3O01
Onset

N
When did that start? / /
USED WEEKLY IN THE LAST 3 MONTHS CHD3I01
Intensity

O
0 = No

2 = Yes

COCAINE USE DAILY

Have you ever used cocaine on a daily basis?
EW EVER: COCAINE USE DAILY Ever:CHD4E01
Intensity
0 = Absent
Have you used cocaine for at least 5 days a week for a
month or more? 2 = Present

When did you start using at that level? Ever:CHD4O01

Onset
VI

Have you used cocaine daily in the last 3 months?

/ /
COCAINE USE DAILY IN PP CHD4I01
Intensity
RE

0 = Absent

2 = Present
R
FO

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CRACK SECTION

When questioning about drugs substitute the

subject's name for them.

CRACK
You said that you have used crack... USED WEEKLY (AT LEAST ONCE PER Ever:CHD5E01
WEEK FOR A MONTH) Intensity

LY
How often have you used it? 0 = No
Have there been times when you have used it more often
than that? 2 = Yes
Do you use it now? Ever:CHD5O01
Onset

N
How often in the last 3 months?
Have you used it as often as once a week for a straight / /
month?
USED WEEKLY (AT LEAST 1 DAY PER CHD5I01

O
When did that start? WEEK FOR A MONTH) IN LAST 3 Intensity
Have you used it as often as every day? MONTHS
Or more than that? 0 = No
When did that start?
What about in the last 3 months? 2 = Yes
EW USED DAILY Ever:CHD6E01
0 = No

2 = Yes

CHD6O01
Onset
VI

/ /
USED DAILY (AT LEAST 5 DAYS PER CHD6I01
WEEK FOR A MONTH) IN LAST 3
RE

MONTHS

0 = No

2 = Yes
R
FO

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MODE OF ADMINISTRATION
(COCAINE/CRACK)

Code the manner in which the drug has been

administered during the last three months. If
more than one method has been used, code
them all.

LY
NOTE LIFETIME CODING FOR
INJECTING/SHARING NEEDLES

COCAINE/CRACK ADMINISTRATION
How do you use it? MODE OF ADMINSTRATION Ever:CHD7X01

N
(COCAINE/CRACK) Intensity
What about snorting it? 0 = No
Do you smoke it?

O
What about freebasing? 2 = Yes
Have you injected it? COCAINE/ CRACK ADMINISTRATION Ever:CHD7I01
METHODS
What about during the last 3 months?
Have you shared a needle with anyone? EW 1 = Oral

2 = Smoked Ever:CHD7I02
Did you do anything to clean the needle?
What did you do? 3 = Freebased

4 = Snorted Ever:CHD7I03
5 = Injected: Subcutaneous/IM

6 = Injected: IV
VI

Ever:CHD7I04
Specify

Ever:CHD7I05
RE

Ever:CHD7I06

SHARED NEEDLES Ever:CHD7E03

R

0 = No

2 = Yes, with attempt at hygienic

FO

precautions

3 = Yes, without attempt at hygienic

precautions

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COCAINE/CRACK USE IN COMBINATION

Did you use anything else with "cocaine" in the last 3 USED IN COMBINATION WITH CHD8I01
months? ALCOHOL

0 = No
What?
What about alcohol? 2 = < 50% of the time
How often was that? 3 = > 50% of the time
When did that start?
CHD8X01

LY
USED IN COMBINATION WITH DRUGS
What other drugs have you used with cocaine/crack in the Intensity
0 = No
last 3 months?
2 = Yes

COCAINE/CRACK USED IN CHD8I02

N
COMBINATION WITH OTHER DRUGS

1 = Cannabis

2 = Cocaine/Crack CHD8I03

O
3 = Amphetamines/Ice/Meth

4 = Inhalants CHD8I04
5 = Heroin/Ecstasy
EW 6 = Opiods/Oxycodone
CHD8I05
7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above CHD8I06

groups
VI

Specify
CHD8I07
RE

CHD8I08

CHD8I09
R

CHD8I10
FO

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COCAINE INTOXICATION
Any of the following signs within 2 hours of using cocaine: COCAINE INTOXICATION Ever:CHD9E01
tachycardia, pupillary dilation, perspriation or chillls, nausea Intensity
0 = No
or vomiting, agitation or retardation, chest pains, confusion
or seizures, unconsciousness or neuromuscular problems. 2 = Has been intoxicated at some time

Ever:CHD9O01
Do you get high when you use "cocaine"? Onset

/ /

LY
What is that like?
Have you ever noticed any physical effects when you
used "cocaine"? INTOXICATED IN LAST 3 MONTHS CHD9I01
Intensity
0 = No
Or have any chills?

N
2 = Has been intoxicated during the last 3
What did you notice? months
When did you first notice that?
CHD9F01
What about during the last 3 months? Frequency

O
How often?
Did you notice your heart beating fast?

Did your heart beat irregularly? EW TACHYCARDIA/ARRHYTHMIA CHD9X01

0 = No
Did you get any chest pain?
2 = Yes
Did you feel nauseous ?
CHEST PAIN CHD9X11
Or vomit?
0 = No
Did you get sweaty? 2 = Yes
VI

Or have any chills? NAUSEA/VOMITING CHD9X02

0 = No
Did anyone notice that your pupils were bigger than
usual? 2 = Yes
RE

Did you notice any problems with your movements? SWEATING CHD9X03
0 = No
Like not being able to control your movements properly?
Did you get delirious on "cocaine"? 2 = Yes

CHILLS CHD9X13
Did you pass out?
R

0 = No
Did you have a fit or seizure?
2 = Yes
How did you feel? PUPILLARY DILATION CHD9X04
FO

Do you feel really happy? 0 = No

Did you get agitated?
2 = Yes

Or get slowed down in your movements? NEUROMUSCULAR PROBLEMS CHD9X15

What was that like? 0 = No

Were you moving around a lot? 2 = Yes
Did you feel nervous or worried about what was going
on around you?

Did you feel that something bad might be going on?

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Did you find yourself keeping a sharp lookout on what CONFUSION CHD9X16
was going on? 0 = No

Did you get suspicious about anything? 2 = Yes

Did you start to feel important? UNCONSIOUSNESS CHD9X17

0 = No
Or that you were a really powerful person?
2 = Yes

LY
Or feel that you could do things that you couldn't usually
SEIZURES CHD9X18
do?
Did you see or hear anything that wasn't really there? 0 = No

Did you start to believe any strange or unusual things? 2 = Yes

N
EUPHORIA CHD9X06
0 = No

2 = Yes

O
PSYCHOMOTOR AGITATION CHD9X07
0 = No

2 = Yes
EW PSYCHOMOTOR RETARDATION CHD9X19
0 = No

2 = Yes

HYPERVIGILANCE CHD9X08
VI

0 = No

2 = Yes

GRANDIOSITY CHD9X09
RE

0 = No

2 = Yes

HALLUCINATIONS CHD9X05
0 = No

2 = Yes
R

DELUSIONS CHD9X10
0 = No
FO

2 = Yes

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IF THE SUBJECT HAS BEEN

HYPERVIGILANT, UNDULY
SUSPICIOUS, AGITATED, OR
GRANDIOSE, PROBE FOR
DELUSIONAL SYNDROME. MAKE A
NOTE HERE THAT "COCAINE" ABUSE
HAS BEEN PRECIPITANT OF

LY
PSYCHOTIC SYMPTOMS. IF IN THE
PAST 3 MONTHS THE SUBJECT HAS
USED COCAINE OR CRACK DAILY
FOR ANY 5 DAY PERIOD, OR USED ON
AT LEAST 10 DAYS, OR BEEN

N
INTOXICATED AT LEAST 2 TIMES,
COMPLETE DESIRE TO CUT DOWN
AND MALADAPTIVE BEHAVIOR

O
SECTION. EVIDENCE OF ADDITIONAL
BEHAVIORAL CHANGE(S) ALSO
REQUIRES COMPLETION OF EW
MALADAPTIVE SECTION. OTHERWISE,
SKIP TO NEXT DRUG.
IF , SKIP TO "AMPHETAMINE", (PAGE
46).
VI
RE
R
FO

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COCAINE: DESIRE TO CUT DOWN

Tthe subject has at certain times felt that s/he would like to COCAINE: DESIRE TO CUT DOWN Ever:CHE0E01
reduce his/her cocaine/crack intake. There is no Intensity
0 = No desire to cut down
requirement that s/he should have actually done so.
2 = Wishes to cut down
Do you want to cut down on how much you use Ever:CHE0O01
"cocaine'? Onset

/ /

LY
Have you ever wanted to?
When was that?

COCAINE: ADVISED TO CUT DOWN

N
Parents, loved ones, friends, professionals, or others have COCAINE: ADVISED TO CUT DOWN Ever:CHE1E01
told or advised the subject to reduce his/her cocaine/crack Intensity
0 = Never advised by parents or others to
intake, on at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHE1O01
Who? Onset
When was the first time?
/ /
What do those people close to you think?
EW
VI
RE
R
FO

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COCAINE: ATTEMPTS TO CUT DOWN

Actual effort at reduced cocaine/crack intake or abstention COCAINE: TRIED TO CUT DOWN Ever:CHE2E01
made, lasting at least 8 hours, but which proved Intensity
0 = Has never made attempt to cut down.
unsuccessful at permanently reducing intake.
2 = Has made unsuccessful attempt at
some time to cut down.
Have you ever tried to cut down?
Ever:CHE2V01
Why was that? Frequency

LY
How many times have you tried?
When was the first time?
What about during the last 3 months?
How long did it last? DAYS Ever:CHE2D01
Duration

N
Ever:CHE2O01
Onset

O
/ /
TRIED TO CUT DOWN IN LAST THREE CHE3I01
MONTHS Intensity
EW 0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHE3D01
Duration
VI
RE
R
FO

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Definitions and questions Coding rules Codes

COCAINE WITHDRAWAL
To be considered symptoms of withdrawal, the following COCAINE WITHDRAWAL Ever:CHE4X01
symptoms must have occurred within 8 hours of ending (or Intensity
0 = Absent
reducing the amount of cocaine ingested during) a period
of heavy ingestion of cocaine/crack (that lasted at least 3 2 = Present
days).
LAST 3 MONTHS CHE4X02
Intensity
What happens if you cut down on your "cocaine" use? 0 = Absent

LY
2 = Present
Tell me about the last time you cut down.
Did you notice any physical symptoms? FATIGUE CHE4I01
0 = Absent
What happened?
Did you use cocaine or other substances to get the

N
2 = Tiredness or lassitude to a degree
symptoms to go away? greater than normal
Did it work?
INSOMNIA CHE4I02
What happened then?

O
When you cut down did you feel tired? 0 = Absent

2 = If the insomnia covers a period between

Was it bad enough to interfere with what you wanted to do? 1 and 2 hours.
Could you do anything or did you take anything to get
yourself going? 3 = If its duration is greater than or equal to
Did it affect your sleep?
EW 2 hours per night.

HYPERSOMNIA CHE4I05
Did it affect your dreams?
0 = Absent
Or your appetite?
2 = Hypersomnia occurs in at least 2
activities and is at least sometimes
Were you slowed down in your movements? uncontrollable.
VI

Or did you move around alot? 3 = Hypersomnia occurs in nearly all

activities and is nearly always
uncontrollable.
Did you have an increase in anxiety or depression or
irritability? UNPLEASANT DREAMS CHE4I06
RE

2 = Unpleasant Dreams

3 = Nightmares

INCREASED APPETITE CHE4I07

0 = No
R

2 = Yes

PSYCHOMOTOR RETARDATION OR CHE4I03

AGITATION
FO

0 = No

2 = Yes

DYSPHORIC MOOD CHE4I04

0 = Absent

2 = Increased depression and/or irritability

and/or anxiety

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IF AMPHETAMINE/ICE/METH USE
ABSENT, SKIP TO "INHALANT", (PAGE
59).

LY
N
O
EW
VI
RE
R
FO

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AMPHETAMINE, ICE, METHAMPHETAMINE

SECTION
AMPHETAMINE
IF SUBJECT USED ONLY "ICE" OR "METH", MARK THIS EVER: USED WEEKLY Ever:CHE5E01
PAGE AS STRUCTURALLY MISSING AND CONTINUE. Intensity
0 = No

You said that you have used amphetamines... 2 = Yes

LY
Ever:CHE5O01
How often have you used it? Onset
Have you ever used amphetamines as often as once / /
per week for a month?
USED WEEKLY IN LAST 3 MONTHS CHE5I01

N
When did that start? Intensity
0 = No
Have you ever used amphetamines on a daily basis?
2 = Yes
For how long?

O
Have you used at a level of 5 days a week for a month EVER: USED DAILY Ever:CHE6E01
or more? 0 = No

When did that start? EW 2 = Yes

How often have you used in the last 3 months?
CHE6O01
Onset

/ /
USED DAILY IN LAST 3 MONTHS CHE6I01
0 = No
VI

2 = Yes
RE
R
FO

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ICE
IF SUBJECT DID NOT USE "ICE", MARK AS EVER: USED WEEKLY Ever:CHE7E01
STRUCTURALLY MISSING. Intensity
0 = No

Have you ever used Ice as often as once per week for a 2 = Yes
month? Ever:CHE7O01
Onset
When did that start?
/ /

LY
Have you ever used Ice daily?

For how long? USED WEEKLY IN LAST 3 MONTHS CHE7I01

How often have you used Ice in the last 3 months? Intensity
0 = No
When did you start using on at least 5 days per week for a
month or more?

N
2 = Yes

EVER: USED DAILY Ever:CHE8E01

0 = No

O
2 = Yes

CHE8O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHE8I01
0 = No

2 = Yes
VI
RE
R
FO

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METHAMPHETAMINE
IF SUBJECT DID NOT USE METHAMPHETAMINE, MARK EVER: USED WEEKLY Ever:ywn0200
AS STRUCTURALLY MISSING. Intensity
0 = No

Have you used methamphetamines as often as once a 2 = Yes

week for a month or more? Ever:ywn0201
Onset
When did that start?
/ /

LY
Have you used that often in the last 3 months?
Have you ever used meth as often as 5 days per week
for a month or more? USED WEEKLY IN LAST 3 MONTHS ywn0202
Intensity
0 = No
When did that start?
How often have you used meth in the last 3 months?

N
2 = Yes

EVER: USED DAILY Ever:ywn0331

0 = No

O
2 = Yes

ywn0301
EW Onset

/ /
USED DAILY IN LAST THREE MONTHS ywn0302
0 = No

2 = Yes
VI
RE
R
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MODE OF ADMINISTRATION
(AMPHETAMINE/ICE/METHAMPHETAMINE)
ADMINISTRATION
(AMPHETAMINE/ICE/METHAMPHETAMINE)
Code the manner in which the drug has been administered USE OF AMPHETAMINES/ICE/METH IN CHE9X01
during the last three months. If more than one method has PP Intensity
been used, code them all. 0 = No

LY
2 = Yes
NOTE: LIFETIME CODING FOR INJECTING/SHARING
NEEDLES. ORAL CHE9I01
0 = No
N.B. ASK IF PILLS HAVE BEEN CRUSHED, DISSOLVED,
OR SUSPENDED, AND THEN INJECTED. 2 = Yes

N
INHALED CHE9I02
You said that you have used amphetamines/ice/meth in
the last 3 months, now I am going to ask you a little 0 = No

O
more about that. 2 = Yes

How did you take it? EVER: INJECTED: SUBCUTANEOUS/IM CHE9E01

0 = No
Was it a pill that you swallowed?
Did you inhale it?
Have you ever injected it?
EW 2 = Yes

INJECTED IN LAST 3 MONTHS: CHE9I03

SUBCUTANEOUS/IM
What about in the last 3 months?
Did you inject it into the muscle or into a vein? 0 = No
Did you ever share a needle with anyone?
2 = Yes
VI

Did you do anything to clean the needle? What? EVER: INJECTED: IV CHE9E02
Have you shared a needle in the last 3 months?
0 = No

2 = Yes
RE

INJECTED IN LAST 3 MONTHS: IV CHE9I04

0 = No

2 = Yes

EVER: SHARED NEEDLES CHE9E03

R

0 = No

2 = Yes, with attempt at hygienic

precautions
FO

3 = Yes, without attempt at hygienic

precautions

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USE IN COMBINATION
(AMPHETAMINE/ICE/METH)
Did you use anything else when you used USED IN COMBINATION PP CHE9X05
amphetamines, ice or meth in the last 3 months? Intensity
0 = No

What was it? 2 = Yes

What about alcohol?
Did you use something else with it more or less than 50% USED IN COMBINATION WITH CHE9I05
ALCOHOL

LY
of the time?
0 = No

2 = < 50% of the time

3 = > 50% of the time

N
USED IN COMBINATION WITH DRUGS CHE9I06
1 = Cannabis

O
2 = Cocaine/Crack
CHE9I07
3 = Amphetamines/Ice/Meth

4 = Inhalants
CHE9I08
5 = Heroin/Ecstasy
EW 6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin CHE9I09
8 = Sedatives

9 = With more than one of the above

groups CHE9I10
VI

CHE9I11
RE

CHE9I12

CHE9I13
R

CHE9I14
FO

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INTOXICATION (AMPHETAMINE/ICE/METH)
Any of the following signs within 2 hours of using EVER: INTOXICATED Ever:CHF0E01
amphetamine/ice/meth: tachycardia, pupillary dilation, Intensity
0 = No
perspiration or chills, nausea or vomiting, agitation,
retardation, chest pains, confusion, convulsion or seizure, 2 = Has been intoxicated at some time
unconsciousness, or neuromuscular problems,
Ever:CHF0O01
suspicousness or paranoia, facial sores or skin lesions. Onset

/ /

LY
Have you ever noticed any physical effects when you
used amphetamines/ice/meth?
INTOXICATED IN LAST 3 MONTHS CHF0I01
What did you notice? Intensity
0 = No
When was the first time you noticed that?

N
What about during the last 3 months? 2 = Has been intoxicated during the last 3
months
How often, in the last 3 months, have you had any of those
effects when you used? CHF0F01
Did you notice your heart beating fast? Frequency

O
Was your heartbeat irregular?

Did you get any chest pain? EW TACHYCARDIA/ARRHYTHMIA CHF0X01

0 = No
Did you feel nauseous?
2 = Yes
Did you vomit?
CHEST PAIN CHF0X12
Did you get sweaty? 0 = No

Or have chills? 2 = Yes

VI

Did anyone notice that your pupils were bigger than NAUSEA/VOMITING CHF0X05
usual? 0 = No

Did you notice any problems with your movements? 2 = Yes

RE

SWEATING CHF0X03
Like not being able to control your movements properly?
Did you get delirious on "amphetamines, ice or meth"? 0 = No

2 = Yes
Did you pass out?
CHILLS CHF0X04
Did you have a seizure or convulsions?
R

0 = No
Did you become suspicious or paranoid around other
2 = Yes
people?
PUPILLARY DILATION CHF0X02
FO

Did you get sores on your face or skin?

0 = No

2 = Yes

NEUROMUSCULAR PROBLEMS CHF0X13

0 = No

2 = Yes

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CONFUSION CHF0X14
0 = No

2 = Yes

UNCONCIOUSNESS CHF0X15
0 = No

2 = Yes

LY
SEIZURE/CONVULSIONS CHF0X16
0 = No

2 = Yes

N
SUSPICION/PARANOIA ywn9991
0 = No

2 = Yes

O
SORES/LESIONS ywn9992
0 = No

2 = Yes
EW
VI
RE
R
FO

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AMPHETAMINE INDUCED BEHAVIORAL

CHANGES
CODE FOR THE PAST 3 MONTHS. BEHAVIORAL CHANGES IN PP CHF0I99
Intensity
0 = Absent
IF THE SUBJECT HAS BEEN HYPERVIGILANT, UNDULY
SUSPICIOUS, AGITATED, OR GRANDIOSE, PROBE 2 = Present
FOR DELUSIONAL SYNDROME. EUPHORIA CHF0X06

LY
0 = No
MAKE A NOTE HERE THAT AMPHETAMINE/ICE/METH
ABUSE HAS BEEN PRECIPITANT OF PSYCHOTIC 2 = Yes
SYMPTOMS.
PSYCHOMOTOR AGITATION CHF0X07

How did you feel? 0 = No

N
2 = Yes
Did you feel really happy?
Did you get agitated? PSYCHOMOTOR RETARDATION CHF0X17

O
Or get slowed down in your movements? 0 = No

2 = Yes
What was that like?
Were you moving around alot or having trouble
EW HYPERVIGILANCE CHF0X08
keeping still?
0 = No

Did you feel nervous or worried about what was going 2 = Yes
on around you?
GRANDIOSITY CHF0X09
Did you feel that something bad might be going on? 0 = No

Did you keep a sharp lookout for what was going on? 2 = Yes
VI

Did you start to feel really important?

HALLUCINATIONS CHF0X10
Or that you were more powerful than usual and could 0 = No
do unusual things?
2 = Yes
RE

Did you see or hear anything that wasn't really there? DELUSIONS CHF0X11
Did you start to believe any strange or unusual things? 0 = No

2 = Yes
R
FO

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IF THE SUBJECT HAS BEEN

HYPERVIGILANT, UNDULY
SUSPICIOUS, AGITATED, OR
GRANDIOSE, PROBE FOR
DELUSIONAL SYNDROME. MAKE A
NOTE HERE THAT AMPHETAMINE
ABUSE HAS BEEN PRECIPITANT OF

LY
PSYCHOTIC SYMPTOMS. IF DURING
THE LAST 3 MONTHS SUBJECT HAS
USED SUBSTANCE DAILY FOR ANY 5
DAY PERIOD, OR HAS USED AT LEAST
10 DAYS, OR BEEN INTOXICATED AT

N
LEAST 2 TIMES, COMPLETE DESIRE
TO CUT DOWN AND MALADAPTIVE
BEHAVIOR. EVIDENCE OF

O
ADDITIONAL BEHAVIORAL CHANGE(S)
ALSO REQUIRES COMPLETION OF
MALADAPTIVE BEHAVIOR SECTION. EW
OTHERWISE, SKIP TO NEXT DRUG.
IF IF DURING THE LAST 3 MONTHS
SUBJECT HAS USED AMPHETAMINE
DAILY...OTHERWISE, SKIP TO
"INHALANT", (PAGE 59).
VI
RE
R
FO

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AMPHETAMINE/ICE/METH: DESIRE TO CUT

DOWN
The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHF1E01
reduce his/her amphetamine/ice/meth intake. There is no Intensity
0 = No desire to cut down
requirement that s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHF1O01
use amphetamines, ice, or meth? Onset

LY
When did you first feel that way? / /

AMPHETAMINE/ICE/METH: ADVISED TO CUT

N
DOWN
Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHF2E01
told or advised the subject to reduce his/her Intensity
0 = Never advised by parents or others to

O
amphetamine/ice/meth intake, on at least one occasion. cut down

2 = Advised to cut down

Has anyone told you that you should cut down?
Ever:CHF2O01
Who? Onset
When was the first time?
What do those who care about you think?
EW / /
VI
RE
R
FO

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AMPHETAMINE/ICE/METH: ATTEMPTS TO CUT

DOWN
Actual effort at reduced amphetamine, ice, or meth intake EVER: TRIED TO CUT DOWN Ever:CHF3E01
or abstention made, lasting at least 8 hours, but which Intensity
0 = Has never made attempt to cut down.
proved unsuccessful at permanently reducing intake.
2 = Has made unsuccessful attempt at
some time to cut down.
Have you ever actually tried to cut down?
Ever:CHF3V01

LY
What happened? Frequency
How many times have you tried?
When was the first time?
Have you tried in the last 3 months?
For how long did you cut down? DAYS Ever:CHF3D01
Duration

N
Ever:CHF3O01

O
Onset

/ /
TRIED TO CUT DOWN IN PP CHF4I01
EW 0 = No attempt in last 3 months to cut
down.
Intensity

2 = Made attempt in last 3 months to cut

down.

DAYS CHF4D01
Duration
VI
RE
R
FO

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AMPHETAMINE/ICE/METH WITHDRAWAL
To be considered symptoms of withdrawal, the following AMPHETAMINE WITHDRAWAL CHF5X01
symptoms must have occurred within 8 hours of ending (or Intensity
0 = No
reducing the amount of amphetamine, ice, or meth
ingested during) a period of heavy ingestion of 2 = Yes
amphetamine, ice or meth (that lasted at least 3 days).
FATIGUE CHF5I01

What happens if you cut down on your amphetamines, 0 = Absent

LY
ice, or meth? 2 = Tiredness or lassitude to a degree
greater than normal
Tell me about the last time you cut down.
Did you notice any physical symptoms? INSOMNIA CHF5I02
0 = Absent
What happened?

N
Did you use amphetamines to make the "symptoms" go 2 = If the insomnia covers a period between
away? 1 and 2 hours.
Did it work? 3 = If its duration is greater than or equal to

O
When you cut down, did you feel tired? 2 hours per night.

Did it interfere with what you wanted to do? HYPERSOMNIA CHF5I03

Could you do anything to get yourself going? 0 = Absent
Did it affect your sleep?

In what way?
EW 2 = Hypersomnia occurs in at least 2
activities and is at least sometimes
uncontrollable.
Did it affect your dreams?
3 = Hypersomnia occurs in nearly all
Or your appetite? activities and is nearly always
uncontrollable.
Were you slowed down in your movements? UNPLEASANT DREAMS CHF5I04
VI

Or did you move around alot? 2 = Unpleasant Dreams

3 = Nightmares
Did you notice that you were more depressed or
irritable than usual? INCREASED APPETITE CHF5I05
RE

0 = No

2 = Yes

PSYCHOMOTOR RETARDATION OR CHF5I06

AGITATION

0 = No
R

2 = Yes

DYSPHORIC MOOD CHF5I07

FO

0 = Absent

2 = Increased depression and/or irritability

and/or anxiety

IF INHALENT/NITRITE INHALENT USE

ABSENT, SKIP TO
"HEROIN/ECSTASY", (PAGE 69).

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LY
N
O
EW
VI
RE
R
FO

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INHALANT/NITRITE INHALANT SECTION

INHALANT
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHF6E01
THE SUBJECT'S NAMES FOR THEM. Intensity
0 = No

You said that you have used inhalants... 2 = Yes

Ever:CHF6O01
Have you ever tried sniffing gas or glue?

LY
Onset
Have you ever sniffed anything else like paint thinner, / /
correction fluid, or markers?
USED WEEKLY IN LAST 3 MONTHS CHF6I01
What all things have you used as an inhalant? Intensity

N
0 = No
Have you ever used inhalants as much as once a week
for a month? 2 = Yes

When did that start? EVER: USED DAILY Ever:CHF7E01

O
Have you ever used it as often as 5 days per week for a 0 = No
month or more?
2 = Yes
When did that start?
CHF7O01
How often have you used inhalants in the last 3 months?
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHF7I01
0 = No
VI

2 = Yes
RE
R
FO

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INHALANT USE IN COMBINATION

Did you use anything else with the inhalants in the last INHALANT USE IN PP CHF8X01
3 months? Intensity
0 = Absent

Did you use alcohol with the inhalants? 2 = Present

Or some other drug?
What was it? USED IN COMBINATION WITH CHF8I01
ALCOHOL
How often was that?

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

USED IN COMBINATION WITH DRUGS CHF8I02

N
1 = Cannabis

2 = Cocaine/Crack

O
3 = Amphetamines/Ice/Meth

4 = Inhalants

EW 5 = Heroin/Ecstasy

6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
FO

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INHALANT INTOXICATION
Any of the following signs within 2 hours of using inhalant: EVER: INTOXICATED Ever:CHF9E01
dizziness, slurred speech, tremor, unsteady gait, Intensity
0 = No
incoordination, lethargy, psychomotor retardation,
generalized muscle weakness, nystagmus, blurred 2 = Has been intoxicated at some time
vision/diplopia, euphoria, stupor/unconciousness.
Ever:CHF9O01
Onset
Did you get high when you used inhalants?
/ /

LY
What about in the last 3 months?
What is that like? INTOXICATED IN LAST 3 MONTHS CHF9I01
Have you ever noticed any physical effects? Intensity
0 = No

What did you notice?

N
2 = Has been intoxicated during the last 3
When did that start? months
How many times in the last 3 months have you been "high" CHF9F01
from it? Frequency

O
Did you get dizzy?

Was your speech affected?

DIZZINESS CHF9X01
What was it like?
Did your hands shake?
EW 0 = Absent

2 = Present
Was your balance affected?
SLURRED SPEECH CHF9X02
Were you unsteady on your feet? 0 = Absent

Could you control your movements properly? 2 = Present

VI

Was your energy affected? TREMOR CHF9X03

0 = Absent
In what way?
Were your movements slowed down at all? 2 = Present
RE

UNSTEADY GAIT CHF9X04

Did you feel weak?
0 = Absent
Did you actually lose power in your muscles?
2 = Present
Could you fix your eyes on things properly?
INCOORDINATION CHF9X05
Or were they jerking about?
R

0 = Absent
Was your vision affected?
2 = Present
Was it blurred? LETHARGY CHF9X06
FO

Did you have double vision at any time?

Did you feel really happy? 0 = Absent

2 = Present
Did you lose conciousness?
PSYCHOMOTOR RETARDATION CHF9X07
0 = Absent

2 = Present

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GENERALIZED MUSCLE WEAKNESS CHF9X08

0 = Absent

2 = Present

NYSTAGMUS CHF9X09
0 = Absent

2 = Present

LY
BLURRED VISION/DIPLOPIA CHF9X10
0 = Absent

2 = Present

N
EUPHORIA CHF9X11
0 = Absent

2 = Present

O
STUPOR/UNCONCIOUSNESS CHF9X12
0 = Absent

2 = Present
EW DELUSIONS CHM3I01
0 = Absent

2 = Present
VI

IF DURING THE LAST 3 MONTHS

SUBJECT HAS USED SUBSTANCE
DAILY FOR ANY 5 DAY PERIOD, OR
RE

HAS USED AT LEAST 10 DAYS, OR

BEEN INTOXICATED AT LEAST 2
TIMES, COMPLETE DESIRE TO CUT
DOWN AND MALADAPTIVE BEHAVIOR.
EVIDENCE OF ADDITIONAL
BEHAVIORAL CHANGE(S) REQUIRES
R

COMPLETION OF MALADAPTIVE
SECTION. OTHERWISE SKIP TO NEXT
DRUG.
FO

IF IF SUBJECT HAS USED INHALANT

FOR ANY 5 DAY
PERIOD...OTHERWISE,, SKIP TO
"NITRITE INHALANT", (PAGE 66).

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INHALANT: DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CGH0E01
reduce his/her inhalant intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Do you want to cut down on how much you use Ever:CHG0O01
inhalants? Onset

/ /

LY
When was the first time you wanted to?

INHALANT: ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHG1E01

N
told or advised the subject to reduce his/her inhalant intake, Intensity
0 = Never advised by parents or others to
on at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHG1O01
Who? Onset
What do your loved ones and parents think?
When was the first time someone told you that you should
EW / /
cut down?
VI
RE
R
FO

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INHALANT: ATTEMPTS TO CUT DOWN

Actual effort at reduced inhalant intake or abstention has EVER: TRIED TO CUT DOWN Ever:CHG2E01
been made, lasting at least 8 hours, but proving Intensity
0 = No attempt in last 3 months to cut
unsuccessful at permanently reducing intake. down.

2 = Made attempt in last 3 months to cut

Have you ever tried to cut down? down.

What happened? Ever:CHG2V01

LY
How many times have you tried? Frequency
What's the longest period of time that you managed to cut
down?
Have you tried to cut down in the last 3 months?
DAYS Ever:CHG2D01
When did you first try to cut down? Duration

N
How long did that last?

Ever:CHG2O01

O
Onset

/ /
EW TRIED TO CUT DOWN CHG3I01
Intensity
0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHG3D01
Duration
VI
RE
R
FO

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INHALANT WITHDRAWAL
To be considered symptoms of withdrawal, the following WITHDRAWAL IN PP CHG4X04
symptoms must have occurred within 8 hours of ending (or Intensity
0 = Absent
reducing the amount of inhalant ingested during) a period
of heavy ingestion of inhalant (that lasted at least 3 days). 2 = Present

FATIGUE CHG4I01
What happens if you cut down on you inhalant use?
0 = Absent

LY
Tell me about the last time you cut down. 2 = Tiredness or lassitude to a degree
Do you notice any physical symptoms? greater than normal

What kind? INSOMNIA CHG4I02

Did you use inhalant or other substances to make the 0 = Absent
symptoms go away?

N
What happened then, did it work? 2 = If the insomnia covers a period between
When you cut down did you feel tired? 1 and 2 hours.

3 = If its duration is greater than or equal to

O
Was it bad enough to interfere with what you wanted to do? 2 hours per night.
Could you do anything or did you take anything to get
yourself going? AGITATION CHG4I03
Did it affect your sleep? EW 0 = Absent

What happened to your sleep? 2 = Agitation is present in at least 2

activities and cannot be entirely controlled,
Did you get agitated? but sometimes the subject can inhibit
his/her agitation with effort.
What was that like?
What do you do about it? 3 = Agitation almost entirely uncontrollable.
How long did it last?
VI
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NITRITE INHALANT
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHM5E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

Have you ever tried poppers? 2 = Yes

Ever:CHM5O01
When was the first time? Onset
How often?
/ /

LY
Do you use poppers now, in the last 3 months?
Have you ever used it as often as once a week, for a
month or more? USED WEEKLY IN LAST 3 MONTHS CHM5I01
Intensity
0 = No
When did that start?
Have you ever used it as often as 5 days a week, for a

N
2 = Yes
month or more?
EVER: USED DAILY Ever:CHM6E01
When did you start using at that level? 0 = No

O
How about in the last 3 months, how much are you using?
2 = Yes

CHM6O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHM6I01
0 = No

2 = Yes
VI
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NITRITE INHALANT: USE IN COMBINATION

Did you use anything else with poppers in the last 3 USED IN COMBINATION WITH CHM7I01
months? ALCOHOL Intensity
0 = No
Did you use alcohol with it?
How often was that? 2 = < 50% of the time
Did you use some other substance? 3 = > 50% of the time
What all did you use?
CHM7I02

LY
Did you start to believe any strange or unusual things? USED IN COMBINATION WITH DRUGS

1 = Cannabis

2 = Cocaine/Crack

3 = Amphetamines/Ice/Meth

N
4 = Inhalants

5 = Heroin/Ecstasy

O
6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

EW 8 = Sedatives

9 = With more than one of the above

groups

DELUSIONS CHM8I01
0 = Absent

2 = Partial delusions.
VI

3 = Full delusional conviction.

IF DURING THE LAST 3 MONTHS

RE

SUBJECT HAS USED SUBSTANCE

DAILY FOR ANY 5 DAY PERIOD, OR
HAS USED AT LEAST 10 DAYS, OR
BEEN INTOXICATED AT LEAST TWICE,
COMPLETE MALADAPTIVE BEHAVIOR.
EVIDENCE OF ADDITIONAL
R

BEHAVIORAL CHANGE REQUIRES

COMPLETION OF MALADAPTIVE
FO

BEHAVIOR SECTION.
IF IF SUBJECT HAS USED NITRITE
INHALANT FOR ANY 5 DAY
PERIOD...OTHERWISE,, SKIP TO
"HEROIN/ECSTASY", (PAGE 69).

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IF HEROIN/EXSTACY USE ABSENT,

SKIP TO "OTHER
OPIODS/OXYCODONE", (PAGE 78).

LY
N
O
EW
VI
RE
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HEROIN/EXSTASY SECTION
HEROIN/ECSTASY
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHG5E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said you have tried heroin or ecstasy before. 2 = Yes

Ever:CHG5O01
How often have you used it?

LY
Onset
Do you use it now?
Have you ever used heroin as often as once a week for / /
a month or more?
USED WEEKLY IN LAST 3 MONTHS CHG5I01
When did that start? Intensity

N
0 = No
Have you ever used it as much as 5 days a week for a
month or more? 2 = Yes

When did you start using at that level? EVER: USED DAILY Ever:CHG6E01

O
How much are you using now, during the last 3 months? 0 = No

2 = Yes

CHG6O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHG6I01
0 = No
VI

2 = Yes
RE
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HEROIN/EXSTACY: MODE OF
ADMINISTRATION
Code the manner in which heroin or ecstasy has been HEROIN USED IN PP CHG7X05
administered during the last three months. If more than one Intensity
0 = No
method has been used, code them all.
2 = Yes
NOTE LIFETIME CODING FOR INJECTING ORAL CHG7I01

LY
0 = No
N.B. ASK IF PILLS HAVE BEEN CRUSHED, DISSOLVED,
OR SUSPENDED, AND THEN INJECTED. 2 = Yes

INHALED CHG7I02
Has there been heroin or ecstasy use in the last 3 months?
0 = No

N
How do you take it?
2 = Yes
Have you ever smoked it? EVER: INJECTED:SUBCUTANEOUS/IM Ever:CHG7E01

O
What about freebasing? Intensity
Have you ever injected it? 0 = No

2 = Yes
What about during the last 3 months?
Have you ever shared a needle with anyone? EW INJECTED IN LAST 3 CHG7I03
MONTHS/SUBCUTANEOUS/IM
Did you do anything to clean the needle? 0 = No
What did you do?
When you used a needle, did you inject into your muscle or 2 = Yes
into a vein?
EVER: INJECTED/IV Ever:CHG7E02
0 = No
VI

2 = Yes

INJECTED IN LAST 3 MONTHS: IV CHG7I04

0 = No
RE

2 = Yes

EVER: SHARED NEEDLES Ever:CHG7E03

0 = No

2 = Yes, with attempt at hygienic

precautions
R

3 = Yes, without attempt at hygienic

precautions
FO

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HEROIN/EXSTACY: USE IN COMBINATION

Did you use anything else with heroin in the last 3 HEROIN USE IN PP CHG7X07
months? Intensity
0 = Absent

What? 2 = Present
What about alcohol?
How often was that? USED IN COMBINATION WITH CHG7I05
ALCOHOL

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

USED IN COMBINATION WITH DRUGS CHG7I06

N
1 = Cannabis

2 = Cocaine/Crack

O
3 = Amphetamines/Ice/Meth

4 = Inhalants

EW 5 = Heroin/Ecstasy

6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
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HEROIN/EXSTACY INTOXICATION
Any of the following signs within 2 hours of using heroin: EVER: INTOXICATED Ever:CHG8E01
drowsiness, slurred speech, impaired attention/memory. Intensity
0 = No

Do you get high when you use heroin? 2 = Has been intoxicated at some time

Ever:CHG8O01
What is that like? Onset
How often do you get high?
/ /

LY
Have you ever noticed any physical effects when you
use heroin?
INTOXICATED IN LAST 3 MONTHS CHG8I01
What did you notice? Intensity
0 = No
When was the first time you got high from heroin?
How many times in the last 3 months have you been high

N
2 = Has been intoxicated at some time
on heroin?
CHG8F01
Did anyone notice or do you know if your pupils were
Frequency
smaller than usual?

O
Did you feel drowsy?
PUPILLARY CONSTRICTION CHG8X01
Did you actually go to sleep?
Was your speech affected? 0 = No

What was it like?

EW 2 = Yes

Was your concentration affected? DROWSINESS CHG8X02

0 = No
What happened?
Could you concentrate or did you find you couldn't be 2 = Yes
bothered by anything?
CHG8X11
VI

UNCONCIOUSNESS
Was your memory affected?
0 = No
What happened with your memory?
Did you lose interest in what was going on around 2 = Yes
you? CHG8X03
RE

SLURRED SPEECH

How did you feel? 0 = No

2 = Yes
Did you start to feel depressed or irritable or anxious
after a while? IMPAIRED ATTENTION/MEMORY CHG8X04

Were you physically slowed down? 0 = No

R

2 = Yes
Did you seem to see, hear, or feel strange things that
weren't really happening? APATHY CHG8X05
FO

0 = No
Did you start to believe any strange or unusual things?
2 = Yes

DYSPHORIA CHG8X06
0 = No

2 = Yes

PSYCHOMOTOR RETARDATION CHG8X07

0 = No

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2 = Yes

AUDITORY, TACTILE, OR VISUAL CHG8X08

ILLUSIONS

0 = No

2 = Yes

AUDITORY, TACTILE, OR VISUAL CHG8X09

HALLUCINATIONS

LY
0 = No

2 = Yes

DELUSIONS CHG8X10

N
0 = No

2 = Yes

O
IF DURING THE LAST 3 MONTHS
SUBJECT HAS USED SUBSTANCE
DAILY FOR ANY 5 DAY PERIOD, OR
HAS USED AT LEAST 10 DAYS, OR
EW
BEEN INTOXICATED AT LEAST 2
TIMES, COMPLETE DESIRE TO CUT
DOWN AND MALADAPTIVE BEHAVIOR.
EVIDENCE OF ADDITIONAL
VI

BEHAVIORAL CHANGE(S) ALSO

REQUIRES COMPLETION OF
MALADAPTIVE SECTION. OTHERWISE,
SKIP TO NEXT DRUG.
RE

IF IF SUBJECT HAS USED HEROIN OR

EXSTACY DAILY FOR ANY 5 DAY
PERIOD...OTHERWISE,, SKIP TO
"OTHER OPIODS/OXYCODONE",
(PAGE 78).
R
FO

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HEROIN/EXSTACY: DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to DESIRE TO CUT DOWN Ever:CHG9E01
reduce his/her heroin intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHG9O01
use heroin? Onset

/ /

LY
When was the first time?

HEROIN/EXSTACY: ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have ADVISED TO CUT DOWN Ever:CHH0E01

N
told or advised the subject to reduce his/her intake of Intensity
0 = Never advised by parents or others to
heroin, on at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHH0O01
Who? Onset
When was the first time?
What do your loved ones or your parents think?
EW / /
VI
RE
R
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HEROIN/EXSTACY: ATTEMPTS TO CUT DOWN

Actual effort at reduced heroin intake or abstention made, EVER: TRIED TO CUT DOWN Ever:CHH1E01
lasting at least 8 hours, but which proved unsuccessful at Intensity
0 = No attempt in last 3 months to cut
permanently reducing intake. down.

2 = Made attempt in last 3 months to cut

Have you ever tried to cut down? down.

What happened? Ever:CHH1V01

LY
How many times have you tried? Frequency
When did you first try to cut down?

DAYS Ever:CHH1D01
Duration

N
Ever:CHH1O01

O
Onset

/ /
EW TRIED TO CUT DOWN CHH2I01
Intensity
0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHH2D01
Duration
VI
RE
R
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HEROIN/EXSTACY: WITHDRAWAL
To be considered symptoms of withdrawal, the following WITHDRAWAL SYMPTOMS IN PP CHH3X11
symptoms must have occured within 8 hours of ending (or Intensity
0 = Absent
reducing the amount of heroin ingested during) a period of
heavy ingestion of heroin (that lasted at least 3 days). 2 = Present

CRAVING CHH3X01
What happens if you cut down on your heroin?
0 = No

LY
Tell me about the last time you cut down. 2 = Yes
Do you notice any physical symptoms?
NAUSEA/VOMITING CHH3X02
What happened?
0 = No
Did you use heroin to make the symptoms go away?
Did it work?

N
2 = Yes
What happened then?
Did you feel that you really needed some heroin very MUSCLE ACHES CHH3X03
badly? 0 = No

O
Did you feel nauseous? 2 = Yes

LACRIMATION/RHINORRHEA CHH3X04
Or vomit?
0 = No
Did your muscles ache?
EW 2 = Yes
Did your eyes water? PILOERECT/SWEATS CHH3X05
Or your nose run? 0 = No

2 = Yes
Did you get goose-bumps?
VI

PUPILLARY DILATION CHH3X06

Or get sweaty?
0 = No
Did anyone notice or did you see that your pupils were 2 = Yes
very large?
RE

DIARRHEA CHH3X07
Did you have diarrhea?
0 = No
Did you yawn a lot? 2 = Yes

Did you get a fever? YAWNING CHH3X08

0 = No
Was your sleep disturbed?
R

2 = Yes
In what way?
FEVER CHH3X09
FO

0 = No

2 = Yes

INSOMNIA CHH3X10
0 = No

2 = Yes

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IF OTHER OPIODS/OXYCODONE USE

ABSENT, SKIP TO "LSD", (PAGE 87).

LY
N
O
EW
VI
RE
R
FO

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OTHER OPIODS/OXYCODONE
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHH4E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said that you have used other opiods and/or 2 = Yes
oxycodone... Ever:CHH4O01
Onset
How often have you used them?
/ /

LY
Have you ever used "other opoids" at least once a
week for a month or more?
USED WEEKLY IN LAST 3 MONTHS CHH4I01
When did that start? Intensity
0 = No
Have you ever used it as often as 5 days a week for a
month or more?

N
2 = Yes

When did you start using at that level? EVER: USED DAILY Ever:CHH5E01
How much do you use now (in the last 3 months)? 0 = No

O
2 = Yes

CHH5O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHH5I01
0 = No

2 = Yes
VI
RE
R
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OTHER OPIODS/OXYCODONE SECTION

OTHER OPIODS/OXYCODONE: MODE OF
ADMINISTRATION
Code the manner in which the drug has been administered ADMINISTERED IN PP CHH6X01
during the last three months. If more than one method has Intensity
0 = No
been used, code them all.
2 = Yes

LY
NOTE LIFETIME CODING FOR INJECTING. ORAL CHH6I01
0 = No
N.B. ASK IF PILLS HAVE BEEN CRUSHED, DISSOLVED,
OR SUSPENDED AND THEN INJECTED. 2 = Yes

INHALED CHH6I02

N
How do you take it?
0 = No
Do you take pills?
2 = Yes
Have you ever smoked it?

O
EVER: INJECTED: SUBCUTANEOUS/IM Ever:CHH6E01
What about freebasing? Intensity
Have you ever injected it? 0 = No

2 = Yes
Into your muscles or into a vein?
What about during the last 3 months?
Have you ever shared a needle with anyone?
EW INJECTED IN LAST 3 MONTHS:
SUBCUTANEOUS/IM
CHH6I03

0 = No
Did you do anything to clean the needle?
What did you do? 2 = Yes

EVER: INJECTED: IV Ever:CHH6E02

VI

0 = No

2 = Yes

INJECTED IN LAST 3 MONTHS: IV CHH6I04

RE

0 = No

2 = Yes

EVER: SHARED NEEDLES Ever:CHH6E03

0 = No

2 = Yes, with attempt at hygienic

R

precautions

3 = Yes, without attempt at hygienic

precautions
FO

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OTHER OPIODS/OXYCODONE: USE IN

COMBINATION
Did you use anything else with "other opiods or USED IN PP CHH6X05
oxycodone" in the last 3 months? Intensity
0 = No

What was it? 2 = Yes

What about alcohol?
How often was that? USED IN COMBINATION WITH CHH6I05
ALCOHOL

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

N
USED IN COMBINATION WITH DRUGS CHH6I06
1 = Cannabis

O
2 = Cocaine/Crack

3 = Amphetamines/Ice/Meth

4 = Inhalants

5 = Heroin/Ecstasy
EW 6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
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OTHER OPIODS/OXYCODONE: INTOXICATION

Any of the following signs within 2 hours of using opiods: EVER: INTOXICATED Ever:CHH7E01
Intensity
0 = No
Check following signs of intoxication:
2 = Has been intoxicated at some time

Do you get high when you use opiods or oxycodone? Ever:CHH7O01

Onset
What is that like?
/ /

LY
How often do you get high?
Have you ever noticed any physical effects when you
use other opiods/oxycodone? INTOXICATED CHH7I01
Intensity
0 = No
What did you notice?

N
When was that? 2 = Has been intoxicated at some time
What about during the last 3 months? CHH7F01
Did you feel sleepy? Frequency

O
Did you actually go to sleep?
Was your speech affected?
PUPILLARY CONSTRICTION CHH7X01
In what way?
0 = No
Was your concentration affected?

What happened?
EW 2 = Yes

Could you concentrate on anything or was that a problem? DROWSINESS CHH7X02

Was your memory affected? 0 = No

Did anyone notice that your pupils were smaller than 2 = Yes
usual? CHH7X03
VI

SLURRED SPEECH

Did you lose interest in what was going on around 0 = No

you?
2 = Yes
How did you feel? CHH7X04
RE

IMPAIRED ATTENTION/MEMORY
Did you start to feel depressed or irritable or anxious
after a while? 0 = No

2 = Yes
Were you physically slowed down?
APATHY CHH7X05
Did you start to believe any strange or unusual things?
0 = No
R

2 = Yes

DYSPHORIA CHH7X06
FO

0 = No

2 = Yes

PSYCHOMOTOR RETARDATION CHH7X07

0 = No

2 = Yes

DELUSIONS CHH7X08
0 = No

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2 = Yes

IF DURING THE LAST 3 MONTHS

SUBJECT HAS USED SUBSTANCE
DAILY FOR ANY 5 DAY PERIOD, OR
HAS USED AT LEAST 10 DAYS, OR

LY
BEEN INTOXICATED AT LEAST 2
TIMES, COMPLETE DESIRE TO CUT
DOWN AND MALADAPTIVE BEHAVIOR.
BEHAVIORAL CHANGE ALSO
REQUIRES COMPLETION OF

N
MALADAPTIVE SECTION. OTHERWISE,
SKIP TO NEXT DRUG.

O
IF IF SUBJECT HAS USED OTHER
OPIODS/OXYCODONE FOR ANY 5 DAY
PERIOD...OTHERWISE,, SKIP TO
"LSD", (PAGE 87). EW
VI
RE
R
FO

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OTHER OPIODS/OXYCODONE: DESIRE TO CUT

DOWN
The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHH8E01
reduce his/her opiod intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHH8O01
use opiods or oxycodone? Onset

LY
When did you first want to cut down? / /

OTHER OPIODS/OXYCODONE: ADVISED TO

N
CUT DOWN
Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHH9E01
told or advised the subject to reduce his/her opiod intake, Intensity
0 = No

O
on at least one occasion.
2 = Yes
Has anyone ever told you that you should cut down? Ever:CHH9O01
Onset
Who?
What do your loved ones and parents think?
EW
When was the first time you were told you should cut
/ /
down?
VI
RE
R
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OTHER OPIODS/OXYCODONE: ATTEMPTS TO

CUT DOWN
Actual effort at reduced opiod intake or abstention made, EVER: TRIED TO CUT DOWN Ever:CHI0E01
lasting at least 8 hours, but which proved unsuccessful at Intensity
0 = Has never made attempt to cut down.
permanently reducing intake.
2 = Has made unsuccessful attempt at
some time to cut down.
Have you ever tried to cut down?
Ever:CHI0V01

LY
What happened? Frequency
How many times have you tried?
When was the first time?
What about during the last 3 months?
What was the longest you were able to cut down for? DAYS Ever:CHI0D01
Duration

N
For how long did you cut down in the last 3 months?

Ever:CHI0O01

O
Onset

/ /
TRIED TO CUT DOWN CHI1I01
EW 0 = No attempt in last 3 months to cut
down.
Intensity

2 = Made attempt in last 3 months to cut

down.

DAYS CHI1D01
Duration
VI
RE
R
FO

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OTHER OPIODS/OXYCODONE: WITHDRAWAL

To be considered symptoms of withdrawal, the following OPIOD WITHDRAWAL IN PP CHI2X11
symptoms must have occurred within 8 hours of ending (or Intensity
0 = Absent
reducing the amount of opiods ingested during) a period of
heavy ingestion of opiods (that lasted at least 3 days). 2 = Present

CRAVING CHI2X01
What happens if you cut down on your use of opiods
or oxycodone? 0 = No

LY
2 = Yes
Tell me about the last time you cut down.
Do you notice any physical symptoms? NAUSEA/VOMITING CHI2X02
0 = No
What happened?
Did you use opiods or oxycodone to make the symptoms

N
2 = Yes
go away?
Did it work? MUSCLE ACHES CHI2X03
What happened then? 0 = No

O
Did you feel that you really needed some opiods or
oxycodone very badly? 2 = Yes

LACRIMATION/RHINORRHEA CHI2X04
Did you feel nauseous?
0 = No
Or vomit?
EW 2 = Yes
Did your muscles ache? PILOERECT/SWEATS CHI2X05

Did your eyes water? 0 = No

2 = Yes
Or your nose run?
VI

PUPILLARY DILATATION CHI2X06

Did you get goosebumps?
0 = No
Or get sweaty? 2 = Yes
RE

Did anyone notice or could you tell that your pupils DIARRHEA CHI2X07
were very large?
0 = No
Did you have diarrhea? 2 = Yes

Did you yawn a lot? YAWNING CHI2X08

0 = No
Did you get a fever?
R

2 = Yes
Was your sleep disturbed?
FEVER CHI2X09
FO

In what way? 0 = No

2 = Yes

INSOMNIA CHI2X10
0 = No

2 = Yes

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IF HALLUCINOGEN USE ABSENT, SKIP

TO "SEDATIVE", (PAGE 104).

LY
N
O
EW
VI
RE
R
FO

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HALLUCINOGENS SECTION
LSD
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHI3E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said you have tried LSD. 2 = Yes

Ever:CHI3O01
How often have you taken it?

LY
Onset
Have you ever taken LSD on at least one day a week for
a month or more? / /
When did that start? USED WEEKLY IN LAST 3 MONTHS CHI3I01
Have you ever used it as often as 5 days a week for a Intensity

N
0 = No
month or more?
2 = Yes
When did you start taking it at that level?
How often have you used LSD in the last 3 months? EVER: USED DAILY Ever:CHI4E01

O
0 = No

2 = Yes

CHI4O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHI4I01
0 = No
VI

2 = Yes
RE
R
FO

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PSILOCYBIN (MAGIC MUSHROOMS)

WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHI5E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said you have tried mushrooms. 2 = Yes

Ever:CHI5O01
How often have you used shrooms? Onset
Have you ever used it at least once a week for a month
/ /

LY
or more?

When did that start? USED WEEKLY IN LAST 3 MONTHS CHI5I01

Have you ever used them for 5 days a week for a month Intensity
0 = No
or more?

N
2 = Yes
When did you start using at that level?
How often have you used them in the last 3 months? EVER: USED DAILY Ever:CHI6E01
0 = No

O
2 = Yes

CHI6O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHI6I01
0 = No

2 = Yes
VI

HALLUCINOGEN: MODE OF ADMINISTRATION

Code the manner in which the drug has been administered USED IN LAST 3 MONTHS CHI7X04
during the last three months. If more than one method has Intensity
0 = Absent
RE

been used, code them all.

2 = Present
How do you use LSD? ORAL CHI7I01

Do you smoke it? 0 = No

How about in eye drops? 2 = Yes
R

SKIN ABSORPTION CHI7I02

0 = No
FO

2 = Yes

EYE DROPS CHI7I03

0 = No

2 = Yes

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HALLUCINOGEN: USE IN COMBINATION

Did you use anything else with "LSD" in the last 3 USE IN COMBINATION IN PP CHI8X04
months? Intensity
0 = Absent

What? 2 = Present
What about alcohol?
How often was that? USED IN COMBINATION WITH CHI8I01
ALCOHOL

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

USED IN COMBINATION WITH DRUGS CHI8I02

N
1 = Cannabis

2 = Cocaine/Crack

O
3 = Amphetamines/Ice/Meth

4 = Inhalants

EW 5 = Heroin/Ecstasy

6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
FO

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HALLUCINOGEN: INTOXICATION
Any of the following signs within 2 hours of using a EVER: INTOXICATED Ever:CHI9E01
Hallucinogen: tachycardia, pupillary dilatation, sweating, Intensity
0 = No
palpitations, blurred vision, tremor, incoordination.
2 = Has been intoxicated at some time
IF EVER USED OF HALLUCINOGEN BE SURE TO ASK Ever:CHI9O01
ABOUT HALLUCINOGEN MOOD DISORDER AND POST Onset
HALLUCINOGEN PERCEPTION DISORDER
/ /

LY
What happens when you use "LSD"?
INTOXICATED IN LAST 3 MONTHS CHI9I01
Intensity
Have you ever gotten high from it? 0 = No
What is that like?

N
2 = Has been intoxicated during the last 3
How often have you gotten high from it in the last 3 months
months?
Have you ever noticed any physical effects when you CHI9F01
used LSD? Frequency

O
What did you notice?
When did that start?
TACHYCARDIA CHI9X01
Has that happened in the last 3 months? EW
How often? 0 = No
Did you notice your heart beating fast?
2 = Yes
Or irregularly? PALPITATIONS CHI9X02

Did you get sweaty? 0 = No

2 = Yes
Or have any chills?
VI

SWEATING/CHILLS CHI9X03
Was your vision affected?
0 = No
What happened to it? 2 = Yes
Did your hands shake?
RE

BLURRED VISION CHI9X04

Was your balance affected?
0 = No
What about your movements, could you control them 2 = Yes
properly?
TREMOR CHI9X05
Did anyone notice that your pupils were bigger than
R

0 = No
usual?
2 = Yes
Did you see or hear any strange things?
INCOORDINATION CHI9X06
FO

What? 0 = No
Did things seem much brighter or louder than usual?
2 = Yes
Did you feel unreal? PUPILLARY DILATATION CHI9X07
Or that the world was unreal? 0 = No

Did you see anything that wasn't really there? 2 = Yes

Or hear anything that wasn't really there?

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Did any sensation seem to get changed into other CHANGED PERCEPTIONS CHI9X08
sensations? 0 = No

Like being able to feel colors or see sounds? 2 = Yes

Did you feel nervous or worried about what was going
on around you? DEREALIZATION CHI9X09
0 = No
Did you feel that something bad might be going on?
2 = Yes

LY
Did you find yourself keeping a sharp lookout on what was
DEPERSONALIZATION CHI9X10
going on?
Did you get suspicious about anything? 0 = No

2 = Yes
Did you start to feel important?

N
HALLUCINATIONS CHI9X11
Or that you were a really powerful person?
0 = No
Or feel that you could do things you couldn't usually 2 = Yes

O
do?
SYNTHESIA CHI9X12
0 = No

2 = Yes
EW HYPERVIGILANCE CHI9X13
0 = No

2 = Yes

GRANDIOSITY CHI9X14
VI

0 = No

2 = Yes

DELUSIONS CHI9X15
RE

0 = No

2 = Yes
R
FO

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IF USE OF HALLUNCINOGEN BE SURE

TO ASK ABOUT HALLUCINOGEN
MOOD DISORDER AND POST
HALLUCINOGEN PERCEPTION
DISORDER. IF DURING THE LAST 3
MONTHS SUBJECT HAS USED
SUBSTANCE DAILY FOR ANY 5 DAY

LY
PERIOD OR HAS USED AT LEAST 10
DAYS, OR BEEN INTOXICATED AT
LEAST 2 TIMES, COMPLETE DESIRE
TO CUT DOWN AND MALADAPTIVE
BEHAVIOR. EVIDENCE OF

N
ADDITIONAL BEHAVIORAL CHANGE
REQUIRES COMPLETION OF
MALADAPTIVE BEHAVIOR SECTION.

O
OTHERWISE, SKIP TO NEXT DRUG.
IF IF USE OF
HALLUCINOGEN...OTHERWISE,, SKIP EW
TO "PCP", (PAGE 95).
VI
RE
R
FO

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HALLUCINOGEN: DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHJ0E01
reduce his/her LSD intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHJ0O01
use LSD? Onset

/ /

LY
When was the first time?

HALLUCINOGEN: ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHJ1E01

N
told or advised the subject to reduce his/her LSD intake, on Intensity
0 = Never advised by parents or others to
at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHJ1O01
Who? Onset
What do your parents and other loved ones think?
When was the first time someone told you that you should
EW / /
cut down?
VI
RE
R
FO

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HALLUCINOGENS: ATTEMPTS TO CUT DOWN

Actual effort at reduced LSD intake or abstention made, EVER: TRIED TO CUT DOWN Ever:CHJ2E01
lasting at least 8 hours, but which proved unsuccessful at Intensity
0 = No attempt in last 3 months to cut
permanently reducing intake. down.

2 = Made attempt in last 3 months to cut

Have you ever tried to cut down? down.

What happened...tell me about the last time. Ever:CHJ2V01

LY
How many times have you tried? Frequency
How long did it last?
When did you first try to cut down?
Have you tried to cut down in the last 3 months?
DAYS Ever:CHJ2D01
How long did that last? Duration

N
Ever:CHJ2O01

O
Onset

/ /
EW TRIED TO CUT DOWN CHJ3I01
Intensity
0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHJ3D01
Duration
VI
RE
R
FO

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PCP
WHEN QUESTIONING ABOUT DRUGS SUBSTITUTE EVER: USED WEEKLY Ever:CHJ4E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said you have tried PCP. 2 = Yes

Ever:CHJ4O01
How often have you taken it? Onset
Have you ever used it as often as once a week for a
/ /

LY
month or more?

When did that start? USED WEEKLY IN LAST 3 MONTHS CHJ4I01

Have you ever used it as often as 5 days per week for a Intensity
0 = No
month or more?

N
2 = Yes
When did you start using at that level?
How often have you used in the last 3 months? EVER: USED DAILY Ever:CHJ5E01
0 = No

O
2 = Yes

CHJ5O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHJ5I01
0 = No

2 = Yes
VI
RE
R
FO

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PCP: MODE OF ADMINISTRATION

Code the manner in which the drug has been administered ADMINISTERED IN PP CHJ6X01
during the last three months. If more than one method has Intensity
0 = No
been used, code them all.
2 = Yes
NOTE LIFETIME CODING FOR INJECTING. ORAL CHJ6I01
0 = No
N.B. ASK IF PILLS HAVE BEEN CRUSHED, DISSOLVED,

LY
OR SUSPENDED, AND THEN INJECTED. 2 = Yes

SMOKED CHJ6I02
How do you take it?
0 = No
Have you ever smoked it?

N
2 = Yes
What about freebasing?
Have you ever injected it? INHALED CHJ6I03
0 = No

O
What about during the last 3 months?
Have you ever shared a needle with anyone? 2 = Yes

EVER: INJECTED Ever:CHJ6E01

Intensity
0 = No
EW 2 = Yes

INJECTED IN LAST 3 MONTHS CHJ6I04

0 = No

2 = Yes
VI

EVER: SHARED NEEDLES Ever:CHJ6E02

0 = No

2 = Yes
RE
R
FO

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PCP: USE IN COMBINATION

Did you use anything else with PCP in the last 3 USED PCP IN PP CHJ6X06
months? Intensity
0 = No

What was it? 2 = Yes

What about alcohol?
How often was it that you used alcohol with PCP, more or USED IN COMBINATION WITH CHJ6I05
ALCOHOL
less than 50% of the time?

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

USED IN COMBINATION WITH DRUGS CHJ6I06

N
1 = Cannabis

2 = Cocaine/Crack

O
3 = Amphetamines/Ice/Meth

4 = Inhalants

EW 5 = Heroin/Ecstasy

6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
FO

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PCP: INTOXICATION
Any of the following signs within 1 hour of using PCP: EVER: INTOXICATED Ever:CHJ7E01
nystagmus, numbness/reduced pain response, ataxia, Intensity
0 = No
dysarthria, muscle rigidity, seizure, hyperacusis.
2 = Has been intoxicated at some time
Did you ever get high when using PCP? Ever:CHJ7O01
Onset
What is it like?
/ /

LY
How often do you get high?
Have you ever noticed any physical effects?
INTOXICATED IN LAST 3 MONTHS CHJ7I01
What did you notice? Intensity
0 = No
Did you notice your heart beating fast?

N
2 = Yes
Did the world seem to be spinning?
CHJ7F01
Did any parts of your body feel numb? Frequency

O
Did you notice that you weren't feeling pain as much as
usual? NYSTAGMUS CHJ7X01
Did you have any difficulty walking? EW 0 = No

2 = Yes
What was the problem?
Were your muscles affected? NUMBNESS/REDUCED PAIN RESPONSE CHJ7X02

How? 0 = No
Did you ever have a fit or seizure? 2 = Yes

Was your speech affected? CHJ7X03

VI

ATAXIA

Was it slurred? 0 = No
Did sounds seem unusually loud? 2 = Yes

CHJ7X04
RE

Or colors seem unusually bright? DYSARTHRIA

0 = No
Did you seem to see, hear, or feel strange things that
weren't really happening? 2 = Yes

Did you start to believe any strange or unusual things? MUSCLE RIGIDITY CHJ7X05
0 = No
R

2 = Yes

SEIZURE CHJ7X06
FO

0 = No

2 = Yes

HYPERACUSIS CHJ7X07
0 = No

2 = Yes

AUDITORY, TACTILE, OR VISUAL CHJ7X09

ILLUSIONS

0 = No

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2 = Yes

AUDITORY, TACTILE, OR VISUAL CHJ7X10

HALLUCINATIONS

0 = No

2 = Yes

DELUSIONS CHJ7X11

LY
0 = No

2 = Yes

N
IF USE OF HALLUCINOGEN,
COMPLETE HALLUCINOGEN MOOD
DISORDER AND POST

O
HALLUCINOGEN PERCEPTION
DISORDER. IF DURING THE LAST 3
MONTHS SUBJECT HAS USED
SUBSTANCE DAILY FOR ANY 5 DAY EW
PERIOD, OR HAS USED AT LEAST 10
DAYS, OR HAS BEEN INTOXICATED AT
LEAST 2 TIMES, COMPLETE DESIRE
TO CUT DOWN AND MALADAPTIVE
BEHAVIOR SECTION. OTHERWISE,
SKIP TO NEXT DRUG.
VI

IF IF USE OF HALLUCINOGEN FOR

ANY 5 DAY PERIOD...OTHERWISE,,
SKIP TO "SEDATIVE", (PAGE 104).
RE
R
FO

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PCP: DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHJ8E01
reduce his/her PCP intake. There is no requirement that Intensity
0 = No desire to cut down
s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHJ8O01
use PCP? Onset

/ /

LY
When did you first think you wanted to cut down?

PCP: ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHJ9E01

N
told or advised the subject to reduce his/her PCP intake, on Intensity
0 = Never advised by parents or others to
at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHJ9O01
Who? Onset
What do your parents and other loved ones think?
When was the first time you were advised to cut down?
EW / /
VI
RE
R
FO

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PCP: ATTEMPTS TO CUT DOWN

Actual effort at reduced PCP intake or abstention made, EVER: TRIED TO CUT DOWN Ever:CHK0E01
lasting at least 8 hours, but which proved unsuccessful at Intensity
0 = No attempt in last 3 months to cut
permanently reducing intake. down.

2 = Made attempt in last 3 months to cut

Have you ever tried to cut down? down.

What happened? Ever:CHK0V01

LY
How many times have you tried? Frequency
When was the first time?
Have you tried to cut down in the last 3 months?
How long did that last?
DAYS Ever:CHK0D01
Duration

N
Ever:CHK0O01

O
Onset

/ /
EW TRIED TO CUT DOWN CHK1I01
Intensity
0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHK1D01
Duration
VI
RE
R
FO

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HALLUCINOGEN MOOD DISORDER

Low mood, Subjective Anxious Affect, or Elevated Mood HALLUCINOGEN MOOD DISORDER CHK2I01
occurring within 3 weeks of beginning hallucinogen use, Intensity
2 = Mood changes have occurred only in
and persisting at least 24 hours after the cessation of such relation to hallucinogen use
use.
3 = Mood changes have occurred both in
relation to hallucinogen use and
IF EVER USED HALLUCINOGEN, ASK ABOUT independently of it
HALLUCINOGEN MOOD DISORDER.

LY
DAYS CHK2D01
Duration
MAKE CAREFUL WRITTEN NOTES OF THE
SYMPTOMATOLOGY ASSOCIATED WITH
HALLUCINOGEN USE.
CHK2F01

N
Frequency
N.B. BE SURE TO ASK ABOUT ALL HALLUCINOGENS
USED.

O
Did your mood change at all when you used CHK2O01
"hallucinogen" in the last 3 months? Onset

How did you feel? / /

What was it like?
How long did the mood change last?
Did you try stopping using "hallucinogen"?
EW
Did that make any difference?
Was your mood still changed after you stopped?
For how long?
When did this first happen?
How often has it happened in the last 3 months?
VI
RE
R
FO

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POST-HALLUCINOGEN PERCEPTION
DISORDER

IF EVER USED ANY HALLUCINOGEN, ASK

ABOUT POST-HALLUCINOGEN PERCEPTION
DISORDER.

N.B. ASK ABOUT ALL HALLUCINOGENS USED.

LY
RE-EXPERIENCED PERCEPTUAL SYMPTOMS
The subject re-experiences one or more of the perceptual RE-EXPERIENCE OF PERCEPTUAL CHK3I01
symptoms that characterized his/her use of a hallucinogen, SYMPTOMS Intensity
when the hallucinogen has not been taken within the 2 = Symptom intrusive into at least 2

N
preceding 24 hours. activities and uncontrollable at least some
of the time

Have you ever had a flashback? (explain if necessary) 3 = Symptom intrusive into almost all

O
activities and hardly ever controllable.
What was it like?
What did you see? DAYS CHK3D01
Duration
Was that like what happens/ed when you took
"hallucinogen"?
How long did it last?
Have you had any in the last 3 months?
EW CHK3F01
How many times? Frequency
When did you first have a flashback?

CHK3O01
Onset
VI

/ /
RE

DISTRESS
During a period of re-experience of perceptual symptoms, DISTRESS CHK4I01
the subject experienced Subjective Anxious Affect, or other Intensity
2 = Symptom intrusive into at least 2
unpleasant mood states. activities and uncontrollable at least some
of the time
How did you feel when you were having the flashback? 3 = Symptom intrusive into almost all
R

activities and hardly ever controllable.

Did you feel frightened?
What were you doing when you felt that way?
Could you stop yourself from feeling that way?
FO

IF SEDATIVE USE ABSENT, SKIP TO

"MALADAPTIVE SCREEN", (PAGE 113).

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SEDATIVE SECTION
SEDATIVE
WHEN QUESTIONING ABOUT DRUGS, SUBSTITUTE EVER: USED WEEKLY Ever:CHK5E01
THE SUBJECT'S NAMES FOR THEM Intensity
0 = No

You said that you have tried "sedatives". 2 = Yes

Ever:CHK5O01
How often have you taken them?

LY
Onset
Have you ever used "sedative" as often as once a week
for a month or more? / /
When did that start? USED WEEKLY IN LAST 3 MONTHS CHK5I01
Have you ever used "sedative" as often as 5 days a Intensity

N
0 = No
week for a month or more?
2 = Yes
When did you start using at that level?
How often have you used "sedative" in the last 3 months? EVER: USED DAILY Ever:CHK6E01

O
0 = No

2 = Yes

CHK6O01
EW Onset

/ /
USED DAILY IN LAST 3 MONTHS CHK6I01
0 = No
VI

2 = Yes
RE
R
FO

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SEDATIVE: MODE OF ADMINISTRATION

Code the manner in which the drug has been administered ADMINISTERED SEDATIVE IN PP CHK7X01
during the last three months. If more than one method has Intensity
0 = No
been used, code them all.
2 = Yes
Note: LIFETIME CODING FOR INJECTING ORAL CHK7I01
0 = No
N.B. ASK IF PILLS HAVE BEEN CRUSHED, DISSOLVED,

LY
OR SUSPENDED, AND THEN INJECTED 2 = Yes

EVER: INJECTED Ever:CHK7E01

Now, I need to know "how" you used sedatives in the Intensity
last 3 months. 0 = No

N
2 = Yes
How do you take it?
INJECTED IN LAST 3 MONTHS CHK7I02
Was it some type of pill?
0 = No

O
Have you ever injected "sedative"? 2 = Yes

Have you done that in the last 3 months? EVER: SHARED NEEDLES Ever:CHK7E02

Have you ever shared needles with anyone? 0 = No

Did you do anything to clean the needle?
What did you do?
EW 2 = Yes, with attempt at hygienic
precautions

3 = Yes, without attempt at hygienic

precautions
VI
RE
R
FO

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SEDATIVE: USE IN COMBINATION

Did you use anything else with the "sedative" in the USED SEDATIVE IN COMBINATION CHK8X01
last 3 months? Intensity
0 = No

What? 2 = Yes
What about alcohol?
How often was that? USED IN COMBINATION WITH CHK8I01
ALCOHOL

LY
0 = No

2 = < 50% of the time

3 = > 50% of the time

USED IN COMBINATION WITH DRUGS CHK8I02

N
1 = Cannabis

2 = Cocaine/Crack

O
3 = Amphetamines/Ice/Meth

4 = Inhalants

EW 5 = Heroin/Ecstasy

6 = Opiods/Oxycodone

7 = Hallucinogens/PCP/Psylocybin

8 = Sedatives

9 = With more than one of the above

groups
VI
RE
R
FO

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SEDATIVE: INTOXICATION
Any of the following signs within 24 hours of using EVER: INTOXICATED Ever:CHK9E01
"sedative": slurred speech, incoordination, unsteady gait, Intensity
0 = No
impaired memory or attention.
2 = Has been intoxicated at some time
Do you get high when you use "sedative"? Ever:CHK9O01
Onset
What is that like?
/ /

LY
How often do you get high?
How do you feel then?
Have you ever noticed any physical effects? INTOXICATED IN LAST 3 MONTHS CHK9I01
Intensity
0 = No
What did you notice?
When was that?

N
2 = Has been intoxicated during the last 3
What about during the last 3 months? months
Was your speech affected? CHK9F01
Frequency

O
What was it like?
Was it slurred?
Were your movements affected?
SLURRED SPEECH CHK9X01
Did you lose your balance?
Could you walk properly?
Or did you tend to stagger a bit?
EW 0 = No

2 = Yes
Did you bump into things at all?
Could you move your arms and hands properly? INCOORDINATION CHK9X02
Was your coordination affected? (explain if necessary) 0 = No
Could you pay attention to things properly?
2 = Yes
VI

Or was your concentration affected? UNSTEADY GAIT CHK9X03

What about your memory?
0 = No
Did it have any effect on that? 2 = Yes
What happened?
RE

Was it difficult to remember things? IMPAIRED MEMORY OR ATTENTION CHK9X04

Did you start to believe any strange or unusual things?
0 = No

2 = Yes

DELUSIONS CHK9X05
R

0 = Absent

2 = Present
FO

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IF DURING THE LAST 3 MONTHS

SUBJECT HAS USED "SEDATIVE" FOR
ANY 5 DAY PERIOD, OR HAS USED AT
LEAST 10 DAYS, OR HAS BEEN
INTOXICATED AT LEAST 2 TIMES,
COMPLETE DESIRE TO CUT DOWN
AND MALADAPTIVE BEHAVIOR.

LY
EVIDENCE OF ADDITIONAL
BEHAVIORAL CHANGE REQUIRES
COMPLETION OF THE MALADAPTIVE
BEHAVIOR SECTION. OTHERWISE,
SKIP TO NEXT SECTION.

N
IF IF SUBJECT HAS USED SEDATIVE
FOR ANY 5 DAY
PERIOD...OTHERWISE,, SKIP TO

O
"SUBJECTIVE NEED FOR
"SUBSTANCE"", (PAGE 114).
EW
VI
RE
R
FO

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SEDATIVE: DESIRE TO CUT DOWN

The subject has at certain times felt that s/he would like to EVER: DESIRE TO CUT DOWN Ever:CHL0E01
reduce his/her "sedative" intake. There is no requirement Intensity
0 = No desire to cut down
that s/he should have actually done so.
2 = Wishes to cut down
Have you ever wanted to cut down on how much you Ever:CHL0O01
use "sedative"? Onset

/ /

LY
When did that start?

SEDATIVE: ADVISED TO CUT DOWN

Parents, loved ones, friends, professionals, or others have EVER: ADVISED TO CUT DOWN Ever:CHL1E01

N
told or advised the subject to reduce his/her "sedative" Intensity
0 = Never advised by parents or others to
intake, on at least one occasion. cut down

O
2 = Advised to cut down
Has anyone ever told you that you should cut down?
Ever:CHL1O01
Who? Onset
What do your parents and other loved ones think?
When was the first time you were advised to cut down?
EW / /
VI
RE
R
FO

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SEDATIVE: ATTEMPTS TO CUT DOWN

Actual effort at reduced "sedative" intake or abstention EVER: TRIED TO CUT DOWN Ever:CHL2E01
made, lasting at least 8 hours, but which proved Intensity
0 = Has never made attempt to cut down.
unsuccessful at permanently reducing intake.
2 = Has made unsuccessful attempt at
some time to cut down.
Have you ever tried to cut down?
Ever:CHL2V01
What happened? Frequency

LY
How many times have you tried?
When was the first time?
Have you tried in the last 3 months?
How long did that last? DAYS Ever:CHL2D01
Duration

N
Ever:CHL2O01
Onset

O
/ /
TRIED TO CUT DOWN CHL3I01
Intensity
EW 0 = No attempt in last 3 months to cut
down.

2 = Made attempt in last 3 months to cut

down.

DAYS CHL3D01
Duration
VI
RE
R
FO

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SEDATIVE: WITHDRAWAL
To be considered symptoms of withdrawal, symptoms must WITHDRAWAL SYMPTOMS PRESENT bbb0I01
have occurred within 8 hours of ending a period of heavy Intensity
0 = No
ingestion of "sedative" (that lasted at least 3 days), or of a
reduction in the amount of "sedative" used. 2 = Yes

SEDATIVE WITHDRAWAL IN PP CHL4X12

Have you experience any withdrawal symptoms in the last
3 months? 0 = No

LY
2 = Yes
What happens if you cut down on your "sedative"?
NAUSEA/VOMITING CHL4X01
Tell me about the last time you cut down.
0 = No
Did you notice any physical symptoms?

N
2 = Yes
What happened?
Did you take any "sedative" to make the symptoms go MALAISE/WEAKNESS CHL4X02
away? 0 = No

O
Did it work?
Did you feel nauseated? 2 = Yes

AUTONOMIC HYPERACTIVITY CHL4X03

Did you vomit?
2 = Code number of symptoms:
Did you feel weak?
EW Palpitations, rapid breathing, stomach
churning, sweating/chills, diarrhea, flushing,
lump in throat
Did it affect your activities at all?
ANXIETY/IRRITABILITY CHL4X04
In what way?
Did you notice your heart beating fast? 2 = Sometimes Uncontrollable

3 = Nearly always uncontrollable

VI

Or irregularly?
Did you notice yourself breathing faster than usual? ORTHOSTATIC HYPOTENSION CHL4X05
Did you notice your stomach churning?
0 = Absent, or fewer than 3 episodes
Did you get sweaty?
Or have diarrhea or have to urinate frequently? 2 = 3 or more episodes
RE

Did you get a lump in your throat?

Or get flushed? TREMOR CHL4X06
Did you feel anxious? 0 = No

Or nervous or worried? 2 = Yes

What was that like? INSOMNIA CHL4X07
Did you get bad-tempered?
R

0 = Absent
Did you get dizzy when you stood up at all?
2 = If the insomnia covers a period between
1 and 2 hours.
FO

Did your hands shake?

3 = If its duration is greater than or equal to
Did you have shakes anywhere else? 2 hours per night.
Was your sleep affected? SEIZURES CHL4X08
Did you have any blackouts? 0 = No

Or fits? 2 = Yes

AUDITORY, TACTILE, OR VISUAL CHL4X10

Did you seem to see, hear or feel strange things that ILLUSIONS
weren't really happening?
0 = No

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Did you ever take "sedative" or anything else to stop 2 = Yes

these symptoms? AUDITORY, TACTILE, OR VISUAL CHL4X11
HALLUCINATIONS

0 = No

2 = Yes

TAKES "SEDATIVE" TO PREVENT CHL4X09

WITHDRAWAL SYMPTOMS

LY
0 = No

2 = Yes

N
O
EW
VI
RE
R
FO

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MALADAPTIVE BEHAVIORAL CHANGES

Complete the Maladaptive section on alcohol

use meeting criteria as well as any drug
meeting criteria.

MALADAPTIVE SCREEN
Alcohol or any drug met criteria for entry into the POSITIVE MALADAPTIVE SCREEN JJJ6I06

LY
Maladaptive Section i.e was used on at least 10 days of the Intensity
0 = Absent
primary period, was used 5 days in a row, or caused
intoxication at least 2x, or any additional behavioral 2 = Present
changes.

N
Let's review then...

Was there alcohol use sufficient to enter the Maladaptive

O
section?
Was there any drug use sufficient to enter the Maladaptive
section?
Which ones?
EW
IF ANY SUBSTANCE USED DAILY FOR
ANY 5 DAY PERIOD DURING THE LAST
3 MONTHS, OR USED ON AT LEAST 10
DAYS, OR SUBJECT HAS BEEN
VI

INTOXICATED AT LEAST TWICE,

COMPLETE THIS SECTION. POSITIVE
CODINGS FOR ADDITIONAL
BEHAVIORAL CHANGE(S) ALSO
RE

REQUIRE ENTRANCE INTO THE

MALADAPTIVE SECTION.
IF ANY SUBSTANCE USED DAILY FOR
ANY 5 DAY PERIOD IN LAST 3 MOS,
OR USED ON > 10 DAYS OR
INTOXICATED 2X, COMPLETE
R

SECTION, OTHERWISE, SKIP TO

""DIAGNOSIS OF PHYSICAL ILLNESS"
FO

NOT PRESENT", (PAGE ERROR!

BOOKMARK NOT DEFINED.).

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SUBJECTIVE NEED FOR "SUBSTANCE"

A feeling of need or craving to consume "substance", that SUBJECTIVE NEED FOR "SUBSTANCE" CIA0I01
is, at least sometimes, intrusive into other thoughts or Intensity
0 = Absent
activities, and cannot always be controlled except through
using "substance". 2 = At least some days feels uncontrollable
need for substance, intrusive into at least 2
activities, unless satisfied
Do you sometimes need "substance" to help you get
through the day? 3 = Most days feels uncontrollable need for

LY
substance, intrusive into at least 2 activities,
unless satisfied
Does it bother you if you don't have "substance" on any
given day? CIA0F01
Do you crave it? Frequency

When did that start?

N
How often in the last 3 months?
When do you have your first "substance" of the day? CIA0O01
Onset
Do you miss it if you can't get "substance" ?

O
What happens if you don't get "substance"?
/ /
SUBSTANCE LIST CIA0I02
1 = Alcohol
EW 2 = Cannabis
CIA0I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA0I04
5 = Inhalants
VI

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA0I05
8 = Sedatives
RE

CIA0I06

CIA0I07
R

CIA0I08
FO

CIA0I09

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USES "SUBSTANCE" TO IMPROVE MOOD

The subject describes using "substance" in an attempt to USES "SUBSTANCE" TO IMPROVE CIA1I01
relieve dysphoria, anxiety,or irritability,or to induce an MOOD Intensity
increased feeling of well-being. 0 = Absent

2 = Sometimes uses substance to improve

Do you sometimes use "substance" to cheer yourself mood (
up when you feel low?
3 = Sometimes uses substance to improve

LY
Or to keep yourself from getting down? mood (>=50% of the time)

CIA1F01
Or to keep from feeling anxious or stressed? Frequency
Do you use to keep from feeling irritable?

N
When did that start? CIA1O01
How often does that happen? Onset
Is that usually why you use "substance"?
/ /

O
SUBSTANCE LIST CIA1I02

EW 1 = Alcohol

2 = Cannabis
CIA1I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA1I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy
VI

7 = Hallucinogens CIA1I05
8 = Sedatives

CIA1I06
RE

CIA1I07

CIA1I08
R
FO

CIA1I09

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TIME SPENT IN "SUBSTANCE" RELATED

BEHAVIOR
Amount of time spent in "substance" related behavior TIME SPENT CIA2I01
including activities associated with getting and consuming Intensity
0 = < 1 hour per day
"substance" and recovering from the effects of using
"substance". 2 = 1-3 hours per day

3 = > 3 hours per day

How much time do you spend using "substance"?

LY
SUBSTANCE LIST CIA2I02
Or getting "substance", including locating it, going 1 = Alcohol
after it, etc.?
2 = Cannabis
CIA2I03
Or getting it ready to use (whatever preparatory
3 = Cocaine/Crack
measures are appropriate for the substances used)?

N
4 = Amphet./Ice/Meth
Or recovering from the effects of using it (being CIA2I04
5 = Inhalants
hungover, sleeping it off, etc.)?

O
6 = Heroin/Opioids/X/Oxy
How much time, in an average day, do you spend in
"substance-related" activities? 7 = Hallucinogens CIA2I05
EW 8 = Sedatives

CIA2I06

CIA2I07
VI

CIA2I08

CIA2I09
RE

COST OF SUBSTANCES PER WEEK IN LAST 3

MONTHS
R

Have you spent any money on substances in the last 3 COST CIA2X02
months, including drugs or alcohol? Intensity
0 = No
FO

How much did you spend per week in the last 3 months 2 = Yes
on drugs and alcohol?
COST PER WEEK FOR ALL CIA2X01
SUBSTANCES COMBINED
How do you pay for your use of "substance"?

Where do you get the money?

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TOLERANCE
The need for increased intake of "substance" (by at least TOLERANCE CIA3I01
50%) to produce previously experienced psychological or Intensity
0 = Does not show tolerance.
behavioral changes associated with "substance" use.
2 = Needs to use "substance" at least 50%
more than previously to obtain desired
Do you need to use more "substance" than you used effect or can tolerate at least 50% more
to, to have the same effect? than previously.

LY
Are you able to tolerate larger amounts of "substance" CIA3O01
than you used to? Onset

How much more? / /

When did you start to need more? SUBSTANCE LIST CIA3I02

N
1 = Alcohol

2 = Cannabis
CIA3I03

O
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA3I04
EW 5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA3I05
8 = Sedatives

CIA3I06
VI

CIA3I07
RE

CIA3I08

CIA3I09
R
FO

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OVERCONSUMPTION
Consumption of more "substance" than intended on a OVERCONSUMPTION CIA4I01
particular occasion. If regular overconsumption is present, Intensity
0 = Has not used "substance" more than
consider carefully whether the subject's behavior also meant to.
conforms to the definition of a Narrowed "Substance" Use
Repertoire. 2 = Sometimes uses "substance" more than
meant to.

Do you sometimes use more "substance" than you CIA4F01

LY
mean to? Frequency

Like intending to have just one or two, but then using much
more?
CIA4O01
How often has that happened in the last 3 months? Onset

N
When did that start?
/ /
SUBSTANCE LIST CIA4I02

O
1 = Alcohol

2 = Cannabis
CIA4I03
3 = Cocaine/Crack
EW 4 = Amphet./Ice/Meth
CIA4I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA4I05
8 = Sedatives
VI

CIA4I06
RE

CIA4I07

CIA4I08
R

CIA4I09
FO

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UNCONTROLLABLE "SUBSTANCE" USE

Episodes in which, whatever his/her original intentions, the UNCONTROLLABLE SUBSTANCE USE CIA5I01
subject keeps on using "substance" until unable to use Intensity
0 = Never unable to resist using
"substance" any more, either because of the unavailability "substance" until no further "substance"
of further "substance" or because of physical incapability available or unable to use "substance" any
(e.g. severe nausea). more.

2 = Sometimes unable to stop (

Once you start using "substance", do you ever find

LY
3 = Usually (> 50% of the time) unable to
that you just can't stop until it's all gone? stop until no further "substance" available or
unable to use "substance" any more.
Or until you physically can't take any more (e.g.
because of unconsciousness, vomiting, "sore lungs", CIA5F01
etc.)? Frequency

N
Do you ever use "substance" just because it's there?
CIA5O01
How often does that happen?
Onset

O
When did that start?
/ /
EW SUBSTANCE LIST CIA5I02
1 = Alcohol

2 = Cannabis
CIA5I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA5I04
5 = Inhalants
VI

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA5I05
8 = Sedatives
RE

CIA5I06

CIA5I07
R

CIA5I08
FO

CIA5I09

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NARROWED "SUBSTANCE" USE REPERTOIRE

The subject tends to use "substance" in the same way in NARROWED "SUBSTANCE" USE CIA6I01
any situation, even when a particular pattern may be REPERTOIRE Intensity
inappropriate. For instance using "substance" heavily when 0 = No
on a first date, or using "substance" as much whether alone
or in company. Subject is unable to have a repertoire of 2 = Yes
substance using behaviors; patterns of heavy use are no CIA6O01
longer differentiated by environment. Onset

LY
Do you "get high (drunk) (use substance)" in / /
inappropriate circumstances?
SUBSTANCE LIST CIA6I02
Like where? 1 = Alcohol

N
Do you have different patterns of using "substance" in
2 = Cannabis
different situations? CIA6I03
3 = Cocaine/Crack
Do you vary how you use "substances" depending on the

O
situation? 4 = Amphet./Ice/Meth
When did that start to happen? CIA6I04
5 = Inhalants
Like when you go on a date, as compared with when you
are with your friends? 6 = Heroin/Opioids/X/Oxy
EW 7 = Hallucinogens

8 = Sedatives
CIA6I05

CIA6I06
VI

CIA6I07

CIA6I08
RE

CIA6I09
R
FO

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MORNING "SUBSTANCE" USE

Use of "substance" within 2 hours of rising. Take into MORNING SUBSTANCE USE CIA7I01
consideration persons who work shift-work and question Intensity
0 = No
"within 2 hours of rising" even if that is not "in the morning".
2 = Yes
Do you use "substance" soon after you get up? CIA7F01
Frequency
How soon after you get up?

LY
How often in the last 3 months?
Do you feel you need it in the morning?
CIA7O01
When did that start? Onset
Do you ever try anything else instead or as a substitute?
/ /

N
SUBSTANCE LIST CIA7I02
1 = Alcohol

O
2 = Cannabis
CIA7I03
3 = Cocaine/Crack
EW 4 = Amphet./Ice/Meth
CIA7I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA7I05
8 = Sedatives
VI

CIA7I06

CIA7I07
RE

CIA7I08

CIA7I09
R
FO

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DISINHIBITED AGGRESSION
After using "substance" the subject has been verbally or DISINHIBITED AGGRESSION CIA8I01
physically aggressive in a way that is not characteristic of Intensity
0 = Not unusually aggressive when under
his/her behavior when not intoxicated. the influence of "substance'.

2 = Has been atypically verbally aggressive

Have you gotten into any arguments when you were when under the infuence of "substance"
"high (drunk)"? during last 3 months.

LY
When you've used a lot of "substance" do you get bad- 3 = Has been atypically physically
aggressive when under the influence of
tempered or angry? "substance" during last 3 months.

More than usual? CIA8F01

How often in last 3 months? Frequency
When did that start?

N
Have you gotten into any physical fights when you
were "high (drunk)" in the last 3 months?
CIA8O01
Onset

O
Do you think you are more aggressive when you use
drugs or alcohol? / /
How often? SUBSTANCE LIST CIA8I02
When did that start?
EW 1 = Alcohol

2 = Cannabis
CIA8I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA8I04
5 = Inhalants
VI

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA8I05
8 = Sedatives
RE

CIA8I06

CIA8I07
R

CIA8I08
FO

CIA8I09

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DISINHIBITED SEXUALITY
After using "substance" the subject is sexually provocative, DISINHIBITED SEXUALITY CIA9I01
or forward in a way that is not characteristic of his/her Intensity
0 = No episodes of disinhibited sexuality
behavior when not intoxicated. during last 3 months.

2 = Has been atypically sexually

Have you made a pass at anyone when you were "high disinhibited while under the influence of
(drunk)'? "substance" during the last 3 months.

LY
Have you tried to pick anyone up when you were "high 3 = Has sexually assualted someone while
under the influence of "substance", during
(drunk)'? the last 3 months.

Have you done anything of a sexual nature while drunk CIA9F01

or high that you would not normally do? Frequency

N
What happened?
Is that the sort of thing that you would do when you hadn't
CIA9O01
been using "substance"?
Onset

O
How often in the last 3 months?
When did that start? / /
EW SUBSTANCE LIST CIA9I02
1 = Alcohol

2 = Cannabis
CIA9I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIA9I04
5 = Inhalants
VI

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIA9I05
8 = Sedatives
RE

CIA9I06

CIA9I07
R

CIA9I08
FO

CIA9I09

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POOR JUDGMENT
After using "substance", the subject shows poor judgment, POOR JUDGMENT CIB0I01
as defined in the Mania section. Intensity
0 = Absent

Uncharacteristic behaviors performed with disregard for 2 = Treatment for alcohol.

possible negative consequences. 3 = Treatment for drugs.

4 = Treatment for both.

Did you do anything that you regret?

LY
CIB0F01
Or anything that seemed really stupid afterwards? Frequency

What?
How many times in the last 3 months have you done
CIB0O01

N
something like that?
When did that start? Onset

/ /

O
SUBSTANCE LIST CIB0I02
1 = Alcohol

2 = Cannabis
CIB0I03
EW 3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIB0I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB0I05
VI

8 = Sedatives

CIB0I06
RE

CIB0I07

CIB0I08
R

CIB0I09
FO

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SOCIAL PROBLEMS AT HOME

Relationship problems with spouse, significant other, SOCIAL PROBLEMS IN FAMILY CIB1I01
parents or siblings that have resulted from "substance" use. Intensity
0 = Absent

CODE AS IN INCAPACITY SECTION. 2 = Partial incapacity

3 = Complete incapacity
Is your "substance" use ever involved in any problems
CIB1O01
at home?

LY
Onset
With whom? / /
How does your spouse/significant other feel about it?
How do your parents react? SUBSTANCE LIST CIB1I02
Has anyone done anything about it?

N
1 = Alcohol
Like what?
When did it start to be a problem at home? 2 = Cannabis
CIB1I03
3 = Cocaine/Crack

O
4 = Amphet./Ice/Meth
CIB1I04
5 = Inhalants
EW 6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB1I05
8 = Sedatives

CIB1I06
VI

CIB1I07

CIB1I08
RE

CIB1I09
R
FO

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SOCIAL PROBLEMS WITH FRIENDS

Relationship problems with peers that have resulted from SOCIAL PROBLEM WITH FRIENDS CIB2I01
"substance use". Intensity
0 = Absent

CODE AS IN INCAPACITY SECTION. 2 = Partial incapacity

3 = Complete incapacity
What do your friends think?
CIB2O01

LY
Onset
Have you changed your friends since you've been
using "substance'? / /
Has it caused any trouble with your friends or other SUBSTANCE LIST CIB2I02
people your own age?

N
1 = Alcohol
What happened? 2 = Cannabis
When did that start? CIB2I03
Have you lost any friends because of using 3 = Cocaine/Crack

O
"substance"? 4 = Amphet./Ice/Meth
CIB2I04
Are there people who just won't hang around you 5 = Inhalants
anymore because of your using? EW 6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB2I05
8 = Sedatives

CIB2I06
VI

CIB2I07

CIB2I08
RE

CIB2I09
R
FO

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REDUCED ACTIVITIES
A reduction in activities that has resulted from "substance" REDUCED ACTIVITIES CIB3I01
use. Intensity
0 = Absent

Have you stopped doing any things that you used to 2 = Partial incapacity
enjoy because of using "substance"? 3 = Complete incapacity

Like sports or hobbies? CIB3O01

LY
What? Onset
Why did you stop?
Have you given up anything else?
/ /
When did that start? SUBSTANCE LIST CIB3I02

N
1 = Alcohol

2 = Cannabis
CIB3I03
3 = Cocaine/Crack

O
4 = Amphet./Ice/Meth
CIB3I04
5 = Inhalants
EW 6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB3I05
8 = Sedatives

CIB3I06
VI

CIB3I07

CIB3I08
RE

CIB3I09
R
FO

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SCHOOL/COLLEGE/UNIVERSITY/WORK
AFFECTED
Negative effects on school/college/university or work, SCHOOL/WORK AFFECTED CIB4I01
performance and/or achievement that have resulted from Intensity
0 = Absent
"substance" use.
2 = Partial incapacity
CODE AS IN INCAPACITY SECTION. 3 = Complete incapacity

LY
CIB4O01
Has your education or work ever been affected
Onset
because you were using "substance"?
/ /
When was that?
What happened? MISSED SCHOOL CIB4F01

N
What about during the last 3 months?
Have you ever been to school/college/university or
work when you were "high (drunk)"?
MISSED WORK CIB4F02

O
What happened?
Have you gotten into any trouble there because
"substance" was involved? SUBSTANCE LIST CIB4I02

What happened? 1 = Alcohol

"substance"?
EW
Have you neglected your studies or work because of 2 = Cannabis
CIB4I03
3 = Cocaine/Crack
Have you missed any classes or work because of
4 = Amphet./Ice/Meth
"substance use"?
CIB4I04
5 = Inhalants
How much?
VI

6 = Heroin/Opioids/X/Oxy
When was that?
What about in the last 3 months? 7 = Hallucinogens CIB4I05
8 = Sedatives
RE

CIB4I06

CIB4I07
R

CIB4I08
FO

CIB4I09

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DANGEROUS ACTIVITIES
Activities that physically endanger either the subject or DANGEROUS ACTIVITIES CIB5I01
others, undertaken while intoxicated, such as driving while Intensity
0 = No
intoxicated,or operating machinery while intoxicated.
2 = Yes
Have you done any dangerous things when you were CIB5F01
"high (drunk)" in the last 3 months? Frequency

LY
Like driving?
Or showing off or taking risky dares?
What happened? CIB5O01
How often in the last 3 months? Onset
When did that start?
/ /

N
SUBSTANCE LIST CIB5I02
1 = Alcohol

O
2 = Cannabis
CIB5I03
3 = Cocaine/Crack
EW 4 = Amphet./Ice/Meth
CIB5I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB5I05
8 = Sedatives
VI

CIB5I06

CIB5I07
RE

CIB5I08

CIB5I09
R
FO

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"SUBSTANCE" RELATED CRIME

Illegal activities undertaken either to obtain "substance", or "SUBSTANCE" RELATED CRIME CIB6I01
associated with intoxication with "substance". Intensity
0 = No

PROSTITUTION IS ALSO CODED AS SEXUAL ACTIVITY 2 = Yes

FOR GAIN. CIB6O01
Onset
DEALING IS ALSO CODED AS DEALING DRUGS.
/ /

LY
Have you done anything illegal while you were "high" DEALING CIB6I02
in the last 3 months?
0 = No
What did you do?

N
2 = Yes
Did you get caught?
What happened? PROSTITUTION CIB6I03
When was the first time?
0 = No

O
Have you ever stolen to get money for "substance"?
2 = Yes
Or stolen any "substance"?
SUBSTANCE LIST CIB6I04
Have you ever been a runner or dealer to get money for
EW 1 = Alcohol
"substance"?
2 = Cannabis
CIB6I05
Have you ever had sex with anyone or engaged in 3 = Cocaine/Crack
prostitution to get "substance"?
4 = Amphet./Ice/Meth
CIB6I06
5 = Inhalants
VI

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB6I07
8 = Sedatives
RE

CIB6I08

CIB6I09
R

CIB6I10
FO

CIB6I11

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MANUFACTURING/DISTRIBUTION OF
SUBSTANCE
Participation in the growing, manufacturing, and/or MANUFACTURING/DISTRIBUTION OF ywn8000
distribution of illegal substances. Include trafficking across SUBSTANCE Intensity
state lines and from other countries. 0 = No

2 = Yes
Have you grown any illegal substances in the last 3
months? ywn8001

LY
Onset
Have you made or manufactured any illegal
substances? / /
Have you been involved in distributing "illegal SUBSTANCE LIST ywn8002
substances"?

N
1 = Alcohol

What did you do? 2 = Cannabis

ywn8003
Have you used your home or vehicle in "substance" 3 = Cocaine/Crack

O
related activity?
4 = Amphet./Ice/Meth
Or have you rented a building or vehicle to use in ywn8004
5 = Inhalants
"substance" related activity?
6 = Heroin/Opioids/X/Oxy

another country?
EW
Have you taken substance across state lines or into
7 = Hallucinogens ywn8005
8 = Sedatives
What "substances" were involved?
When was the first time you did something like that? ywn8006
VI

ywn8007

ywn8008
RE

ywn8009
R
FO

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TROUBLE WITH THE LAW

Any involvement with the police associated with using TROUBLE WITH LAW CIB7I01
"substance". Intensity
0 = No

Have you been in trouble with the police in the last 3 2 = Yes
months on account of using "substance"? CIB7O01
Onset
Have you been arrested, been to Court, been in jail or
/ /

LY
on probation because of drugs or alcohol?

What happened? SUBSTANCE LIST CIB7I02

When was the first time?
1 = Alcohol

N
2 = Cannabis
CIB7I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth

O
CIB7I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB7I05
EW 8 = Sedatives

CIB7I06

CIB7I07
VI

CIB7I08
RE

CIB7I09
R
FO

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MOOD LABILITY
Unstable mood swings, often from excessive joviality to MOOD LABILITY CIB8I01
maudlin misery or anxiety. Mood lability should only be Intensity
0 = Absent
coded here if it is sufficiently pronounced as to lead to
effects that seem inappropriate to the situation (such as 2 = Symptom intrusive into at least 2
copious, apparently unprovoked, weeping in a bar), or activities and uncontrollable at least some
of the time.
appear to have interfered with the normal course of
conversation or activities. 3 = Symptom intrusive into almost all

LY
activities and hardly ever controllable.

Does your mood change at all when you are high? CIB8O01
Onset
How do you feel?
What is it like? / /

N
Does you mood go way up and down?
What about in the last 3 months? SUBSTANCE LIST CIB8I02
When did that start? 1 = Alcohol

O
2 = Cannabis
CIB8I03
3 = Cocaine/Crack

4 = Amphet./Ice/Meth
CIB8I04
EW 5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIB8I05
8 = Sedatives

CIB8I06
VI

CIB8I07
RE

CIB8I08

CIB8I09
R
FO

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PHYSICAL PROBLEMS
Include any physcial problems that either stem directly from PHYSICAL PROBLEMS CIB9I01
intoxication (such as those resulting from injuries from an Intensity
0 = Absent
accident while intoxicated), or that a physician has told the
subject are related to "substance" use. 2 = Symptom occurs or increases in
response to cues prompting recall or
reliving of the "life event".
MAKE WRITTEN NOTE OF NATURE OF PHYSICAL
PROBLEMS. CIB9O01

LY
Onset
Have you had any other physical problems on account / /
of "substance" in the last 3 months?
SUBSTANCE LIST CIB9I02
Like coughing, shortness of breath, nausea, headaches,

N
etc. 1 = Alcohol
Have you been to a Doctor as a result of substance use 2 = Cannabis
in the last 3 months? CIB9I03
3 = Cocaine/Crack

O
When did that start? 4 = Amphet./Ice/Meth
Did anyone tell you that using "substance" was CIB9I04
responsible? 5 = Inhalants
Were you hospitalized because of it? EW 6 = Heroin/Opioids/X/Oxy
Did you keep on using "substance" anyway?
7 = Hallucinogens CIB9I05
8 = Sedatives

CIB9I06
VI

CIB9I07

CIB9I08
RE

CIB9I09
R
FO

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BLACKOUTS
Episodes of amnesia lasting at least 1 hour that occur in EVER: BLACKOUTS Ever:CIC0E01
relation to bouts of heavy "substance" use. Intensity
0 = No

Have there been any times when you couldn't 2 = Yes

remember what had happened when you were using BLACKOUTS CIC0I01
"substance"? Intensity
0 = No

LY
Did you black out? 2 = Yes
Tell me about it.
When did that start? CIC0F01
Has it happened in the last 3 months? Frequency
How often?

N
How long was the period that you couldn't remember?
HOURS : MINUTES CIC0D01
Duration

O
CIC0O01
Onset

/ /
EW
SUBSTANCE LIST CIC0I02
1 = Alcohol

2 = Cannabis
CIC0I03
3 = Cocaine/Crack
VI

4 = Amphet./Ice/Meth
CIC0I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy
RE

7 = Hallucinogens CIC0I05
8 = Sedatives

CIC0I06
R

CIC0I07
FO

CIC0I08

CIC0I09

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UNCONSCIOUSNESS
Code here episodes in which the subject uses "substance" UNCONSCIOUSNES CIC1I01
until unconscious. Intensity
0 = No

Have you ever passed out? 2 = Yes

CIC1F01
How about in the last 3 months? Frequency
When did that first happen?

LY
How many times have you passed out from substance use
in the last 3 months? CIC1O01
Onset

/ /

N
SUBSTANCE LIST CIC1I02
1 = Alcohol

O
2 = Cannabis
CIC1I03
3 = Cocaine/Crack
EW 4 = Amphet./Ice/Meth
CIC1I04
5 = Inhalants

6 = Heroin/Opioids/X/Oxy

7 = Hallucinogens CIC1I05
8 = Sedatives
VI

CIC1I06

CIC1I07
RE

CIC1I08

CIC1I09
R
FO

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LIFE EVENTS
Events occurring in the life and environment of
the subject. Life threatening events are events
that have caused, or had the potential to cause,
death or severe injury. The events should be
those in which people actually died or were
seriously injured and/or property was
extensively damaged, or those events which
had the potential to have these outcomes.

LY
MOST EVENTS SHOULD HAVE BEEN NOTED
IN THE INTERVIEW BY THIS POINT. FOR EACH
EVENT THAT OCCURRED, ASK ABOUT
ATTRIBUTION AND PAINFUL RECALL. IF
PAINFUL RECALL PRESENT AS ABOUT

N
AVIODANCE, AND HYPERAROUSAL.
Attributions: Subject states that life event has
contributed to a problem or symptom already

O
identified. Painful Recall: Subject experiences
unwanted, painful and distressing
recollections, memories, thoughts, or images of
life event. May include repetitive play or
trauma-specific reenactment. Avoidance: EW
Subject avoids situations, thoughts, or feelings
that might provoke painful recall. Hyperarousal:
Symptoms of anxiety or increased arousal not
present before the trauma (or exacerbated by
the trauma) that may include difficulty falling or
staying asleep, hypervigilance (increased
general level of awareness and alertness
VI

toward the subject's surroundings, in the

absence of imminent danger which may be
manifested by an exaggerated startle response,
jumpiness, scanning the environment for
danger). Some individuals report irritability,
RE

anger or difficulty concentrating or completing

tasks. IF PAINFUL RECALL, AVOIDANCE, AND
HYPERAROUSAL SCREEN ALL POSTIIVE,
NOTE ON THE PTSD SCREEN PAGE
(CHECKLIST). NOTE: IF MORE THAN ONE
EVENT IS CHECKED ON THE PTSD SCREEN
PAGE (CHECKLIST), THE PTSD SECTION WILL
R

BE COMPLETED TWICE: ONCE FOR THE LIFE

EVENT GROUP B OR GROUP A THAT THE
SUBJECT DESCRIBES AS THE MOST
FO

UPSETTING IN THE LAST 3 MONTHS, AND

SECONDLY FOR THE LIFE EVENT IN GROUP B
THAT THE SUBJECT DESCRIBES AS THE
MOST UPSETTING EVENT EVER.

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GROUP A EVENTS
NEW CHILD(REN) LIVING IN HOME
New child(ren) (less than 18 years of age) who have come NEW CHILD(REN) LIVING IN HOME CKA0I90
to live in the home permanently during the primary period. Intensity
0 = Absent
May be newborn or adopted child, foster child, or child(ren)
of a previous relationship. 2 = Present

NEW CHILD #1 IN HOME CKA0I01

LY
CODE ID # OF SIBLING FROM FAMILY SECTION.
1 = Sibling #1

Have any children come to live in your home in the last 2 = Sibling #2
3 months?
3 = Sibling #3
Who is that?

N
4 = Sibling #4
When did s/he come to live with you?
Does your "parent" look after him/her? 5 = Sibling #5

6 = Sibling #6

O
Who is that?
When did s/he come to live with you? 7 = Sibling #7

8 = Sibling #8
Who is that?
When did s/he come to live with you? 9 = Sibling #9
EW ONSET OF NEW CHILD #1 CKA0O01

/ /
NEW CHILD #2 IN HOME CKA0I02
1 = Sibling #1
VI

2 = Sibling #2

3 = Sibling #3

4 = Sibling #4
RE

5 = Sibling #5

6 = Sibling #6

7 = Sibling #7

8 = Sibling #8

9 = Sibling #9
R

ONSET OF NEW CHILD #2 CKA0O02

/ /
FO

NEW CHILD #3 IN HOME CKA0I03

1 = Sibling #1

2 = Sibling #2

3 = Sibling #3

4 = Sibling #4

5 = Sibling #5

6 = Sibling #6

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7 = Sibling #7

8 = Sibling #8

9 = Sibling #9

ONSET OF CHILD #3 CKA0O03

/ /

LY
IF "NEW CHILD(REN) LIVING IN HOME"
NOT PRESENT, SKIP TO "PARENTAL
SEPARATION", (PAGE 6).

N
O
EW
VI
RE
R
FO

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NEW CHILD(REN) LIVING IN HOME -

ATTRIBUTION
In the last 3 months, has this "life event" affected any ATTRIBUTION CKA0I99
of the problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKA0X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKA0X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKA0X03
5 = Depression

O
6 = Mania
CKA0X04
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKA0X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKA0X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

NEW CHILD(REN) LIVING IN HOME: PAINFUL

FO

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKA1I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF PAINFUL RECALL PRESENT,

COMPLETE AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "PARENTAL SEPARATION", (PAGE
6).

LY
N
O
EW
VI
RE
R
FO

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NEW CHILD(REN) LIVING IN HOME -

AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKA1I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
NEW CHILD(REN) LIVING IN HOME -
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKA1I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
PARENTAL SEPARATION
Parental figures have separated durning the primary PARENTAL SEPARATION CKA2I01
EW
period. One parental figure has moved out of the house,
apparently permanently. Either parent may have begun
0 = Absent
Intensity

divorce proceedings. 2 = Present

CKA2O01
Have your "parents" split up in the last 3 months? Onset

What happened? / /
VI

Are you planning to get back together again?

PARENT WHO HAS MOVED OUT CKA2I02
0 = Male parental figure
RE

2 = Female parental figure

IF PARENTAL SEPARATION PRESENT,

COMPLETE. OTHERWISE, SKIP TO
"EVER: PARENTAL DIVORCE", (PAGE
R

9).
FO

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PARENTAL SEPARATION - ATTRIBUTION

In the last 3 months have thoughts or pictures of "life ATTRIBUTION CKA1I99
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like? ATTRIBUTION OF "LIFE EVENT" AS CKA2X01

CONTRIBUTION TO PROBLEM WITH:
In what way?

LY
1 = School non-attendance.

2 = Separation anxiety. CKA2X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKA2X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

PARENTAL SEPARATION - PAINFUL RECALL

R

In the last 3 months have thoughts or pictures of "life PAINFUL RECALL SCREEN CKA3I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didnt want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

IF PAINFUL RECALL PRESENT, ASK

AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "EVER:
PARENTAL DIVORCE", (PAGE 9).

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LY
N
O
EW
VI
RE
R
FO

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PARENTAL SEPARATION - AVOIDANCE

Do certain things/thoughts remind you of "life event"? AVIODANCE SCREEN CKA3I02
Intensity
0 = Absent
What things?
Do you try to aviod these things/thoughts? 2 = Present

PARENTAL SEPARATION - HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKA3I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EVER: PARENTAL DIVORCE
Parental figures have ever completed divorce proceedings. EVER: PARENTAL DIVORCE Ever:CKA4E01
Intensity
0 = Absent
Code dates of up to three other divorces between parental
figures with whom child has lived.
EW 2 = Present

EVER: PARENTAL DIVORCE #1 Ever:CKH8O01

Have your parents ever been divorced?
/ /
EVER: PARENTAL DIVORCE #2 Ever:CKH8O02

/ /
VI

EVER: PARENTAL DIVORCE #3 Ever:CKH8O03

/ /
RE

PARENTAL DIVORCE
Parental figures have completed divorce proceedings in the 0 = Absent CKA4I01
last 3 months. Intensity
2 = Divorce finalized in last three months.
R

Have your "parents" finalized their divorce in the last 3

months? ONSET: DIVORCE IN LAST THREE CKA4O01
MONTHS
/ /
FO

When did that happen?

IF "PARENTAL DIVORCE" NOT

PRESENT, SKIP TO "NEW PARENTAL
FIGURE", (PAGE 12).

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PARENTAL DIVORCE - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKA2I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what ways?
ATTRIBUTION OF "LIFE EVENT" AS CKA4X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKA4X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKA4X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

PARENTAL DIVORCE-PAINFUL RECALL

R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKA5I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF PARENTAL DIVORCE PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "NEW PARENTAL FIGURE",
(PAGE 12).

LY
N
O
EW
VI
RE
R
FO

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PARENTAL DIVORCE-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKA5I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

PARENTAL DIVORCE-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKA5I03
irritable? Intensity
0 = Absent

Have youe had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
NEW PARENTAL FIGURE
New Parental figure moved into the child's home during the NEW PARENTAL FIGURE CKA6I01
last 3 months and has been there as least one month, due Intensity
0 = Absent
to remarriage or establisment of apparently permanent
relationship.
EW 2 = Present

CKA6O01
Did a new "parent" move into your home in the last 3 Onset
months?
/ /
Is s/he there to stay?
VI

IF NEW PARENTAL FIGURE PRESENT,

COMPLETE ATTRIBUTION AND
RE

PAINFUL RECALL. OTHERWISE, SKIP

TO "PLACES LIVED IN LAST 5 YEARS",
(PAGE 15).
R
FO

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NEW PARENTAL FIGURE - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKA3IXX 00
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKA6X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKA6X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKA6X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

NEW PARENTAL FIGURE - PAINFUL RECALL

R

In the last 3 months have thoughts or pictures of "life PAINFUL RECALL SCREEN CKA7I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF NEW PARENTAL FIGURE PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "PLACES LIVED IN LAST 5
YEARS", (PAGE 15).

LY
N
O
EW
VI
RE
R
FO

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NEW PARENTAL FIGURE - AVOIDANCE

Do certain things/thoughs remind you of "life event"? AVIODANCE SCREEN CKA7I02
Intensity
0 = Absent
What things?
Do you try to aviod these things/thoughts? 2 = Present

NEW PARENTAL FIGURE - HYPERAROUSAL

LY
Have you had any trouble sleeping? HYPERAROUSAL SCREEN CKA7I03
Intensity
0 = Absent
Since "life event", have you been more jumpy or
irritable? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
PLACES LIVED IN LAST 5 YEARS
Subject moved, with or without change of family structure. MOVING HOUSE CKA9E01
Intensity
0 = Absent
REMEMBER TO CODE PARENTAL SEPARATION,
CHANGE OF SCHOOL, LOSS OF FRIENDS, ETC. IN
RELEVANT SECTIONS.
EW 2 = Present

PLACES LIVED IN LAST 5 YEARS- CKA9F01

CODE NUMBER OF PLACES LIVED IN
LAST 5 YEARS
How many places have you lived in the last 5 years?

How many places has s/he lived in the last 5 years? DATE OF LAST MOVE IN LAST FIVE CKA9O01
YEARS
/ /
VI

When was the last time that s/he moved?

Date of last move in last 5 years

RE

MOVING HOUSE
Subject moved, with or without change of family structure. MOVING HOUSE CKA8I01
Intensity
0 = Absent
REMEMBER TO CODE PARENTAL SEPARATION,
CHANGE OF SCHOOL, LOSS OF FRIENDS, ETC. IN 2 = Present, without change of family
structure.
R

RELEVANT SECTIONS.
3 = Present, with change of family structure.
Have you moved to a new place in the last 3 months? CKA8O01
FO

Onset
Is your home in the same neighborhood?
When did you move? / /

IF MOVING NOT PRESENT, SKIP TO

"CHANGE OF SCHOOL", (PAGE 19).

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LY
N
O
EW
VI
RE
R
FO

Life Events 16
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Definitions and questions Coding rules Codes

MOVING HOUSE - ATTRIBUTION

In the last 3 months have thoughts or pictures of "life ATTRIBUTION CKA8ABC 00
event" come into your mind? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKA8X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKA8X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKA8X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

MOVING HOUSE-PAINFUL RECALL

R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKB0I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the the event?

IF "MOVING HOUSE" PAINFUL RECALL

PRESENT, ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "CHANGE OF SCHOOL", (PAGE 19).

Life Events 17
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Definitions and questions Coding rules Codes

LY
N
O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

MOVING HOUSE-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKB0I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

MOVING HOUSE-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKB0I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
CHANGE OF SCHOOL
Subject changed schools. Change may be routine because CHANGE OF SCHOOL CKB1I01
subject was promoted (e.g. elementary to middle school, or Intensity
0 = No
iddle school to high scool) or non-routine, either because of

previous school.
EW
moving, family choice, necessity, or expulsion from 1 = Routine change with other schoolmates
including friends

2 = Routine change but not friends from

Have you changed schools in the last 3 months? former school at new school

3 = Non-routine change
When did you last change schools?
CKB1O01
VI

Why was that? Onset

When did you leave the old school?
When did/do you start at the new school? / /
Will any friends from your old school be at the new school?
Do you know nayone at the new school?
RE

IF CHANGE OF SCHOOL NOT

PRESENT, SKIP TO "LOSS OF BEST
FRIEND THROUGH MOVING", (PAGE
R

22).
FO

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Definitions and questions Coding rules Codes

CHANGE OF SCHOOLS - ATTRIBUTION

In the las 3 months, has "life event" affected any of the ATTRIBUTION CKB1I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKB1X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKB1X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKB1X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

CHANGE OF SCHOOLS-PAINFUL RECALL

R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKB2I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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Definitions and questions Coding rules Codes

IF CHANGE OF SCHOOLS PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "LOSS OF BEST FRIEND
THROUGH MOVING", (PAGE 22).

LY
N
O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

CHANGE OF SCHOOLS-AVOIDANCE
Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKB2I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

CHANGE OF SCHOOLS-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKB2I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

IF ALL SCREENS ARE POSITIVE, PLACE CHECKMARK

O
ON PTSD CHECKLIST.

LOSS OF BEST FRIEND THROUGH MOVING EW

Move by subject or significant other resulted in the end of a LOSS OF BEST FRIEND THROUGH CKB3I01
close relationship, with significant figure no longer available MOVING Intensity
for sharing confidences and doing things together. Do not 0 = Absent
include friendships maintained after move through phone
calls, letters, and/or visits. 2 = Present

CKB3O01
CODE BOY/GIRLFRIEND SEPARATELY Onset
VI

Have you lost contact with someone you cared about

/ /
in the last 3 months because one of them moved?
RE

Who moved?
Do you still have some contact with him/her?

IF LOSS OF BEST FRIEND THROUGH

MOVING NOT PRESENT, SKIP TO
R

"BREAKUP WITH BEST FRIEND",

(PAGE 25).
FO

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Definitions and questions Coding rules Codes

LOSS OF BEST FRIEND THROUGH MOVING -

ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKB2ABC 00
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKB3X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKB3X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKB3X03
5 = Depression

O
6 = Mania
CKB3X04
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKB3X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKB3X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

LOSS OF BEST FRIEND THROUGH MOVE-

FO

PAINFUL RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKB4I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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Definitions and questions Coding rules Codes

IF LOSS OF BEST FRIEND THROUGH

MOVING PAINFUL RECALL PRESENT,
ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "BREAKUP WITH BEST FRIEND",
(PAGE 25).

LY
N
O
EW
VI
RE
R
FO

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LOSS OF BEST FRIEND THROUGH MOVING-

AVOIDANCE
Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKB4I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
LOSS OF BEST FRIEND THROUGH MOVE-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKB4I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
BREAKUP WITH BEST FRIEND
Loss of a best friend through conflict or quarrel. Loss BREAKUP WITH BEST FRIEND CKB5I01
should seem permanent.
EW 0 = Absent
Intensity

CODE BREAKUP WITH BOYFRIEND/GIRLFRIEND 2 = Present

SEPARATELY. IF MORE THAN ONE BREAKUP, CODE CKB5O01
THE ONE SUBJECT SAID WAS THE MOST UPSETTING. Onset

/ /
VI

Have you ended a relationship with a best friend in the

last 3 months?

Who was that?

What happened?
RE

IF BREAKUP WITH BEST FRIEND

PRESENT CONTINUE, OTHERWISE,
SKIP TO "BREAKUP WITH
R

BOY/GIRLFRIEND", (PAGE 28).

FO

Life Events 25
CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BREAKUP WITH BEST FRIEND-ATTRIBUTION

Loss of a best friend throught conflict or quarrel. Loss ATTRIBUTION CKB5ABC 00
should seem permanent. Intensity
0 = Absent

Have you broken up with a best friend in the last 3 2 = Present

months? ATTRIBUTION OF "LIFE EVENT" AS CKB5X01
CONTRIBUTING TO PROBLEM WITH:
Who was that?

LY
What happened? 1 = School non-attendance.

2 = Separation anxiety. CKB5X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKB5X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

BREAKUP WITH BEST FRIEND-PAINFUL

RECALL
R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKB6I01
event" come into your mind? Intensity
0 = Absent
FO

What was that like? 2 = Present

Have you had any nightmares about the event?

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Definitions and questions Coding rules Codes

IF BREAKUP WITH BEST FRIEND

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "BREAKUP
WITH BOY/GIRLFRIEND", (PAGE 28).

LY
N
O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

BREAKUP WITH BEST FRIEND-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKB6I05
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

BREAKUP WITH BEST FRIEND-

LY
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKB6I0600
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
BREAKUP WITH BOY/GIRLFRIEND
Relationships with boy/girlfriend ends because of conflict, BREAKUP WITH BOY/GIRLFRIEND CKB7I01
"falling out of love", or geographical move. Do not include Intensity
EW
love relationships that turn into regular friendships without
conflict, or love relationships maintained by phone calls,
0 = No

2 = Yes
letters, and/or visits.
CKB7O01
Onset
IF MORE THAN ONE BREAKUP IN THE LAST 3
MONTHS, CODE THE ONE MOST IMPORTANT TO THE / /
SUBJECT.
VI

Have you broken up with a boy/girlfriend in the last 3

months?
RE

What happened?
Have you broken up for good?
Are you still friends?

IF BREAKUP PRESENT, COMPLETE

R

ATTRIBUTION AND PAINFUL RECALL.

OTHERWISE, SKIP TO
FO

"LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE
ENVIRONMENT", (PAGE 31).

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Definitions and questions Coding rules Codes

BREAKUP WITH BOY/GIRLFRIEND -

ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKB7ABC 00
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKB7X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKB7X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKB7X03
5 = Depression

O
6 = Mania

7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

BREAKUP WITH BOY/GIRLFRIEND - PAINFUL

R

RECALL
In the last 3 months have thoughts or pictures of "life PAINFUL RECALL SCREEN CKB8I01
Intensity
FO

event" come into your mind? 0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?
Have you had any nightmares about the event?

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Definitions and questions Coding rules Codes

IF BREAKUP WITH BOY/GIRLFRIEND

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO
"LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE
ENVIRONMENT", (PAGE 31).

LY
N
O
EW
VI
RE
R
FO

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Definitions and questions Coding rules Codes

BREAKUP WITH BOY/GIRLFRIEND -

AVOIDANCE
Do certain things/thoughts remind you of "life event"? ATTRIBUTION CKB8I02
Intensity
0 = Absent
What things?
Do you try to avoid these thing/thoughts? 2 = Present

LY
BREAKUP WITH BOY/GIRLFRIEND -
HYPERAROUSAL
Since "life event", have you been more jumpy or ATTRIBUTION CKB8I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE ENVIRONMENT EW
Subject lives, attends school/college/university or works in LIVES, ATTENDS CKB9I01
an area seen as chronically unsafe or threatening. SCHOOL/COLLEGE/UNIVERSITY, OR Intensity
WORKS IN CHRONICALLY UNSAFE
ENVIRONMENT
CODE DISCRETE THREATENING EVENTS WITNESSED
0 = Absent
BY SUBJECT SEPARATELY.
2 = Present
VI

Do you live or go to school in an unsafe place?

CKB9O01
Onset
Or work in an unsafe place?
/ /
What is it like?
RE

Have you been afraid that you might be hurt? MONTHS CKB9D01
Or that you would die? Duration
R

IF "LIVES/ATTENDS SCHOOL/WORKS
IN CHRONICALLY UNSAFE
ENVIRONMENT" NOT PRESENT, SKIP
FO

TO "PARENTAL ARREST", (PAGE 34).

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Definitions and questions Coding rules Codes

LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE ENVIRONMENT -
ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKB9I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION: CKB9X01

LY
1 = School non-attendance.

2 = Separation anxiety.
CKB9X02
3 = Worries/anxiety.

N
4 = Obsessions/compulsions.
CKB9X03
5 = Depression

O
6 = Mania

7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R
FO

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Definitions and questions Coding rules Codes

LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE ENVIRONMENT-
PAINFUL RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKC0I01
event" come into your mind? Intensity
0 = Absent

Even when you doesn't want them to? 2 = Present

LY
What was that like?
Have you had any nightmares about the event?

IF PAINFUL RECALL PRESENT, ASK

N
ABOUT AVOIDANCE AND
HYPERAROUSAL. OTHERWISE , SKIP

O
TO "PARENTAL ARREST", (PAGE 34).

EW
VI
RE
R
FO

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE ENVIRONMENT-
AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKC0I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
LIVES/ATTENDS SCHOOL/WORKS IN
CHRONICALLY UNSAFE ENVIRONMENT-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKC0I03

N
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

O
Have you been "on the alert" for bad things
happening?

PARENTAL ARREST
Either of subject's parental figures is arrested.
EW PARENTAL ARREST CKC1I01
Intensity
0 = No
IF MORE THAN ONE ARREST, CODE THE MOST
UPSETTING. 2 = Yes

CKC1O01
Onset
VI

Have either of your "parents" been arrested in the last

3 months?
/ /
What happened?
Was it for something serious?
RE

IF PARENTAL ARREST PRESENT,

COMPLETE ATTRIBUTION AND
PAINFUL RECALL. OTHERWISE, SKIP
R

TO "REDUCTION IN STANDARD OF
LIVING", (PAGE 37).
FO

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL ARREST - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKC1I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKC1X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKC1X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKC1X03

N
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

PARENTAL ARREST - PAINFUL RECALL

R

In the last 3 months have thoughts or pictures of "life PAINFUL RECALL SCREEN CKC2I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IF PARENTAL ARREST PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "REDUCTION IN STANDARD
OF LIVING", (PAGE 37).

LY
N
O
EW
VI
RE
R
FO

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PARENTAL ARREST -AVOIDANCE

Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKC2I02
Intensity
0 = Absent
What things?
2 = Present
Do you try to aviod these things/thoughts?

LY
PARENTAL ARREST -HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKC2I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
REDUCTION IN STANDARD OF LIVING
Noticeable reduction of family standard of living as REDUCTION IN STANDARD OF LIVING CKC3I01
evidenced by inability to pay bills, need to sell things, need Intensity
EW
to move (including moving in with relatives), going on
welfare or food stamps, inadequate food, clothing, heat.
0 = Absent

2 = Present, without change of family

May be result of changes in household status and needs structure.
such as parental separation or divorce, death, taking in 3 = Present, with change of family structure.
additional dependents, high medical bills or loss of
household income due to cutback in hours, layoff or loss of DATE OF CHANGE IN FINANCIAL CKC3O01
STATUS
job, inability to find employment, under-employment, loss of
/ /
VI

unemployment benefits, depletion of savings, etc.

Has your family's income been less than usual in the

last 3 months?
RE

What changes have resulted?

Why have things changed?
When did the change occur?
R

IF "REDUCTION IN STANDARD OF
LIVING" NOT PRESENT, SKIP TO
"FORCED SEPARATION FROM HOME",
FO

(PAGE 40).

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Definitions and questions Coding rules Codes

REDUCTION IN STANDARD OF LIVING -

ATTRIBUTION
In the last 3 months, has this "life event" affected any ATTRIBUTION CKC3I99
of the problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKC3X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKC3X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKC3X03
5 = Depression

O
6 = Mania

7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

REDUCTION IN STANDARD OF LIVING-

FO

PAINFUL RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKC4I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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Definitions and questions Coding rules Codes

IF REDUCTION IN STANDARD OF
LIVING PAINFUL RECALL PRESENT,
ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "FORCED SEPARATION FROM
HOME", (PAGE 40).

LY
N
O
EW
VI
RE
R
FO

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

REDUCTION IN STANDARD OF LIVING-

AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKC4I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
REDUCTION IN STANDARD OF LIVING-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKC4I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
FORCED SEPARATION FROM HOME
Subject has to be away from home for at least one week at FORCED SEPARATION FROM HOME CKC5I01
EW
a time, against his/her weill. Include visits to grandparents,
other relatives, friends, if necessitated by aduly needs (e.g.
0 = No
Intensity

mother in hispital) not child's wishes. Do not include 2 = Yes

absences if accompanied by parental figures, or camp,
CKC5O01
even if subject is reluctant to go. Onset

In the last 3 months have you had to go and stay away / /

VI

from home, when s/he would rather have stayed at

home? NUMBER OF SEPARATIONS CKC5F01

When was that?

RE

Why did you have to go away? DAYS CKC5D01

How long were you gone? Duration
Was a parent with you?
Or your "sibling"?

CODE NUMBER OF SEPARATIONS LASTING AT LEAST

A WEEK
R

CODE NUMBER OF DAYS IN ALL SEPARATIONS

FO

IF FORCED SEPARATION FROM HOME

PRESENT, COMPLETE OTHERWISE,
SKIP TO "DIAGNOSIS OF PHYSICAL
ILLNESS", (PAGE 44).

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FORCED SEPARATION FROM HOME -

ATTRIBUTION
In the last 3 months, has this affected any of the ATTRIBUTION CKC5XYZ 00
problems we've been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION CKC5X01

LY
1 = School non-attendance.

2 = Separation anxiety.
CKC5X02
3 = Worries/anxiety.

4 = Obsessions/compulsions.

N
CKC5X03
5 = Depression

6 = Mania

O
7 = Physical symptoms.

8 = Food-related behavior.

EW 9 = Hyperactivity/ADD

10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

FORCED SEPARATION FROM HOME-PAINFUL

R

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKC6I01
event" come into your mind? Intensity
FO

0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF "FORCED SEPARATION FROM

HOME" PAINFUL RECALL PRESENT,
ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "DIAGNOSIS OF PHYSICAL
ILLNESS", (PAGE 44).

LY
N
O
EW
VI
RE
R
FO

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FORCED SEPARATION FROM HOME-

AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKC6I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
FORCED SEPARATION FROM HOME-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKC6I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
EW
VI
RE
R
FO

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GROUP B EVENTS
DIAGNOSIS OF PHYSICAL ILLNESS
Diagnosis of an illness carrying current risk of death or DIAGNOSIS OF PHYSICAL ILLNESS Ever:CKC7E01
chronic disability (e.g. cancer, AIDS, diabetes, MS). Intensity
0 = Absent

NB: Asthma requiring more than 24 hour hospitalization. 2 = Present

Specify

LY
Have you ever gotten very sick?

Have you been in the hospital? Ever:CKC7O01

Onset
When did that happen?
What illness did/do you have? / /

N
When did you get better?
Are you going to get better? DIAGNOSIS OF PHYSICAL ILLNESS CKC7I01
Have you had it in the last 3 months? Intensity
0 = Absent

O
Has it gotten worse?
2 = Diagnosis of illness, or recurrence of
illness in remission, in last 3 months.

CKC7O02
Onset
EW / /

IF "DIAGNOSIS OF PHYSICAL
ILLNESS" NOT PRESENT, SKIP TO
VI

"ACCIDENT", (PAGE 47).

RE
R
FO

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DIAGNOSIS OF PHYSICAL ILLNESS -

ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKC7I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKC7X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKC7X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKC7X03
5 = Depression

O
6 = Mania

7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

DIAGNOSIS OF PHYSICAL ILLNESS-PAINFUL

FO

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKC8I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you has any nightmares about the event?

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IF DIAGNOSIS OF PHYSICAL ILLNESS

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "ACCIDENT",
(PAGE 47).

LY
N
O
EW
VI
RE
R
FO

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DIAGNOSIS OF PHYSICAL ILLNESS-

AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKC8I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
DIAGNOSIS OF PHYSICAL ILLNESS-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKC8I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
ACCIDENT
Serious physical harm caused involuntarily by self or others ACCIDENT Ever:CKC9E01
EW
(e.g. car accident, boating accident, other accident) that is
life-threatening or carries risk of long-term disfigurement or
0 = Absent
Intensity

disability. Code accidents involving fire under Fire. 2 = Present

Ever:CKC9V01
IF ACCIDENT IN LAST 3 MONTHS OR IF RESULTS OF Frequency
PREVIOUS ACCIDENT STILL POSE THREAT TO LIFE,
DISFIGUREMENT, OR DISABILITY, COMPLETE
VI

ATTRIBUTION AND SCREENS. OTHERWISE SKIP TO

DEATH OF LOVED ONE. Ever:CKC9O01
Onset

Have you ever been in a serious accident? / /

RE

Or been badly hurt in an accident? SERIOUS ACCIDENT: PRIMARY PERIOD CKC9I01

Intensity
What happened? 0 = Absent
Could you have died? 2 = Present
Did it change the way your body looks or works?
Are you still affected by it? CKC9O02
Onset
R

/ /
FO

IF ACCIDENT IN LAST 3 MONTHS OR IF

RESULT OF PREVIOUS ACCIDENT
STILL POSE THREAT OR DISABILITY,
COMPLETE. OTHERWISE, SKIP TO
"PREGNANCY (GIRLS) - FIRST
PREGNANCY", (PAGE 52).

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LY
N
O
EW
VI
RE
R
FO

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ACCIDENT: ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKC2I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION CKC9X01
1 = School non-attendance.

LY
2 = Separation anxiety.
CKC9X02
3 = Worries/anxiety.

4 = Obsessions/compulsions.
CKC9X03

N
5 = Depression

6 = Mania

7 = Physical symptoms. CKC9X04

O
8 = Food-related behavior.

9 = Hyperactivity/ADD
CKC9X05
10 = Conduct disorder.
EW 11 = Alcohol/drugs
CKC9X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.

14 = Relationships with other parent #1

VI

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.

17 = Peer relationships.
RE

18 = Relationships with spouse or romantic

partner

ACCIDENT-PAINFUL RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKD0I01
R

event" come into your mind? Intensity

0 = Absent

Even when you didn't want them to? 2 = Present

FO

What was that like?

Have youe had any nightmares about the event?

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IF ACCIDENT PAINFUL RECALL

PRESENT, ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "PREGNANCY (GIRLS) - FIRST
PREGNANCY", (PAGE 52).

LY
N
O
EW
VI
RE
R
FO

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ACCIDENT-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKD0I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

ACCIDENT-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKD0I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
IF SUBJECT IS FEMALE COMPLETE.
OTHERWISE, SKIP TO "MAKES
SOMEONE PREGNANT (BOYS)", (PAGE
65).
EW
VI
RE
R
FO

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PREGNANCY (GIRLS) - FIRST PREGNANCY

Subject ever pregnant. PREGNANCY Ever:CKD1E11
Intensity
0 = No
Have you ever been pregnant?
2 = Yes
When did you find out you were pregnant? Ever:CKD1O11
When did you get pregnant? Onset
How did you find out?
/ /

LY
Were you planning to get pregnant?
Did you want to be pregnant?
DATE OF AWARENESS - (GIRLS) FIRST Ever:CKD1O12
DATE OF CONCEPTION. PREGNANCY
/ /

N
INTENTIONALITY Ever:CKD1X11
1 = Planned pregnancy

O
2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

IF SUBJECT IS EVER PREGNANT

(GIRLS), COMPLETE SECTION ON UP
EW
TO THREE PREGNANCIES.
OTHERWISE, SKIP TO "DEATH OF
LOVED ONE", (PAGE 78).
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(GIRLS) - FIRST PREGNANCY
Pregnancy ends for a reason other than birth (e.g. PREMATURE TERMINATION OF Ever:CKD2E11
miscarriage, abortion). PREGNANCY Intensity
0 = No
What happened when you found out you were
2 = Miscarriage
pregnant?
3 = Abortion

LY
Who decided what should happen?
Were your parents involved? Ever:CKD2O11
The father of the child? Onset
IF ABORTION, ASK: / /
Do you feel OK about how the decsion was made?

N
WEEK OF PREGNANCY WHEN Ever:CKD2X11
TERMINATED
DATE OF TERMINATION.

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD2X12
0 = Subject's decision, with or without
consultation with other(s).

2 = Other(s) made decision, with subject's

EW agreement.

3 = Other(s) made decision against

subject's own wishes.
VI
RE
R
FO

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CHILDBIRTH (GIRLS) - FIRST PREGNANCY

Pregnancy ends in childbirth, or is expected to end in CHILDBIRTH Ever:CKD3E11
childbirth. Intensity
1 = Still Pregnant

IF SUBJECT STILL PREGNANT, CODE AND SKIP TO 2 = Stillbirth

MOST UPSETTING PREGNANCY. 3 = Perinatal death

4 = Live birth, mother or both kept child

Did you have the baby?

LY
5 = Live birth, father kept child
When was that?
6 = Live birth, child adopted/cared for by
What happened with the child? another family member

DATE OF PLACEMENT WITH OTHERS. 7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

DATE OF BIRTH OF CHILD Ever:CKD3011

O
/ /
DATE OF PLACEMENT - (GIRLS) - FIRST Ever:CKD4O11
PREGNANCY
/ /
EW INVOLVEMENT IN PLACEMENT Ever:CKD4I11
DECISION

0 = Subject's decision

2 = Other(s) made decision, with subject's

agreement.
VI

3 = Other(s) made decision against

subject's own wishes.
RE

PREGNANCY (GIRLS) - SECOND PREGNANCY

Subject ever pregnant. PREGNANCY Ever:CKD1E21
Intensity
0 = No
Have you ever been pregnant?
2 = Yes
When did you find our you were pregnant? Ever:CKD1O21
When did you get pregnant?
R

Onset
How did you find out?
Were you planning to get pregnant? / /
Did you want to be pregnant?
FO

DATE OF AWARENESS - (GIRLS) - Ever:CKD1O22

SECOND PREGNANCY
/ /
INTENTIONALITY Ever:CKD1X21
1 = Planned pregnancy

2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

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IF PREGNANT A SECOND TIME,

COMPLETE. OTHERWISE, SKIP TO
"PREGNANCY (GIRLS) -
ATTRIBUTION", (PAGE 62).

LY
N
O
EW
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(GIRLS) - SECOND PREGNANCY
Pregnancy ends for reason other than birth (e.g. PREMATURE TERMINATION OF Ever:CKD2E21
miscarriage, abortion). PREGNANCY Intensity
0 = No
What happened when you found out you were
2 = Miscarriage
pregnant?
3 = Abortion

LY
Who decided that should happen?
Were your parents involved? Ever:CKD2O21
The father of the child? Onset
IF ABORTION, ASK: / /
Do you feel OK about how the decision was made?

N
Ever:CKD2X21
Frequency

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD2X22
0 = Subject's decision, with or without
EW consultation with other(s).

2 = Other(s) made decision, with subject's

agreement.

3 = Other(s) made decision against

subject's own wishes.
VI
RE
R
FO

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CHILDBIRTH (GIRLS) - SECOND PREGNANCY

Pregnancy ends in childbirth, or is expected to end in CHILDBIRTH Ever:CKD3E21
childbirth. Intensity
1 = Still Pregnant

IF SUBJECT STILL PREGNANT, CODE AND SKIP TO 2 = Stillbirth

MOST UPSETTING PREGNANCY. 3 = Perinatal death

4 = Live birth, mother or both kept child

Did you have the baby?

LY
5 = Live birth, father kept child
When was that?
6 = Live birth, child adopted/cared for by
What happened with the child? another family member

7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

Ever:CKD3O21

O
Onset

/ /
DATE OF PLACEMENT - (GIRLS) Ever:CKD4O21
EW SECOND PREGNANCY
/ /
INVOLVEMENT IN PLACEMENT Ever:CKD4I21
DECISION

0 = Subject's decision

2 = Other(s) made decision, with subject's

VI

agreement.

3 = Other(s) made decision against

subject's own wishes.
RE
R
FO

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PREGNANCY (GIRLS) - THIRD PREGNANCY

Subject ever pregnant. PREGNANCY Ever:CKD1E31
Intensity
0 = No
Have you ever been pregnant?
2 = Yes
When did you get pregnant? Ever:CKD1O31
How did you find out? Onset
Were you planning to get pregnant?
/ /

LY
Did you want to be pregnant?

DATE OF AWARENESS - (GIRLS) - Ever:CKD1O32

THIRD PREGNANCY
/ /

N
INTENTIONALITY Ever:CKD1X31
1 = Planned pregnancy

O
2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

IF PREGNANT THIRD TIME, COMPLETE

SECTION. OTHERWISE, SKIP TO
EW
"MOST UPSETTING PREGNANCY",
(PAGE 61).
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(GIRLS) - THIRD PREGNANCY
Pregnancy ends for reason other than birth (e.g. PREMATURE TERMINATION OF Ever:CKD2E31
miscarriage, abortion). PREFGNANCY Intensity
0 = No
What happened when you found out you were
2 = Miscarriage
pregnant?
3 = Abortion

LY
Who decided what should happen?
Were your parents involved? Ever:CKD2O31
The father of the child? Onset
IF ABORTION, ASK: / /
Do you feel OK about how the decision was made?

N
Ever:CKD2X31
Frequency

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD2X32
0 = Subject's decision, with or without
EW consultation with other(s).

2 = Other(s) made decision, with subject's

agreement.

3 = Other(s) made decision against

subject's own wishes.
VI
RE
R
FO

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CHILDBIRTH (GIRLS) THIRD PREGNANCY

Pregnancy ends in childbrith, or is expected to end in CHILDBIRTH Ever:CKD3E31
childbirth. Intensity
1 = Still Pregnant

Did you have the baby? 2 = Stillbirth

3 = Perinatal death
When was that?
What happened wtih the child? 4 = Live birth, mother or both kept child

LY
5 = Live birth, father kept child

6 = Live birth, child adopted/cared for by

another family member

7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

Ever:CKD3O31

O
Onset

/ /
DATE OF PLACEMENT - (GIRLS) - THIRD Ever:CKD4O31
EW PREGNANCY
/ /
INVOLVEMENT IN PLACEMENT Ever:CKD4I31
DECISION

0 = Subject's decision

2 = Other(s) made decision, with subject's

VI

agreement.

3 = Other(s) made decision against

subject's own wishes.
RE

IF MORE THAN ONE PREGNANCY

ASK. OTHERWISE, SKIP TO
"PREGNANCY (GIRLS) -
ATTRIBUTION", (PAGE 62).
R
FO

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MOST UPSETTING PREGNANCY

What part of the pregnancy was the most upsetting for UPSETTING PART OF PREGNANCY Ever:CKD5I01
you? Intensity
0 = No upsetting part

IF SUBJECT EVER PREGNANT, COMPLETE 2 = Finding out girl was pregnant

ATTRUBUTION AND PAINFUL RECALL ON THE PART
3 = Miscarriage
OF THE PREGNANCY THAT WAS THE MOST
UPSETTING TO THE SUBJECT 4 = Decision to have abortion

LY
5 = Having abortion

6 = Stillbirth or perinatal death

7 = Birth

N
8 = Placement decision

9 = Whole experience

Ever:CKD5O01

O
Onset

/ /
EW
VI
RE
R
FO

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PREGNANCY (GIRLS) - ATTRIBUTION

In the last 3 months, has "life event" affected any of the PREGNANCY (GIRLS) - ATTRIBUTION IIOT506
problems we have been talking about? Intensity
0 = No

In what way? 2 = Yes

Which ones?
ATTRIBUTION OF "LIFE EVENT" AS CKD5X01
CONTRIBUTION TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKD5X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKD5X03

N
5 = Depression

6 = Mania
CKD5X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKD5X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKD5X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2. CKD5X07
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults. CKD5X08

16 = Sibling relationships.
RE

17 = Peer relationships. CKD5X09

18 = Relationships with spouse or romantic
partner

CKD5X10
R

CKD5X11
FO

CKD5X12

CKD5X13

CKD5X14

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CKD5X15

CKD5X16

CKD5X17

LY
PREGNANCY (GIRLS) - PAINFUL RECALL
In the last 3 months, has "life event" affected any of the PAINFUL RECALL SCREEN CKD6I01

N
problems we have been talking about? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

O
What was that like?
Have you had any nightmareas about the event?

IF PREGNANCY PAINFUL RECALL

EW
PRESENT, ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "DEATH OF LOVED ONE", (PAGE
78).
VI
RE
R
FO

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PREGNANCY (GIRLS) - AVOIDANCE

Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKD6I02
Intensity
0 = Absent
What things?
Do ypi try to avoid these things/thoughts? 2 = Present

PREGNANCY (GIRLS) - HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKD6I03
irritable? Intensity
0 = Absent

Have you had trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
IF SUBJECT IS MALE COMPLETE.
OTHERWISE,, SKIP TO "DEATH OF
LOVED ONE", (PAGE 78).
EW
VI
RE
R
FO

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MAKES SOMEONE PREGNANT (BOYS)

Have you ever gotten a girl pregnant? MAKES SOMEONE PREGNANT Ever:CKD7E11
Intensity
0 = No
When did you find out she was pregnant?
When did she get pregnant? 2 = Yes
How did you find out?
Were you planning to get her pregnant? Ever:CKD7O11
Onset
Did she want to be pregnant?
/ /

LY
DATE OF AWARENESS - MAKES Ever:CKD7O12
SOMEONE PREGNANT (BOYS)
/ /

N
INTENTIONALITY Ever:CKD7X11
1 = Planned pregnancy

O
2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

IF EVER PRESENT, COMPLETE

SECTION ON UP TO THREE
EW
PREGNANCIES. OTHERWISE, SKIP TO
"DEATH OF LOVED ONE", (PAGE 78).
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(BOYS) - FIRST PREGNANCY
What happened when she got pregnant? PREMATURE TERMINATION OF Ever:CKD8E11
Is she still pregnant? PREGNANCY Intensity
0 = No
Did she have the baby?
Who decided what should happen? 2 = Miscarriage
Were you involved in the decision? 3 = Abortion

LY
IF ABORTION, ASK:
Ever:CKD8O11
Do you feel OK about how the decision was made? Onset

/ /

N
Ever:CKD8X11
Frequency

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD8X12
0 = Aware an part of the decision process.

2 = Informed but not involved in the

EW decision though willing to be.

3 = Not informed until after termination, or

not involved.

4 = Refused to be involved.
VI
RE
R
FO

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CHILDBIRTH (BOYS) - FIRST PREGNANCY

Did she have the baby? CHILDBIRTH Ever:CKD9E11
When was that? Intensity
1 = Still Pregnant
What happened with the child?
Do you get to see the baby at all? 2 = Stillbirth

3 = Perinatal death
Do you want to?
How often do you see him/her? 4 = Live birth, mother or both kept child

LY
5 = Live birth, father kept child

6 = Live birth, child adopted/cared for by

another family member

7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

Ever:CKD9O11

O
Onset

/ /
DATE OF PLACEMENT - MAKES Ever:CKE0O11
EW SOMEONE PREGNANT (BOYS)
/ /
CONTACT WITH CHILD Ever:CKE0I11
0 = Lives with and helps care for child

1 = Sees child at least once a week

VI

2 = Sees child at least once a month

3 = Sees child less than once a month

4 = Never sees child

RE
R
FO

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MAKES SOMEONE PREGNANT (BOYS) -

SECOND PREGNANCY
Subject became aware that he has ever made a girl MAKES SOMEONE PREGNANT Ever:CKD7E21
pregnant. Intensity
0 = Absent

Have you ever gotten a girl pregnant? 2 = Present

Ever:CKD7O21
When did he find out she was pregnant? Onset

LY
When did she get pregnant?
How did you find out? / /
Were you planning to get her pregnant?
Did she want to be pregnant? DATE OF AWARENESS - MAKES Ever:CKD7O22
SOMEONE PREGNANT (BOYS) -
SECOND PREGNANCY / /

N
INTENTIONALITY Ever:CKD7X21
0 = Planned Pregnancy

O
2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

IF PRESENT, COMPLETE SECTION ON

EW
UP TO THREE PREGNANCIES.
OTHERWISE, SKIP TO "MAKES
SOMEONE PREGNANT (BOYS) -
ATTRIBUTION", (PAGE 75).
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(BOYS) - SECOND PREGNANCY
Pregnancy ends for reason other than birth (e.g. PREMATURE TERMINATION OF Ever:CKD8E21
miscarriage abortion). PREGNANCY Intensity
0 = No
What happened when she got pregnant?
2 = Miscarriage
Is she still pregnant? 3 = Abortion

LY
Did she have the baby?
Who decided what should happen? Ever:CKD8O21
Were you involved in the decision? Onset
IF ABORTION, ASK: / /
Do you feel OK about how the decision was made?

N
Ever:CKD8X21
Frequency

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD8X22
0 = Aware an part of the decision process.

2 = Informed but not involved in the

EW decision though willing to be.

3 = Not informed until after termination, or

not involved.

4 = Refused to be involved.
VI
RE
R
FO

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CHILDBIRTH (BOYS) - SECOND PREGNANCY

Pregnancy ends in childbirth or is expected to end in CHILDBIRTH Ever:CKD9E21
childbirth. Intensity
1 = Still Pregnant

Did she have the baby? 2 = Stillbirth

When was that? 3 = Perinatal death
What happened with the child?
4 = Live birth, mother or both kept child

LY
5 = Live birth, father kept child

6 = Live birth, child adopted/cared for by

another family member

7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

Ever:CKD9O21

O
Onset

/ /
DATE OF PLACEMENT Ever:CKE0O21
EW / /
CONTACT WITH CHILD Ever:CKE0I21
0 = Lives with and helps care for child

1 = Sees child at least once a week

VI

2 = Sees child at least once a month

3 = Sees child less than once a month

4 = Never sees child

RE
R
FO

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MAKES SOMEONE PREGNANT (BOYS) - THIRD

PREGNANCY
Subject became aware that he has ever made a girl EVER: MAKES SOMEONE PREGNANT Ever:CKD7E31
pregnant. Intensity
0 = Absent

Have you ever gotten a girl pregnant? 2 = Present

Ever:CKD7O31
When did he find out she was pregnant? Onset

LY
When did she get pregnant?
How did you find out? / /
Were you planning to get her pregnant?
Did she want to be pregnant? DATE OF AWARENESS - THIRD Ever:CKD7O32
PREGNANCY
/ /

N
INTENTIONALITY Ever:CKD7X31
0 = Planned Pregnancy

O
2 = Pregnancy unplanned, wanted

3 = Pregnancy unplanned, unwanted

IF THIRD PREGNANCY PRESENT,

EW
COMPLETE SECTION. OTHERWISE,
SKIP TO "MOST UPSETTING
PREGNANCY (BOYS)", (PAGE 74).
VI
RE
R
FO

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PREMATURE TERMINATION OF PREGNANCY

(BOYS) - THIRD PREGNANCY
Pregnancy ends for reason other than birth (e.g. PREMATURE TERMINATION OF Ever:CKD8E31
miscarriage, abortion). PREGNANCY Intensity
0 = No
What happened when she got pregnant?
2 = Miscarriage
Is she still pregnant? 3 = Abortion

LY
Did she have the baby?
Who decided what should happen? Ever:CKD8O31
Were you involved in the decision? Onset
IF ABORTION, ASK: / /
Do you feel OK about how the decision was made?

N
Ever:CKD8X31
Frequency

O
INVOLVEMENT IN ABORTION DECISION Ever:CKD8X32
0 = Aware an part of the decision process.

2 = Informed but not involved in the

EW decision though willing to be.

3 = Not informed until after termination, or

not involved.

4 = Refused to be involved.
VI
RE
R
FO

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CHILDBIRTH (BOYS) - THIRD PREGNANCY

Pregnancy ends in childbirth or is expected to end in CHILDBIRTH Ever:CKD9E31
childbirth. Intensity
1 = Still Pregnant

Did she have the baby? 2 = Stillbirth

When was that? 3 = Perinatal death
What happened with the child?
Do you get to see the baby at all? 4 = Live birth, mother or both kept child

LY
5 = Live birth, father kept child
Do you want to?
How often do you see him/her? 6 = Live birth, child adopted/cared for by
another family member

7 = Live birth, child in foster care

N
8 = Live birth, child released for extra-
familial adoption

Ever:CKD9O31

O
Onset

/ /
DATE OF PLACEMENT - CHILDBIRTH Ever:CKE0O31
EW (BOYS) - THIRD PREGNANCY
/ /
CONTACT WITH CHILD Ever:CKE0I31
0 = Lives with and helps care for child

1 = Sees child at least once a week

VI

2 = Sees child at least once a month

3 = Sees child less than once a month

4 = Never sees child

RE

IF MORE THAN ONE PREGNANCY,

ASK MOST UPSETTING PREGNANCY
(BOYS), SKIP TO "MAKES SOMEONE
PREGNANT (BOYS) - ATTRIBUTION",
R

(PAGE 75).
FO

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MOST UPSETTING PREGNANCY (BOYS)

IF MORE THAN ONE PREGNANCY, ASK WHICH UPSETTING PART OF PREGNANCY Ever:CKE1I01
PREGNANCY WAS THE MOST UPSETTING. Intensity
0 = No upsetting part

What part of that pregnancy was the most upsetting for 2 = Finding out girl was pregnant
you?
3 = Miscarriage

4 = Decision to have abortion

LY
5 = Having abortion

6 = Stillbirth or perinatal death

7 = Birth

N
8 = Placement decision

9 = Whole experience

Ever:CKE1O01

O
Onset

/ /
EW
VI
RE
R
FO

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MAKES SOMEONE PREGNANT (BOYS) -

ATTRIBUTION
In the last 3 months has "life event" affected anything we've PRESENT 2 abcx111
talked about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKE1X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKE1X02

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKE1X03
5 = Depression

O
6 = Mania

7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

MAKES SOMEONE PREGNANT (BOYS) -

R

PAINFUL RECALL
In the last 3 months have thoughts or pictures of "life PAINFUL RECALL SCREEN CKE2I01
Intensity
FO

event" come into your mind? 0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF MAKES SOMEONE PREGNANT

PAINFULL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "DEATH OF
LOVED ONE", (PAGE 78).

LY
N
O
EW
VI
RE
R
FO

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MAKES SOMEONE PREGNANT (BOYS) -

AVOIDANCE
Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKE2I02
Intensity
0 = Absent
What things?
In what way? 2 = Present

LY
MAKES SOMEONE PREGNANT (BOYS) -
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKE2I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
EW
VI
RE
R
FO

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DEATH OF LOVED ONE

Death of someone close to the subject: biological parent, DEATH OF LOVED ONE #1: Ever:CKE3E01
other parental figure, other relative with whom subject has RELATIONSHIP TO SUBJECT Intensity
close ties, other adult who has played a significant role in 0 = Absent
the child's life, subjects own child, or pet.
1 = Biological parent.

IF MORE THEN 2 DEATHS, CODE DEATH OR 2 = Step/adoptive/foster parent.

PARENTAL FIGURE AND ANOTHER THAT THE

LY
3 = Other parental figure.
SUBJECT DESCRIBES AS THE MOST UPSETTING
4 = Grandparent
Has anyone close to you died? 5 = Aunt or uncle.

Who was that? 6 = Close unrelated adult.

N
What happened? 8 = Other close related adult.
When did it happen?
What did s/he die of? EVER: DATE OF DEATH LOVED ONE #1 Ever:CKE3O01

O
/ /
CAUSE OF DEATH - 1 Ever:CKE3X01
EW 1 = Physical illness.

2 = Accident

3 = Suicide

4 = Natural disaster (flood, earthquake).

5 = Fire

6 = War or terrorism.
VI

7 = Riots or urban violence.

8 = Noxious agent.

9 = Physical violence.
RE

10 = Physical abuse.

11 = Captivity

DEATH OF LOVED ONE #2: Ever:CKE4E01

RELATIONSHIP TO SUBJECT

0 = Absent
R

1 = Biological parent.

2 = Step/adoptive/foster parent.
FO

3 = Other parental figure.

4 = Grandparent

5 = Aunt or uncle.

6 = Close unrelated adult.

8 = Other close related adult.

EVER: DATE OF DEATH OF LOVED ONE Ever:CKE4O01

#2
/ /

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CAUSE OF DEATH - 2 Ever:CKE4X01

1 = Physical illness.

2 = Accident

3 = Suicide

4 = Natural disaster (flood, earthquake).

5 = Fire

LY
6 = War or terrorism.

7 = Riots or urban violence.

8 = Noxious agent.

9 = Physical violence.

N
10 = Physical abuse.

11 = Captivity

O
IF DEATH OF ADULT LOVED ONE NOT
PRESENT, SKIP TO "DEATH OF
SIBLING OR PEER", (PAGE 83).
EW
VI
RE
R
FO

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DEATH OF LOVED ONE - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKE3X09
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKE3X02
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKE3X03

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKE3X04

N
5 = Depression

6 = Mania
CKE3X05

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKE3X06
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKE3X07
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

DEATH OF LOVED ONE-PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKE5I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any disturbing memories of the event?

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IF DEATH OF LOVED ONE PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "DEATH OF SIBLING OR
PEER", (PAGE 83).

LY
N
O
EW
VI
RE
R
FO

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DEATH OF LOVED ONE-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKE5I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

DEATH OF LOVED ONE-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKEI003
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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DEATH OF SIBLING OR PEER

Death of subject's sibling, close friend or other peer. DEATH OF A CHILD Ever:CKE6E01
Intensity
0 = Absent
IF MORE THAN 2 DEATHS, CODE THOSE THAT THE
SUBJECT REPORTS AS MOST UPSETTING. 1 = Biological child

2 = Adoptive child
Has a friend of you ever died?
3 = Step or foster child

LY
Or one of your brothers or sisters or cousins? 4 = Cousin or other close child
Who was that?
5 = Non-biological child living in the home
What happened?
When did it happen? 6 = Childhood friend from school
What did s/he die of?
Ever:CKE6O01

N
Have you known anyone around your age who has ONSET: DEATH OF A SIBLING OR PEER
#1
committed suicide? / /
What happened?

O
DEATH OF A SIBLING OR PEER: CAUSE Ever:CKE6X01
When did it happen? OF DEATH

1 = Physical illness.
EW 2 = Accident

3 = Suicide

4 = Natural disaster (flood, earthquake).

5 = Fire

6 = War or terrorism.

7 = Riots or urban violence.

VI

8 = Noxious agent.

9 = Physical violence.

10 = Physical abuse.
RE

11 = Captivity

DEATH OF A SIBLING OR PEER Ever:CKE7E01

0 = Absent

1 = Biological Sibling
R

2 = Step/Adopted/Foster Sibling

3 = Close Friend
FO

4 = Other Friend

5 = Acquaintance at school

6 = Other related child

ONSET: DEATH OF A SIBLING OR PEER Ever:CKE7O01

#2
/ /
DEATH OF A SIBLING OR PEER #2: Ever:CKE7X01
CAUSE OF DEATH

1 = Physical illness.

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2 = Accident

3 = Suicide

4 = Natural disaster (flood, earthquake).

5 = Fire

6 = War or terrorism.

7 = Riots or urban violence.

LY
8 = Noxious agent.

9 = Physical violence.

10 = Physical abuse.

11 = Captivity

N
O
IF DEATH OF A SIBLLING PRESENT,
COMPLETE ATTRIBUTION AND
PAINFUL RECALL FOR THE MOST
UPSETTING DEATH. OTHERWISE, SKIPEW
TO "NATURAL DISASTER", (PAGE 88).
VI
RE
R
FO

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DEATH OF A SIBLING OR PEER -

ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKE6I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKE6X02
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKE6X03

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKE6X04
5 = Depression

O
6 = Mania
CKE6X05
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKE6X06
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKE6X07
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

DEATH OF A SIBLING OR PEER-PAINFUL

FO

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKE8I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF DEATH OF A SIBLING PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "NATURAL DISASTER",
(PAGE 88).

LY
N
O
EW
VI
RE
R
FO

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DEATH OF A SIBLING OR PEER-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKE8I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

DEATH OF A SIBLING OR PEER-

LY
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKE8I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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NATURAL DISASTER
Events not caused by intentional human actions (e.g. NATURAL DISASTER Ever:CKE9E01
floods, hurricanes, tornadoes) in which people actually died Intensity
0 = No
or were badly injured or property was extensively
damaged, or there was serious risk of these outcomes. 2 = Storm

3 = Tornado
Have you ever been in a terrible storm, tornado, or
hurricane? 4 = Hurricane

LY
5 = Earthquake
Or an earthquake?
6 = Flood
Or a flood? 7 = More than one type.

What happened? Ever:CKE9O01

N
How bad was it? Onset
Were people killed?
Were you afraid that people would be killed or badly hurt? / /

O
Or that you would die or be badly hurt?
Ever:CKE9V01
When did that happen?
Frequency

EW NATURAL DISASTER CKE9I01

Intensity
0 = No

2 = Storm

3 = Tornado

4 = Hurricane
VI

5 = Earthquake

6 = Flood

7 = More than one type.

RE

CKE9O02
Onset

/ /
CKE9F01
Frequency
R
FO

IF NATURAL DISASTER PRESENT

COMPLETE. OTHERWISE, SKIP TO
"FIRE", (PAGE 91).

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NATURAL DISASTER - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKE9I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKE9X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKE9X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKE9X03

N
5 = Depression

6 = Mania
CKE9X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKE9X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKE9X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

NATURAL DISASTER: PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKF0I01
event" come into you mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF NATURAL DISASTER PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "FIRE", (PAGE 91).

LY
N
O
EW
VI
RE
R
FO

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NATURAL DISASTER: AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKF0I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

NATURAL DISASTER: HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKF0I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
FIRE
Fire, either accidentally or deliberately set, in which people FIRE Ever:CKF1E01
actually died or were badly injured or property was Intensity
0 = Absent
extensively damaged, or there was serious risk of these
outcomes.
EW 2 = Accidental fire.

3 = Intentionally set fire.

Have you ever been in a terrible fire?
Ever:CKF1V01
What happened? Frequency
How bad was it?
Were people killed?
VI

Were you afraid that people would be killed or badly hurt? Ever:CKF1O01
Or that you would die or be badly hurt? Onset
When did that happen?
How do you think that the fire started? / /
RE

Was it an accident? FIRE CKF1I01

Intensity
0 = Absent

2 = Accidental fire.

3 = Intentionally set fire.

CKF1O02
R

Onset

/ /
FO

IF "FIRE" NOT PRESENT, SKIP TO

"WAR OR TERRORISM", (PAGE 94).

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FIRE - ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKF1I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKF1X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKF1X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKF1X03

N
5 = Depression

6 = Mania
CKF1X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKF1X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKF1X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

FIRE: PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKF2I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF FIRE PAINFUL RECALL PRESENT,

ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "WAR OR TERRORISM", (PAGE 94).

LY
N
O
EW
VI
RE
R
FO

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FIRE: AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKF2I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

FIRE: HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKF2I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
WAR OR TERRORISM
Subject has lived for at least a day in an area in which civil WAR OR TERRORISM Ever:CKF3E01
law was disrupted (e.g. a country at war or an area in which Intensity
0 = No
civil war or terrorism has disrupted normal life).

Have you ever been in a war?

EW 2 = Yes

Ever:CKF3O01
Onset
Or somewhere where armies or terrorists were
fighting? / /
What happened? DAYS Ever:CKF3D01
VI

When did that happen? Duration

What did you see?
Were people killed?
Were you afraid that people would be killed? WAR OR TERRORISM CKF3I01
Were you afraid that you might be hurt?
RE

Intensity
Or that you would die? 0 = No
How long were you there? 2 = Yes

CKF3O02
Onset

/ /
R

DAYS CKF3D02
Duration
FO

IF WAR OR TERRORISM NOT

PRESENT, SKIP TO "WITNESS TO
EVENT THAT CAUSED, OR HAD
POTENTIAL TO CAUSE, DEATH OR
SEVERE INJURY", (PAGE 99).

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LY
N
O
EW
VI
RE
R
FO

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WAR OR TERRORISM - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKF3I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKF3X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKF3X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKF3X03

N
5 = Depression

6 = Mania
CKF3X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKF3X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKF3X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

WAR OR TERRORISM: PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKF4I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF WAR OR TERRORISM PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "WITNESS TO EVENT THAT
CAUSED, OR HAD POTENTIAL TO
CAUSE, DEATH OR SEVERE INJURY",
(PAGE 99).

LY
N
O
EW
VI
RE
R
FO

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WAR OR TERRORISM: AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKF4I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

WAR OR TERRORISM: HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKF4I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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WITNESS TO EVENT THAT CAUSED, OR HAD

POTENTIAL TO CAUSE, DEATH OR SEVERE
INJURY
Person saw or heard but was not the object of an event WITNESS TO EVENT Ever:CKF5E01
with potential for life threat or severe physical injury. Intensity
0 = Absent
Include seeing someone shot or killed, hearing someone
raped or beaten in an adjacent room, seeing another 2 = Present, to stranger.
person killed or severely injured in an accident. 3 = Present, to acquaintance.

LY
Do not include events seen in movies or on the news. 4 = Present, to friend.

5 = Present, to family member.

Have you ever seen or heard something really terrible
Ever:CKF5O01
happen to anyone?
Onset

N
Like someone dying? / /
Or being badly hurt?
Or being beaten up? Ever:CKF5X01

O
PERPETRATOR
What happened?
0 = No perpetrator.
Have you ever seen or heard someone in your family
hurting or beating up someone else in your family? 2 = Unknown perpetrator.

3 = Acquaintance
EW 4 = Friend

5 = Family member.

WITNESS TO EVENT CKF5I01

Intensity
0 = Absent
VI

2 = Present, to stranger.

3 = Present, to acquaintance.

4 = Present, to friend.
RE

5 = Present, to family member.

CKF5O02
Onset

/ /
PERPETRATOR CKF5X02
R

0 = No perpetrator.

2 = Unknown perpetrator.
FO

3 = Acquaintance

4 = Friend

5 = Family member.

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IF WITNESS TO EVENT THAT CAUSED,

OR HAD POTENTIAL TO CAUSE,
DEATH OR SEVERE INJURY NOT
PRESENT, SKIP TO "LEARNED ABOUT
EVENT POSSIBLY CAUSING SEVERE
INJURY OR DEATH", (PAGE 104).

LY
N
O
EW
VI
RE
R
FO

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WITNESS TO EVENT-ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKF5I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKF5X04
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKF5X05

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKF5X06

N
5 = Depression

6 = Mania
CKF5X07

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKF5X08
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKF5X09
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

WITNESS TO EVENT-PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKF6I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF WITNESS TO EVENT PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "LEARNED ABOUT EVENT
POSSIBLY CAUSING SEVERE INJURY
OR DEATH", (PAGE 104).

LY
N
O
EW
VI
RE
R
FO

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WITNESS TO EVENT-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKF6I02
Intensity
0 = Absent
What happened?
Do you try to avoid these things/thoughts? 2 = Present

WITNESS TO EVENT-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKF6I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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LEARNED ABOUT EVENT POSSIBLY CAUSING

SEVERE INJURY OR DEATH
Person learned about, but did not see or hear, an event LEARNED ABOUT EVENT Ever:CKF7E01
with serious potential for life threat or severe physical injury Intensity
0 = Absent
to a loved one (e.g. first or second degree relative or close
personal friend). 2 = Present, to friend

3 = Present, to 2nd degree relative

Has someone you really care about ever had anything

LY
really terrible happen to them? 4 = Present, to 1st degree relative

Ever:CKF7O01
Or been badly hurt? Onset
Or been beaten up?
What happened? / /

N
EVER: PERPETRATOR Ever:CKF7X01
0 = No perpetrator.

O
2 = Unknown perpetrator.

3 = Acquaintance

EW 4 = Friend

5 = Family member.

LEARNED ABOUT EVENT CKF7I01

Intensity
0 = Absent

2 = Present, to friend

3 = Present, to 2nd degree relative

VI

4 = Present, to 1st degree relative

CKF7O02
Onset

/ /
RE

PERPETRATOR CKF7X02
0 = No perpetrator.

2 = Unknown perpetrator.

3 = Acquaintance
R

4 = Friend

5 = Family member.
FO

IF LEARNED ABOUT EVENT POSSIBLY

CAUSING SEVERE INJURY OR DEATH
NOT PRESENT, SKIP TO "LEARNED
ABOUT EXPOSURE TO NOXIOUS
AGENT", (PAGE 108).

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LY
N
O
EW
VI
RE
R
FO

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LEARNED ABOUT EVENT - ATTRIBUTION

In the last 3 months, has this affected any of the ATTRIBUTION CKF7E02
problems we've been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF LIFE EVENT AS CKF7X03
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKF7X04

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKF7X05

N
5 = Depression

6 = Mania
CKF7X06

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKF7X07
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKF7X08
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

LEARNED ABOUT EVENT-PAINFUL RECALL

R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKF8I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF LEARNED ABOUT EVENT PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "LEARNED ABOUT
EXPOSURE TO NOXIOUS AGENT",
(PAGE 108).

LY
N
O
EW
VI
RE
R
FO

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LEARNED ABOUT EVENT-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKF8I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LEARNED ABOUT EVENT-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKF8I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
LEARNED ABOUT EXPOSURE TO NOXIOUS
AGENT
Person learned about exposure to noxious agent such as EXPOSURE TO NOXIOUS AGENT Ever:CKF9E01
chemicals, environmental contaminants, infectious agents Intensity
EW
such as HIV, or other poisons capable of causing death or
severe physical injury. Include radiation exposure after a
0 = No

2 = Yes, exposure to chemical

nuclear power plant accident or accidental ingestion of a 3 = Yes, exposure to infectious agent
toxic substance like pesticide. Do not include fluoridated
water or common illnesses like chicken pox. Ever:CKF9O01
Onset
Have you ever had contact with anything that you / /
VI

thought might make you sick or die?

EXPOSURE TO NOXIOUS AGENT CKF9I01
Like chemicals, radiation, or other poisons? Intensity
Or to a disease that you could die from? 0 = No
RE

2 = Yes, exposure to chemical

How did that happen?
3 = Yes, exposure to infectious agent

CKF9O02
Onset

/ /
R
FO

IF LEARNED ABOUT EXPOSURE TO

NOXIOUS AGENT ABSENT, SKIP TO
"CAUSING DEATH OR SEVERE HARM",
(PAGE 112).

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LEARNED ABOUT EXPOSURE TO NOXIOUS

AGENT - ATTRIBUTION
Which ones? ATTRIBUTION OF LIFE EVENT AS CKF9X01
In what way? CONTRIBUTING TO PROBLEM WITH:

1 = School non-attendance.

2 = Separation anxiety. CKF9X02

3 = Worries/anxiety.

LY
4 = Obsessions/compulsions. CKF9X03
5 = Depression

6 = Mania
CKF9X04

N
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKF9X05

O
10 = Conduct disorder.

11 = Alcohol/drugs
CKF9X06
12 = Psychosis
EW 13 = Relationships with parent #1 and/or
parent #2.

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

VI

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner
RE

In the last 3 months, has this affected any of the ATTRIBUTION CKF9E02
problems we've been talking about? Intensity
0 = Absent

2 = Present

LEARNED ABOUT EXPOSURE-PAINFUL

R

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKG0I01
Intensity
FO

event" come into your mind? 0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF LEARNED ABOUT EXPOSURE TO

NOXIOUS AGENT PAINFUL RECALL
PRESENT, ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "CAUSING DEATH OR SEVERE
HARM", (PAGE 112).

LY
N
O
EW
VI
RE
R
FO

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LEARNED ABOUT EXPOSURE-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKG0I02
Intensity
0 = Absent
What happened?
Do you try to avoid these things/thoughts? 2 = Present

LEARNED ABOUT EXPOSURE-

LY
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKG0I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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CAUSING DEATH OR SEVERE HARM

Person caused an event resulting in death or severe CAUSING DEATH OR SEVERE HARM Ever:CKG1E01
physical injury. Intensity
0 = Absent

Include causing a car accident, shooting or otherwise 2 = Severe Harm

injuring another person, i.e. starting a fire. Do not include 3 = Death
delusional guilt over events not under subject's control.
Ever:CKG1O01

LY
Onset
Have you or someone you were with ever hurt another
person badly? / /
Or caused another person to die? PERSON HURT Ever:CKG1X01

N
What happened? 2 = Stranger
Did you mean to hurt him/her? 3 = Acquaintance
Was it an accident?
4 = Friend

O
5 = Family member

INTENTIONALITY Ever:CKG1X02
0 = Harm was accidental.
EW 2 = Intended to hurt.

3 = Intended to kill.

CAUSING DEATH OR SEVERE HARM CKG1I01

Intensity
0 = Absent
VI

2 = Severe Harm

3 = Death

CKG1O02
Onset
RE

/ /
PERSON HURT CKG1X03
2 = Stranger

3 = Acquaintance
R

4 = Friend

5 = Family member
FO

INTENTIONALITY CKG1X04
0 = Harm was accidental.

2 = Intended to hurt.

3 = Intended to kill.

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IF CAUSING DEATH OR SEVERE

INJURY NOT PRESENT, SKIP TO
"VICTIM OF PHYSICAL VIOLENCE (NOT
ABUSE)", (PAGE 117).

LY
N
O
EW
VI
RE
R
FO

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CAUSING DEATH OR SEVERE HARM -

ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKG1I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKG1X05
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKG1X06

3 = Worries/anxiety.

N
4 = Obsessions/compulsions. CKG1X07
5 = Depression

O
6 = Mania
CKG1X08
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKG1X09
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKG1X10
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

RE

16 = Sibling relationships.

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

CAUSING DEATH OR SEVERE HARM-PAINFUL

FO

RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKG2I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF CAUSING DEATH OR SEVERE HARM

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "VICTIM OF
PHYSICAL VIOLENCE (NOT ABUSE)",
(PAGE 117).

LY
N
O
EW
VI
RE
R
FO

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CAUSING DEATH OR SEVERE HARM-

AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKG2I02
Intensity
0 = Absent
What happened?
Do you try to avoid these things/thoughts? 2 = Present

LY
CAUSING DEATH OR SEVERE HARM-
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKG2I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
EW
VI
RE
R
FO

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VICTIM OF PHYSICAL VIOLENCE (NOT ABUSE)

Subject has been the victim of physical violence, with one VICTIM OF PHYSICAL VIOLENCE Ever:CKG3E01
or more people using force against the subject with Intensity
0 = Absent
potential to cause death or serious injury. Force may have
been used in order to get something (e.g. mugging, 2 = Some physical injury (e.g., black eye,
robbery), or to intimidate or frighten subject, or for its own cuts), or force with potential for such.
sake (assault, fight, torture). Victim may have been 3 = Serious injury (e.g., broken limb,
threatened with a weapon. unconsciousness, hospitalization), or force

LY
with potential for such.

Code physical abuse by family member separately. Ever:CKG3V01

Frequency
Has anyone ever hit or hurt you badly?

N
Has anyone ever robbed or mugged you?
Ever:CKG3O01
Onset
Or beaten you up really badly?
What happened? / /

O
Did they threaten you with a weapon?
Why did they do it? PERSON USING FORCE Ever:CKG3X01
Do you know who did it?
2 = Known peer.
When was the first time?
EW 3 = Known non-familial adult.

4 = Unknown adult.

5 = Unknown peer.

6 = More than one person.

THREATENED WITH WEAPON Ever:CKG3E02

VI

0 = Absent

2 = Weapon used to threaten but not to hurt

victim.

3 = Weapon used to threaten and injure

RE

victim.

VICTIM OF PHYSICAL VIOLENCE CKG3I01

Intensity
0 = Absent

2 = Some physical injury (e.g., black eye,

cuts), or force with potential for such.
R

3 = Serious injury (e.g., broken limb,

unconsciousness, hospitalization), or force
with potential for such.
FO

CKG3F01
Frequency

CKG3O02
Onset

/ /

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PERSON USING FORCE CKG3X02

2 = Known peer.

3 = Known non-familial adult.

4 = Unknown adult.

5 = Unknown peer.

6 = More than one person.

LY
THREATENED WITH WEAPON CKG3I02
0 = Absent

2 = Weapon used to threaten but not to hurt

victim.

N
3 = Weapon used to threaten and injure
victim.

O
IF VICTIM OF PHYSICAL VIOLENCE
(NOT ABUSE) NOT PRESENT, SKIP TO
"VICTIM OF PHYSICAL ABUSE", (PAGE
122).
EW
VI
RE
R
FO

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VICTIM OF PHYSICAL VIOLENCE (NOT ABUSE)

- ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKG3I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION: CKG3X03

LY
1 = School non-attendance.

2 = Separation anxiety.
CKG3X04
3 = Worries/anxiety.

4 = Obsessions/compulsions.

N
CKG3X05
5 = Depression

6 = Mania

O
7 = Physical symptoms. CKG3X06
8 = Food-related behavior.

9 = Hyperactivity/ADD
CKG3X07
EW 10 = Conduct disorder.

11 = Alcohol/drugs

12 = Psychosis CKG3X08

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

VICTIM OF PHYSICAL VIOLENCE (NOT

FO

ABUSE)-PAINFUL RECALL
In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKG4I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF PHYSICAL VIOLENCE (NOT ABUSE)

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "VICTIM OF
PHYSICAL ABUSE", (PAGE 122).

LY
N
O
EW
VI
RE
R
FO

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VICTIM OF PHYSICAL VIOLENCE (NOT

ABUSE)-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKG4I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

LY
VICTIM OF PHYSICAL VIOLENCE (NOT
ABUSE)-HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKG4I03
irritable? Intensity
0 = Absent

N
Have you had any trouble sleeping? 2 = Present

Have you been "on the alert" for bad things

happening?

O
EW
VI
RE
R
FO

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VICTIM OF PHYSICAL ABUSE

Subject has been the victim of physical abuse by a member VICTIM OF PHYSICAL ABUSE Ever:CKG5E01
of the family. Intensity
0 = Absent

Has anyone in your family ever hit or hurt you badly? 2 = Some physical injury (e.g., black eye,
cuts), or force with potential for such.
Or beaten you up really badly? 3 = Serious injury (e.g., broken limb,
What happened? unconsciousness, hospitalization), or force

LY
Did they threaten you with a weapon? with potential for such.
Why did they do it? Ever:CKG5O01
Onset

/ /

N
PERSON USING FORCE Ever:CKG5X01
1 = Parent #1

O
2 = Parent #2

3 = Other Parent #1

EW 4 = Other Parent #2

5 = Grandparent (including step

grandparent).

6 = Other adult family member.

7 = Sibling in the home.

8 = Sibling not in the home.

VI

9 = Babysitter/Daycare provider.

10 = Unrelated child (peer) living in the

home

11 = Other
RE

12 = Spouse or Romantic Partner

Specify

Ever:CKG5V01
Frequency
R

THREATENED WITH WEAPON Ever:CKG5E02

FO

0 = Absent

2 = Weapon used to threaten but not to hurt

victim.

3 = Weapon used to threaten and injure

victim.

VICTIM OF PHYSICAL ABUSE PP CKG5I01

Intensity
0 = Absent

2 = Some physical injury (e.g., black eye,

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cuts), or force with potential for such.

3 = Serious injury (e.g., broken limb,

unconsciousness, hospitalization), or force
with potential for such.

CKG5O02
Onset

/ /

LY
PERSON USING FORCE CKG5X02
1 = Parent #1

2 = Parent #2

N
3 = Other Parent #1

4 = Other Parent #2

5 = Grandparent (including step

O
grandparent).

6 = Other adult family member.

7 = Sibling in the home.

EW 8 = Sibling not in the home.

9 = Babysitter/Daycare provider.

10 = Unrelated child (peer) living in the

home

11 = Other

12 = Spouse or Romantic Partner

VI

CKG5F01
Frequency
RE

THREATENED WITH WEAPON CKG5I02

0 = Absent

2 = Weapon used to threaten but not to hurt

victim.

3 = Weapon used to threaten and injure

R

victim.
FO

IF SUBJECT NOT A VICTIM OF

PHYSICAL ABUSE, SKIP TO
"CAPTIVITY", (PAGE 128).

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SEEKING HELP (PHYSICAL ABUSE)

Three forms of supportive response are coded: listening, SEEKING HELP (PHYSICAL ABUSE) Ever:CKG6X99
which could provide social support and emotional relief; Intensity
0 = Absent
personal intervention, which is personally attempting to
prevent the reoccurrence of the situation; or intervention 2 = Present
involving a professional agency, which might be phoning
SUPPORTIVE REPONSE Ever:CKG6X01
the police, contacting appropriate services, referring the
subject to such services, or removing the subject from what 2 = Listening

LY
s/he experiences as an unsafe environment. Unsupportive
3 = Personal intervention.
responses include unwillingness to listen, reluctance to get
involved, denial of the truth of the story, and threatening the 4 = Intervention involving professional
subject if anyone else ever told. agency.

SUPPORTIVE RESPONSE Ever:CKG6X02

N
Did you ever tell anyone about these things?
2 = Listening
Someone you age? 3 = Personal intervention.
A family member?

O
An adult outside your family? 4 = Intervention involving professional
agency.
Did s/he help?
SUPPORTIVE RESPONSE Ever:CKG6X03
What happened?
What did s/he do? 2 = Listening
Did you feel s/he/they could have done more?
EW 3 = Personal intervention.

4 = Intervention involving professional

agency.

UNSUPPORTIVE RESPONSE Ever:CKG6X04

2 = Unwillingness to listen.
VI

3 = Reluctance to get involved.

4 = Denial of truth of story.

5 = Threaten subject if ever tell anyone.

RE

UNSUPPORTIVE RESPONSE Ever:CKG6X05

2 = Unwillingness to listen.

3 = Reluctance to get involved.

4 = Denial of truth of story.

R

5 = Threaten subject if ever tell anyone.

UNSUPPORTIVE RESPONSE Ever:CKG6X06

FO

2 = Unwillingness to listen.

3 = Reluctance to get involved.

4 = Denial of truth of story.

5 = Threaten subject if ever tell anyone.

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VICTIM OF PHYSICAL ABUSE - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKG6I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKG6X07
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKG6X08

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKG6X09

N
5 = Depression

6 = Mania
CKG6X10

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKG6X11
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKG6X12
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

VICTIM OF PHYSICAL ABUSE-PAINFUL

RECALL
FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKG7I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any disturbing memories of the event?

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IF SEEKING HELP (PHYSICAL ABUSE)

PAINFUL RECALL PRESENT, ASK
AVOIDANCE AND HYPERAROUSAL.
OTHERWISE, SKIP TO "CAPTIVITY",
(PAGE 128).

LY
N
O
EW
VI
RE
R
FO

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VICTIM OF PHYSICAL ABUSE-AVOIDANCE

Do certain things/thoughts remind you of "life event"? AVOIDANCE SCREEN CKG7I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

VICTIM OF PHYSICAL ABUSE-

LY
HYPERAROUSAL
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKG7I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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CAPTIVITY
Being held against one's will (usually by someone older) CAPTIVITY Ever:CKG8E01
under circumstances with potential for death, severe Intensity
0 = Absent
physical injury, sexual or physical assault. Include being
kidnapped or held hostage. Do not include grounding, time 2 = Held captive against will for at least a
outs, or being required to stay with a non-desired person or day.
in a non-desired setting such as day care, camp, a hospital, 3 = Captivity included threats of death,
or prison. severe injury, or never seeing family

LY
member(s) again.

Have you ever been kidnapped? Ever:CKG8V01

Frequency
Or taken as a hostage?

Have you ever been locked up against your will?

N
Ever:CKG8O01
What happened? Onset
Who did it?
/ /

O
How did they treat you?
What did they want you to do? CAPTIVITY CKG8I01
How did they make you do what they wanted? Intensity
How did you feel at the time? EW 0 = Absent

2 = Held captive against will for at least a

day.

3 = Captivity included threats of death,

severe injury, or never seeing family
member(s) again.

CKG8F01
Frequency
VI

CKG8O02
Onset
RE

/ /

IF CAPTIVITY NOT PRESENT, SKIP TO

"SEXUAL ABUSE OR RAPE", (PAGE
R

132).
FO

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CAPTIVITY - ATTRIBUTION
In the last 3 months, has "life event" affected any of the ATTRIBUTION CKG8I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKG8X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKG8X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKG8X03

N
5 = Depression

6 = Mania
CKG8X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKG8X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKG8X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

CAPTIVITY-PAINFUL RECALL
FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKG9I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF CAPTIVITY PAINFUL RECALL

PRESENT, ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "SEXUAL ABUSE OR RAPE",
(PAGE 132).

LY
N
O
EW
VI
RE
R
FO

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CAPTIVITY-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKG9I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

CAPTIVITY-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKG9I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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SEXUAL ABUSE OR RAPE

Sexual abuse episode(s) in which a person, termed a SEXUAL ABUSE OR RAPE Ever:CKH0X99
perpetrator, involves a child or adolescent in activities for Intensity
0 = Absent
the purpose of the perpetrator's own sexual gratification.
These activities can include kissing (that makes a person 2 = Present
uncomfortable), genital fondling (over or under clothing),
SEXUAL ABUSE OR RAPE IN LAST 3 CKH0X98
oral-genital or oral-anal contact, genital or anal intercourse, MONTHS Intensity
or use of instruments. Sexual abuse does not include

LY
medical exams or mutually desires sexual relations with a 0 = Absent
peer. 2 = Present

Rape is a sudden unexpected (usually isolated) event SEXUAL ABUSE Ever:CKH0E01

involving non-consensual sexual intercourse. 0 = Absent

N
2 = Present
Has anyone ever touched you in places where they
shouldn't? NUMBER OF TIMES SEXUAL ABUSE Ever:CKH0V01

O
Has anyone ever touched you in ways that made you
feel funny?
ONSET SEXUAL ABUSE Ever:CKH0O01
Or seemed wrong to you?
/ /
Has anyone ever made you touch them in ways that
made you feel uncomfortable?
EW SEXUAL ABUSE CKH0I01
0 = Absent
What happened?
2 = Present
Who was involved?
How did you feel about it? LAST 3 MONTHS: NUMBER OF TIMES CKH0F01
Were you upset? SEXUAL ABUSE
VI

When did it first happen?

How many times has it happened?
Has it happened in the last 3 months? LAST 3 MONTHS: ONSET OF SEXUAL CKH0O02
ABUSE
/ /
RE

How about in the last 3 months?

RAPE Ever:CKH0E02
0 = Absent

2 = Present

NUMBER OF TIMES RAPE Ever:CKH0V02

R

ONSET OF RAPE Ever:CKH0O03

FO

/ /
RAPE CKH0I02
0 = Absent

2 = Present

LAST 3 MONTHS: NUMBER OF TIMES CKH0F02

RAPE

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LAST 3 MONTHS: ONSET OF RAPE CKH0O04

/ /
PERPETRATOR Ever:CKH0X01
2 = Perpetrator is stranger

3 = Perpetrator is known individual

Ever:CKH0X02
Specify

LY
Ever:CKH0X03

N
IF NO EVIDENCE OF POSSIBLE

O
SEXUAL ABUSE, SKIP TO "OTHER
EVENT", (PAGE 138).
EW
VI
RE
R
FO

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COERCION (SEXUAL ABUSE)

Use of threat of violence to constrain victim. COERCION Ever:CKH2E01
Intensity
0 = Absent
Did the person ever threaten to hurt you or get you in
trouble if youdidn't do what s/he/they wanted? 2 = Low coercion: little threat of severe
injury or death, but use of criticism,
rewards, punishment or loss of privileges to
Or if you told someone? constrain victim.

LY
Did s/he/they actually hurt you? 3 = Moderate coercion: threats (of death or
sever physical injury to victim or another
person) but not actual use of force.
Did you get any cuts, bruises, or marks?
4 = High coercion: use of force involving
threat or death or severe physical injury to
victim or another person.

N
COERCION CKH2I01
Intensity
0 = Absent

O
2 = Low coercion: little threat of severe
injury or death, but use of criticism,
rewards, punishment or loss of privileges to
constrain victim.
EW 3 = Moderate coercion: threats (of death or
sever physical injury to victim or another
person) but not actual use of force.

4 = High coercion: use of force involving

threat or death or severe physical injury to
victim or another person.
VI
RE
R
FO

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SEEKING HELP (SEXUAL ABUSE)

Three forms of supportive response to requests for help are SEEKING HELP (SEXUAL ABUSE) Ever:XYZ3I15
coded: listening, which could provide social support and Intensity
0 = Absent
emotional relief; personal intervention, which is personally
attempting to prevent the reoccurrence of the situation; or 2 = Present
intervention involving a professional agency, which might
SUPPORTIVE RESPONSE: PEERS Ever:CKH3X01
be phoning the police, contacting appropriate services,
referring the subject to such services, or removing the 2 = Listening

LY
subject from what s/he experiences as an unsafe
3 = Personal intervention.
environment. Unsupportive responses include
unwillingness to listen, reluctance to get involved, denial of 4 = Intervention involving professional
the truth of the story, and threatening the child if anyone agency.
else ever told. SUPPORTIVE RESPONSE: FAMILY Ever:CKH3X02

N
MEMBER
Did you ever tell anyone about these things? 2 = Listening

Did you tell someone you age? 3 = Personal intervention.

O
A family member? 4 = Intervention involving professional
agency.
Did s/he help?
SUPPORTIVE RESPONSE: OTHER Ever:CKH3X03
What happened? ADULT
What did s/he do?
Did you feel s/he/they could have done more?
EW 2 = Listening

3 = Personal intervention.
What did s/he do?
4 = Intervention involving professional
An adult outside your family? agency.

Did you feel s/he/they could have done more UNSUPPORTIVE RESPONSE- PEERS Ever:CKH4X01
VI

What happened? 2 = Unwillingness to listen.

Did s/he help? 3 = Reluctance to get involved.

4 = Denial of truth of story.

RE

5 = Threaten subject if ever tell anyone.

UNSUPPORTIVE RESPONSE: FAMILY Ever:CKH4X02

MEMBER

2 = Unwillingness to listen.

3 = Reluctance to get involved.

R

4 = Denial of truth of story.

5 = Threaten subject if ever tell anyone.

FO

UNSUPPORTIVE RESPONSE- OTHER Ever:CKH4X03

ADULT

2 = Unwillingness to listen.

3 = Reluctance to get involved.

4 = Denial of truth of story.

5 = Threaten subject if ever tell anyone.

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SEXUAL ABUSE: ATTRIBUTION

In the last 3 months, has this affected any of the ATTRIBUTION CKH4X10
problems we've been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF LIFE EVENT AS CKH4X04
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKH4X05

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKH4X06

N
5 = Depression

6 = Mania
CKH4X07

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKH4X08
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKH4X09
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

SEXUAL ABUSE OR RAPE-PAINFUL RECALL

R

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKH5I01
event" come into your mind? Intensity
0 = Absent
FO

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

IF SEXUAL ABUSE OR RAPE PAINFUL

RECALL PRESENT, ASK AVOIDANCE
AND HYPERAROUSAL. OTHERWISE,
SKIP TO "OTHER EVENT", (PAGE 138).

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LY
N
O
EW
VI
RE
R
FO

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SEXUAL ABUSE OR RAPE-AVOIDANCE

Do certain things remind you of "life event"? AVOIDANCE SCREEN CKH5I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

SEXUAL ABUSE OR RAPE-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKH5I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
OTHER EVENT
Other event that has made subject feel really terrible, OTHER EVENT Ever:CKH6E01
upset, frightened, or shook up. Intensity
EW 0 = Absent

Has anything else really bad happened to you? 2 = Present

Specify
Or made you feel really terrible?

Or really upset or frightened you?

Ever:CKH6V01
What happened? Frequency
VI

When was that?

How many times have you had upsetting things like that
Ever:CKH6O01
happen? Onset
RE

Has anything like that happened in the last 3 months? / /

OTHER EVENT CKH6I01
Intensity
0 = Absent

2 = Present
R

Specify
FO

CKH6F01
Frequency

CKH6O02
Onset

/ /

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IF OTHER EVENT NOT PRESENT, SKIP

TO "ACTIVE RECALL", (PAGE 10).

LY
N
O
EW
VI
RE
R
FO

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OTHER EVENT - ATTRIBUTION

In the last 3 months, has "life event" affected any of the ATTRIBUTION CKH6I99
problems we have been talking about? Intensity
0 = Absent

Which ones? 2 = Present

In what way?
ATTRIBUTION OF "LIFE EVENT" AS CKH6X01
CONTRIBUTING TO PROBLEM WITH:

LY
1 = School non-attendance.

2 = Separation anxiety. CKH6X02

3 = Worries/anxiety.

4 = Obsessions/compulsions. CKH6X03

N
5 = Depression

6 = Mania
CKH6X04

O
7 = Physical symptoms.

8 = Food-related behavior.

9 = Hyperactivity/ADD CKH6X05
EW 10 = Conduct disorder.

11 = Alcohol/drugs
CKH6X06
12 = Psychosis

13 = Relationships with parent #1 and/or

parent #2.
VI

14 = Relationships with other parent #1

and/or other parent #2.

15 = Relationships with other adults.

16 = Sibling relationships.
RE

17 = Peer relationships.

18 = Relationships with spouse or romantic

partner

Specify
R

OTHER EVENT-PAINFUL RECALL

FO

In the last 3 months, have thoughts or pictures of "life PAINFUL RECALL SCREEN CKH7I01
event" come into your mind? Intensity
0 = Absent

Even when you didn't want them to? 2 = Present

What was that like?

Have you had any nightmares about the event?

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IF OTHER PAINFUL RECALL PRESENT,

ASK AVOIDANCE AND
HYPERAROUSAL. OTHERWISE, SKIP
TO "ACTIVE RECALL", (PAGE 10).

LY
N
O
EW
VI
RE
R
FO

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OTHER EVENT-AVOIDANCE
Do certain things remind you of "life event"? AVOIDANCE SCREEN CKH7I02
Intensity
0 = Absent
What things?
Do you try to avoid these things/thoughts? 2 = Present

OTHER EVENT-HYPERAROUSAL

LY
Since "life event", have you been more jumpy or HYPERAROUSAL SCREEN CKH7I03
irritable? Intensity
0 = Absent

Have you had any trouble sleeping? 2 = Present

N
Have you been "on the alert" for bad things
happening?

O
EW
VI
RE
R
FO

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POST TRAUMATIC STRESS - A

SCREEN FOR LIFE EVENT IN LAST 3 MONTHS
Mark "Present" if any Life Event in last 3 months had a SCREEN FOR LIFE EVENT IN LAST 3 CLA9X89
positive screen. MONTHS Intensity
0 = Absent
INTERVIEWER NOTE: Was there a Life Event in the last
2 = Present
3 months with a positive screen?

LY
IF LIFE EVENT IN LAST 3 MONTHS
ABSENT, SKIP TO "ACTIVE RECALL",
(PAGE 10).

N
O
EW
VI
RE
R
FO

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ACUTE RESPONSES TO TRAUMATIC EVENT

ACUTE EMOTIONAL RESPONSES
Emotional responses to the event when it occurred. LIFE EVENT IN THE LAST 3 MONTHS CLA0I01
Intensity
1 = New Child(ren) in Home
Now I would like to ask you about feelings you may
have had when the "life event" occurred. 2 = Parental Separation

3 = Parental Divorce

LY
5 = Moving House

6 = Change of School/College/University

7 = Loss of Best Friend Through Moving

N
8 = Breakup With Best Friend

9 = Breakup With Boy/Girlfriend, Spouse,

Or Romantic Partner

O
10 = Chronically Unsafe Neighborhood

11 = Parental Arrest

12 = Reduction in Standard of Living

EW 13 = Forced Separation From Home

14 = Diagnosis of Physical Illness

15 = Accident

Were you suprised by what happened? SURPRISE CLA1X01

0 = Absent
VI

2 = Present

Did you feel helpless? HELPLESSNESS CLA1X02

0 = Absent
Like you couldn't do anything to make it better?
RE

2 = Present

Did you feel like it wasn't really happening? DEREALIZATION CLA1X03

0 = Absent
Like it was only a story, not the real thing?
2 = Present

Were you afraid or scared? CLA1X04

R

FEAR

0 = Absent

2 = Present
FO

Were you worried that you weren't safe? WORRY CLA1X05

0 = Absent
Or that you might die?
2 = Present

Did you get angry? ANGER CLA1X06

0 = Absent

2 = Present

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Did you feel nothing at all? EMOTIONAL NUMBNESS CLA1X07

0 = Absent
Like you couldn't feel anything?
Or didn't want to feel anything? 2 = Present

Were you grossed out or disgusted by what happened? DISGUST/REVULSION CLA1X08

0 = Absent

2 = Present

LY
Did you feel out of control? OUT OF CONTROL CLA1X09
0 = Absent
That you might not be able to control your feelings?
2 = Present

N
Did you feel sad? SAD CLA1X10
0 = Absent

O
2 = Present

Did you feel confused? CONFUSED CLA1X11

0 = Absent
Like you couldn't understand what was happening?
Like it didn't make any sense? 2 = Present

Did you feel out of touch with yourself?

EW DETACHED CLA1X12
0 = Absent
Or cut off from yourself?
2 = Present
As if you were in a dream?
As if "event" wasn't happening to you?
VI

Did you feel guilty? GUILTY CLA1X13

0 = Absent
Like it was your fault?
2 = Present
RE

Did you feel like someone you trusted had tricked you? BETRAYED CLA1X14
0 = Absent

2 = Present

Did you feel embarrassed by what was happening? EMBARRASSED CLA1X15

R

0 = Absent
Or ashamed?
2 = Present
FO

ACUTE SOMATIC RESPONSES

Physical responses to the life event when it occurred. ACUTE SOMATIC RESPONSES CLA2I90
Intensity
0 = Absent
When "life event" occurred, did it affect you physically
at all? 2 = Present

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Did you get dizzy or giddy or faint? DIZZINESS/FAINTNESS CLA2X01

0 = Absent

2 = Present

Did you get a dry mouth? DRY MOUTH CLA2X02

0 = Absent

2 = Present

LY
Did it affect your breathing? CHOKING/SMOTHERING CLA2X03
0 = Absent
How?
2 = Present

N
DIFFICULTY BREATHING CLA2X04
0 = Absent

2 = Present

O
RAPID BREATHING CLA2X05
0 = Absent

2 = Present

Did it affect your heart?

EW PALPITATIONS CLA2X06
0 = Absent

2 = Present

Did you get a pain in your chest? TIGHTNESS OR PAIN IN CHEST CLA2X07
VI

0 = Absent

2 = Present

Did you get sweaty? SWEATING CLA2X08

RE

0 = Absent

2 = Present

Or feel sick? NAUSEA CLA2X09

0 = Absent

2 = Present
R

Did you have to go to the bathroom? URINATING FREQUENTLY CLA2X10

0 = Absent
FO

2 = Present

Did it affect your stomach? BUTTERFLIES IN THE STOMACH CLA2X11

0 = Absent

2 = Present

Did you get diarrhea? DIARRHEA CLA2X12

0 = Absent

2 = Present

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Did you get shaky? TREMBLING/SHAKING CLA2X13

0 = Absent

2 = Present

Did your muscles get sore? MUSCLE SORENESS CLA2X14

0 = Absent

2 = Present

LY
Did you get flushed? FLUSHING CLA2X15
0 = Absent

2 = Present

N
Or pale? PALLOR CLA2X16
0 = Absent

2 = Present

O
Did you have funny feelings in your fingers or toes? PARAESTHESIAE CLA2X17
0 = Absent

2 = Present

Did you get a lump in your throat?

EW LUMP IN THE THROAT CLA2X18
0 = Absent

2 = Present

Did your abdomen churn? ABDOMINAL CHURNING CLA2X19

VI

0 = Absent

2 = Present

INTERVENTION FANTASIES
RE

During the event, subject imagines doing something INTERVENTION FANTASIES CLA3X01
extraordinary to stop the event. Intensity
0 = Absent

During "life event", did you imagine or wish that you 2 = Present during event and realized.
could do something superhuman to get you or 3 = Present during event but unrealized.
someone else out of danger?
R

What did you imagine?

What happened?
FO

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RESCUE FANTASIES DURING EVENT

During the event, subject imagines being rescued. RESCUE FANTASIES DURING EVENT CLA3X02
Intensity
0 = Absent
During "life event" did you imagine or wish that
"person at risk" would be rescued? 2 = Present during event and realized.

3 = Present during event but unrealized.

What did you imagine?
What happened?

LY
REVENGE FANTASIES
During the event, subject imagines something that REVENGE FANTASIES CLA3X03
punishes the "cause" of the trauma. Intensity

N
0 = Absent

During "life event", did you imagine or wish that you 2 = Present during event and realized.
could get revenge or punish "the cause of the 3 = Present during event but unrealized.

O
trauma"?

Or that someone else or something would get revenge?

What did you imagine?
What happened?
EW
VI
RE
R
FO

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COGNITIVE INTRUSIONS
PAINFUL RECALL OF LIFE EVENT
Unwanted, painful and distressing recollections, memories, PAINFUL RECALL OF LIFE EVENT CLA4XYZ 00
thoughts, or images of life event. Intensity
0 = Absent

In the last 3 months have upsetting memories or 2 = Present

pictures in your mind of "life event" come back to you?

LY
EXTERNALLY CUED PAINFUL RECALL
Painful recall occurring in response to external cues or EXTERNALLY CUED PAINFUL RECALL CLA4I01
stimuli, such as particular sights, sounds, smells or Intensity
0 = Externally cued painful recall absent.

N
situations.
2 = Painful recall is intrusive into at least
two activities and uncontrollable at least
Do any things or places remind you of "life event"? some of the time.

O
What about sounds or things you see? 3 = Painful recall is intrusive into most
activities and nearly always uncontrollable.
When that happens does it bring back unpleasant
CLA4F01
memories of "life event"? EW Frequency

HOURS : MINUTES CLA4D01

Duration
VI

ONSET: EXTERNALLY CUED PAINFUL CLA4O01

RECALL
/ /
RE
R
FO

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PAINFUL RECALL OF LIFE EVENT -

AVOIDANCE
Unwanted, painful and distressing recollections, memories, AVOIDANCE CLA5I01
thoughts, or images of "life event" occurring in response to Intensity
0 = Absent
external cues or stimuli, such as particular sights, sounds,
smells or situations. 2 = Avoids situations that might provoke
painful recall at least sometimes, but not to
a degree that prevents a normal lifestyle.
Do you try to avoid any things or places that might

LY
remind you of "life event"? 3 = Avoidance leads to disruption of normal
life and activities and results in a highly
restricted lifestyle.
Do you notice any phsyical effects when you remember
"life event"? CLA5O01
Onset
Like your heart racing?

N
Or being short of breath? / /
Or feeling shaky ot sick to your stomach?
What do you notice? NORMAL SUPPRESSION CLA6I01

O
Do you get panicky? 0 = Absent
Would other people notice when you are remembering
2 = Uses normal thoughts or normal
"life event"?
activities in attempt to reduce painful recall.

What do they see? CLA6I02

When you remember event, whet do you do to feel
better?
EW OBSESSIONAL SUPPRESSION

0 = Absent

2 = Uses obsessional thoughts or

Do you try to think about other things or do things you like obsessional rituals in attempt to reduce
to do to take your mind off of it? painful recall.
Do you talk to you or someone else and ask them for help?
COMPULSIVE SUPPRESSION CLA6I03
Do you have a routine of things you can think about or do
VI

to feel better? 0 = Absent

2 = Uses compulsive behaviors in attempt

to reduce painful recall.

AUTONOMIC EFFECTS CLA7I01

RE

0 = Absent

2 = Notices autonomic changes in responce

to painful recall, but these do not amount to
panic attacks

3 = Panic attacks in responce to painful

recall
R

NOTICEABLE TO OTHERS CLA7I02

0 = No
FO

2 = Child reports others notice changes

(anxiety, daydreaming, etc.).

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PAINFUL RECALL NOT EXTERNALLY CUED

Recollections not cued by external cues or stimuli. PAINFUL RECALL NOT EXTERNALLY CLA8I01
CUED Intensity
May be internally cued responses, occurring in response to 0 = Absent
emotional states, feelings, particular thoughts, autonomic
2 = Painful recall is intrusive into at least
symptoms, bodily sensations, or any other internal cue or two activities and uncontrollable at least
stimulus. If internal cues are a response to external some of the time.
stimulus, code as Externally Cued Recollections.

LY
3 = Painful recall is intrusive into most
activities and nearly always uncontrollable.
Recollections also may occur without apparent relationship
to either external or internal cues or stimuli. CLA8F01
Frequency
In the last three months have any feelings or emotions

N
reminded you of "life event"?
HOURS : MINUTES CLA8D01
Have any physical feelings or changes in your body Duration

O
reminded you of it?

When that happens, does it bring back unpleasant

memories of "life event"? CLA8O01
Onset
What are they like? EW
How often does that happen? / /
How long does it last?
When that happens, do you try not to have those NORMAL SUPPRESSION CLA9I01
"feelings", so you won't be reminded of "life event"?
0 = Absent
Do you do anything so as not to have those "feelings" 2 = Uses normal thoughts or normal
that remind you of "life event"? activities in attempt to reduce painful recall.
VI

Do you try not to think about life event? OBSESSIONAL SUPPRESSION CLA9I02
Do you do anything to stop yourself thinking about it? 0 = Absent
Can you stop thinking about it?
What do you do? 2 = Uses obsessional thoughts or
RE

obsessional rituals in attempt to reduce

Would other people notice when you are rememering painful recall.
"life event"?
COMPULSIVE SUPPRESSION CLA9I03
What would they see?
0 = Absent
When you "think aobut life event", do you notice any
phsyical effects? 2 = Uses compulsive behaviors in attempt
to reduce painful recall.
R

What do you notice?

PAINFUL RECALL NOTICABLE TO CLB0I01
Do you get panicky? OTHERS
FO

0 = No

2 = Child reports others notice changes

(anxiety, daydreaming, etc.).

AUTONOMIC EFFECTS CLB0I02

0 = Absent

2 = Notices autonomic changes in response

to painful recall, but these do not amount to
panic attacks.

3 = Panic attacks in response to painful

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recall.

ACTIVE RECALL
Intentional recall of event. ACTIVE RECALL CLB1I01
Intensity
0 = Absent
Do you ever think about "life event" on purpose?
2 = Present

LY
Have you in the last three months? CLB1F01
When you do so, how do you feel? Frequency
Are the feelings painful for you?
Do you get worried?
Or sad?
Or angry? HOURS : MINUTES CLB1D01

N
Or feel guilty? Duration
Do you feel better able to cope with what happened?

O
CLB1O01
Onset

EW / /
WORRY CLB2I01
0 = Absent

2 = Present

SADNESS CLB2I02
0 = Absent
VI

2 = Present

ANGER CLB2I03
0 = Absent
RE

2 = Present

GUILT CLB2I04
0 = Absent

2 = Present
R

SENSE OF MASTERY CLB2I05

0 = Absent
FO

2 = Present

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FAILURES OF RECALL
Inability to recall important aspects of the "life event", such FAILURES OF RECALL CLB2I06
as the names and faces of participants, or parts of the Intensity
0 = No failure of recall.
chronology of the event.
1 = Some difficulty recalling certain aspects
of the event that can usually be overcome
Do not include deliberate attempts not to recall the event. by concentrated attempt to remember.

2 = At least some aspects of the event

Do you have difficulty remembering some things about

LY
cannot be recalled, even with effort.
"life event"?
3 = Most or all details of the event cannot
What things are hard to remember? be recalled.
Is that because you don't want to remember them, or that CLB2O01
you just can't? Onset

N
How much can you remember?
Are those memories real clear? / /
Has it happened in the last three months?

O
EW
VI
RE
R
FO

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RELIVING OF LIFE EVENT

Behaving or feeling as though the "life event" were RELIVING OF LIFE EVENT CLB3I01
recurring. The experience may involve a sense of reliving Intensity
0 = Absent
the event, illusory or hallucinatory phenomena, or
"flashbacks". Flashbacks involve hallucinatory phenomena 2 = Able to report sensory phenomena
of sufficient intensity to impair perception of the real world associated with "life event", but still aware
of real surroundings to at least some extent.
to a substantial degree.
3 = No, or almost no, awareness of real

LY
surroundings (flashback).
Include panic attacks where the mental content of the panic
episode is related to the "life event". CLB3F01
Frequency
Include such phenomena even if they occurred at times of
intoxication with alcohol or drugs or during sleep cycle.

N
HOURS : MINUTES CLB3D01
CODE NIGHTMARES IN ITEMS THAT FOLLOW. Duration

O
In the last 3 months, have you felt as though the "life
event" was happening to you again, even when it CLB3O01
wasn't? Onset

What was that like? / /

What did you do?
How long did it last?
EW ASSOCIATED PANIC CLB3I02
How often did it happen? 0 = No associated panic attacks.
How real did it seem?
Did you feel as though you were really there, and that it 2 = With panic attacks.
was really happening again?
HYPNOGOGIC (ON FALLING ASLEEP) CLB3I03
When it was happening were you aware of what was really
VI

going on around you and where you really were? 0 = Absent

Did the memory of "life event" seem more real than your
2 = Present
actual surroundings?
Did this happen when you were falling asleep? HYPNOPOMPIC (ON WAKING) CLB3I04
Or waking up?
RE

0 = Absent
Do you ever wake up in the middle of the night feeling this
way? 2 = Present

NOCTURNAL CLB3I05
0 = Absent

2 = Present
R

DAYLIGHT (WHEN UP AND ABOUT) CLB3I06

0 = Absent
FO

2 = Present

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NIGHTMARES
Frightening dreams that waken subject, with content NIGHTMARES CLB4I01
related to the "life event" (either about "life event" or Intensity
0 = Absent
reminding subject of it). Unpleasant affect apparent when
wakening, which may be followed rapidly by feelings of 2 = Present
relief.
CLB4O01
Onset
In the last 3 months, have you had any nightmares or
/ /

LY
bad dreams about "life event"?

Or nightmares or bad dreams that aren't about it but AUTONOMIC EFFECTS CLB4I02
remind you of it? 0 = Absent

Tell me about them.

N
2 = Notices autonomic changes in response
Do they wake you up? to nightmares.

3 = Has panic attack in response to

How often do they happen? nightmares.

O
When you wake up, do you notice any physical effects?
When you wake up are you panicky? REASSURANCE CLB4I03
Is it hard for you to get back to sleep afterwards? 0 = Absent
What do you do?
Does fear of these dreams make it hard for you to get to 2 = Upon waking from nightmare, seeks
sleep?
Do you have trouble sleeping alone?
EW time limited reassurance or contact.

3 = Upon waking, seeks extended

reassurance or contact (e.g. won't go back
to bed, conflict arises over need for
reassurance).

ANTICIPATORY REASSURANCE CLB4I04

VI

0 = Absent

2 = At bedtime, seeks time limited

reassurance or contact (e.g. extended
bedtime ritual).
RE

3 = Seeks extended reassurance or contact

(e.g. won't go to bed, conflict arises over
need for reassurance).
R
FO

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HYPERAROUSAL
NON-RESTORATIVE SLEEP
Disturbance of usual sleep pattern since "life event" so that NON-RESTORATIVE SLEEP CLB5I01
subject does not feel rested upon waking and feels tired Intensity
0 = Absent
during the day. Do not include insomnia; sleep is normal
but subject feels sleepy during the day. 2 = Present but does not interfere with
functioning.

LY
DO NOT INCLUDE INSOMNIA. 3 = Present and interfered with functioning.

CLB5O01
Have you been having problems sleeping well in the Onset
last three months?
/ /
Do you feel rested when you wake up in the morning?

N
CLB5F01
Has that changed since "life event"? Frequency
Do you feel tired during the day from not sleeping well?

O
Does this make it harder for you to do your work?
How much of the time do you feel this way?
AROUSAL CLB5I02
Is it worse when you have been thinking about "life event"?
0 = Absent
EW 2 = Symptom present 0-25% of the time.

3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLB5I03

VI

0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
RE
R
FO

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INATTENTION
Difficulty maintaining sufficient involvement to allow INATTENTION CLB6I01
completion of age-appropriate and developmentally Intensity
0 = Inattention absent in interesting
appropriate tasks requiring concentration. activities.

2 = At least sometimes uncontrollable by

In the last three months, have you had more trouble the child or by admonition, present in at
paying attention than before "life event"? least 2 interesting activities in any situation.

LY
Is it more difficult for you to concentrate? 3 = Nearly always uncontrollable by the
child or by admonition, present in most
interesting activities.
Do you have trouble remembering things?
Has this caused you any problems? CLB6O01
How much of the time do you feel this way? Onset
Is it worse when you have been thinking about "life event"?

N
/ /
AROUSAL CLB6I02

O
0 = Absent

2 = Symptom present 0-25% of the time.

EW 3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLB6I03

0 = Absent

2 = Symptom occurs or increases in

VI

response to cues prompting recall or

reliving of the "life event".
RE
R
FO

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ANGER
Increased ease of precipitation of externally directed ANGER CLB7I01
feelings of anger, bad temper, short temper, resentment, or Intensity
0 = Absent
annoyance.
2 = Present but does not interfere with
fuctioning or relationships.
Since "life event" have things "gotten on your nerves"
more easily? 3 = Present and interfered with functioning
or relationships.

LY
What kinds of things?
CLB7O01
Is that more than usual? Onset
Or have you been more irritable?
/ /
Has this affected how you get along with people?
How so? CLB7I02

N
AROUSAL
How much of the time do you feel this way?
0 = Absent
Is it worse when you have been thinking about "life event"?
2 = Symptom present 0-25% of the time.

O
3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

EW PHASIC EXACERBATION CLB7I03
0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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ANGER DYSCONTROL
Increased outbursts of anger have resulting from inability to ANGER DYSCONTROL CLB8I01
control expression of anger as well as used to. Intensity
0 = Absent

In the last three months, have you gotten angry very 2 = Present but does not interfere with
fuctioning or relationships.
often?
3 = Present and interfered with functioning
More than before "life event"? or relationships.

LY
What has happened?
CLB8O01
When you get angry, can you control your anger as Onset
much as you used to?
/ /
What do you do now?
Has it affected how you get along with other people? CLB8I02

N
AROUSAL
How so?
0 = Absent
How much of the time do you feel this way?
Is it worse when you have been thinking about "life event"? 2 = Symptom present 0-25% of the time.

O
3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

EW PHASIC EXACERBATION CLB8I03
0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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HYPERVIGILANCE
Increased general level of awareness and alertness HYPERVIGILANCE CLB9I01
towards surroundings in the absence of imminent danger. Intensity
0 = Absent

In the last 3 months, have you been more "on the alert" 1 = Subjective hypervigilance not
manifested in any overt behavioral change.
for bad things happening than before "life event"?
2 = Behavioral manifestations of
What do you do? hypervigilance (e.g. taking care over

LY
Are you like that even when there isn't much chance of seating or scanning environment for
danger) but they do not limit activities to
anything bad happening? any major extent.
How much has that affected your life?
How much of the time are you like that? 3 = Behavioral manifestations of
hypervigilance that preclude the
Have you given up doing any thing because you don't want performance of many or most normal

N
to take any chances? activities.
Is it worse when you have been thinking about "life event"?
When did that start? CLB9O01
Onset

O
/ /
AROUSAL CLB9I02
0 = Absent
EW 2 = Symptom present 0-25% of the time.

3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

VI

PHASIC EXACERBATION CLB9I03

0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
RE

reliving of the "life event".

R
FO

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EXAGGERATED STARTLE RESPONSE

Increase in susceptibility to being startled by minor EXAGGERATED STARTLE RESPONSE CLC0I01
unexpected stimuli since "life event". Intensity
0 = Absent

INTERVIEWER SHOULD DEMONSTRATE STARTLE 2 = Present, but not noticeable to others.

RESPONSE. 3 = Present, noticeable to others.

CLC0O01
In the last 3 months have you startled more easily than

LY
Onset
before "life event"?
/ /
Or have you been more jumpy than usual?
AROUSAL CLC0I02
Do unexpected noises make you jump more easily than

N
they used to? 0 = Absent
What is it like when that happens? 2 = Symptom present 0-25% of the time.
How often does it happen?
How long do you stay "jumpy" afterwards? 3 = Symptom present 26-50% of the time.

O
How much of the time do you feel this way? 4 = Symptom present 51-75% of the time.
Is it worse when you have been thinking about "life event"?
When did that start? 5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLC0I03

EW 0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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NUMBING
DETACHMENT
A generalized subjective sense of being emotionally cut off DETACHMENT CLC1I01
from other people that has appeared since the occurrence Intensity
0 = Absent
of a "life event".
2 = Feels that it is more difficult to relate
emotionally to people than before "life
Since "life event" have you felt cut off from other event", but has not reduced social contacts.

LY
people?
3 = Has reduced social contacts because of
Have you been less interested in seeing your friends? difficulty relating emotionally to people.

CLC1O01
Have you actually seen less of your friends? Onset
Can you tell me why?
/ /

N
Would you like to see more of them?
Or have you "gone off" on them?

O
LOSS OF POSITIVE AFFECT
Complaint of loss of a previously existing ability to feel or LOSS OF POSITIVE AFFECT CLC2I01
experience emotion. Code loss of positive and negative Intensity
0 = Absent
affect separately.
EW 2 = Loss of affect in at least 2 activities and
uncontrollable at least some of the time.
Since "life event" has it seemed as though you have
lost some of your feelings? 3 = Affect is felt to be lost in almost all
activities.
Have you got any feelings left?
ONSET: LOSS OF POSITIVE AFFECT CLC2O01
Can you feel happy or good feelings?
/ /
VI

LOSS OF NEGATIVE AFFECT

RE

Complaint of loss of a previously existing ability to feel or LOSS OF NEGATIVE AFFECT CLC3I01
experience emotion. Code loss of positive and negative Intensity
0 = Absent
affect separately.
2 = Loss of affect in at least 2 activities and
uncontrollable at least some of the time.
Since "life event" has it seemed like you have lost
some of your unhappy or negative feelings? 3 = Affect is felt to be lost in almost all
activities.
R

CLC3O01
Onset

/ /
FO

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LOSS OF POSITIVE EMOTIONAL EXPRESSION

Since "life event", unable or unwilling to express emotions LOSS OF POSITIVE EMOTIONAL CLC4I01
to the degree existing before the "life event." EXPRESSION Intensity
0 = Absent
Do not include inexpressiveness that predated the "life
2 = Less able or willing to talk about or
event" unless there has clearly been an exacerbation show emotions, or to discuss topics with
following the "life event". emotional content or which stimulate
emotions.

LY
Is it harder for you to show happy or good feelings? 3 = Almost always unable or unwilling to
talk about or show emotions or to discuss
topics with emotional content or which
stimulate emotions.

ONSET: LOSS OF POSITIVE CLC4O01

N
EMOTIONAL EXPRESSION
/ /

O
LOSS OF NEGATIVE EMOTIONAL
EXPRESSION
Since life event, unable or unwilling to express emotions to LOSS OF NEGATIVE EMOTIONAL CLC5I01
the degree existing before the "life event". EXPRESSION Intensity
EW
Do not include inexpressiveness that predated the "life
0 = Absent

2 = Less able or willing to talk about or

event" unless there has clearly been an exacerbation show emotions, or to discuss topics with
following the "life event". emotional content or which stimulate
emotions.
Is it harder for him/her to show unhappy or bad 3 = Almost always unable or unwilling to
VI

feelings? talk about or show emotions or to discuss

topics with emotional content or which
stimulate emotions.

CLC5O01
Onset
RE

/ /
R
FO

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OTHER BEHAVIORS
PLAY RECAPITULATING "LIFE EVENT"
Play involving activities that recapitulate all or some PLAY RECAPITULATING "LIFE EVENT" CLC6I01
aspects of "life event" (e.g. preoccupation with crashing Intensity
0 = Absent
cars after being in a car accident, or behaviors that mimic
"life event"). 2 = Present to an extent greater than before
the event.

LY
Has the way you play changed at all since "life event"? 3 = Actions recapitulating life event has
become the most frequent or dominant
In what way? subject of play.
In the last 3 months have you played games that are CLC6O01
like "life event"? Onset

/ /

N
Or acted out what happened?

What do you do?

O
DANGEROUS ACTIVITIES (PTSD - A)
Activities that physically endanger the subject or others. DANGEROUS ACTIVITIES CLC7I01
Intensity
EW
Since "life event", have you taken chances and done
risky things?
0 = No

2 = Yes

CLC7O01
Or dangerous things? Onset
What have you done in the last 3 months? / /
Is this more than before "life event"?
VI

INCREASED ATTENTION TO RELIGION

Increased interest in or observance of religious ideas and INCREASED ATTENTION TO RELIGION CLC8I01
RE

practices since "life event". Intensity

0 = Absent

Have you become more religious since "life event"? 1 = Subjective report of greater interest in,
or mental attention to, religious matters.
Include increased level of reading religious
Do you think more about God? works here.

Or the Devil? 2 = Increase in level of religious

R

observances, including normal prayer.

Do you go to "church" more often? 3 = Increase in religious observances
Do you read "scripture" more often? including obsessional rituals and
FO

Or pray more? compulsive behaviours.

CLC8O01
Onset

/ /

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DECREASED ATTENTION TO RELIGION

Decreased interest in or observance of religious ideas and DECREASED ATTENTION TO RELIGION CLC9I01
practices since "life event". Intensity
0 = Absent

Do you have less interest in religion since "life event"? 2 = Subjective report of decreased interest
in, or mental attention to, religious matters.
Do you care less about God? Include decreased level of reading religious
Or the Devil? works here.
Do you go to "church" less frequently?

LY
3 = Decrease in level of religious
Do you read "scripture" less? observances, including prayer.
Or pray less?
CLC9O01
Onset

/ /

N
OMEN FORMATION

O
Following the "life event", subject has developed OMEN FORMATION CLD0I01
superstitious beliefs or practices to mitigate or prevent Intensity
0 = Not present.
recurrences of the event or other possible or imagined "life
events". EW 1 = Superstitious beliefs not resulting in any
overt behavior.

Are you superstitious about things? 2 = Superstitious beliefs that have resulted
in overt behavior (e.g. carrying charms or
Are there signs that mean bad things will happen? rabbits feet).

3 = Activities meeting criteria for

Or signs that make you think that you'll be OK? obsessional rituals or compulsive
behaviors.
VI

What are they?

Do you think that these signs are really true? CLD0O01
Onset
Did you believe in them before "life event" or are they new?
/ /
RE
R
FO

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SURVIVOR GUILT
A subjective belief or feeling of responsibility for the "life SURVIVOR GUILT CLD1I01
event" or its prevention, or a feeling that the subject should Intensity
0 = Absent
have substituted (or been substituted) for another who was
more severely affected. 2 = Present

CLD1O01
Do you feel guilty about what happened during "life Onset
event"?
/ /

LY
Do you ever feel it was your fault, even though it
wasn't?

Do you sometimes feel that you should have prevented "life

event" even though you couldn't?

N
Do you ever wish that you and not "specific other person"
should have "specific other person's" fate?
Do you ever feel bad about what you did during "life

O
event"?
IF THE CHILD FEELS GUILTY OR RESPONSIBLE,
PROVIDE REASSURANCE AND COMFORT

REVENGE FANTASIES AFTER EVENT

EW
In the last 3 months subject imagined doing something to REVENGE FANTASIES CLD2I01
punish the "cause" of the trauma. Intensity
0 = Absent

Do you still wish that you could get revenge or punish 2 = Present
"the cause of the trauma"? CLD2O01
VI

Onset
Or that something would happen to get back at "the
cause"? / /
What do you wish would happen?
RE
R
FO

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CHANGED EXPECTATION OF LONG-TERM

FUTURE
Marked change in the subject's expectations of the future, CHANGED EXPECTATIONS OF LONG- CLD3I01
involving the expectation that some or all adult roles will TERM FUTURE Intensity
NOT be attained. Code regardless of justification, except in 0 = Absent
the case of subjects with a current life-threatening illness.
2 = Expects to reach adulthood, but
predicts poor attainment of adult roles (e.g.
Has "life event" changed what you think the future will does not expect to get married, get a job, or

LY
be like? have children); or expects to reach
adulthood but is not certain about it.
In what way? 3 = Does not expect to survive to
Has it changed what you think about getting married? adulthood.

Or having children? CLD3O01

N
Onset
In what way?
How long do you expect to live? / /

O
Has that changed?

EW
VI
RE
R
FO

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POST TRAUMATIC STRESS - B

SCREEN FOR LIFE EVENT: LIFETIME
Mark "Present" if any Lifetime Life Event had a positive SCREEN FOR LIFE EVENT: LIFETIME Ever:CLA8X38
screen. Intensity
0 = Absent

INTERVIEWER NOTE: Is there a Lifetime Life Event 2 = Present

with a positive screen?

LY
IF LIFETIME LIFE EVENT ABSENT,
SKIP TO ""PSYCHOTIC"
ABNORMALITIES OF THOUGHT AND

N
SPEECH", (PAGE 5).

O
EW
VI
RE
R
FO

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ACUTE RESPONSES TO TRAUMATIC EVENT

ACUTE EMOTIONAL RESPONSES
Emotional responses to the event when it occurred. PTSD B PRESENT CLM0E90
Intensity
0 = Absent

2 = Present

Now I would like to ask you about feelings you may PTSD B-EVENT CLE0E01

LY
have had when the "life event" occurred. 18 = Death of Loved One

19 = Death of Sibling or Peer

20 = Natural Disaster

N
21 = Fire

22 = War or Terrorism

23 = Witness to Event

O
24 = Learned About Event

25 = Exposure to Noxious Agent

26 = Causing Death or Severe Harm

EW 27 = Victim of Physical Violence

28 = Victim of Physical Abuse

29 = Captivity

30 = Sexual Abuse or Rape

31 = Other
VI

32 = Stalking

33 = Sexual Harassment

Were you surprised by what happened? SURPRISE CLE1X01

RE

0 = Absent

2 = Present

Did you feel helpless? HELPLESSNESS CLE1X02

0 = Absent
Like you couldn't do anything to make it better?
R

2 = Present

Did you feel like it wasn't really happening? DEREALIZATION CLE1X03

FO

0 = Absent
Like it was only a story, not the real thing?
2 = Present

Were you afraid or scared? FEAR CLE1X04

0 = Absent

2 = Present

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Were you worried that you weren't safe? WORRY CLE1X05

0 = Absent
Or that you might die?
2 = Present

Did you get angry? ANGER CLE1X06

0 = Absent

2 = Present

LY
Did you feel nothing at all? EMOTIONAL NUMBNESS CLE1X07
0 = Absent
Like you couldn't feel anything?
2 = Present

N
Were you grossed out or disgusted by what happened? DISGUST/REVULSION CLE1X08
0 = Absent

2 = Present

O
Did you feel out of control? OUT OF CONTROL CLE1X09
0 = Absent
That you might not be able to control your feelings?
2 = Present

Did you feel sad?

EW SAD CLE1X10
0 = Absent

2 = Present

Did you feel confused? CONFUSED CLE1X11

VI

0 = Absent
Like you couldn't understand what was happening?
Like it didn't make any sense? 2 = Present

Did you feel out of touch with yourself? DETACHED CLE1X12

RE

0 = Absent
Or cut off from yourself?
2 = Present
As if you were in a dream?
As if it wasn't happening to you?

Did you feel guilty? GUILTY CLE1X13

R

0 = Absent
Like it was your fault?
2 = Present

CLE1X14
FO

Did you feel like someone you trusted had tricked you? BETRAYED

0 = Absent

2 = Present

Did you feel embarrassed by what was happening? EMBARRASSED CLE1X15

0 = Absent
Or ashamed?
2 = Present

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EVER: ACUTE SOMATIC RESPONSES

Physical responses to the life event when it occurred. EVER: ACUTE SOMATIC RESPONSES CLE2I90
Intensity
0 = Absent
When "life event" occurred, did it affect you physically
at all? 2 = Present

What did you notice?

LY
Did you get dizzy or giddy or faint? DIZZINESS/FAINTNESS CLE2X01
0 = Absent

2 = Present

Did you get a dry mouth? DRY MOUTH CLE2X02

N
0 = Absent

2 = Present

O
Did it affect your breathing? How? CHOKING/SMOTHERING CLE2X03
0 = Absent

EW 2 = Present

DIFFICULTY BREATHING CLE2X04

0 = Absent

2 = Present

RAPID BREATHING CLE2X05

0 = Absent
VI

2 = Present

Did it affect your heart? PALPITATIONS CLE2X06

0 = Absent
RE

2 = Present

Did you get a pain in your chest? TIGHTNESS OR PAIN IN CHEST CLE2X07
0 = Absent

2 = Present
R

Did you get sweaty? SWEATING CLE2X08

0 = Absent
FO

2 = Present

Or feel sick? NAUSEA CLE2X09

0 = Absent

2 = Present

Did you have to go to the bathroom? URINATING FREQUENTLY CLE2X10

0 = Absent

2 = Present

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Did it affect your stomach? BUTTERFLIES IN THE STOMACH CLE2X11

0 = Absent

2 = Present

Did you get diarrhea? DIARRHEA CLE2X12

0 = Absent

2 = Present

LY
Did you get shaky? TREMBLING/SHAKING CLE2X13
0 = Absent

2 = Present

N
Did your muscles get sore? MUSCLE SORENESS CLE2X14
0 = Absent

2 = Present

O
Did you get flushed? FLUSHING CLE2X15
0 = Absent

2 = Present

Or pale?
EW PALLOR CLE2X16
0 = Absent

2 = Present

Did you have funny feelings in your fingers or toes? PARAESTHESIAE CLE2X17
VI

0 = Absent

2 = Present

Did you get a lump in your throat? LUMP IN THE THROAT CLE2X18
RE

0 = Absent

2 = Present

Did your abdomen churn? ABDOMINAL CHURNING CLE2X19

0 = Absent

2 = Present
R

EVER: INTERVENTION FANTASIES

FO

During the event, subject imagines doing something EVER: INTERVENTION FANTASIES CLE3X01
extraordinary to stop the event. Intensity
0 = Absent

During "life event", did you imagine or wish that you 2 = Present during event and realized.
could do something superhuman to get you or 3 = Present during event but unrealized.
someone else out of danger?

What did you imagine?

What happened?

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EVER: RESCUE FANTASIES DURING EVENT

During the event, subject imagines being rescued. EVER: RESCUE FANTASIES CLE3X02
Intensity
0 = Absent
During "life event" did you imagine or wish that
"person at risk" would be rescued? 2 = Present during event and realized.

3 = Present during event but unrealized.

What did you imagine?
What happened?

LY
EVER: REVENGE FANTASIES
During the event, subject imagines something that EVER: REVENGE FANTASIES CLE3X03
punishes the "cause" of the trauma. Intensity

N
0 = Absent

During "life event", did you imagine or wish that you 2 = Present during event and realized.
could get revenge or punish "the cause of the 3 = Present during event but unrealized.

O
trauma"?

Or that someone else or something would get revenge?

What did you imagine?
What happened?
EW
VI
RE
R
FO

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COGNITIVE INTRUSIONS
PAINFUL RECALL OF LIFE EVENT -B
Unwanted, painful and distressing recollections, memories, PAINFUL RECALL OF LIFE EVENT CYZAB02
thoughts, or images of life event. Intensity
0 = Absent

In the last 3 months have upsetting memories or 2 = Present

pictures in your mind of "life event" come back to you?

LY
EXTERNALLY CUED PAINFUL RECALL - PTS-B
Painful recall occurring in response to external cues or EXTERNALLY CUED PAINFUL RECALL CLE4I01
stimuli, such as particular sights, sounds, smells, or Intensity
0 = Externally cued painful recall absent.

N
situations.
2 = Painful recall is intrusive into at least
two activities and uncontrollable at least
ASK AVOIDANCE AND SUPRESSION QUESTIONS IF some of the time.

O
NO EXTERNALLY CUED PAINFUL RECALL PRESENT.
3 = Painful recall is intrusive into most
activities and nearly always uncontrollable.
Do any things or places remind you of "life event"?
CLE4F01
What about sounds or things you see? Frequency

When that happens does it bring back unpleasant

EW
memories of "life event"?
HOURS : MINUTES CLE4D01
Duration
VI

CLE4O01
Onset

/ /
RE
R
FO

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COGNITIVE INTRUSION - AVOIDANCE

Do you try to avoid any things or places that might AVOIDANCE CLE5I01
remind you of "life event"? Intensity
0 = Absent

Do you notice any physical effects when you remember 2 = Avoids situations that might provoke
"life event"? painful recall at least sometimes, but not to
a degree that prevents a normal lifestyle.
Like your heart racing? 3 = Avoidance leads to disruption of normal

LY
Or being short of breath? life and activities and results in a highly
Or feeling shaky or sick to your stomach? restricted lifestyle.
What do you notice?
ONSET: AVOIDANCE CLE5O01
Do you get panicky?
Do other people notice when you is remembering / /
event?

N
NORMAL SUPRESSION CLE6I01
What do they see?
0 = Absent
When you remember event, what do you do to feel

O
better? 2 = Uses normal thoughts or normal
activities in attempt to reduce painful recall.
Do you try to think about other things or do things you like
to do to take your mind off of it? OBSESSIONAL SUPPRESSION CLE6I02
Do you talk to someone and ask them for help? EW 0 = Absent

2 = Uses obsessional thoughts or

obsessional rituals in attempt to reduce
painful recall.

COMPULSIVE SUPPRESSION CLE6I03

0 = Absent
VI

2 = Uses compulsive behaviors in attempt

to reduce painful recall.

AUTONOMIC EFFECTS CLE7I01

0 = Absent
RE

2 = Notices autonomic changes in response

to painful recall, but these do not amount to
panic attacks.

3 = Panic attacks in response to painful

recall.

PAINFUL RECALL NOTICEABLE TO CLE7I02

R

OTHERS

0 = No
FO

2 = Child reports others notice changes

(anxiety, daydreaming, etc.).

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PAINFUL RECALL NOT EXTERNALLY CUED

Recollections not cued by external cues or stimuli. PAINFUL RECALL NOT EXTERNALLY CLE8I01
CUED Intensity
May be internally cued responses, occurring in response to 0 = Absent
emotional states, feelings, particular thoughts, autonomic
2 = Painful recall is intrusive into at least
symptoms, bodily sensations, or any other internal cue or two activities and uncontrollable at least
stimulus. If internal cues are a response to external some of the time.
stimulus, code as Externally Cued Recollections.

LY
3 = Painful recall is intrusive into most
activities and nearly always uncontrollable.
Recollections also may occur without apparent relationship
to either external or internal cues or stimuli. CLE8F01
Frequency
In the last three months have any feelings or emotions

N
reminded you of "life event"?
HOURS : MINUTES CLE8D01
Have any physical feelings or changes in your body Duration

O
reminded you of it?

When that happens, does it bring back unpleasant

memories of "life event"? CLE8O01
Onset
What are they like? EW
How often does that happen? / /
How long does it last?
NORMAL SUPRESSION CLE9I01
When that happens, do you try not to have those
"feelings", so you won't be reminded of "life event"? 0 = Absent

2 = Uses normal thoughts or normal

Do you do anything so as not to have those "feelings" activities in attempt to reduce painful recall.
VI

that remind you of "life event"?

OBSESSIONAL SUPPRESSION CLE9I02
Do you try not to think about "life event"? 0 = Absent
Do you do anything to stop yourself thinking about "life
event"? 2 = Uses obsessional thoughts or
RE

obsessional rituals in attempt to reduce

Can you stop thinking about it?
painful recall.
What do you do?
COMPULSIVE SUPPRESSION CLE9I03
Would other people notice when you are remembering
0 = Absent
"life event"?
2 = Uses compulsive behaviors in attempt
What would they see? to reduce painful recall.
R

When you "think about life event", do you notice any PAINFUL RECALL NOTICABLE TO CLF0I01
OTHERS
physical effects?
FO

0 = No
What do you notice?
Do you get panicky? 2 = Child reports others notice changes
(anxiety, daydreaming, etc.).

AUTONOMIC EFFECTS CLF0I02

0 = Absent

2 = Notices autonomic changes in response

to painful recall, but these do not amount to
panic attacks.

3 = Panic attacks in response to painful

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recall.

ACTIVE RECALL
Intentional recall of event. ACTIVE RECALL CLF1I01
Intensity
0 = Absent
Do you ever think about "life event" on purpose?
2 = Present

LY
Have you in the last three months? CLF1F01
When you do so, how do you feel? Frequency
Are the feelings painful for you?
Do you get worried?
Or sad?
Or angry? HOURS : MINUTES CLF1D01

N
Or feel guilty? Duration
Do you feel better able to cope with what happened?

O
CLF1O01
Onset

EW / /
WORRY CLF2I01
0 = Absent

2 = Present

SADNESS CLF2I02
0 = Absent
VI

2 = Present

ANGER CLF2I03
0 = Absent
RE

2 = Present

GUILT CLF2I04
0 = Absent

2 = Present
R

SENSE OF MASTERY CLF2I05

0 = Absent
FO

2 = Present

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FAILURES OF RECALL
Inability to recall important aspects of the "life event", such FAILURES OF RECALL CLF2I06
as the names and faces of participants, or parts of the Intensity
0 = No failure of recall.
chronology of the event.
1 = Some difficulty recalling certain aspects
of the event that can usually be overcome
Do not include deliberate attempts not to recall the event. by concentrated attempt to remember.

2 = At least some aspects of the event

Do you have difficulty remembering some things about

LY
cannot be recalled, even with effort.
"life event"?
3 = Most or all details of the event cannot
What things are hard to remember? be recalled.
Is that because you don't want to remember them, or that CLF2O01
you just can't? Onset

N
How much can you remember?
Are those memories real clear? / /
Has it happened in the last three months?

O
EW
VI
RE
R
FO

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RELIVING OF LIFE EVENT

Behaving or feeling as though the "life event" were RELIVING OF "LIFE EVENT" CLF3I01
recurring. The experience may involve a sense of reliving Intensity
0 = Absent
the event, illusory or hallucinatory phenomena, or
"flashbacks". Flashbacks involve hallucinatory phenomena 2 = Able to report sensory phenomena
of sufficient intensity to impair perception of the real world associated with "life event", but still aware
of real surroundings to at least some extent.
to a substantial degree.
3 = No, or almost no, awareness of real

LY
surroundings (flashback).
Include panic attacks where the mental content of the panic
episode is related to the "life event". CLF3F01
Frequency
Include such phenomena even if they occurred at times of
intoxication with alcohol or drugs or during sleep cycle.

N
HOURS : MINUTES CLF3D01
CODE NIGHTMARES IN ITEMS THAT FOLLOW. Duration

O
In the last 3 months, have you felt as though the "life
event" was happening to you again, even when it CLF3O01
wasn't? Onset

What was that like? / /

What did you do?
How long did it last?
EW ASSOCIATED PANIC CLF3I02
How often did it happen? 0 = No associated panic attacks.
How real did it seem?
Did you feel as though you were really there, and that it 2 = With panic attacks.
was really happening again?
HYPNOGOGIC (ON FALLING ASLEEP) CLF3I03
When it was happening were you aware of what was really
VI

going on around you and where you really were? 0 = Absent

Did the memory of "life event" seem more real than your
2 = Present
actual surroundings?
Did this happen when you were falling asleep? HYPNOPOMPIC (ON WAKING) CLF3I04
Or waking up?
RE

0 = Absent
Do you ever wake up in the middle of the night feeling this
way? 2 = Present

NOCTURNAL CLF3I05
0 = Absent

2 = Present
R

DAYLIGHT (WHEN UP AND ABOUT) CLF3I06

0 = Absent
FO

2 = Present

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NIGHTMARES
Frightening dreams that waken subject, with content NIGHTMARES CLF4I01
related to the "life event" (either about "life event" or Intensity
0 = Absent
reminding subject of it). Unpleasant affect apparent when
wakening, which may be followed rapidly by feelings of 2 = Present
relief.
CLF4O01
Onset
In the last 3 months, have you had any nightmares or
/ /

LY
bad dreams about "life event"?

Or nightmares or bad dreams that aren't about it but AUTONOMIC EFFECTS CLF4I02
remind you of it? 0 = Absent

Tell me about them.

N
2 = Notices autonomic changes in response
Do they wake you up? to nightmares.

3 = Has panic attack in response to

How often do they happen? nightmares.

O
When you wake up, do you notice any physical effects?
When you wake up are you panicky? REASSURANCE CLF4I03
Is it hard for you to get back to sleep afterwards? 0 = Absent
What do you do?
Does fear of these dreams make it hard for you to get to 2 = Upon waking from nightmare, seeks
sleep?
Do you have trouble sleeping alone?
EW time limited reassurance or contact.

3 = Upon waking, seeks extended

reassurance or contact (e.g. won't go back
to bed, conflict arises over need for
reassurance).

ANTICIPATORY REASSURANCE CLF4I04

VI

0 = Absent

2 = At bedtime, seeks time limited

reassurance or contact (e.g. extended
bedtime ritual).
RE

3 = Seeks extended reassurance or contact

(e.g. won't go to bed, conflict arises over
need for reassurance).
R
FO

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HYPERAROUSAL
NON-RESTORATIVE SLEEP
Disturbance of usual sleep pattern since "life event" so that NON-RESTORATIVE SLEEP CLF5I01
subject does not feel rested upon waking and feels tired Intensity
0 = Absent
during the day. Do not include insomnia; sleep is normal
but subject feels sleepy during the day. 2 = Present but does not interfere with
functioning.

LY
DO NOT INCLUDE INSOMNIA 3 = Present and interfered with functioning.

CLF5O01
Have you been having problems sleeping well in the Onset
last three months?
/ /
Do you feel rested when you wake up in the morning?

N
CLF5F01
Has that changed since "life event"? Frequency
Do you feel tired during the day from not sleeping well?

O
Does this make it harder for you to do work?
How much of the time do you feel this way?
AROUSAL CLF5I02
Is it worse when you have been thinking about "life event"?
0 = Absent
EW 2 = Symptom present 0-25% of the time.

3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLF5I03

VI

0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
RE
R
FO

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INATTENTION
Difficulty maintaining sufficient involvement to allow INATTENTION CLF6I01
completion of age-appropriate and developmentally Intensity
0 = Inattention absent in interesting
appropriate tasks requiring concentration. activities.

2 = At least sometimes uncontrollable by

In the last three months, have you had more trouble the child or by admonition, present in at
paying attention than before "life event"? least 2 interesting activities in any situation.

LY
Is it more difficult for you to concentrate? 3 = Nearly always uncontrollable by the
child or by admonition, present in most
interesting activities.
Do you have trouble remembering things?
Has this caused you any problems? CLF6O01
How much of the time do you feel this way? Onset
Is it worse when you have been thinking about "life event"?

N
/ /
AROUSAL CLF6I02

O
0 = Absent

2 = Symptom present 0-25% of the time.

EW 3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLF6I03

0 = Absent

2 = Symptom occurs or increases in

VI

response to cues prompting recall or

reliving of the "life event".
RE
R
FO

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ANGER
Increased ease of precipitation of externally directed ANGER CLF7I01
feelings of anger, bad temper, short temper, resentment, or Intensity
0 = Absent
annoyance.
2 = Present but does not interfere with
fuctioning or relationships.
Since "life event" have things "gotten on your nerves"
more easily? 3 = Present and interfered with functioning
or relationships.

LY
What kinds of things?
CLF7O01
Is that more than usual? Onset
Or have you been more irritable?
/ /
Has this affected how you get along with people?
How so? CLF7I02

N
AROUSAL
How much of the time do you feel this way?
0 = Absent
Is it worse when you have been thinking about "life event"?
2 = Symptom present 0-25% of the time.

O
3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

EW PHASIC EXACERBATION CLF7I03
0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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ANGER DYSCONTROL
Since "life event", increased outbursts of anger have ANGER DYSCONTROL CLF8I01
resulted from inability to control expression of anger as well Intensity
0 = Absent
as you used to.
2 = Present but does not interfere with
fuctioning or relationships.
In the last three months, have you gotten angry very
often? 3 = Present and interfered with functioning
or relationships.

LY
More than before "life event"?
CLF8O01
What has happened? Onset
When you get angry, can you control your anger as
much as you used to? / /
What do you do now? CLF8I02

N
AROUSAL
Has it affected how you get along with other people?
0 = Absent
How so?
How much of the time do you feel this way? 2 = Symptom present 0-25% of the time.

O
Is it worse when you have been thinking about "life event"?
3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

EW PHASIC EXACERBATION CLF8I03
0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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HYPERVIGILANCE
Increased general level of awareness and alertness HYPERVIGILANCE CLF9I01
towards surroundings in the absence of imminent danger. Intensity
0 = Absent

In the last 3 months, have you been more "on the alert" 1 = Subjective hypervigilance not
manifested in any overt behavioral change.
for bad things happening than before "life event"?
2 = Behavioral manifestations of
What do you do? hypervigilance (e.g. taking care over

LY
Are you like that even when there isn't much chance of seating or scanning environment for
danger) but they do not limit activities to
anything bad happening? any major extent.
How much has that affected your life?
How much of the time are you like that? 3 = Behavioral manifestations of
hypervigilance that preclude the
Have you given up doing any things because you don't performance of many or most normal

N
want to take any chances? activities.
Is it worse when you have been thinking about "life event"?
CLF9O01
Onset

O
/ /
AROUSAL CLF9I02
0 = Absent
EW 2 = Symptom present 0-25% of the time.

3 = Symptom present 26-50% of the time.

4 = Symptom present 51-75% of the time.

5 = Symptom present 76-100% of the time.

VI

PHASIC EXACERBATION CLF9I03

0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
RE

reliving of the "life event".

R
FO

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EXAGGERATED STARTLE RESPONSE

Increase in susceptibility to being startled by minor EXAGGERATED STARTLE RESPONSE CLG0I01
unexpected stimuli since "life event". Intensity
0 = Absent

INTERVIEWER SHOULD DEMONSTRATE STARTLE 2 = Present, but not noticeable to others.

RESPONSE. 3 = Present, noticeable to others.

CLG0O01
In the last 3 months have you startled more easily than

LY
Onset
before "life event"?
/ /
Or have you been more jumpy than usual?
AROUSAL CLG0I02
Do unexpected noises make you jump more easily than

N
they used to? 0 = Absent
What is it like when that happens? 2 = Symptom present 0-25% of the time.
How often does it happen?
How long do you stay "jumpy" afterwards? 3 = Symptom present 26-50% of the time.

O
How much of the time do you feel this way? 4 = Symptom present 51-75% of the time.
Is it worse when you have been thinking about "life event"?
5 = Symptom present 76-100% of the time.

PHASIC EXACERBATION CLG0I03

EW 0 = Absent

2 = Symptom occurs or increases in

response to cues prompting recall or
reliving of the "life event".
VI
RE
R
FO

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NUMBING
DETACHMENT
A generalized subjective sense of being emotionally cut off DETACHMENT CLG1I01
from other people that has appeared since the occurrence Intensity
0 = Absent
of a "life event".
2 = Feels that it is more difficult to relate
emotionally to people than before "life
Since "life event" have you felt cut off from other event", but has not reduced social contacts.

LY
people?
3 = Has reduced social contacts because of
Have you been less interested in seeing your friends? difficulty relating emotionally to people.

CLG1O01
Have you actually seen less of your friends? Onset
Can you tell me why?
/ /

N
Would you like to see more of them?
Or have you "gone off" them?

O
LOSS OF AFFECT - POSITIVE
Complaint of loss of a previously existing ability to feel or LOSS OF POSITIVE AFFECT CLG2I01
experience emotion. Code loss of positive and negative Intensity
0 = Absent
affect separately.
EW 2 = Loss of affect in at least 2 activities and
uncontrollable at least some of the time.
Since "life event" has it seemed as though you have
lost some of your feelings? 3 = Affect is felt to be lost in almost all
activities.
Do you have any feelings left?
CLG2O01
Can you feel happy or good feelings? Onset
VI

/ /

LOSS OF AFFECT - NEGATIVE

RE

Complaint of loss of a previously existing ability to feel or LOSS OF NEGATIVE AFFECT CLG3I01
experience emotion. Code loss of positive and negative Intensity
0 = Absent
affect separately.
2 = Loss of affect in at least 2 activities and
uncontrollable at least some of the time.
What about unhappy or negative feelings?
3 = Affect is felt to be lost in almost all
R

activities.

CLG3O01
Onset
FO

/ /

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LOSS OF EMOTIONAL EXPRESSION -

POSITIVE
Since life event, unable or unwilling to express emotions to LOSS OF POSITIVE EMOTIONAL CLG4I01
the degree existing before the life event. EXPRESSION Intensity
0 = Absent
Do not include inexpressiveness that predated the life
2 = Less able or willing to talk about or
event unless there has clearly been an exacerbation show emotions, or to discuss topics with
following the life event. emotional content or which stimulate

LY
emotions.
Is it harder for you to show happy or good feelings? 3 = Almost always unable or unwilling to
talk about or show emotions or to discuss
topics with emotional content or which
stimulate emotions.

N
CLG4O01
Onset

/ /

O
LOSS OF EMOTIONAL EXPRESSION -
NEGATIVE EW
Since life event, unable or unwilling to express emotions to LOSS OF NEGATIVE EMOTIONAL CLG5I01
the degree existing before the life event. EXPRESSION Intensity
0 = Absent
Do not include inexpressiveness that predated the life
2 = Less able or willing to talk about or
event unless there has clearly been an exacerbation show emotions, or to discuss topics with
following the life event. emotional content or which stimulate
emotions.
VI

What about unhappy for bad feelings? 3 = Almost always unable or unwilling to
talk about or show emotions or to discuss
topics with emotional content or which
stimulate emotions.
RE

CLG5O01
Onset

/ /
R
FO

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OTHER BEHAVIORS
PLAY RECAPITULATING LIFE EVENT
Activity that recapitulates all or some aspects of "life event" PLAY RECAPITULATING "LIFE EVENT" CLG6I01
(e.g. preoccupation with crashing toy cars after being in a Intensity
0 = Absent
car accident).
2 = Present to an extent greater than before
the event.
Has the way you play changed at all since "life event"?

LY
3 = Actions recapitulating life event has
In what way? become the most frequent or dominant
In the last three months have you played games that subject of play.
are like "life event"? CLG6O01
Onset
Or acted out what happened?
/ /

N
What do you do?

O
DANGEROUS ACTIVITIES
Activities that physically endanger the subject or others. EVER: DANGEROUS ACTIVITIES CLG7I01
Intensity
EW 0 = No
Since "life event", have you taken chances and done
risky things? 2 = Yes

CLG7O01
Or dangerous things? Onset
What have you done in the last 3 months? / /
Is this more than before "life event"?
VI

INCREASED ATTENTION TO RELIGION

Increased interest in or observance of religious ideas and INCREASED ATTENTION TO RELIGION CLG8I01
practices since life event. Intensity
RE

0 = Absent

Have you become more religious since "life event"? 1 = Subjective report of greater interest in,
or mental attention to, religious matters.
Include increased level of reading religious
Do you think more about God? works here.

Or the Devil? 2 = Increase in level of religious

observances, including normal prayer.
R

Do you go to "church" more often? 3 = Increase in religious observances

Do you read "scripture" more often? including obsessional rituals and
Or pray more often? compulsive behaviours.
FO

CLG8O01
Onset

/ /

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DECREASED ATTENTION TO RELIGION

Decreased interest in or observance of religious ideas and DECREASED ATTENTION TO RELIGION CLG9I01
practices since life event. Intensity
0 = Absent

Do you have less interest in religion since "life event"? 2 = Subjective report of decreased interest
in, or mental attention to, religious matters.
Include decreased level of reading religious
Do you care less about God? works here.
Or the Devil?

LY
Do you go to "church" less frequently? 3 = Decrease in level of religious
observances, including prayer.
Do you read "scripture" less?
Or pray less? CLG9O01
Onset

/ /

N
OMEN FORMATION

O
Following the life event, child has developed superstitious OMEN FORMATION CLH0I01
beliefs or practices to mitigate or prevent recurrences of the Intensity
0 = Not present.
event or other possible or imagined life events.
EW 1 = Superstitious beliefs not resulting in any
overt behavior.
Are you superstitious about things?
2 = Superstitious beliefs that have resulted
Are there signs that mean bad things will happen? in overt behavior (e.g. carrying charms or
rabbits feet).
Or signs that make you think that you'll be OK? 3 = Activities meeting criteria for
obsessional rituals or compulsive
What are they? behaviors.
VI

Do you think that these signs are really true?

Did you believe in them before "life event" or are they new? CLH0O01
Onset

/ /
RE
R
FO

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SURVIVOR GUILT
A subjective belief or feeling of responsibility for the life SURVIVOR GUILT CLH1I01
event or its prevention, or a feeling that the subject should Intensity
0 = Absent
have substituted (or been substituted) for another who was
more severely affected. 2 = Present

CLH1O01
Do you feel guilty about what happened during "life Onset
event"?
/ /

LY
Do you ever feel it was your fault, even though it
wasn't?

Do you sometimes feel that you should have prevented "life

event" even though you couldn't?

N
Do you ever wish that you and not "specific other person"
should have "specific other person's" fate?
Do you ever feel bad about what you did during "life

O
event"?
IF THE CHILD FEELS GUILTY OR RESPONSIBLE,
PROVIDE REASSURANCE AND COMFORT.

REVENGE FANTASIES AFTER EVENT

EW
In the last 3 months subject imagined doing something to REVENGE FANTASIES CLH2I01
punish the "cause" of the trauma. Intensity
0 = Absent

Do you still wish that you could get revenge or punish 2 = Present
"the cause of the trauma"? CLH2O01
VI

Onset
Or that something would happen to get back at "the
cause"? / /
What do you wish would happen?
RE
R
FO

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CHANGED EXPECTATION OF LONG-TERM

FUTURE
Marked change in the subject's expectations of the future, CHANGED EXPECTATIONS OF LONG- CLH3I01
involving the expectation that some or all adult roles will TERM FUTURE Intensity
NOT be attained. Code regardless of justification, except in 0 = Absent
the case of subjects with a current life-threatening illness.
2 = Expects to reach adulthood, but
predicts poor attainment of adult roles (e.g.
Has "life event" changed what you think the future will does not expect to get married, get a job, or

LY
be like? have children); or expects to reach
adulthood but is not certain about it.
In what way? 3 = Does not expect to survive to
Has it changed what you think about getting married? adulthood.

Or having children? CLH3O01

N
Onset
In what way?
How long do you expect to live? / /

O
Has that changed?

EW
VI
RE
R
FO

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PSYCHOSIS
PERCEPTUAL DISORDERS AND
HALLUCINATIONS

DO NOT CODE SYMPTOMS INDUCED SOLELY

BY USE OF DRUGS OR ALCOHOL

Now I'm going to ask you some questions

LY
about unusual things that we ask everyone with
whom we do this interview.

DEREALIZATION
The subject experiences his/her surroundings as unreal. A DEREALIZATION CJA0I01

N
classroom or a bus or a street seems like a stage set with Intensity
0 = Absent
actors, rather than real people going about their ordinary
business. Everything may seem colorless, artificial, or 2 = The subject simply experiences a lack

O
dead. of color and life, so that any tendency
towards the artificial tends to be
exaggerated.
Have you felt that things around you didn't seem real?
3 = The subject feels as though the world is
made of plastic, as though it is not really
Or it was like a stage set with people acting like robots
instead of being themselves?
EW there at all.

CJA0F01
What was it like? Frequency
Did you really believe that the world wasn't real?
How do you explain it?
Has that happened in the last 3 months?
HOURS : MINUTES CJA0D01
How often? Duration
VI

When did you first notice it?

CJA0O01
Onset
RE

/ /
R
FO

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DEPERSONALIZATION
The subject feels as if s/he him/herself is unreal, that s/he DEPERSONALIZATION CJA1I01
is acting a part rather than being spontaneous and natural, Intensity
0 = Absent
that s/he is a sham, a shadow of a real person. S/he feels
detached from his/her experiences. 2 = The subject feels as if s/he himself is
unreal.

Derealization is often present at the same time and should 3 = The subject feels as if s/he is actually
be rated independently. dead.

LY
CJA1F01
Have you ever felt as if you weren't real? Frequency

What was it like?

Did you feel as if you were acting your life rather than being
CJA1D01

N
natural? HOURS : MINUTES
Have you felt that you were outside looking at yourself Duration
from outside your body?

O
Have you ever felt that you were not a person, not in the CJA1O01
living world? Onset
Or that you looked unreal in the mirror?
Or that some part of your body did not belong to you?
EW / /
Did you feel as if you were actually dead?
Did you really believe that you weren't real?
VI
RE
R
FO

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CHANGED PERCEPTION - TIME AND

HALLUCINATIONS
Include here any changes in perception such as PRESENT 2 CAJ2I01
heightened and dull perception. The subject may complain Intensity
0 = Absent
that objects change in shape or size or color or that people
change their appearance. 2 = Present

CJA2F01
CHANGED PERCEPTION OF TIME Frequency

LY
The subject's perception of time seems to change, so that
events appear to move very slowly or very rapidly or to
HOURS : MINUTES CJA2D01
change their tempo or to be completely timeless. Time may Duration
appear to stop altogether.

N
HALLUCINATIONS
CJA2O01
Onset

O
Hallucinations are false perceptions occuring in clear
consciousness. The subject may see images, visions, or / /
hear voices in the absence of any real stimulus to the
perception. EW
**************PHENOMENA NOT TO BE CODED AS
PERCEPTUAL DISORDERS****************

Illusions (false perceptions stimulated by real perceptions

that are then momentarily transformed)
VI

Hypnogogic Hallucinations (occurring only on falling

asleep)

Hypnopompic Hallucinations (occurring only on awakening)

RE

Eidetic Imagery (voluntary production of vivid images,

never confuses with reality)

Elaborated Fantasies

Imaginary Companions
R

Hallucinations occuring only as part of a seizure or in

clouded consciousness.
FO

Spots, stripes before the eyes

Sensory changes associated with headaches

Non-specific verbal hallucinations ( a voice but not

recognizable words except name being called)

Alcohol or drug induced symptoms

Psychosis (Long Form) 3

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Have there been any changes in the way things look or

sound?

Sometimes people hear things or see things when

there's no one and nothing to explain it. Has that
happened to you?

Do you ever get the feeling that something odd is

going on that you can't explain?

LY
Do you ever hear things that other people can't hear?

Or see things that other people can't see?

Do you ever notice smells or tastes that other people

N
don't?

O
EW
VI
RE
R
FO

Psychosis (Long Form) 4

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DISORDERS OF PERCEPTION, THOUGHT, AND

THE CONTENT OF THOUGHT

DO NOT INCLUDE SYMPTOMS INDUCED BY

USE OF DRUGS OR ALCOHOL.

"PSYCHOTIC" ABNORMALITIES OF THOUGHT

AND SPEECH

LY
Subjects thinking or language has become disordered. PSYCHOTIC ABNORMALITIES OF CJA3I01
Sentences may be hard to follow or completely THOUGHT AND SPEECH Intensity
nonsensical. Ideas may be linked together in unusual ways 0 = Absent
(such as because of rhymes or puns, as in flight of ideas)
or may have no ordinarily comprehensible links (as in 2 = Present

N
"knight's move" thinking). CJA3O01
Onset
Distinguish from delusional content or speech; it is quite
/ /

O
possible for a child's ideas to be entirely delusional but for
the process of thinking and expressing thoughts to be quite
normal.

Differentiate from developmental disorders of speech and

EW
language (such as language delay and dysarthria) where
speech may be difficult to follow. These disorders will
usually always have been present and will not represent a
change in the child's language.

Is there anything unusual happening to your thoughts?

VI

Is there any interference with your thoughts?

What happens?
Is there anything like hypnotism or telepathy affecting
RE

you?
R
FO

Psychosis (Long Form) 5

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DELUSIONS AND DELUSIONAL

INTERPRETATIONS
A delusion is a firmly-held false belief that is out of keeping DELUSIONS AND DELUSIONAL CJA4I01
with the subject's social and cultural background. INTERPRETATION Intensity
0 = Absent
A delusional interpretation also has these characteristics,
2 = Present
but is an explanation of some other experience (often of
other "psychotic" experiences, such as hallucinations) e.g., CJA4O01

LY
a subject might interpret hearing voices talking about him Onset
as evidence of a police conspiracy. The conspiracy would
be a delusional interpretation. / /

IF THERE IS EVIDENCE OF DELUSIONS OR

N
DELUSIONAL INTERPRETATION, OBTAIN AS FULL AN
ACCOUNT OF THE PHENOMENA AS THE PARENT IS
ABLE TO PROVIDE.

O
WRITE THE DETAILS DOWN VERBATIM.

Do you know any things to be true that other people

don't believe?

Is there anything strange or unusual happening to

EW
you?

Is anyone out to get you?

Is anyone (or anything) trying to control your body or your

VI

mind?

IF ANY EVIDENCE OF DELUSIONS AND

RE

DELUSIONAL INTERPRETATIONS OR
SENSORY CHANGES AND
HALLUCINATIONS, THEN OBTAIN AS
FULL AN ACCOUNT OF THE
PHENOMENA AS THE PARENT IS
R

ABLE TO PROVIDE, AND COMPLETE

"TEMPORAL CO-OCCURRENCE" AND
"THEMATIC CONSISTENCY".
FO

IF THERE IS NO EVIDENCE, SKIP TO

"ANY MEDICATION TAKEN CONTINUE.
OTHERWISE", (PAGE ERROR!
BOOKMARK NOT DEFINED.).

Psychosis (Long Form) 6

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PERCEPTUAL DISORDERS AND

HALLUCINATIONS SCREEN
PERCEPTUAL DISORDERS SCREEN CJA2I01
POSITIVE Intensity
0 = No

2 = Yes

LY
PSYCHOTIC ABNORMALITIES IN THOUGHT
PROCESSES
PSYCHOTIC ABNORMALITIES IN CJA3I01
THOUGHT SCREEN POSITIVE Intensity

N
0 = No

2 = Yes

O
DELUSIONS
DELUSIONS SCREEN POSITIVE CJA4I01
Intensity
0 = No
EW 2 = Yes
VI
RE
R
FO

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CHANGES IN PERCEPTION

ALWAYS WRITE DOWN AN EXAMPLE OF ANY

SYMPTOM ELICITED

DEJA VU/DEJA VECU

The subject has the feeling that s/he has seen or DEJA VU/DEJA VECU CJB0I01
experienced and lived through the current situation before. Intensity

LY
0 = Absent
The subject knows this feeling to be inaccurate.
2 = Present

CJB0F01
Frequency

N
HOURS : MINUTES CJB0D01
Duration

O
CJB0O01
Onset
EW / /

JAMAIS VU/JAMAIS VECU

The subject feels that a familiar situation is unfamilar, but JAMAIS VU/JAMAIS VECU CJB1I01
knows this feeling to be inaccurate. Intensity
VI

0 = Absent

2 = Present

CJB1F01
Frequency
RE

HOURS : MINUTES CJB1D01

Duration
R

CJB1O01
Onset

/ /
FO

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CHANGED PERCEPTION
Include here any changes in perception such as CHANGED PERCEPTION CJB2I99
heightened or dulled perception. The subject may complain Intensity
0 = Absent
that objects change in shape or size or color or that people
change their appearances. 2 = The symptom has quite clearly and
definitely been present during the past 3
months, even if briefly.

HEIGHTENED PERCEPTION CJB2I01

LY
0 = Absent

2 = The symptom has quite clearly and

definitely been present during the past 3
months, even if briefly.

N
DULLED PERCEPTION CJB2I02
0 = Absent

O
2 = The symptom has quite clearly and
definitely been present during the past 3
months, even if briefly.

OTHER CHANGED PERCEPTION CJB2I03

0 = Absent
EW 2 = The symptom has quite clearly and
definitely been present during the past 3
months, even if briefly.

CJB2F01
Frequency
VI

HOURS : MINUTES CJB2D01

Duration
RE

CJB2O01
Onset

/ /
R
FO

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CHANGED PERCEPTION OF TIME

The subject's perception of time seems to change, so that CHANGED PERCEPTION OF TIME CJB3I01
events appear to move very slowly or very rapidly or to Intensity
0 = Absent
change their tempo or to be completely timeless. Time may
appear to stop altogether. 2 = The symptom has quite clearly and
definitely been present during the past 3
months, even if briefly.

CJB3F01

LY
Frequency

HOURS : MINUTES CJB3D01

Duration

N
CJB3O01

O
Onset

/ /

DELUSIONAL MOOD
EW
The subject that his/her familiar environment has changed DELUSIONAL MOOD CJB4I01
in a way that puzzles him/her and which s/he may not be Intensity
0 = Absent
able to describe clearly. The feeling often accompanies
delusion formation. 2 = The subject definitely describes
symptom, but no delusions have actually
been formulated, though the subject may
VI

feel various delusional explanations are

possible.

3 = Delusional crystallization has been

present during the past 3 months.
RE

HOURS : MINUTES CJB4D01

Duration

CJB4O01
Onset
R

/ /
FO

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HALLUCINATIONS

LY
N
O
EW
VI
RE
R
FO

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AUDITORY HALLUCINATIONS

ALWAYS WRITE DOWN EXAMPLES OF EACH

SYMPTOM ELICITED

NON-VERBAL HALLUCINATIONS AND NON-

SPECIFIC VERBAL HALLUCINATIONS
This symptom includes noises, other than words, that have NON-VERBAL HALLUCINATIONS AND CJB5I01

LY
no real origin in the world outside the subject but also have NON-SPECIFIC VERBAL Intensity
HALLUCINATIONS
no explicable origin in bodily processes, and which the
subject regards as separate from his/her own mental 0 = Absent
processes. Exclude any auditory hallucinations taking the
2 = Subject hears noises such as music,
form of recognized words. tapping, central heating noises, etc., or the

N
subject hears whispering, muttering, or
mumbling but cannot make out the words.

3 = The subject hears a voice, but not

O
recognizable words other than his/her name
being called.

HALLUCINATIONS SPECIFICALLY EW
ASSOCIATED WITH BEREAVEMENT
The subject has recently (within the past 1 year) been HALLUCINATIONS SPECIFICALLY CJB6I01
bereaved and hears only the dead friend or relative. These ASSOCIATED WITH BEREAVEMENT Intensity
hallucinations are often brief and may be comforting. The 0 = No
hallucinations must be confined to the voice or other
sounds (e.g. footsteps) of the dead person, and they must 2 = Yes
have arisen following the death of that person in the last 12 CJB6F01
VI

months. Frequency

HOURS : MINUTES CJB6D01

RE

Duration

CJB6O01
Onset

/ /
R
FO

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VERBAL HALLUCINATIONS SPOKEN ABOUT

THE SUBJECT
This symptom includes only a voice or voices heard by the VERBAL HALLUCINATIONS SPOKEN CJB7I01
subject speaking about him/her, and therefore referring to ABOUT THE SUBJECT Intensity
him/her in the third person. Consciousness is clear. 0 = Absent

2 = Voice commenting on his/her thoughts

or actions, and thus speaking about him/her
in the third person.

LY
3 = Voices talking to each other about
him/her in the third person.

CJB7F01
Frequency

N
HOURS : MINUTES CJB7D01

O
CJB7O01
EW Onset

/ /

VERBAL HALLUCINATIONS SPOKEN TO THE

SUBJECT
This symptom includes only a voice or voices heard by the VERBAL HALLUCINATIONS SPOKEN TO CJB8I01
Intensity
VI

subject speaking directly to him/her. Consciousness is THE SUBJECT

clear. 0 = Absent

2 = Tone and content are pleasant,

supportive or neutral.
RE

3 = Tone and content are hostile or

threatening or accusatory.

CJB8F01
Frequency
R

HOURS : MINUTES CJB8D01

FO

CJB8O01
Onset

/ /

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LOCATION OF AUDITORY HALLUCINATIONS

EXPERIENCES
TRUE AUDITORY HALLUCINATIONS
Experience as occurring in the outside world. TRUE AUDITORY HALLUCINATIONS CJB9I01
Intensity
0 = Absent

2 = Present

LY
AUDITORY PSEUDOHALLUCINATIONS
Experienced as occurring in the subject's head or mind, but AUDITORY HALLUCINATIONS CJB9I02
still has the other qualities of a perception. Intensity
0 = Absent

N
(Both may be present) 2 = Present

O
EW
VI
RE
R
FO

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VISUAL HALLUCINATIONS

ALWAYS WRITE DOWN AN EXAMPLE OF ANY

SYMPTOM ELICITED

VISUAL HALLUCINATIONS IN CLEAR

CONSCIOUSNESS
Consciousness is clear. The vision may appear to be in the VISUAL HALLUCINATIONS IN CLEAR CJC0I01

LY
external world (true hallucinations) or within the subject's CONSCIOUSNESS Intensity
own mind (pseudohallucinations). 0 = Absent

2 = Subject simply sees formless image,

shadows or colored lights.

N
3 = Subject sees objects, people, images
that other people cannot see.

O
VISUAL HALLUCINATIONS SPECIFICALLY
ASSOCIATED WITH BEREAVEMENT
The subject has recently (within the past 1 year) been HALLUCINATIONS SPECIFICALLY CJC0I01
bereaved and sees only the dead friend or relative. These ASSOCIATED WITH BEREAVEMENT Intensity
EW
hallucinations are often brief and may be comforting. The
hallucinations must be confined to sight of the dead person,
0 = Absent

and they must have arisen following the death of that 2 = Present
person during the last 12 months. CJC1F01
Frequency
VI

HOURS : MINUTES CJC1D01

RE

CJC1O01
Onset

/ /
R
FO

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LOCATION OF VISUAL HALLUCINATORY

EXPERIENCES
TRUE VISUAL HALLUCINATIONS
Experienced as occurring in the outside world in clear TRUE VISUAL HALLUCINATIONS CJC2I01
consciousness. Intensity
0 = Absent

2 = Present

LY
VISUAL PSEUDOHALLUCINATIONS
Experienced as occurring inside the subject's head or mind VISUAL PSEUDOHALLUCINATIONS CJC2I02
but still has the other qualities of a perception. In clear Intensity
0 = Absent
consciousness.

N
2 = Present

O
HALLUCINATIONS OCCURRING ONLY AS
PART OF A SEIZURE
The subject may have almost any variety of visual HALLUCINATIONS OCCURING ONLY AS CJC3I01
experience from complete scenes witnessed as on a stage
EW PART OF A SEIZURE Intensity
or flashes of light. Small animals are not particularly 0 = Absent
characteristic. The hallucinations must be confined to the
period during or immediately after an epileptic fit. 2 = Subject simply sees formless images,
shadows or colored light.

3 = Subject seens objects, people, images

that other people cannot see.

CJC3O01
VI

Onset

/ /
RE

HALLUCINATIONS OCCURRING ONLY IN A

CLOUDED SENSORIUM
The hallucinations are strictly confined to a period of high HALLUCINATIONS OCCURRING ONLY CJC4I01
fever or illness or post-traumatic confusion when the IN A CLOUDED SENSORIUM Intensity
subject has clouding of consciousness. 0 = Absent

2 = Subject simply sees formless images,

R

shadows or colored lights.

3 = Subject sees objects, people, images

that other people cannot see.
FO

CJC4O01
Onset

/ /

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OTHER HALLUCINATIONS

WRITE DOWN AN EXAMPLE OF ANY

SYMPTOM ELICITED

OLFACTORY HALLUCINATIONS AND

DELUSIONS
The subject has a hallucination that involves smelling OLFACTORY HALLUCINATIONS AND CJC5I01

LY
something that other people cannot smell. Be sure that DELUSIONS Intensity
there is no more obvious cause such as sinusitis, or a 0 = Absent
misinterpretation of a smell that really is present.
2 = Simple olfactory hallucinations, such as
a smell of orange peel or perfume, or a
smell of "death" or burning that other people

N
cannot smell.

3 = The experience is delusionally

elaborated, e.g. the subject not only smells

O
gas but thinks that gas is deliberately being
let into the room.

CJC5F01
EW Frequency

HOURS : MINUTES CJC5D01

CJC5O01
Onset
VI

/ /
RE
R
FO

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DELUSION THAT SUBJECT SMELLS

Subject believes s/he gives off a smell (that others can DELUSION THAT SUBJECT SMELLS CJC6I01
smell). Intensity
0 = Abstract

Do not include simple preoccupation with body odor, e.g., 2 = Subject is uncertain, or simply thinks it
possible.
in an anxious subject who sweats a lot.
3 = Subject is certain that s/he gives off a
smell and that others notice it and react

LY
accordingly.

CJC6F01
Frequency

N
HOURS : MINUTES CJC6D01
Duration

O
CJC6O01
Onset

/ /
EW
OTHER HALLUCINATIONS INCLUDING
TACTILE HALLUCINATIONS AND DELUSIONAL
ELABORATIONS
Refers to hallucinations that are other than auditory, visual, OTHER HALLUCINATIONS CJC7I01
VI

or olfactory - e.g. food tastes burnt or acidy, something Intensity

0 = Absent
seems to touch subjects, ants seem to crawl over skin.
2 = The subject does not delusionally
elaborate.
Exclude other obvious explanations for the experience.
RE

3 = There is delusional elaboration.

CJC7F01
Frequency

HOURS : MINUTES CJC7D01

Duration
R
FO

CJC7O01
Onset

/ /

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THOUGHT INTRUSION/INSERTION
The essence of the symptom is that the subject THOUGHT INTRUSION/INSERTION CJC8I01
experiences thoughts that are not his/her own, intruding Intensity
0 = Absent
into his/her mind. The symptom is not that s/he has been
caused to have unusual thoughts but that the thoughts 2 = In very rare instances, the subject may
themselves are not his/hers. postulate that they came from his/her own
unconscious mind - while still consciously
experiencing them as alien.

LY
3 = In the most typical case, the alien
thoughts are said to have been inserted into
the mind from outside, by means of radar or
telepathy or some other means.

N
THOUGHT BROADCAST OR THOUGHT
SHARING
Thought broadcating is only rated when the subject actually THOUGHT BROADCAST OR THOUGHT CJC9I01
Intensity

O
experiences his/her thoughts being shared by others. SHARING

0 = Absent
If thoughts are repeated, rate as "Thought Echo".
2 = Subject says that his/her own thoughts
seem to sound "aloud" in his/her head,
almost as though someone standing nearby
EW could hear them.

3 = Subject experiences his/her thoughts

actually being shared with others.

THOUGHT ECHO OR COMMENTARY

VI

The subject experiences his/her own thoughts as being THOUGHT ECHO OR COMMENTARY CJD0I01
repeated or echoed (not just spoken aloud) with very little Intensity
0 = Absent
interval between the original and the echo.
2 = Repetition may not be a simple echo,
however, but subtly or grossly changed in
RE

quality.

3 = Subject experiences alien thoughts in

association with his/her own, or as
comments upon his/her own. (Not
hallucinations)
R

THOUGHT BLOCK OR THOUGHT

WITHDRAWAL
The subject experiences a sudden stopping of his/her THOUGHT BLOCK OR THOUGHT CJD1I01
FO

thoughts, quite unexpectedly while they are flowing freely, WITHDRAWAL Intensity
and in the absence of anxiety. When it occurs it is fairly 0 = Absent
dramatic and it happens on several occasions.
2 = Subject just experiences a sudden
stopping of his/her thoughts.

3 = The subject is unable to describe pure

thought block, but it is very recognizable in
the form of an explanatory delusion of
thought withdrawal.

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DELUSIONS OF THOUGHTS BEING READ

Usually an explanatory delusion, often occurring with DELUSIONS OF THOUGHTS BEING CJD2I01
Delusions of Reference of Misinterpretation which require READ Intensity
some explanation of how other people know so much about 0 = Absent
subject's future movements. It may be an elaborate
Thought Broadcast, Thought Insertion, Auditory 2 = Subject seriously entertains the
possibility that his/her thoughts might be
Hallucinations, Delusions of Control, Delusions of read, but is not certain aboutit.
Persecution, or Delusions of Influence.

LY
3 = Delusional conviction.

Do not mistake it for Thought Insertion or Thought

Broadcast, which are diagnostically more important
symptoms.

N
Exclude those who think that people can read their
thoughts as a result of belonging to a group that practices
"thought reading".

O
DELUSIONS OF CONTROL
The subject's will is replaced by that of some external DELUSIONS OF CONTROL CJD3I01
agency. A simple statement that the subject is "being Intensity
0 = Absent

replacement of will by some other force.

EW
controlled" is not sufficient, the subject must describe a
2 = Partial delusion

3 = Full delusional conviction

Do not include feeling that life is planned and directed by
fate, or that the future is already present in embryo, or that
subject is not very strong-willed, or that voices give subject
orders. Do not include simple identification with God or
VI

being under God's Direction.

Do not include subculture or hysterical possession states or

multiple personality.
RE

DELUSIONS OF REFERENCE
Delusion that people or situations or broadcasts make DELUSIONS OF REFERENCE CJD4I01
special reference to the subject. There must be elaborate, Intensity
0 = Absent
e.g. someone crosses their knees in order to indicate that
the subject in homosexual, or the whole neighborhood is 2 = Partial delusion
gossiping.
R

3 = Full delusional conviction

Include Delusions of Misinterpretation and Misidentification:

Situations appear to be deliberately created to test the
FO

subject (exclude situations of medical treatment), or objects

to have special meaning.

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DELUSIONS OF PERSECUTION
The subject believes that someone, or some organization, DELUSIONS OF PERSECUTION CJD5I01
or some force or power, is trying to harm him/her in some Intensity
0 = Absent
way; to damage his/her reputation, to cause him/her bodily
injury, to drive him/her mad or to bring about his/her death. 2 = Partial delusion

3 = Full delusional conviction

LY
DELUSIONS OF ASSISTANCE
The subject believes that someone, or some organization, DELUSIONS OF ASSISTANCE CJD6I01
or some force or power, is trying to help him/her. Intensity
0 = Absent

2 = Partial delusion

N
3 = Full delusional conviction

O
DELUSIONS OF GUILT
The subject believes s/he has brought ruin to his/her family, DELUSIONS OF GUILT CJD7I01
or others by being in his/her present condition or that Intensity
0 = Absent
his/her symptoms are a punishment for not doing better.
EW
Distinguish from pathological guilt without delusional
2 = Subject may have a fluctuating
awareness that his/her feelings are an
exaggeration of normal guilt.
elaboration, in which the subject is in general aware that
the guilt originates within him/herself and is exaggerated. 3 = The subject has a full delusional
conviction that s/he has sinned greatly, etc.
VI

DELUSIONS OF DEPERSONALIZATION OR
NIHILISM
The subject has a strong feeling as if he had no brain, DELUSIONS OF DEPERSONALIZATION CJD8I01
hollow within his skull, no thoughts in his head, etc. OR NIHILISM Intensity
RE

0 = Absent

2 = Partial delusion

3 = Full delusional conviction

HYPOCHONDRIACAL DELUSIONS
R

The subject feels that his/her body is unhealthy, rotten or HYPOCHONDRIACAL DELUSIONS CJD9I01
diseased, and can only be reassured for a short while that Intensity
0 = Absent
this is not the case.
FO

2 = Partial delusion

3 = Full delusional conviction

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SIMPLE DELUSIONS CONCERNING

APPEARANCE
The subject has a delusional belief that something is wrong SIMPLE DELUSION CONCERNING CJE0I01
with his/her appearance. There may only be one particular APPEARANCE Intensity
complaint but there is no elaboration of any kind. Exclude 0 = Absent
self-consciousness, concern about real skin disease, e.g.,
acne, etc. 2 = Partial delusion

3 = Full delusional conviction

LY
Differentiate from Depersonalizing and Delusions of
Depersonalization.

Differentiate from the body image disturbance of Anorexia

Nervosa, which relates specifically to a misperception of

N
fatness.

DELUSIONS OF GRANDIOSE ABILITY OR

O
IDENTITY
The subject thinks s/he is chosen by some power, or by DELUSIONS OF GRANDIOSE ABILITY CJE1I01
destiny for a special mission or purpose, because of his/her OR IDENTITY Intensity
unusual talents; or the subject believes s/he is famous,
EW 0 = Absent
rich, a pop star, or super-hero, titled or related to prominent
people. 2 = Partial delusion

3 = Full delusional conviction

DELUSIONAL EXPLANATIONS
Include here any delusional explanation or elaboration of DELUSIONAL EXPLANATIONS CJE2I01
VI

other abnormal experiences, e.g., explanations of Thought Intensity

0 = Absent
Broadcast in terms of occult phenomena.
2 = Partial delusion

3 = Full delusional conviction

RE

PRIMARY DELUSIONS
Primary delusions are based upon sensory experience PRIMARY DELUSIONS CJE3I01
(delusional perceptions) in which a subject suddenly Intensity
0 = Absent
becomes convinced that a particular set of events has a
special meaning. 2 = It will rarely be necessary to rate
R

primary delusions as partial since they

usually enter the mind with full conviction.

3 = Full delusional conviction.

FO

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DELUSIONAL MATERIAL NOT SPECIFIED

ELSEWHERE
E.g. morbid jealousy or delusions of pregnancy. DELUSIONAL MATERIAL NOT CJE4I01
SPECIFIED ELSEWHERE Intensity
Question as appropriate, if subject's answers to earlier 0 = Absent
questions suggest these or other delusions not already
2 = Partial delusion
coded.
3 = Full delusional conviction

LY
ONSET OF DELUSIONS
Code date of onset of first delusional experience. ANY DELUSIONS PRESENT CJE5I99
Intensity

N
0 = Absent

2 = Present

CJE5O01

O
Onset

/ /
EW
VI
RE
R
FO

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GENERAL RATINGS OF DELUSIONS AND

HALLUCINATIONS

CONSIDER BOTH DELUSIONS AND

HALLUCINATIONS IN THE FOLLOWING
RATINGS

SYSTEMATIZATION OF DELUSIONS AND

LY
HALLUCINATIONS
SYSTEMATIZATION OF DELUSIONS CJA5I01
AND HALLUCINATIONS Intensity
0 = Delusions and hallucinations not
elaborated into a general system affecting

N
much of the subject's experience, including
encapsulated delusions or isolated
hallucinations.

O
2 = Some systematic elaboration but
substantial areas of the subject's
experience are not affected.

3 = Subject interprets practically all

EW experience in delusional terms.

PEOCCUPATION WITH DELUSIONS AND

HALLUCINATIONS
PREOCCUPATIONS WITH DELUSIONS CJA6I01
AND HALLUCINATIONS Intensity
0 = Absent
VI

2 = At least sometimes uncontrollably

preoccupied with delusions or
hallucinations in at least 2 activities.

3 = Uncontollably preoccupied with

RE

delusions or hallucinations in most

activities.

ACTING UPON DELUSIONS OR

HALLUCINATIONS
ACTING UPON DELUSIONS OR CJA7I01
R

HALLUCINATIONS Intensity
0 = Absent
FO

2 = The subject has acted upon the

delusions or hallucinations during the past 3
months or expressed them in public (i.e.,
outside the small circle of people who
would be expected to be sympathetic). This
has not, however, resulted in severe social
crisis.

3 = As above, but the acting out, or public

expression, has resulted in severe social
disturbance or a social crisis, e.g. the
subject has attacked a stranger at the
command of an hallucinatory voice.

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THEMATIC CONSISTENCY OF DELUSIONS OR

HALLUCINATIONS WITH MOOD DISORDER
Extent to which contents of the delusions or hallucinations THEMATIC CONSISTENCY OF CJA8I01
are consistent with either Elated or Depressed Mood. DELUSIONS OR HALLUCINATIONS Intensity
WITH MOOD DISTURBANCE

2 = Partially mood congruent.

LY
3 = Almost always mood congruent.

ASSOCIATED MOOD: DEPRESSED CJA8I02

0 = Absent

2 = Present

N
ASSOCIATED MOOD: ELATED CJA8I03
0 = Absent

O
2 = Present

TEMPORAL, CO-OCCURRENCE OF
DELUSIONS OR HALLUCINATIONS WITH
MOOD DISORDER
EW CJA9I01
Extent, onset, and course of delusions or hallucinations are TEMPORAL CO-0CCURENCE OF
temporally related to the onset and course of mood DELUSIONS OR HALLUCINATIONS Intensity
WITH MOOD DISORDER
disorder.
2 = Partial temporal co-occurence.
When you were (in psychotic state), were you miserable or 3 = Delusions/hallucinations only present in
VI

depressed? association with mood disorder.

Was your mood affected in any other way?
Were you always like that when you were (in psychotic ASSOCIATED MOOD: DEPRESSED CJA9I02
state)? 0 = Absent
RE

2 = Present

ASSOCIATED MOOD: ELATED CJA9I03

0 = Absent

2 = Present
R
FO

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INCAPACITY SECTION
REVIEW BRIEFLY WITH THE SUBJECT THE
AREAS WHERE PROBLEMS OR SYMPTOMS
HAVE EMERGED DURING THE INTERVIEW.
TAKING ONE AREA AT A TIME, REVIEW THE
AREAS OF SYMPTOMATOLOGY TO
DETERMINE WHETHER SYMPTOMS IN THAT
AREA HAVE CAUSED INCAPACITY. USE THIS,
AND INFORMATION COLLECTED

LY
THROUGHOUT THE INTERVIEW, TO
COMPLETE THE INCAPACITY RATINGS.
REMEMBER, YOU NEED ONLY TO ASK THE
SPECIFIC QUESTIONS IF YOU HAVE NOT
ALREADY COLLECTED THE INFORMATION

N
WHILE COVERING THE APPROPRIATE
SYMPTOM SECTION. IF INCAPACITY IS
PRESENT FIND OUT WHEN IT BEGAN.

O
REMEMBER TO OBTAIN SEPARATE TIMINGS
FOR THE ONSET OF PARTIAL AND SEVERE
INCAPACITIES.
SUMMARY OF RULES FOR RATING
INCAPACITY EW
IMPAIRMENT/INCAPACITY

Two levels of disturbance or impaired

functioning are distinguished:
VI

Partial Incapacity; refers to a notable reduction

of function in a particular area. If a person is
still able to do things, but does them less well,
or more slowly, then code as a Partial
Incapacity.
RE

Severe Incapacity; refers to a complete, or

almost complete, inability to function in a
particular area.

With the exception of the lifelong symptoms

mentioned below, most incapacities require a
R

decrement or change in functioning. The

decrement can predate the primary period but
must still be present during the primary period.
FO

SYMPTOM DEPENDENCE

Incapacity Ratings 1
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For incapacity to be rated it must arise

demonstrably from the presence of some
particular symptoms or disordered behaviors.
For instance, a child who has lost friends
because her mother would not allow her to
associate with them, would not have that loss
of friends rated as an incapacity here.
Although, of course, it might have had crippling
effects on her social life, it would not count as

LY
an incapacity because it was not secondary to
any psychopathology of the child. However, it
would count if the child was too frightened to
leave the house and lost her friends because of
it.

N
The specific area of psychopathology
responsible for the secondary incapacity

O
should be noted. It is not enough to record that
a child was incapacitated in certain ways and
that the child had certain psychopathological
problems. The incapacity must be linked to the
problems that seem to have generated it. Often
this is difficult when children have multiple
problems and incapacities, but the attempt
EW
should be made nevertheless. However, this
does not mean that a particular incapacity has
to be assigned to one single problem. It will
sometimes be the case that several symptoms
of different types will contribute to a particular
VI

incapacity. When this is the case, each

contributing problem area should be recorded.

It follows that if an incapacity is to be seen as

RE

being secondary to other symptoms, then

those other symptoms must have been present
before the onset of that incapacity. They must
also have resulted in a fall-off from a previous
level of attainment or proficiency if they are to
be regarded as having resulted in an
incapacity. Thus a child who had previously
R

been able to function well enough in class

might show a reduced ability to participate in
group activities, because he felt too miserable
FO

to do so. This would be regarded as an

incapacity secondary to the affective
symptoms. On the other if a child had always
been unable to participate in group activities
and later became depressed, an incapacity,
secondary to depression, would be recorded
only if his capacity to participate in group
activities suffered a further decrement from its
already low level. If there had been no further
decrement, an incapacity in relation to
depression would not be recorded.

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LIFELONG SYMPTOMS/BEHAVIORS

In the case of symptoms that have been

present throughout life, it will be impossible to
show a decrement secondary to the symptoms,
because both the symptoms and the putative
incapacity will have been present
simultaneously. In this situation, provided
always that the incapacity can be directly

LY
related to the symptoms, it is acceptable to rate
it as such. An example might be the social
incapacities of a hyperactive child who had
always shown such behavior from his earliest
years and thus always had disturbed peer

N
relationships.

SITUATION NOT ENTERED

O
If the subject has not entered a particular social
situation (e.g. daycare/school) during the
preceding three months, but there is clear EW
evidence from past experience that incapacity
would have been manifested had s/he been in
the situation (e.g. discordant peer relationships
would have been present) then that incapacity
is rated as being present, and its date of onset
should be determined. The intensity rating
should not be higher than the previously
VI

actually occurring highest intensity. Quite often

in such a situation, the incapacity will have
been contributory to the failure to enter the
social situation under consideration.
RE

The incapacitating effects of the

psychopathology do not have to be directly due
to the behavior of the child but may be
mediated by others. For instance, if a boy were
excluded from school for constant fighting and
trouble making, that would be counted as an
incapacitation of school performance just as
R

much as if the child had failed to attend

because of his own anxiety about leaving
home.
FO

ONSETS

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The rules for dating the onset of incapacities

are essentially the same as those for dating
symptom onsets. That is, the decision is first
made as to whether or not a particular
incapacity was present during the 3 month
primary period. If it was, then its onset is coded
as the date it appeared at the minimum criterion
level required by the glossary definition. Once
again, there is a proviso that if the incapacity

LY
has been present only intermittently, the onset
is dated from when the incapacity began again
following the last period of one year (or longer)
without incapacity. The dates of exacerbations
from partial to complete incapacity are also

N
recorded.

Even if a child did not code for any problems in

O
the a particular section of the PAPA, the
Incapacity section can not be skipped. If you
have enough information, not every question
needs to be asked. EW
TREATMENT

Referrals to professional agencies or

professional concerned with child's symptoms
or behavior.
VI

Note the name of the site where treatment was

received and the professionals seen.

Treatment may be coded even if symptoms did

not code in the PAPA.
RE
R
FO

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PARENTAL RELATIONSHIPS - PARENT #1

A child should be able to maintain relationships with his/her PROBLEMS WITH PARENTAL CMA0I90
parents that are relatively harmonious and capable of RELATIONSHIPS - PARENT #1 Intensity
containing positive and nurturant communication. The 0 = Absent
number of arguments or fights that a subject is involved in
is rated separately. A change in the relationships, 2 = Present
temporally associated with other symptomatology, should WITHDRAWAL CMA0I01
ordinarily be expected in order to rate incapacity.

LY
0 = Absent

WITHDRAWAL: Incapacity involving refusal or inability to 2 = Partial Incapacity.

be involved with, or talk to, parent.
3 = Severe Incapacity.

DISCORD: Incapacity involving aggression, arguments, DISCORD CMA0I02

N
fights, or disruptive behavior. 0 = Absent

Does it affect how you get along with your "parent"? 2 = Partial Incapacity.

O
3 = Severe Incapacity.
How?
What does s/he do about it? SYMPTOM AREAS CAUSING CMA0X03
What do you do about it? INCAPACITY
Does it cause any arguments? 1 = School Non-Attendance
Can you tell me about the last time it did?
EW 2 = Separation Anxiety CMA0X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA0X05
5 = Depression
VI

6 = Mania
CMA0X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMA0X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMA0X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMA0X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMA0X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA0X11

21 = Alcohol/Drugs

CMA0X12

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CMA0X13

CMA0X14

CMA0X15

LY
CMA0X16

N
CMA0X17

O
CMA0X18

CMA0X19
EW
CMA0X20

CMA0X21
VI

CMA0X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMA0O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA0O02

/ /
R
FO

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PARENTAL RELATIONSHIPS - PARENT #2

A child should be able to maintain relationships with his/her PROBLEMS WITH PARENTAL CMA1I90
parents that are relatively harmonious and capable of RELATIONSHIP - PARENT #2 Intensity
containing positive and nurturant communication. The 0 = Absent
number of arguments or fights that a subject is involved in
is rated separately. A change in the relationships, 2 = Present
temporally associated with other symptomatology, should WITHDRAWAL CMA1I01
ordinarily be expected in order to rate incapacity.

LY
0 = Absent

WITHDRAWAL: Incapacity involving refusal or inability to 2 = Partial Incapacity.

be involved with, or talk to, parent.
3 = Severe Incapacity.

DISCORD: Incapacity involving aggression, arguments, DISCORD CMA1I02

N
fights, or disruptive behavior. 0 = Absent

Does it affect how you along with "other parent"? 2 = Partial Incapacity.

O
3 = Severe Incapacity.
How?
What does "other parent" do about it? SYMPTOM AREAS CAUSING CMA1X03
What do you do about it? INCAPACITY
Does it cause any arguments? 1 = School Non-Attendance
Can you tell me about the last time it did?
EW 2 = Separation Anxiety CMA1X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA1X05
5 = Depression
VI

6 = Mania
CMA1X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMA1X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMA1X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMA1X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMA1X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA1X11

21 = Alcohol/Drugs

CMA1X12

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Definitions and questions Coding rules Codes

CMA1X13

CMA1X14

CMA1X15

LY
CMA1X16

N
CMA1X17

O
CMA1X18

CMA1X19
EW
CMA1X20

CMA1X21
VI

CMA1X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMA1O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA1O02

/ /
R
FO

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Definitions and questions Coding rules Codes

PARENTAL RELATIONSHIPS - OTHER PARENT

#1
A child should be able to maintain relationships with his/her PROBLEMS WITH PARENTAL CMA2I90
parents that are relatively harmonious and capable of RELATIONSHIP - OTHER PARENT #1 Intensity
containing positive and nurturant communication. The 0 = Absent
number of arguments or fights that a subject is involved in
is rated separately. A change in the relationships, 2 = Present
temporally associated with other symptomatology, should WITHDRAWAL CMA2I01

LY
ordinarily be expected in order to rate incapacity.
0 = Absent

WITHDRAWAL: Incapacity involving refusal or inability to 2 = Partial Incapacity.

be involved with, or talk to, parent.
3 = Severe Incapacity.

N
DISCORD: Incapacity involving aggression, arguments, DISCORD CMA2I02
fights, or disruptive behavior. 0 = Absent

O
Does it affect how you along with "Other Parent #1"? 2 = Partial Incapacity.

3 = Severe Incapacity.
How?
What does s/he do about it? SYMPTOM AREAS CAUSING CMA2X03
What do you do about it?
EW INCAPACITY
Does it cause any arguments? 1 = School Non-Attendance
Can you tell me about the last time it did?
2 = Separation Anxiety CMA2X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA2X05
5 = Depression
VI

6 = Mania
CMA2X06
7 = Physical Symptoms

8 = Food-Related Behavior
RE

9 = Hyperactivity CMA2X07

13 = Conduct

14 = Psychosis
CMA2X08
15 = Relationships with Parent #1 and/or
Parent #2
R

16 = Relationships with Other Parent #1 CMA2X09

and/or Other Parent #2
FO

17 = Relationships with Other Adults

18 = Sibling Relationships CMA2X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA2X11

21 = Alcohol/Drugs

CMA2X12

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Definitions and questions Coding rules Codes

CMA2X13

CMA2X14

CMA2X15

LY
CMA2X16

N
CMA2X17

O
CMA2X18

CMA2X19
EW
CMA2X20

CMA2X21
VI

CMA2X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMA2O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA2O02

/ /
R
FO

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Definitions and questions Coding rules Codes

PARENTAL RELATIONSHIPS - OTHER PARENT

#2
A child should be able to maintain relationships with his/her PROBLEMS WITH PARENTAL CMA3I90
parents that are relatively harmonious and capable of RELATIONSHIP - OTHER PARENT #2 Intensity
containing positive and nurturant communication. The 0 = Absent
number of arguments or fights that a subject is involved in
is rated separately. A change in the relationships, 2 = Present
temporally associated with other symptomatology, should WITHDRAWAL CMA3I01

LY
ordinarily be expected in order to rate incapacity.
0 = Absent

WITHDRAWAL: Incapacity involving refusal or inability to 2 = Partial Incapacity.

be involved with, or talk to, parent.
3 = Severe Incapacity.

N
DISCORD: Incapacity involving aggression, arguments, DISCORD CMA3I02
fights, or disruptive behavior. 0 = Absent

O
Does it affect how you get along with "Other Parent 2 = Partial Incapacity.
#2"? 3 = Severe Incapacity.

How? SYMPTOM AREAS CAUSING CMA3X03

What does "other parent" do about it?
EW INCAPACITY
What do you do about it? 1 = School Non-Attendance
Does it cause any arguments?
2 = Separation Anxiety CMA3X04
Can you tell me about the last time it did?
3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA3X05
5 = Depression
VI

6 = Mania
CMA3X06
7 = Physical Symptoms

8 = Food-Related Behavior
RE

9 = Hyperactivity CMA3X07

13 = Conduct

14 = Psychosis
CMA3X08
15 = Relationships with Parent #1 and/or
Parent #2
R

16 = Relationships with Other Parent #1 CMA3X09

and/or Other Parent #2
FO

17 = Relationships with Other Adults

18 = Sibling Relationships CMA3X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA3X11

21 = Alcohol/Drugs

CMA3X12

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Definitions and questions Coding rules Codes

CMA3X13

CMA3X14

CMA3X15

LY
CMA3X16

N
CMA3X17

O
CMA3X18

CMA3X19
EW
CMA3X20

CMA3X21
VI

CMA3X22
RE

ONSET OF FIRST PARTIAL ICAPACITY CMA3O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA3O02

/ /
R
FO

IF NO CHILDREN IN HOUSEHOLD, SKIP

TO "SIBLING RELATIONSHIPS: OUT OF
HOME", (PAGE 15).

Incapacity Ratings 12
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Definitions and questions Coding rules Codes

SIBLING RELATIONSHIPS: IN HOME

A child should be able to live in reasonable harmony with a PROBLEMS WITH SIBLING CMA4I90
sibling or siblings. Some arguments and fights are to be RELATIONSHIPS - IN HOME Intensity
expected, but harmonious conversations and interactions 0 = Absent
should predominate. They should not be in constant
jealous competition for attention or parental time. A change 2 = Present
in relationships, temporally associated with other WITHDRAWAL CMA4I01
symptomatology, should ordinarily be expected in order to

LY
rate incapacity. 0 = Absent

2 = Partial Incapacity.
WITHDRAWAL: Incapacity involving refusal or inability to
3 = Severe Incapacity.
be involved with, or talk to, parent.
DISCORD CMA4I02

N
DISCORD: Incapacity involving aggression, arguments, 0 = Absent
fights, or disruptive behavior.
2 = Partial Incapacity.

O
Does it affect how you along with (brothers and 3 = Severe Incapacity.
sisters)?
SYMPTOM AREAS CAUSING CMA4X03
How? INCAPACITY
What do they do about it? 1 = School Non-Attendance
What do you do?
Does it create any arguments?
EW 2 = Separation Anxiety CMA4X04
Can you tell me about the last time it did? 3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA4X05
5 = Depression
VI

6 = Mania
CMA4X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMA4X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMA4X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMA4X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMA4X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA4X11

21 = Alcohol/Drugs

CMA4X12

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Definitions and questions Coding rules Codes

CMA4X13

CMA4X14

CMA4X15

LY
CMA4X16

N
CMA4X17

O
CMA4X18

CMA4X19
EW
CMA4X20

CMA4X21
VI

CMA4X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMA4O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA4O02

/ /
R
FO

IF NO SIBLINGS OUT OF HOME, SKIP

TO "CHORES", (PAGE 18).

Incapacity Ratings 14
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Definitions and questions Coding rules Codes

SIBLING RELATIONSHIPS: OUT OF HOME

A child should be able to live in reasonable harmony with a PROBLEMS WITH SIBLING CMA5I90
sibling or siblings. Some arguments and fights are to be RELATIONSHIP - OUT OF HOME Intensity
expected, but harmonious conversations and interactions 0 = Absent
should predominate. They should not be in constant
jealous competition for attention or parental time. A change 2 = Present
in relationships, temporally associated with other WITHDRAWAL CMA5I01
symptomatology, should ordinarily be expected in order to

LY
rate incapacity. 0 = Absent

2 = Partial Incapacity.
WITHDRAWAL: Incapacity involving refusal or inability to
3 = Severe Incapacity.
be involved with, or talk to, parent.
DISCORD CMA5I02

N
DISCORD: Incapacity involving aggression, arguments, 0 = Absent
fights, or disruptive behavior
2 = Partial Incapacity.

O
Does it affect how you along with (brothers and/or 3 = Severe Incapacity.
sisters) who don't live at home?
SYMPTOM AREAS CAUSING CMA5X03
How? INCAPACITY
What do they do about it? 1 = School Non-Attendance
What do you do about it?
Does it create any arguments?
EW 2 = Separation Anxiety CMA5X04
Can you tell me about the last time? 3 = Worries/Anxieties

4 = Obsessions/Compulsions CMA5X05
5 = Depression
VI

6 = Mania
CMA5X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMA5X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMA5X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMA5X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMA5X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA5X11

21 = Alcohol/Drugs

CMA5X12

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Definitions and questions Coding rules Codes

CMA5X13

CMA5X14

CMA5X15

LY
CMA5X16

N
CMA5X17

O
CMA5X18

CMA5X19
EW
CMA5X20

CMA5X21
VI

CMA5X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMA5O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA5O02

/ /
R
FO

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Definitions and questions Coding rules Codes

SELF CARE
A child should be able to keep him/herself clean and tidy to SELF CARE CMA6I01
a degree consonant with his/her age. Intensity
0 = Absent

The reduction in level of self-care must be marked enough 2 = Partial incapacity.

to have led to visible or smellable changes, or to require 3 = Severe incapacity.
unusual perental efforts to maintain appearance.
SYMPTOM AREAS CAUSING CMA6X02

LY
INCAPACITY
What about keeping yourself clean and tidy? Has that
been affected at all? 1 = School Non-Attendance

2 = Separation Anxiety
How long has it been affected?
What is it that makes it hard for you to keep yourself clean 3 = Worries/Anxieties

N
and tidy?
4 = Obsessions/Compulsions

5 = Depression

O
6 = Mania

7 = Physical Symptoms

EW 8 = Food-Related Behavior

9 = Hyperactivity

13 = Conduct

14 = Psychosis

15 = Relationships with Parent #1 and/or

Parent #2
VI

16 = Relationships with Other Parent #1

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships
RE

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

21 = Alcohol/Drugs

ONSET OF FIRST PARTIAL INCAPACITY CMA6O01

- SELF CARE
/ /
R

ONSET OF FIRST SEVERE INCAPACITY CMA6O02

/ /
FO

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Definitions and questions Coding rules Codes

CHORES
A child should be able to perform reasonable work tasks PROBLEMS WITH COOPERATIVE CMA7I90
expected of him/her at home, such as keeping the bedroom HELPING Intensity
tidy, helping out around the house and yard. Remember 0 = Absent
that in most cases a decrement in ability or willingness to
perform the tasks is required for an incapacity to be noted. 2 = Partial incapacity.

3 = Severe incapacity.
What about the jobs you have to do at home?
CMA7X02

LY
SYMPTOM AREAS CAUSING
INCAPACITY
Like chores?
Has it affected you at home at all? 1 = School Non-Attendance

2 = Separation Anxiety CMA7X03

In what way?
Are there any things that you can't do properly or that

N
3 = Worries/Anxieties
you've stopped doing because of (the way you've been
4 = Obsessions/Compulsions CMA7X04
feeling)?
5 = Depression

O
Would it make a difference if s/he didn't...(have
symptoms)? 6 = Mania
CMA7X05
7 = Physical Symptoms
What difference would it make?
How do you know that it's...(symptom)...that causes the 8 = Food-Related Behavior
trouble?
EW 9 = Hyperactivity CMA7X06

13 = Conduct

14 = Psychosis
CMA7X07
15 = Relationships with Parent #1 and/or
Parent #2
VI

16 = Relationships with Other Parent #1 CMA7X08

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships CMA7X09

RE

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA7X10

21 = Alcohol/Drugs

CMA7X11
R
FO

CMA7X12

CMA7X13

CMA7X14

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Definitions and questions Coding rules Codes

CMA7X15

CMA7X16

CMA7X17

LY
CMA7X18

N
CMA7X19

O
CMA7X20

CMA7X21
EW
ONSET OF FIRST PARTIAL INCAPACITY CMA7O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA7O02
VI

/ /
RE
R
FO

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HOMEWORK
A child should be able to do reasonable homework HOMEWORK CMA8I01
assignments at home. Remember that in most cases a Intensity
0 = Absent
decrement in ability or willingness to perform the tasks is
required for an incapacity to be noted. 2 = Partial incapacity.

3 = Severe incapacity.
What about doing your homework?
SYMPTOM AREAS CAUSING CMA8X02

LY
Has it affected you at all? INCAPACITY

1 = School Non-Attendance
In what way?
Are there any things that you can't do properly or that 2 = Separation Anxiety
you've stopped doing because of (the way you've been 3 = Worries/Anxieties
feeling)?

N
4 = Obsessions/Compulsions
Would it make a difference if you didn't...(have
5 = Depression
symptoms)?

O
6 = Mania
How do you know that it's...(symptom)...that causes the
7 = Physical Symptoms
trouble?
What difference would it make? EW 8 = Food-Related Behavior

9 = Hyperactivity

13 = Conduct

14 = Psychosis

15 = Relationships with Parent #1 and/or

Parent #2
VI

16 = Relationships with Other Parent #1

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships
RE

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

21 = Alcohol/Drugs

ONSET OF FIRST PARTIAL INCAPACITY CMA8O01

/ /
R

ONSET OF FIRST SEVERE INCAPACITY CMA8O02

/ /
FO

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Definitions and questions Coding rules Codes

LEAVING HOUSE
A child should be able to leave his/her house without LEAVING HOUSE CMA9I01
difficulty. Obviously the range of activities that might induce Intensity
0 = Absent
a child to go outside the house varies widely with age, and
judgment must be used in deciding what is consonant with 2 = Partial incapacity.
the child's developmental stage. 3 = Severe incapacity.

Does...(symptom)...make it hard for you to leave the SYMPTOM AREAS CAUSING CMA9X02

LY
INCAPACITY
house?
1 = School Non-Attendance

2 = Separation Anxiety CMA9X03

3 = Worries/Anxieties

N
4 = Obsessions/Compulsions CMA9X04
5 = Depression

O
6 = Mania
CMA9X05
7 = Physical Symptoms

8 = Food-Related Behavior
CMA9X06
EW 9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMA9X07
15 = Relationships with Parent #1 and/or
Parent #2

CMA9X08
VI

16 = Relationships with Other Parent #1

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships CMA9X09

RE

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMA9X10

21 = Alcohol/Drugs

CMA9X11
R

CMA9X12
FO

CMA9X13

CMA9X14

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Definitions and questions Coding rules Codes

CMA9X15

CMA9X16

CMA9X17

LY
CMA9X18

N
CMA9X19

O
CMA9X20

CMA9X21
EW
ONSET OF FIRST PARTIAL INCAPACITY CMA9O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMA9O02
VI

/ /
RE
R
FO

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SCHOOL LIFE
SCHOOL PERFORMANCE
Deterioration in behavior or ability to participate in DAYCARE/SCHOOL PERFORMANCE CMB0I90
school/daycare routines (e.g. circle time, rest time, story Intensity
0 = Absent
time) is considered to be evidence of an incapacity. A
description of things that the child used to be able to do but 2 = Partial incapacity.
can do no longer is required for a rating here; do not 3 = Severe incapacity.
include children whose low intelligence limits their ability to

LY
perform at daycare/school and have, therefore, always had SYMPTOM AREAS CAUSING CMB0X02
poor results. INCAPACITY

1 = School Non-Attendance
However, a child that has never been able to perform due CMB0X03
2 = Separation Anxiety
to hyperactivity or chronic conduct problems would code if

N
it is clear that these problems contribute to difficulties with 3 = Worries/Anxieties
school performance.
4 = Obsessions/Compulsions CMB0X04

O
What about at school, does it affect how you get along 5 = Depression
there? 6 = Mania
CMB0X05
Or affect how well you can do your lessons? EW 7 = Physical Symptoms

8 = Food-Related Behavior
How?
Can you tell me about the last time that it did? 9 = Hyperactivity CMB0X06

13 = Conduct

14 = Psychosis
CMB0X07
15 = Relationships with Parent #1 and/or
VI

Parent #2

16 = Relationships with Other Parent #1 CMB0X08

and/or Other Parent #2

17 = Relationships with Other Adults

RE

18 = Sibling Relationships CMB0X09

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

CMB0X10
21 = Alcohol/Drugs
R

CMB0X11
FO

CMB0X12

CMB0X13

CMB0X14

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Definitions and questions Coding rules Codes

CMB0X15

CMB0X16

CMB0X17

LY
CMB0X18

N
CMB0X19

O
CMB0X20

CMB0X21
EW
ONSET OF FIRST PARTIAL INCAPACITY CMB0O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMB0O02
VI

/ /
RE
R
FO

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Definitions and questions Coding rules Codes

SCHOOL SUSPENSION
Exclusion from school for any length of time. SUSPENSION Ever:CMB1E90
Intensity
0 = Absent
Have you ever been suspended from daycare/school?
2 = Present
Has it happened in the last three months? Ever:CMB1V01
Frequency

LY
Ever:CMB1O01
Onset

/ /

N
SUSPENSION IN LAST 3 MONTHS CMB1I01
Intensity
0 = Absent

O
2 = Present

DURATION OF LONGEST SUSPENSION CMB1D01

EW IN LAST 3 MONTHS (IN DAYS)

SYMPTOM AREAS CAUSING Ever:CMB1X02

INCAPACITY

1 = School Non-Attendance

2 = Separation Anxiety Ever:CMB1X03

3 = Worries/Anxieties
VI

4 = Obsessions/Compulsions Ever:CMB1X04
5 = Depression

6 = Mania
RE

Ever:CMB1X05
7 = Physical Symptoms

8 = Food-Related Behavior

9 = Hyperactivity Ever:CMB1X06

13 = Conduct
R

14 = Psychosis
Ever:CMB1X07
15 = Relationships with Parent #1 and/or
Parent #2
FO

16 = Relationships with Other Parent #1 Ever:CMB1X08

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships Ever:CMB1X09

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

Ever:CMB1X10
21 = Alcohol/Drugs

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Definitions and questions Coding rules Codes

Ever:CMB1X11

Ever:CMB1X12

Ever:CMB1X13

LY
Ever:CMB1X14

N
Ever:CMB1X15

O
Ever:CMB1X16

Ever:CMB1X17
EW
Ever:CMB1X18

Ever:CMB1X19
VI

Ever:CMB1X20
RE

Ever:CMB1X21
R
FO

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Definitions and questions Coding rules Codes

IN-SCHOOL SUSPENSION
Exclusion from school for any length of time. IN-SUSPENSION Ever:CMB2E90
Intensity
0 = Absent
Have you ever been suspended in school?
2 = Present
Has it happened in the last three months? Ever:CMB2V01
Frequency

LY
Ever:CMB2O01
Onset

/ /

N
SUSPENSION IN LAST 3 MONTHS CMB2I01
Intensity
0 = Absent

O
2 = Present

DURATION OF LONGEST SUSPENSION CMB2D01

EW IN LAST 3 MONTHS (IN DAYS)

SYMPTOM AREAS CAUSING Ever:CMB2X02

INCAPACITY

1 = School Non-Attendance

2 = Separation Anxiety Ever:CMB2X03

3 = Worries/Anxieties
VI

4 = Obsessions/Compulsions Ever:CMB2X04
5 = Depression

6 = Mania
RE

Ever:CMB2X05
7 = Physical Symptoms

8 = Food-Related Behavior

9 = Hyperactivity Ever:CMB2X06

13 = Conduct
R

14 = Psychosis
Ever:CMB2X07
15 = Relationships with Parent #1 and/or
Parent #2
FO

16 = Relationships with Other Parent #1 Ever:CMB2X08

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships Ever:CMB2X09

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

Ever:CMB2X10
21 = Alcohol/Drugs

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Definitions and questions Coding rules Codes

Ever:CMB2X11

Ever:CMB2X12

Ever:CMB2X13

LY
Ever:CMB2X14

N
Ever:CMB2X15

O
Ever:CMB2X16

Ever:CMB2X17
EW
Ever:CMB2X18

Ever:CMB2X19
VI

Ever:CMB2X20
RE

Ever:CMB2X21
R
FO

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SCHOOL EXPULSION
Expulsion from daycare/school or asked to withdraw EXPULSION Ever:CMB3E90
voluntarily. Intensity
0 = Absent

Have you ever been expelled from school? 2 = Present

Ever:CMB3V01
Has that happened in the last three months? Frequency

LY
DATE OF FIRST EXPULSION Ever:CMB3O01

/ /

N
EXPULSION IN LAST 3 MONTHS CMB3I01
Intensity
0 = Absent

O
2 = Present

SYMPTOM AREAS CAUSING Ever:CMB3X02

INCAPACITY
EW 1 = School Non-Attendance

2 = Separation Anxiety Ever:CMB3X03

3 = Worries/Anxieties

4 = Obsessions/Compulsions Ever:CMB3X04
5 = Depression

6 = Mania
VI

Ever:CMB3X05
7 = Physical Symptoms

8 = Food-Related Behavior

9 = Hyperactivity Ever:CMB3X06
RE

13 = Conduct

14 = Psychosis
Ever:CMB3X07
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 Ever:CMB3X08

R

and/or Other Parent #2

17 = Relationships with Other Adults

Ever:CMB3X09
FO

18 = Sibling Relationships

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress Ever:CMB3X10

21 = Alcohol/Drugs

Ever:CMB3X11

Incapacity Ratings 29
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Definitions and questions Coding rules Codes

Ever:CMB3X12

Ever:CMB3X13

Ever:CMB3X14

LY
Ever:CMB3X15

N
Ever:CMB3X16

O
Ever:CMB3X17

Ever:CMB3X18
EW
Ever:CMB3X19

Ever:CMB3X20
VI

Ever:CMB3X21
RE
R
FO

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Definitions and questions Coding rules Codes

TEACHER RELATIONSHIPS
A deterioration in a child's relationships with his/her PROBLEMS WITH DAYCARE CMB4I90
daycare providers/teachers is regarded as an incapacity. PROVIDER/TEACHER RELATIONSHIPS Intensity
The need to use increasing levels of disciplinary action, or 0 = Absent
a withdrawal from contact with caregivers with whom the
child has previously had good relationships, is evidence of 2 = Present
disturbance here. Include all nonparental caregivers (e.g. WITHDRAWAL CMB4I01
nanny) identified in the child care sections.

LY
0 = Absent

WITHDRAWAL: Incapacity involving refusal or inability to 2 = Partial Incapacity.

be involved with or talk to teachers.
3 = Severe Incapacity.

DISCORD: Incapacity involving aggression, arguments, DISCORD CMB4I02

N
fights or disruptive behavior. 0 = Absent

Does it affect how s/he gets along with the teachers? 2 = Partial Incapacity.

O
3 = Severe Incapacity.
How?
Can you tell me about the last time that it did? SYMPTOM AREAS CAUSING CMB4X03
INCAPACITY

1 = School Non-Attendance
EW 2 = Separation Anxiety CMB4X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMB4X05
5 = Depression
VI

6 = Mania
CMB4X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMB4X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMB4X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMB4X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMB4X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMB4X11

21 = Alcohol/Drugs

CMB4X12

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Definitions and questions Coding rules Codes

CMB4X13

CMB4X14

CMB4X15

LY
CMB4X16

N
CMB4X17

O
CMB4X18

CMB4X19
EW
CMB4X20

CMB4X21
VI

CMB4X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMB4O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMB4O02

/ /
R
FO

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Definitions and questions Coding rules Codes

PEER RELATIONSHIPS AT SCHOOL

Children should be able to form mutually interested PROBLEMS WITH PEER CMB5I90
relationships and to undertake activities together (playing, RELATIONSHIPS AT Intensity
DAYCARE/SCHOOL
chatting constitute activities in this setting). The loss of
friends or withdrawal from peer activities indicates 0 = Absent
incapacity in this area.
2 = Present

WITHDRAWAL: Incapacity involving refusal or inability to WITHDRAWAL CMB5I01

LY
be involved with or talk to peers. 0 = Absent

DISCORD: Incapacity involving aggressions, arguments, 2 = Partial Incapacity.

fights or disruptive behavior. 3 = Severe Incapacity.

N
DISCORD CMB5I02
What about how you get along with other children at
school; does it affect that? 0 = Absent

2 = Partial Incapacity.

O
What about your friends at school?
3 = Severe Incapacity.
Has it made you see friends less than you used to?
Or try to avoid them? SYMPTOM AREAS CAUSING CMB5X03
INCAPACITY
Or do they seem to want to do things with you less than
EW
they used to? 1 = School Non-Attendance
Why is that? CMB5X04
2 = Separation Anxiety

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMB5X05
5 = Depression
VI

6 = Mania
CMB5X06
7 = Physical Symptoms

8 = Food-Related Behavior
RE

9 = Hyperactivity CMB5X07

13 = Conduct

14 = Psychosis
CMB5X08
15 = Relationships with Parent #1 and/or
Parent #2
R

16 = Relationships with Other Parent #1 CMB5X09

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMB5X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMB5X11

21 = Alcohol/Drugs

CMB5X12

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Definitions and questions Coding rules Codes

CMB5X13

CMB5X14

CMB5X15

LY
CMB5X16

N
CMB5X17

O
CMB5X18

CMB5X19
EW
CMB5X20

CMB5X21
VI

CMB5X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMB5O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMB5O02

/ /
R
FO

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Definitions and questions Coding rules Codes

SPARE TIME ACTIVITIES

Reduction of spontaneous play by at least one third and to SPARE TIME ACTIVITIES CMB6I01
a degree outside their normal range of variation. Care Intensity
0 = Absent
should be taken to ensure that the subject has not lost
interest I an activity for no particular reason. That is to say 2 = Partial incapacity.
that the reduction in involvement must clearly be a 3 = Severe incapacity.
response to some symptomatology.
SYMPTOM AREAS CAUSING CMB6X02

LY
INCAPACITY
Play here includes many activities: imaginary play; playing
with dolls, cars, trains; outdoor play; playing on 1 = School Non-Attendance
computer/gameboy/nintendo, etc. CMB6X03
2 = Separation Anxiety

Does it affect what you do in your spare time? 3 = Worries/Anxieties

N
4 = Obsessions/Compulsions CMB6X04
For example, has this made it difficult to (refer to subject's
interests/hobbies/leasiure activities)? 5 = Depression

O
6 = Mania
CMB6X05
7 = Physical Symptoms

8 = Food-Related Behavior
CMB6X06
EW 9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMB6X07
15 = Relationships with Parent #1 and/or
Parent #2

CMB6X08
VI

16 = Relationships with Other Parent #1

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships CMB6X09

RE

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMB6X10

21 = Alcohol/Drugs

CMB6X11
R

CMB6X12
FO

CMB6X13

CMB6X14

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Definitions and questions Coding rules Codes

CMB6X15

CMB6X16

CMB6X17

LY
CMB6X18

N
CMB6X19

O
CMB6X20

CMB6X21
EW
ONSET OF FIRST PARTIAL INCAPACITY CMB6O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMB6O02
VI

/ /
RE
R
FO

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Definitions and questions Coding rules Codes

RELATIONSHIPS WITH ADULTS IN SPARE

TIME ACTIVITIES
Both withdrawal from such relationships and disturbances PROBLEMS WITH RELATIONSHIPS CMB7I90
of their harmony are evidence to be borne on mind for the WITH ADULTS OUTSIDE THE HOME OR Intensity
DAYCARE/SCHOOL
purposes of a rating here.
0 = Absent
WITHDRAWAL: Incapacity involving refusal or inability to 2 = Present
be involved with or talk to adults.

LY
WITHDRAWAL CMB7I01
DISCORD: Incapacity involving aggression, arguments, 0 = Absent
fights or disruptive behavior.
2 = Partial Incapacity.

Does it affect how you get along with other people 3 = Severe Incapacity.

N
outside the home or school - such as neighbors...or
DISCORD CMB7I02
people at (youth club, etc.)?
0 = Absent

O
Who?
2 = Partial Incapacity.
How?
Can you tell me about the last time that it did? 3 = Severe Incapacity.
Has it made you see less of other adults?
Or try to avoid them?
EW SYMPTOM AREAS CAUSING CMB7X03
INCAPACITY
Or do they treat you differently?
Why? 1 = School Non-Attendance

2 = Separation Anxiety CMB7X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMB7X05
VI

5 = Depression

6 = Mania
CMB7X06
7 = Physical Symptoms
RE

8 = Food-Related Behavior

9 = Hyperactivity CMB7X07

13 = Conduct

14 = Psychosis
CMB7X08
15 = Relationships with Parent #1 and/or
R

Parent #2

16 = Relationships with Other Parent #1 CMB7X09

and/or Other Parent #2
FO

17 = Relationships with Other Adults

18 = Sibling Relationships CMB7X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMB7X11

21 = Alcohol/Drugs

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Definitions and questions Coding rules Codes

CMB7X12

CMB7X13

CMB7X14

LY
CMB7X15

N
CMB7X16

O
CMB7X17

CMB7X18
EW
CMB7X19

CMB7X20
VI

CMB7X21
RE

CMB7X22

ONSET OF FIRST PARTIAL INCAPACITY CMB7O01

/ /
R

ONSET OF FIRST SEVERE INCAPACITY CMB7O02

FO

/ /

Incapacity Ratings 38
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Definitions and questions Coding rules Codes

RELATIONSHIPS WITH PEERS

Children should be able to form mutually interested PROBLEMS WITH PEER CMB8I90
relationships and to undertake activities together (chatter RELATIONSHIPS Intensity
and playing constitute activities in this setting). The loss of 0 = Absent
friends or withdrawal from peer activities indicates
incapacity in this area. 2 = Present

WITHDRAWAL CMB8I01
WITHDRAWAL: Incapacity involving refusal or inability to

LY
0 = Absent
be involved with or talk to peers.
2 = Partial Incapacity.
DISCORD: Incapacity involving aggression, arguments, 3 = Severe Incapacity.
fights or disruptive behavior.
DISCORD CMB8I02

N
Has it affected how you get along with friends at all - I 0 = Absent
mean outside school?
2 = Partial Incapacity.

O
How? 3 = Severe Incapacity.
Can you tell me more about the last time that it did?
Has it made you see less of your friend(s) than you used SYMPTOM AREAS CAUSING CMB8X03
to? INCAPACITY
Why is that? 1 = School Non-Attendance

neighborhood?
EW
What about with other children/young people in your
2 = Separation Anxiety CMB8X04

3 = Worries/Anxieties

4 = Obsessions/Compulsions CMB8X05
5 = Depression
VI

6 = Mania
CMB8X06
7 = Physical Symptoms

8 = Food-Related Behavior
CMB8X07
RE

9 = Hyperactivity

13 = Conduct

14 = Psychosis
CMB8X08
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1 CMB8X09

R

and/or Other Parent #2

17 = Relationships with Other Adults

FO

18 = Sibling Relationships CMB8X10

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress CMB8X11

21 = Alcohol/Drugs

CMB8X12

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Definitions and questions Coding rules Codes

CMB8X13

CMB8X14

CMB8X15

LY
CMB8X16

N
CMB8X17

O
CMB8X18

CMB8X19
EW
CMB8X20

CMB8X21
VI

CMB8X22
RE

ONSET OF FIRST PARTIAL INCAPACITY CMB8O01

/ /
ONSET OF FIRST SEVERE INCAPACITY CMB8O02

/ /
R
FO

Incapacity Ratings 40
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Definitions and questions Coding rules Codes

EMPLOYMENT
Many adolescents have jobs, and they may prove unable to EMPLOYMENT CMB9I90
perform these jobs adequately as a result of Intensity
0 = Absent
psychopathology, in which case an incapacity should be
recorded as being present as a result of that 2 = Present
psychopathology. Ther performance of the job must
WITHDRAWAL CMB9I01
actually be substandard to some degree. It is not enough
that the subject should simply describe it as being more 0 = Absent

LY
difficult or tiring.
2 = Partial Incapacity.

Do you have a job? 3 = Severe Incapacity.

DISCORD CMB9I02
Has that been affected at all?

N
0 = Absent

2 = Partial Incapacity.

3 = Severe Incapacity.

O
SYMPTOM AREAS CAUSING CMB9X03
INCAPACITY

EW 1 = School Non-Attendance

2 = Separation Anxiety

3 = Worries/Anxieties

4 = Obsessions/Compulsions

5 = Depression

6 = Mania
VI

7 = Physical Symptoms

8 = Food-Related Behavior

9 = Hyperactivity
RE

13 = Conduct

14 = Psychosis

15 = Relationships with Parent #1 and/or

Parent #2

16 = Relationships with Other Parent #1

and/or Other Parent #2
R

17 = Relationships with Other Adults

18 = Sibling Relationships
FO

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

21 = Alcohol/Drugs

ONSET OF FIRST PARTIAL INCAPACITY CMB9O01

- EMPLOYMENT
/ /

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ONSET OF FIRST SEVERE INCAPACITY CMB9O02

- EMPLOYMENT
/ /

LY
N
O
EW
VI
RE
R
FO

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MEDICATION
Any medication prescribed by a medical practitioner (either MEDICATION CMC0I90
mainstream or alternative) or given by parents or guardian. Intensity
0 = Absent
Do not include analgesics taken less than once per week
for sporadic headaches, etc. However, such drugs should 2 = Present
be included if they are taken more regularly than this.
MINOR TRANQUILIZERS/SEDATIVES CMC0I01

Note: Type and daily dose if known for any medication 0 = Absent

LY
mentioned. 2 = Present

Are you on any medication? BEGINNING OF MINOR CMC0O01

TRANQUILIZERS/SEDATIVES

Or tablets?
TREATMENT / /

N
ANTI-PSYCHOTICS/MAJOR CMC1I01
Or anything from your doctor? TRANQUILIZERS

What? 0 = Absent

O
What is that? 2 = Present

BEGINNING OF ANTI- CMC1O01

PSYCHOTICS/MAJOR TRANQUILIZERS
TREATMENT / /
EW STIMULANTS CMC2I01
0 = Absent

2 = Present

BEGINNING OF STIMULANTS CMC2O01

TREATMENT
VI

/ /
STRATERRA (NON-STIMULANT) CMC2I02
0 = Absent
RE

2 = Present

BEGINNING OF STRATTERA (NON- CMC2O02

STIMULANT) TREATMENT
/ /
ANTIDEPRESSANTS CMC3I01
R

0 = Absent

2 = Present
FO

BEGINNING OF ANTIDEPRESSANTS CMC3O01

TREATMENT
/ /
LITHIUM CMC4I01
0 = Absent

2 = Present

BEGINNING OF LITHIUM TREATMENT CMC4O01

/ /

Incapacity Ratings 43
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ANTICONVULSANTS CMC5I01
0 = Absent

2 = Present

BEGINNING OF ANTICONVULSANTS CMC5O01

TREATMENT
/ /
ANTIBIOTICS CMF0I01

LY
0 = Absent

2 = Present

BEGINNING OF ANTIBIOTICS CMF0O01

TREATMENT

N
/ /
ASTHMA MEDICATION CMF1I01

O
0 = Absent

2 = Present

EW BEGINNING OF ASTHMA MEDICATION CMF1O01

TREATMENT
/ /
OTHER CMC6I01
0 = Absent

2 = Present
VI

Specify

BEGINNING OF TREATMENT CMC6O01

/ /
RE

IF ANY MEDICATION TAKEN

CONTINUE. OTHERWISE, SKIP TO
R

"OFFSETS", (PAGE 53).

FO

Incapacity Ratings 44
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MEDICATION - RX 1
Which medication are you on? 0 = No Medication POAAX03
Intensity
1 = Abilify
How many milligrams do you take?
2 = Accutane
NUMBER OF DOSES AT THIS NUMBER OF MG. IN 24
3 = Anafranil (clompramine)
HOURS.
4 = Atarax
IF DOSE VARIES WITHIN 24 HOURS, ASK:

LY
5 = Benadryl
DATE MEDICATION STARTED. 6 = Benezedrine

Did the doctor explain what problem(s) and/or 7 = Celexa

symptom(s) this medication was supposed to help?
8 = Concerta

N
What did the doctor say? (Record verbatim) 9 = Cylert

Did the Doctor mention any side effects that you need 10 = Daytrana

O
to watch out for? 11 = Dexedrine

IF YES ASK: 12 = Effexor

13 = Elivil
What are they?

RECORD NUMBER OF SIDE EFFECTS MENTIONED BY

EW 14 = Focalin

15 = Gabapentin
PARENT.
16 = Geodon
Have you experienced any side effects from this
medicine? 17 = Lamictal

18 = Lexapro
VI

How often do you return to the doctor's office to have your

reaction to the medication checked? 19 = Lithium

20 = Marplan
INTERVIEWER: I LOOKED AT THE MEDICATION
BOTTLE. 21 = Metadate
RE

22 = Norpramin

23 = Paxil

24 = Prednisone

25 = Prozac
R

26 = Ritalin

27 = Seroquel
FO

28 = Tegretol

29 = Tenex

30 = Tofranil

31 = Topamax

32 = Trileptal

33 = Uniphyl

34 = Valproate

35 = Wellbutrin

Incapacity Ratings 45
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36 = Zoloft

37 = Zyrtek

38 = Other Medication.

DOSE IN MG - RX 1 POAAX01

POAAF01

LY
Frequency

DOSE IN MG - (IF VARIES WITHIN 24 POAAX02

HOURS) - RX 2

N
NUMBER OF DOSES AT THIS NUMBER POAAF02
OF MG IN 24 HOURS ( IF VARIES WITHIN

O
24 HOURS) - RX 2

POAAO01
Onset

/ /
EW
DOCTOR EXPLANATION POAAX05
0 = No

2 = Yes

MENTION OF SIDE EFFECTS P0AAX07

VI

0 = No

2 = Yes

NUMBER OF SIDE EFFECTS - RX 1 POAAX08

RE

CHECKING REACTION TO MEDICATION POAAX09

P0AAX10
R

VIEWED MEDICATION BOTTLE

0 = No

2 = Yes
FO

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MEDICATION - RX 2
WHICH MEDICATION ARE YOU ON? DETAILED MEDICATION LIST POABX03
Intensity
0 = No Medication
How many milligrams do you take?
1 = Abilify
NUMBER OF DOSES AT THIS NUMBER OF MG. IN 24
HOURS. 2 = Accutane

3 = Anafranil (clompramine)
IF DOSE VARIES WITHIN 24 HOURS, ASK:

LY
4 = Atarax
DATE MEDICATION STARTED. 5 = Benadryl

Did the doctor explain what problem(s) and/or 6 = Benezedrine

symptom(s) this medication was supposed to help?

N
7 = Celexa
What did the doctor say? (Record verbatim) 8 = Concerta

Did the Doctor mention any side effects that you need 9 = Cylert

O
to watch out for? 10 = Daytrana

IF YES ASK: 11 = Dexedrine

12 = Effexor
What are they?

RECORD NUMBER OF SIDE EFFECTS MENTIONED BY

EW 13 = Elivil

PARENT. 14 = Focalin

15 = Gabapentin
Have you experienced any side effects from this
medicine? 16 = Geodon

17 = Lamictal
VI

How often do you return to the doctor's office to have your

reaction to the medication checked? 18 = Lexapro

19 = Lithium
INTERVIEWER: I LOOKED AT THE MEDICATION
BOTTLE. 20 = Marplan
RE

21 = Metadate

22 = Norpramin

23 = Paxil

24 = Prednisone
R

25 = Prozac

26 = Ritalin
FO

27 = Seroquel

28 = Tegretol

29 = Tenex

30 = Tofranil

31 = Topamax

32 = Trileptal

33 = Uniphyl

34 = Valproate

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35 = Wellbutrin

36 = Zoloft

37 = Zyrtek

38 = Other Medication.

DOSE IN MG - RX 2 POABX01

LY
POABF01
Frequency

N
DOSE IN MG (IF VARIES WITHIN 24 POABX02
HOURS) - RX 2

O
NUMBER OF DOSES AT THIS NUMBER POABF02
OF MG IN 24 HOURS ( IF VARIES WITHIN
24 HOURS) - RX 2

EW POABO01
Onset

/ /
DOCTOR EXPLANATION POABX05
0 = No

2 = Yes
VI

MENTION OF SIDE EFFECTS POABX07

0 = No

2 = Yes
RE

NUMBER OF SIDE EFFECTS - RX 2 POABX08

CHECKING REACTION TO MEDICATION POABX09

R

VIEWED MEDICATION BOTTLE POABX10

0 = No
FO

2 = Yes

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MEDICATION - RX 3
WHICH MEDICATION ARE YOU ON? DETAILED MEDICATION LIST POACX03
Intensity
0 = No Medication
How many milligrams do you take?
1 = Abilify
NUMBER OF DOSES AT THIS NUMBER OF MG. IN 24
HOURS. 2 = Accutane

3 = Anafranil (clompramine)
IF DOSE VARIES WITHIN 24 HOURS, ASK:

LY
4 = Atarax
DATE MEDICATION STARTED. 5 = Benadryl

Did the doctor explain what problem(s) and/or 6 = Benezedrine

symptom(s) this medication was supposed to help?

N
7 = Celexa
What did the doctor say? (Record verbatim) 8 = Concerta

Did the Doctor mention any side effects that you need 9 = Cylert

O
to watch out for? 10 = Daytrana

IF YES ASK: 11 = Dexedrine

12 = Effexor
What are they?

RECORD NUMBER OF SIDE EFFECTS MENTIONED BY

EW 13 = Elivil

PARENT. 14 = Focalin

15 = Gabapentin
Have you experienced any side effects from this
medicine? 16 = Geodon

17 = Lamictal
VI

How often do you return to the doctor's office to have your

reaction to the medication checked? 18 = Lexapro

19 = Lithium
INTERVIEWER: I LOOKED AT THE MEDICATION
BOTTLE. 20 = Marplan
RE

21 = Metadate

22 = Norpramin

23 = Paxil

24 = Prednisone
R

25 = Prozac

26 = Ritalin
FO

27 = Seroquel

28 = Tegretol

29 = Tenex

30 = Tofranil

31 = Topamax

32 = Trileptal

33 = Uniphyl

34 = Valproate

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35 = Wellbutrin

36 = Zoloft

37 = Zyrtek

38 = Other Medication.

DOSE IN MG - RX 3 POACX01

LY
POACF01
Frequency

N
DOSE IN MG (IF VERIES WITHIN 24 POACX02
HOURS) - RX 3

O
NUMBER OF DOSES AT THIS NUMBER POACF02
OF MG IN 24 HOURS ( IF VARIES WITHIN
24 HOURS) - RX 3

EW POACO01
Onset

/ /
DOCTOR EXPLANATION POACX05
0 = No

2 = Yes
VI

MENTION OF SIDE EFFECTS POACX07

0 = No

2 = Yes
RE

NUMBER OF SIDE EFFECTS - RX 3 POACX08

CHECKING REACTION TO MEDICATION POACX09

R

VIEWED MEDICATION BOTTLE POACX10

0 = No
FO

2 = Yes

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MEDICATION - RX 4
WHICH MEDICATION ARE YOU ON? 0 = No Medication POADX03
Intensity
1 = Abilify
How many milligrams do you take?
2 = Accutane
NUMBER OF DOSES AT THIS NUMBER OF MG. IN 24
3 = Anafranil (clompramine)
HOURS.
4 = Atarax
IF DOSE VARIES WITHIN 24 HOURS, ASK:

LY
5 = Benadryl
DATE MEDICATION STARTED. 6 = Benezedrine

Did the doctor explain what problem(s) and/or 7 = Celexa

symptom(s) this medication was supposed to help?
8 = Concerta

N
What did the doctor say? (Record verbatim) 9 = Cylert

Did the Doctor mention any side effects that you need 10 = Daytrana

O
to watch out for? 11 = Dexedrine

IF YES ASK: 12 = Effexor

13 = Elivil
What are they?

RECORD NUMBER OF SIDE EFFECTS MENTIONED BY

EW 14 = Focalin

15 = Gabapentin
PARENT.
16 = Geodon
Have you experienced any side effects from this
medicine? 17 = Lamictal

18 = Lexapro
VI

How often do you return to the doctor's office to have your

reaction to the medication checked? 19 = Lithium

20 = Marplan
INTERVIEWER: I LOOKED AT THE MEDICATION
BOTTLE. 21 = Metadate
RE

22 = Norpramin

23 = Paxil

24 = Prednisone

25 = Prozac
R

26 = Ritalin

27 = Seroquel
FO

28 = Tegretol

29 = Tenex

30 = Tofranil

31 = Topamax

32 = Trileptal

33 = Uniphyl

34 = Valproate

35 = Wellbutrin

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CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

36 = Zoloft

37 = Zyrtek

38 = Other Medication.

DOSE IN MG - RX 4 POADX01

POADF01

LY
Frequency

DOSE IN MG (IF VARIES WITHIN 24 POADX02

HOURS) - RX 4

N
NUMBER OF DOSES AT THIS NUMBER POADF02
OF MG IN 24 HOURS ( IF VARIES WITHIN

O
24 HOURS) - RX 4

POADO01
Onset

/ /
EW
DOCTOR EXPLANATION POADX05
0 = No

2 = Yes

MENTION OF SIDE EFFECTS POADX07

VI

0 = No

2 = Yes

NUMBER OF SIDE EFFECTS - RX 4 POADX08

RE

CHECKING REACTION TO MEDICATION POADX09

POADX10
R

VIEWED MEDICATION BOTTLE

0 = No

2 = Yes
FO

Incapacity Ratings 52
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OFFSETS
Code here if symptoms coded in the symptom section have PRESENT 2 CMC7XYZ 00
ceased within the 3 months primary period. Intensity
0 = Absent

CODE HERE IF SYMPTOMS CODED IN THE SYMPTOM 2 = Present

SECTION HAVE CEASED WITHIN THE 3 MONTHS CMC7O01
PRIMARY PERIOD. Onset

/ /

LY
SCHOOL NON-ATTENDANCE OFFSET

SEPARATION ANXIETY CMC7O02

/ /

N
WORRIES/ANXIETY CMC7O03

/ /

O
OBSESSIONS/COMPULSIONS CMC7O04

/ /
DEPRESSION CMC7O05
EW / /
MANIA CMC7O06

/ /
PHYSICAL SYMPTOMS CMC7O07
VI

/ /
FOOD-RELATED BEHAVIOR CMC7O08

/ /
RE

HYPERACTIVITY CMC7O19

/ /
CONDUCT DISORDER CMC7O09

/ /
R

ALCOHOL/DRUGS CMC7O10
FO

/ /
SMOKING CIGARETTES CMC7O18

/ /
PSYCHOSIS CMC7O11

/ /

Incapacity Ratings 53
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RELATIONSHIPS WITH PARENT #1 CMC7O12

AND/OR PARENT #2
/ /
RELATIONSHIPS WITH OTHER PARENT CMC7O13
#1 AND/OR OTHER PARENT #2
/ /
RELATIONSHIPS WITH OTHER ADULTS CMC7O14

/ /

LY
SIBLING RELATIONSHIPS CMC7O15

/ /

N
PEER RELATIONSHIPS CMC7O16

/ /

O
LIFE EVENTS/POST-TRAUMATIC CMC7O17
STRESS
/ /
EW
VI
RE
R
FO

Incapacity Ratings 54
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Definitions and questions Coding rules Codes

ENDING THE INTERVIEW

PERCEPTION OF PROBLEMS
We have covered quite a lot of ground, but is there PERCEPTION OF PROBLEM(S) PMC8I90
anything that worries you, or causes problems, that I Intensity
0 = Absent
haven't asked about?
2 = Present
What?
Can you tell me more about that? PROBLEMS WITH: PMC8X01

LY
You have told me about many different things; do you 1 = School Non-Attendance
think that any of them are problems for you?
2 = Separation Anxiety
PMC8X02
3 = Worries/Anxieties

N
4 = Obsessions/Compulsions
PMC8X03
5 = Depression

6 = Mania

O
7 = Physical Symptoms PMC8X04
8 = Food-Related Behavior

9 = Hyperactivity
PMC8X05
EW 13 = Conduct

14 = Psychosis

15 = Relationships with Parent #1 and/or PMC8X06

Parent #2

16 = Relationships with Other Parent #1

VI

and/or Other Parent #2

17 = Relationships with Other Adults

18 = Sibling Relationships

19 = Peer Relationships
RE

20 = Life Events/Post-Traumatic Stress

21 = Alcohol/Drugs
R
FO

Incapacity Ratings 55
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HELP NEEDED WITH:

Are there any things that you think you need help with? HELP NEEDED PMC9I90
Intensity
0 = Absent
What?
What sort of help do you need? 2 = Present

HELP NEEDED WITH: PMC9X01

1 = School Non-Attendance

LY
2 = Separation Anxiety
PMC9X02
3 = Worries/Anxieties

4 = Obsessions/Compulsions
PMC9X03

N
5 = Depression

6 = Mania

7 = Physical Symptoms PMC9X04

O
8 = Food-Related Behavior

9 = Hyperactivity
PMC9X05
13 = Conduct
EW 14 = Psychosis
PMC9X06
15 = Relationships with Parent #1 and/or
Parent #2

16 = Relationships with Other Parent #1

and/or Other Parent #2
VI

17 = Relationships with Other Adults

18 = Sibling Relationships

19 = Peer Relationships

20 = Life Events/Post-Traumatic Stress

RE

21 = Alcohol/Drugs
R
FO

Incapacity Ratings 56
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CHILD HEALTH SERVICES SCREEN

SERVICES SCREEN

Because it's easy to forget, I'm going to go

through a list of places where you might have
gotten help or treatment (for any concerns or
problems you might have experienced).

LY
I want you to tell me whether you have been to
any of them in your life, and in the last 3
months.

PSYCHIATRIC HOSPITAL

N
Because it 's easy to forget, I'm going to go through a PSYCHIATRIC HOSPITAL Ever:CNA0E01
list of places where you might have gotten help (for Intensity
0 = No
these difficulties).

O
2 = Yes
I want you to tell me whether you've ever been to any
of them. Ever:CNA0O01
Onset

/ /
EW LAST 3 MONTHS CNA0I01
Intensity
0 = No

2 = Yes
VI

GENERAL HOSPITAL PSYCHIATRIC UNIT

A hospital inpatient unit? GENERAL HOSPITAL PSYCHIATRIC Ever:CNA1E01
UNIT Intensity
Do you know what sort of hospital it was? 0 = No
RE

Was it a medical or a psychiatric hospital?

Was it an ordinary medical ward or a special psychiatric 2 = Yes
ward? Ever:CNA1O01
when did you first (go there)? Onset
Have you (been there) in the last 3 months?
/ /
CNA1I01
R

LAST 3 MONTHS
Intensity
0 = No
FO

2 = Yes

Child Health Services Screen 1

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DETOX UNIT OR INPATIENT DRUG/ALCOHOL

UNIT
An inpatient alcohol or drug treatment unit? DETOX UNIT OR INPATIENT Ever:CNA2E01
DRUG/ALCOHOL UNIT Intensity
Or an inpatient detoxification unit? 0 = No

2 = Yes

Ever:CNA2O01

LY
Onset

/ /
LAST 3 MONTHS CNA2I01
Intensity

N
0 = No

2 = Yes

O
HOSPITAL MEDICAL INPATIENT UNIT
A medical inpatient unit, for any of the kinds of HOSPITAL MEDICAL I/P UNIT Ever:CNA3E01
problems that you told me about? Intensity
0 = No

In the last 3 months?

When was the first time?
EW 2 = Yes

Ever:CNA3O01
Onset

/ /
CNA3I01
VI

LAST 3 MONTHS
Intensity
0 = No

2 = Yes
RE

RESIDENTIAL TREATMENT CENTER

A residential treatment center because of the problems RESIDENTIAL TREATMENT CENTER Ever:CNA4E01
you told me about? Intensity
0 = No

Where was that? 2 = Yes

Have you been there in the last 3 months?
R

When was the first time? Ever:CNA4O01

Onset

/ /
FO

LAST 3 MONTHS CNA4I01

Intensity
0 = No

2 = Yes

Child Health Services Screen 2

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DETENTION CENTER/TRAINING SCHOOL/JAIL

Have you ever been in a detention center or training DETENTION CENTER/TRAINING Ever:CNA5E01
school? SCHOOL/JAIL Intensity
0 = No
In jail or prison?
2 = Yes
How many times?
Ever:CNA5O01
Have you been there in the last 3 months?
Onset

LY
When was the first time?
/ /
LAST 3 MONTHS CNA5I01
Intensity
0 = No

N
2 = Yes

O
GROUP HOME/EMERGENCY SHELTER
Have you ever been in a group home? GROUP HOME/EMERGENCY SHELTER Ever:CNA6E01
Intensity
0 = No
Or an emergency shelter? EW 2 = Yes
Where was that?
Have you been there in the last 3 months? Ever:CNA6O01
When was the first time? Onset

/ /
LAST 3 MONTHS CNA6I01
Intensity
VI

0 = No

2 = Yes
RE

THERAPEUTIC FOSTER CARE

Have you been in therapeutic foster care? THERAPEUTIC FOSTER CARE Ever:CNA7E01
Intensity
0 = No
Where foster parents had been trained to provide care?
2 = Yes

Ever:CNA7O01
R

Onset

/ /
FO

LAST 3 MONTHS CNA7I01

Intensity
0 = No

2 = Yes

Child Health Services Screen 3

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

BOARDING SCHOOL
Or gone to a boarding school for the kinds of problems BOARDING SCHOOL Ever:CNA8E01
you told me about? 0 = No

When did you first (go there)? 2 = Yes

Have you (been there) in the last 3 months?
Was it any help? Ever:CNA8O01
Onset
In what way?
/ /

LY
Did it make things even worse?
How?
LAST THREE MONTHS Ever:CNA8I01
Intensity
0 = No

N
2 = Yes

DAY HOSPITAL/PARTIAL HOSPITALIZATION

O
Have you been to a day hospital? DAY HOSPITAL/PARTIAL Ever:CNA9E01
HOSPITALIZATION Intensity
Or a partial day program at a hospital? 0 = No

Has that been in the last 3 months?

When was the first time?
EW 2 = Yes

Ever:CNA9O01
Onset

/ /
LAST 3 MONTHS CNA9I01
Intensity
VI

0 = No

2 = Yes
RE

OUTPATIENT DRUG OR ALCOHOL CLINIC

Have you been to an outpatient drug or alcohol clinic? OUTPATIENT DRUG OR ALCOHOL Ever:CNB0E01
CLINIC Intensity
Where at? 0 = No
Have you been in the last 3 months?
When did you first go there? 2 = Yes

Ever:CNB0O01
R

Onset

/ /
FO

LAST 3 MONTHS CNB0I01

Intensity
0 = No

2 = Yes

Child Health Services Screen 4

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

MENTAL HEALTH CENTER

A mental health center? MENTAL HEALTH CENTER Ever:CNB1E01
Intensity
0 = No

2 = Yes

Ever:CNB1O01
Onset

/ /

LY
LAST 3 MONTHS CNB1I01
Intensity
0 = No

N
2 = Yes

COMMUNITY HEALTH CENTER

O
A community health center? COMMUNITY HEALTH CENTER Ever:CNB2E01
Intensity
0 = No
Have you been in the last 3 months?
When did you first go there? EW 2 = Yes

Ever:CNB2O01
Onset

/ /
LAST 3 MONTHS CNB2I01
Intensity
0 = No
VI

2 = Yes

CRISIS CENTER
RE

Have you ever been to a crisis center for any kind of CRISIS CENTER Ever:CNB3E01
help? Intensity
0 = No

Have you been in the last 3 months? 2 = Yes

When was the first time?
Ever:CNB3O01
Onset
R

/ /
LAST 3 MONTHS CNB3I01
FO

Intensity
0 = No

2 = Yes

Child Health Services Screen 5

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

IN-HOME COUNSELING/CRISIS SERVICES

Have you ever had in-home counseling or crisis IN-HOME COUNSELING/CRISIS Ever:CNB4E01
services? SERVICES Intensity
0 = No
In the last 3 months?
When did you first have in-home services? 2 = Yes

Ever:CNB4O01
Onset

LY
/ /
LAST 3 MONTHS CNB4I01
Intensity
0 = No

N
2 = Yes

O
PRIVATE PROFESSIONAL TREATMENT
Have you been to a private professional for help with PRIVATE PROFESSIONAL TREATMENT Ever:CNB5E01
any problems? Intensity
0 = No

Or a social worker or a psychiatric nurse?

Has s/he seen them in the last 3 months?

EW 2 = Yes

Ever:CNB5O01
When was the first time? Onset

/ /
LAST 3 MONTHS CNB5I01
Intensity
VI

0 = No

2 = Yes
RE
R
FO

Child Health Services Screen 6

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SCHOOL GUILDANCE COUNSELOR/SCHOOL

PSYCHOLOGIST/SCHOOL SOCIAL WORKER
Have you seen a school guidance counselor for help SCHOOL GUIDANCE Ever:CBP0E01
with the problems we have talked about? COUNSELOR/SCHOOL Intensity
PSYCHOLOGIST/SCHOOL SOCIAL
WORKER
Or a school psychologist?
0 = No
Or a school social worker?
2 = Yes

LY
Or gotten any other sort of help at school? Ever:CBP0O01
Onset
When was the first time?
Have you seen them in the last 3 months? / /

N
LAST 3 MONTHS CBP0I01
Intensity
0 = No

O
2 = Yes

Specify

EW
SPECIAL CLASS (BEHAVIORALLY OR
VI

EMOTIONALLY HANDICAPPED)
Have you been in any special classes? SPECIAL CLASS (BEHAVIORALLY OR Ever:CNB7E01
EMOTIONALLY HANDICAPPED) Intensity
Was it for emotional or behavioral reasons? 0 = No
RE

2 = Yes

Ever:CNB7O01
Onset

/ /
LAST 3 MONTHS CNB7I01
R

Intensity
0 = No

2 = Yes
FO

Specify

Child Health Services Screen 7

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SPECIAL CLASS (LEARNING DISABILITIES/MR)

Have you been in any special classes for other SPECIAL CLASS (LEARNING Ever:CND0E01
reasons? DISABILITIES/MR) Intensity
0 = No
Was it for learning problems?
2 = Yes
Have you seen them in the last 3 months?
Ever:CND0O01
When was the first time?
Onset

LY
/ /
LAST 3 MONTHS CND0I01
Intensity
0 = No

N
2 = Yes

Specify

O
EW
SCHOOL TEACHER
Have you gone to a school teacher for special help SCHOOL TEACHER Ever:CND7E01
about feelings or behaviors? Intensity
0 = No
VI

In the last 3 months? 2 = Yes

When was the first time?
Ever:CND7O01
Onset

/ /
RE

LAST 3 MONTHS CND7I01

Intensity
0 = No

2 = Yes
R
FO

Child Health Services Screen 8

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

SCHOOL NURSE
Or a school nurse? SCHOOL NURSE Ever:CND8E01
Intensity
0 = No
In the last 3 months?
When was the first time? 2 = Yes

Ever:CND8O01
Onset

/ /

LY
LAST 3 MONTHS CND8I01
Intensity
0 = No

N
2 = Yes

EDUCATIONAL TUTORING

O
Have you had educational tutoring (outside of a special EDUCATIONAL TUTORING Ever:CND1E01
class)? Intensity
0 = No

By whom? EW 2 = Yes
What was it for?
Ever:CND1O01
Onset

/ /
LAST 3 MONTHS CND1I01
Intensity
0 = No
VI

2 = Yes

SOCIAL SERVICES
RE

Include visits to Social Services and visits by Social SOCIAL SERVICES Ever:CNB8E01
Services to the home if related to subject's problems. Intensity
0 = No
Include child-related visits if subject's symptoms are related
to children i.e. anxiety, conduct, etc. 2 = Yes

Ever:CNB8O01
Have you seen social services for any of the kinds of Onset
R

problems that you told me about?

/ /
Have you gone there in the last 3 months?
When was the first time? LAST 3 MONTHS CNB8I01
FO

Intensity
0 = No

2 = Yes

Child Health Services Screen 9

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PROBATION OFFICER/JUVENILE
CORRECTION COUNSELOR
Have you ever had a Probation Officer or Juvenile PROBATION OFFICER/JUVENILE Ever:CNB9E01
Correction Counselor? CORRECTION COUNSELOR Intensity
0 = No
When did you first go?
Have you seen them in the last 3 months? 2 = Yes

Ever:CNB9O01

LY
Onset

/ /
LAST 3 MONTHS CNB9I01
Intensity

N
0 = No

2 = Yes

O
FAMILY DOCTOR/OTHER MD
Have you seen your family doctor for any of the kinds FAMILY DOCTOR/OTHER MD Ever:CNC0E01
of problems that you told me about? Intensity
0 = No

Or any other medical doctor?

EW 2 = Yes

In the last 3 months? Ever:CNC0O01

When did you first see a doctor for problems like that? Onset

/ /
CNC0I01
VI

LAST 3 MONTHS
Intensity
0 = No

2 = Yes
RE

HOSPITAL EMERGENCY ROOM

Have you been to a hospital emergency room? HOSPITAL EMERGENCY ROOM Ever:CNC1E01
Intensity
0 = No
Have you been there in the last 3 months?
When was the first time? 2 = Yes
R

Ever:CNC1O01
Onset

/ /
FO

LAST 3 MONTHS CNC1I01

Intensity
0 = No

2 = Yes

Child Health Services Screen 10

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

RELIGIOUS COUNSELOR
If Religious Counselor is a paid pastoral counselor, code RELIGIOUS COUNSELOR Ever:CNC2E01
under Private Professional. Intensity
0 = No

Code here religious, spiritual, faith-based counselors i.e. 2 = Yes

priest, rabbi, minister. Ever:CNC2O01
Onset
Have you seen a minister (priest, rabbi, etc.) for any of
/ /

LY
the kinds of problems you told me about?

Or any other spiritual or faith-based counselor? LAST 3 MONTHS CNC2I01

Intensity
0 = No
Have you seen them in the last 3 months?

N
When was the first time? 2 = Yes

ALTERNATIVE PRACTITIONER/OTHER

O
HEALER
Have you seen any other healers? ALTERNATIVE PRACTITIONER/OTHER Ever:CNC3E01
HEALER Intensity
Such as a faith healer?
Or a medicine man/woman?
Or a curandero?
EW 0 = No

2 = Yes
Or a traditional Indian healer? Ever:CNC3O01
Or an herbalist? Onset
Or a root doctor?
Or a "New Age" practitioner? / /
Or a natural therapist?
VI

Or a touch or health therapist? LAST 3 MONTHS CNC3I01

When did you first (go there)? Intensity
0 = No
Have you seen any of those in the last 3 months?
2 = Yes
RE
R
FO

Child Health Services Screen 11

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

OTHER "NON-PROFESSIONAL" HELP

Assistance from others who are not

professionally trained, licensed, and/or certified
to provide mental health services for fees.

CRISIS HOTLINE
Have you had any other sort of treatmetn of help, such CRISIS HOTLINE Ever:CNC4E01

LY
as: Intensity
0 = No

A crisis hotline? 2 = Yes

When did you first (go there)?
Have you called in the last 3 months? Ever:CNC4O01
Onset

N
/ /
CNC4I01

O
LAST 3 MONTHS
Intensity
0 = No

2 = Yes

SELF-HELP GROUP
EW
Self-help groups, like AA or NA? SELF-HELP GROUP Ever:CNC5E01
Intensity
0 = No
Have you (been there) in the last 3 months?
When did you first (go there)? 2 = Yes
VI

Ever:CNC5O01
Onset

/ /
CNC5I01
RE

LAST 3 MONTHS
Intensity
0 = No

2 = Yes

INTERNET SUPPORT GROUP

R

Internet web sites or chat rooms specific to discussion of INTERNET SUPPORT GROUP Ever:ISG0E01
certain problems, emotions, disorders, or disabilities. Intensity
0 = No
FO

Have you ever sought help from an internet support 2 = Yes

group for the kinds of problems we have talked about? Ever:ISG0O01
Onset
Or participated in chat room conversations about those
kinds of issues or concerns? / /
Have you done that in the last 3 months? LAST 3 MONTHS ISG0I01
When was the first time you sought help online? Intensity
0 = No

2 = Yes

Child Health Services Screen 12

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

HELP FROM RELATIVES

Have you tried to get help from relatives, and this could HELP FROM RELATIVES Ever:CNC6E01
include parents? Intensity
0 = No

Have you talked to them about that in the last 3 months? 2 = Yes
When was the first time?
Ever:CNC6O01
Onset

/ /

LY
LAST 3 MONTHS CNC6I01
Intensity
0 = No

N
2 = Yes

OTHER NON-PROFESSIONAL ADULT HELP

O
Or from other adults, for any of the kinds of problems HELP FROM RELATIVES Ever:CNC7E01
that you told me about? Intensity
0 = No

Have you talked to them about that in the last 3 months?

EW 2 = Yes
When was the first time?
Ever:CNC7O01
Onset

/ /
LAST 3 MONTHS CNC7I01
Intensity
0 = No
VI

2 = Yes

HELP FROM FRIENDS

RE

Have you spoken to friends to get help? HELP FROM FRIENDS Ever:CNC8E01
Intensity
0 = No
Have you talked with them about problems in the last 3
months? 2 = Yes
When was the first time?
Ever:CNC8O01
Onset
R

/ /
HELP FROM FRIENDS CNC8I01
FO

Intensity
0 = No

2 = Yes

Child Health Services Screen 13

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

GENERAL SERVICES USE

This page is to be asked of every subject

interviewed. The intent is to gather inclusive
general information. Detailed Service Forms are
not completed on Non-Mental Health related
services.

LY
*We have asked you in detail about all services
used for emotional, behavioral, or substance
related reasons. Now we would like to briefly
ask about four services used in general over
the last year and over the last 3 months. This
will include any services already mentioned

N
plus services used for reasons other than
emotional, behavioral or substance related
reasons.

O
SPECIAL SERVICES AT SCHOOL
Have you used any student services at school (e.g. SPECIAL SERVICES AT SCHOOL Ever:CND2I01
guidance counselor or special class? Intensity

Have you used them in the last 3 months?

EW 0 = No

2 = Yes

LAST 3 MONTHS CND2I02

Intensity
0 = No

2 = Yes
VI

DEPARTMENT OF SOCIAL SERVICES

Have you received any services from DSS (The DEPARTMENT OF SOCIAL SERVICES Ever:CND3I01
Department of Social Services)? Intensity
RE

0 = No

In the last 3 months? 2 = Yes

LAST 3 MONTHS CND3I02

Intensity
0 = No

2 = Yes
R
FO

Child Health Services Screen 14

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

CONTACT WITH COURT OR JUVENILE

JUSTICE
Have you had any contact with the court or juvenile CONTACT WITH COURT OR JUVENILE Ever:CND4I01
justice services? JUSTICE Intensity
0 = No
In the last 3 months?
2 = Yes

LAST 3 MONTHS CND4I02

LY
Intensity
0 = No

2 = Yes

N
HEALTH PROVIDER
Have you made a visit to a health provider (e.g. family HEALTH PROVIDER Ever:CND5I01
doctor, health center, clinic, ER)? Intensity
0 = No

O
Have you been in the last 3 months? 2 = Yes

LAST 3 MONTHS CND5I02

Intensity
0 = No
EW 2 = Yes

MENTAL HEALTH SERVICES FOR OTHER

THAN CHILD'S OWN PROBLEMS
Have you been to a mental health center or seen a MENTAL HEALTH SERVICES FOR Ever:CND6I01
VI

mental health professional privately for other than your OTHER THAN CHILD'S OWN PROBLEMS Intensity
own mental health problems (mostly for those of 0 = No
another family member)?
2 = Yes
Have you been in the last 3 months?
CND6I02
RE

LAST 3 MONTHS
Intensity
0 = No

2 = Yes
R
FO

Child Health Services Screen 15

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

DETAILED CHILD SERVICES FORM 1

COMPLETE ONE OF THESE FORMS FOR EACH
SETTING WHERE SERVICES HAVE BEEN
USED DURING THE LAST 3 MONTHS
TREATMENT SETTING -
INPATIENT/OUTPATIENT (FORM 1)
Where did you go/whom did you see? TREATMENT SETTING COA0X0Z 00
Intensity
0 = Absent

LY
2 = Present

OVERNIGHT/INPATIENT COA0X99
0 = Absent

N
1 = Psychiatric hospital

2 = Psychiatric unit in general hospital

O
3 = Drug/Alcohol/Detoxification unit

4 = Medical inpatient unit in hospital

5 = Residential Treatment Center

EW 6 = Detention Center/Training School/Jail

7 = Group home/Emergency shelter

8 = Therapeutic Foster Care

9 = Boarding School

OUTPATIENT MENTAL HEALTH COA0X98

TREATMENT
VI

0 = Absent

1 = Partial hospitalization/day program

2 = Drug/Alcohol
RE

3 = Mental health center/Clinic

4 = Communiy health center

5 = Crisis center

6 = In-home counseling/crisis services

R

7 = Private professional treatment

TREATMENT SETTING- FAMILY DOCTOR

FO

Did you see a family doctor? FAMILY DOCTOR COA0X95

Intensity
0 = No

2 = Yes

Detailed Child Services Form 1 1

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

TREATMENT SETTING - PROFESSIONAL/NON-

PROFESSIONAL HELP
Where did you go/whom did you see? TREATMENT SETTING COA0X0X 00
Intensity
0 = Absent

2 = Present

OTHER PROFESSIONAL HELP COA0X97

LY
0 = Absent

1 = School guidance counselor/school

psychologist; school social worker

2 = Special class/BEH

N
3 = Social services

4 = Probation officer/juenile correctional

counselor

O
5 = Family doctor/Other MD

6 = Hospital ER

EW 7 = Religious counselor

8 = Other healer/lternative practitioner

9 = Special class/LD or MR

10 = Educational tutoring

11 = School Teacher

12 = School Nurse
VI

OTHER NON-PROFESSIONAL HELP COA0X96

0 = Absent

1 = Crisis hotline
RE

2 = Self-help group (AA, NA, etc)

3 = Adult family member/Relative

4 = Non-professional adult help

5 = Peer help
R
FO

Detailed Child Services Form 1 2

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PROVIDER'S FOCUS OF TREATMENT

Code here the areas of psychopathology that were a focus ATTENDED TREATMENT SETTING COA0XYZ 00
of treatment provided in this service setting, in the order of Intensity
0 = Absent
their apparent importance. In determining this order,
consider the reason for referral, statements about the aim 2 = Present
of the treatment remembered by the interviewee, and the
FOCUS OF TREATMENT COA0X03
type of treatment provided.
0 = Absent

LY
ATTENDED TREATMENT SETTING. 1 = School non-attendance
COA0X04
What were the main reasons that you "went to 2 = Separation anxiety
treatment setting?" 3 = Worries/anxiety
COA0X05
Were there any other reasons?

N
4 = Obsessions/compulsions
What were they?
5 = Depression
How often (long) did you go/stay in the last 3 months? 6 = Mania

O
AVERAGE LENGTH OF EACH SESSION (IN MINUTES) 7 = Physical symptoms
WITH THAT PARTICULAR PROVIDER. 8 = Food-related behavior

How long was each visit/session? 9 = Hyperactivity/ADD

EW
When did you first go there for this current treatment?
10 = Conduct disorder

11 = Alcohol/Drugs
Are you still going?
12 = Psychosis
IF CHILD HAS STOPPED ATTENDING TREATMENT 13 = Relationships with Parent #1, #2
DURING THE LAST 3 MONTHS, CONTINUE.
14 = Relationships with Other Parent #1, #2
VI

OTHERWISE, SKIP TO SERVICE CONTACT

15 = Relationships with other adults
When did you stop?
16 = Sibling relationships
What were the reasons you stopped treatment?
17 = Peer relationships
RE

CODE 3 REASONS IN ORDER OF APPARENT 18 = Post-Traumatic Stress

IMPORTANCE
19 = Psychological testing/evaluation

20 = Follow-Up care

21 = Other
R

COA0F01
Frequency
FO

LENGTH OF VISIT (FORM 1) COA0D01

COA0O01
Onset

/ /

Detailed Child Services Form 1 3

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STILL ATTENDING COA6I01

0 = No

2 = Yes

DATE STOPPED WITHIN PRIMARY COA6O01

PERIOD (FORM 1)
/ /
REASON(S) STOPPED COA6X01

LY
1 = Planned termination of treatment

2 = Planned termination of treatment

3 = Child improved so stopped going

N
4 = Parent felt "provider" did not understand
what the problem was

5 = Parent disagreed with "provider" about

O
what should be done

6 = Parent and/or child had a bad

experience with this "provider"
EW 7 = Parent and/or child felt discriminated
against

8 = "Provider" was no longer available

(moved or left setting)

9 = Child refused to go

10 = Insurance/managed care company

limited treatment
VI

11 = Too expensive

12 = Parent or child moved

13 = Other
RE

IF INPATIENT, OUTPATIENT OR
FAMILY DOCTOR/OTHER MD,
CONTINUE. OTHERWISE, SKIP TO
"FORMAT OF SERVICE CONTACT
R

(FORM 2)", (PAGE 5).

FO

Detailed Child Services Form 1 4

CAPA-Omnibus Child Version 5.0.0

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FORMAT OF SERVICE CONTACT

I am going to ask you about the different types of FORMAT OF SERVICE CONTACT COA7X01
treatment that you or family may have received in this Intensity
0 = No
setting
2 = Yes
Did you receive .....
ASSESSMENT/EVALUATION/TESTING COA7I01
An assessment/evaluation or psychological testing? 0 = No

LY
Individual therapy? 2 = Yes

INDIVIDUAL THERAPY FOR CHILD COA7I03

Group therapy?
0 = No
Did you or your family receive.....

N
2 = Yes
Family therapy, when "provider" meets with parents and GROUP THERAPY COA7I04
children together?
0 = No

O
Counseling for your "parents" by themselves?
2 = Yes
Family support or educational groups, such as group FAMILY THERAPY COA7I07
meetings with other families?
0 = No
Case management, that is someone who helps
coordinate the services you receive?
EW 2 = Yes

COUNSELING FOR PARENT AND/OR COA7I08

Did your "provider"...... PARTNER

0 = No
Contact or work with your child's school?
2 = Yes
VI

Contact or work with any other services or agencies?

FAMILY GROUP COA7I06
0 = No

2 = Yes
RE

CASE MANAGEMENT COA7I09

0 = No

2 = Yes

CONTACTED SCHOOL COA7I11

R

0 = No

2 = Yes
FO

CONTACTED OTHER SERVICES OR COA7I12

AGENCIES

0 = No

2 = Yes

Detailed Child Services Form 1 5

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PARENTAL INVOLVEMENT
Did your parents participate in any sessions with you? PARENTAL INVOLVEMENT COA1X01
Intensity
0 = Adequate involvement.
How many?
Did you feel they should be more involved? 2 = Parent feels his/her involvement was
insufficient.
Or less involved?
3 = Parent feels his/her involvement was
too extensive.
CODE NUMBER OF SESSIONS ATTENDED IN LAST 3

LY
MONTHS. COA1F01
Frequency

N
OTHER FAMILY INVOLVEMENT
Were other family members involved (apart from your OTHER FAMILY INVOLVEMENT COA2X01

O
parents)? Intensity
0 = Adequate involvement.

Who? 2 = Parent feels his/her involvement was

Did they participate in any sessions? insufficient.

How many?
Did you feel they should be more involved?
EW 3 = Parent feels his/her involvement was
too extensive.

COA2F01
Or less involved? Frequency
VI
RE
R
FO

Detailed Child Services Form 1 6

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TREATMENT APPROACHES
Now I want to ask you about what went on in any of the TREATMENT APPROACHES COA8XYZ 00
treatment sessions you had Intensity
0 = No

Did your "provider" (or any of your "providers")... 2 = Yes

Have you keep a diary of your behavior? KEEP DIARY COA8I01

0 = No
Help you set up a plan for rewarding your good

LY
behavior? 2 = Yes

REWARDS COA8I02
Set up a behavioral contract?
0 = No
Give you any "homework" to practice?

N
2 = Yes
Suggest using "time-outs"? BEHAVIORAL CONTRACT COA8I03
Teach you ways to manage your behavior? 0 = No

O
Teach you ways to relax? 2 = Yes

"HOMEWORK" COA8I04
Teach you how your thoughts can affect how you feel
and behave? 0 = No

Teach you social skills?

EW 2 = Yes

"TIME - OUTS" COA8I05

Teach you how to deal with depressing or anxious
thoughts? 0 = No

2 = Yes
Was medication prescribed for you?
VI

MANAGE BEHAVIOR COA8I06

Are you still taking it?
0 = No
When did you stop?
2 = Yes
OFFSET OF MEDICATION.
RE

RELAXING COA8I07
When did you stop? 0 = No

2 = Yes

THOUGHTS AFFECTING BEHAVIOR COA8I08

0 = No
R

2 = Yes

SOCIAL SKILLS COA8I09

FO

0 = No

2 = Yes

COPING WITH DEPRESSION COA8I10

0 = No

2 = Yes

MEDICATIONS COA8I11
0 = No

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2 = Yes

STILL TAKING COA8I12

0 = No

2 = Yes

COA8O01
Onset

/ /

LY
N
O
EW
VI
RE
R
FO

Detailed Child Services Form 1 8

CAPA-Omnibus Child Version 5.0.0

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RELATIONSHIP WITH PROVIDER

I am now going to read you some statements about your RELATIONSHIPS WITH PROVIDER POA9XYZ 00
experiences with "therapist/clinic." I want you to tell me if Intensity
0 = No
each statement is always true, often true, sometimes true,
rarely true or never true. 2 = Yes

The "health care provider" does a better job helping me ALWAYS/NEVER TRUE POA9I01
than my parents (caretaker) can. 1 = Always True

LY
Does not have as much time for me as I would like. 2 = Often True

3 = Sometimes True
Does not understand what I need.
4 = Rarely True
Criticizes what my parents (caretaker) do with me.

N
5 = Never True
Expects too much from my family and me. ALWAYS/NEVER TRUE POA9I02

Accepts what I have to say when I make recommendations. 1 = Always True

O
2 = Often True
Helps me understand what is going on with my me.
3 = Sometimes True
Respects my wishes and experiences.
4 = Rarely True
Shares information with me.
EW 5 = Never True

Treats me as a partner in my child's care. ALWAYS/NEVER TRUE POA9I03

1 = Always True
Does a good job finding programs suitable for my
child. 2 = Often True
VI

Respects our family's beliefs, customs, and the way in 3 = Sometimes True
which we do things in our family. 4 = Rarely True

Shows concerns about our entire family, not just the 5 = Never True
child with special needs. POA9I04
RE

ALWAYS/NEVER TRUE

Points out what my child and family do well. 1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE POA9I05

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE POA9I06

1 = Always True

Detailed Child Services Form 1 9

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE POA9I07

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE POA9I08
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

ALWAYS/NEVER TRUE POA9I09

1 = Always True

2 = Often True
VI

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE POA9I10

RE

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE POA9I11

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE POA9I12

1 = Always True

Detailed Child Services Form 1 10

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE POA9I13

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE POA9I14
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

OUTCOMES - LESS STRESSED

PERCEIVED BENEFITS OF TREATMENT. LESS STRESSED POA4I04
Intensity
0 = No
VI

DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS

WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

Because of the treatment received with "provider" are

RE

you feeling less stressed about your child?

OUTCOMES - BEHAVIOR IMPROVED

PERCEIVED BENEFITS OF TREATMENT. YES 2 COA4I01
Intensity
R

0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.
FO

Because of the treatment received with "provider" .....

Has your behavior improved?

Detailed Child Services Form 1 11

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OUTCOMES - RELATIONSHIP IMPROVED

PERCEIVED BENEFITS OF TREATMENT. YES 2 COA4I03
Intensity
0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

Have your family relationships improved (less fighting,

LY
more positive interaction, feel better about each
other)?

PATIENT SATISFACTION

N
INTERVIEWER: ALWAYS ANSWER YES TO ASK PATIENT OPINION COA5XYZ 00
FOLLOWING QUESTIONS. Intensity
0 = No

O
If you needed a "provider" in the furutre, would you 2 = Yes
return to the same "provider" again?
RETURN TO CLINIC COA5I01
IF NO, EW 0 = No

Why not? 2 = Yes

RECOMMEND COA5I02
If you were going to recommend a "provider" to a
friend, would you recommend this "provider"? 0 = No

IF NO, 2 = Yes
VI

Why not?

PAYMENT
COA3XYZ 00
RE

Do you know how this was paid for? PAYMENT

Intensity
0 = No
Did you pay any of the cost yourself?
Did your "parent" pay anything? 2 = Yes

How much have you paid in the last 3 months? FAMILY OUT-OF-POCKET EXPENSE COA3X01
0 = Parent or child paid all of cost of
R

services

1 = Parent or child paid some of cost.

FO

2 = Parent or child paid none of cost.

COA3X02
Frequency

Detailed Child Services Form 1 12

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DETAILED CHILD SERVICES FORM 2

TREATMENT SETTING -
INPATIENT/OUTPATIENT (FORM 2)
Where did you go/whom did you see? TREATMENT SETTING COB0X0Z 00
Intensity
0 = Absent

2 = Present

OVERNIGHT/INPATIENT COB0X99

LY
0 = Absent

1 = Psychiatric hospital

2 = Psychiatric unit in general hospital

N
3 = Drug/Alcohol/Detoxification unit

4 = Medical inpatient unit in hospital

O
5 = Residential Treatment Center

6 = Detention Center/Training School/Jail

7 = Group home/Emergency shelter

8 = Therapeutic Foster Care

EW 9 = Boarding School

OUTPATIENT MENTAL HEALTH COB0X98

TREATMENT

0 = Absent

1 = Partial hospitalization/day program

VI

2 = Drug/Alcohol

3 = Mental health center/Clinic

4 = Communiy health center

RE

5 = Crisis center

6 = In-home counseling/crisis services

7 = Private professional treatment

R

TREATMENT SETTING- FAMILY DOCTOR

(FORM 2)
Did you see a family doctor? FAMILY DOCTOR COB0X95
FO

Intensity
0 = No

2 = Yes

Detailed Child Services Form 2 1

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

TREATMENT SETTING - PROFESSIONAL/NON-

PROFESSIONAL HELP (FORM 2)
Where did you go/whom did you see? TREATMENT SETTING COB0X0X 00
Intensity
0 = Absent

2 = Present

OTHER PROFESSIONAL HELP COB0X97

LY
0 = Absent

1 = School guidance counselor/school

psychologist; school social worker

2 = Special class/BEH

N
3 = Social services

4 = Probation officer/juenile correctional

counselor

O
5 = Family doctor/Other MD

6 = Hospital ER

EW 7 = Religious counselor

8 = Other healer/lternative practitioner

9 = Special class/LD or MR

10 = Educational tutoring

11 = School Teacher

12 = School Nurse
VI

OTHER NON-PROFESSIONAL HELP COB0X96

0 = Absent

1 = Crisis hotline
RE

2 = Self-help group (AA, NA, etc)

3 = Adult family member/Relative

4 = Non-professional adult help

5 = Peer help
R
FO

Detailed Child Services Form 2 2

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

PROVIDER'S FOCUS OF TREATMENT (FORM 2)

Code here the areas of psychopathology that were a focus ATTENDED TREATMENT SETTING COB0XYZ 00
of treatment provided in this service setting, in the order of Intensity
0 = Absent
their apparent importance. In determining this order,
consider the reason for referral, statements about the aim 2 = Present
of the treatment remembered by the interviewee, and the
FOCUS OF TREATMENT COB0X03
type of treatment provided.
0 = Absent

LY
What were the main reasons that you "went to 1 = School non-attendance
treatment setting"? COB0X04
2 = Separation anxiety
Were there any other reasons? 3 = Worries/anxiety
What were they?
COB0X05

N
4 = Obsessions/compulsions
How often (long) did you go/stay in the last 3 months?
5 = Depression
AVERAGE LENGTH OF EACH SESSION (IN MINUTES) 6 = Mania

O
WITH THAT PARTICULAR PROVIDER.
7 = Physical symptoms
How long was each visit/session? 8 = Food-related behavior

When did you first go there for this current treatment? 9 = Hyperactivity/ADD

Are you still going?

EW 10 = Conduct disorder

11 = Alcohol/Drugs
IF CHILD HAS STOPPED ATTENDING TREATMENT
12 = Psychosis
DURING THE LAST 3 MONTHS, CONTINUE.
OTHERWISE, SKIP TO SERVICE CONTACT 13 = Relationships with Parent #1, #2

14 = Relationships with Other Parent #1, #2

VI

When did you stop?

15 = Relationships with other adults
What were the reasons you stopped treatment?
16 = Sibling relationships
code 3 reasons in order of apparent importance
17 = Peer relationships
RE

18 = Post-Traumatic Stress

19 = Psychological testing/evaluation

20 = Follow-Up care

21 = Other
R

COB0F01
Frequency
FO

LENGTH OF VISIT (FORM 1) COB0D01

COB0O01
Onset

/ /

Detailed Child Services Form 2 3

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STILL ATTENDING COB6I01

0 = No

2 = Yes

DATE STOPPED WITHIN PRIMARY COB6O01

PERIOD (FORM 1)
/ /
REASON(S) STOPPED POB6X01

LY
1 = Planned termination of treatment

2 = Planned termination of treatment

3 = Child improved so stopped going

N
4 = Parent felt "provider" did not understand
what the problem was

5 = Parent disagreed with "provider" about

O
what should be done

6 = Parent and/or child had a bad

experience with this "provider"
EW 7 = Parent and/or child felt discriminated
against

8 = "Provider" was no longer available

(moved or left setting)

9 = Child refused to go

10 = Insurance/managed care company

limited treatment
VI

11 = Too expensive

12 = Parent or child moved

13 = Other
RE

IF INPATIENT, OUTPATIENT OR
FAMILY DOCTOR/OTHER MD,
CONTINUE. OTHERWISE, SKIP TO
"FORMAT OF SERVICE CONTACT
R

(FORM 3)", (PAGE 5).

FO

Detailed Child Services Form 2 4

CAPA-Omnibus Child Version 5.0.0

Definitions and questions Coding rules Codes

FORMAT OF SERVICE CONTACT (FORM 2)

I am going to ask you about the different types of FORMAT OF SERVICE CONTACT COB7X01
treatment that you or family may have received in this Intensity
0 = No
setting.
2 = Yes
Did you recieve......
ASSESSMENT/EVALUATION/TESTING COB7I01
An assessment/evaluation or psychological testing? 0 = No

LY
Individual therapy? 2 = Yes

INDIVIDUAL THERAPY FOR CHILD COB7I03

Group therapy?
0 = No
Did you or your family receive.....

N
2 = Yes
Family therapy, when "provider" meets with parents GROUP THERAPY COB7I04
and children together?
0 = No

O
Counseling for you alone or counseling for you and
2 = Yes
your partner?
FAMILY THERAPY COB7I07
Family support or educational groups, such as group
meetings with other families? 0 = No

Case management, that is someone who helps

EW 2 = Yes

coordinate the services you receive? COUNSELING FOR PARENT AND/OR COB7I08
PARTNER
Did your "provider"....... 0 = No

Contact or work with your child's school? 2 = Yes

VI

Contact or work with any other services or agencies? FAMILY GROUP COB7I06
0 = No

2 = Yes
RE

CASE MANAGEMENT COB7I09

0 = No

2 = Yes

CONTACTED SCHOOL COB7I11

R

0 = No

2 = Yes
FO

CONTACTED OTHER SERVICES OR COB7I12

AGENCIES

0 = No

2 = Yes

Detailed Child Services Form 2 5

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PARENTAL INVOLVEMENT (FORM 2)

Did your parents participate in any sessions with you? PARENTAL INVOLVEMENT COB1X01
Intensity
0 = Adequate involvement.
How many?
Did you feel they should be more involved? 2 = Parent feels his/her involvement was
insufficient.
Or less involved?
3 = Parent feels his/her involvement was
too extensive.
CODE NUMBER OF SESSIONS ATTENDED IN LAST 3

LY
MONTHS. COB1F01
Frequency

N
OTHER FAMILY INVOLVEMENT (FORM 2)
Were other family members involved (apart from you OTHER FAMILY INVOLVEMENT COB2X01

O
and your parents)? Intensity
0 = Adequate involvement.

Who? 2 = Parent feels his/her involvement was

Did they participate in any sessions? insufficient.

How many?
Or less involved?
EW 3 = Parent feels his/her involvement was
too extensive.

COB2F01
Did you feel they should be more involved? Frequency
VI
RE
R
FO

Detailed Child Services Form 2 6

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TREATMENT APPROACHES (FORM 2)

Now I want to ask you about what went on in any of the TREATMENT APPROACHES COB8XYZ 00
treatment sessions you had. Intensity
0 = No

Did your "provider" (or any of your "providers")... 2 = Yes

Have you keep a diary of your behavior? KEEP DIARY COB8I01

0 = No
Help you set up a plan for rewarding your good

LY
behavior? 2 = Yes

REWARDS COB8I02
Set up a behavioral contract?
0 = No
Give you any "homework" to practice?

N
2 = Yes
Suggest using "time-outs"? BEHAVIORAL CONTRACT COB8I03
Teach you ways to manage your behavior? 0 = No

O
Teach you ways to relax? 2 = Yes

"HOMEWORK" COB8I04
Teach you how thoughts can affect how you feel and
behave? 0 = No

Teach you social skills?

EW 2 = Yes

"TIME - OUTS" COB8I05

Teach you how to deal with depressing or anxious
thoughts? 0 = No

2 = Yes
Was medication prescribed for you?
VI

MANAGE BEHAVIOR COB8I06

Are you still taking it?
0 = No
Are you still taking it? 2 = Yes
RE

OFFSET OF MEDICATION. RELAXING COB8I07

0 = No
When did you stop?
2 = Yes

THOUGHTS AFFECTING BEHAVIOR COB8I08

0 = No
R

2 = Yes

SOCIAL SKILLS COB8I09

FO

0 = No

2 = Yes

COPING WITH DEPRESSION COB8I10

0 = No

2 = Yes

MEDICATIONS COB8I11
0 = No

Detailed Child Services Form 2 7

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2 = Yes

STILL TAKING COB8I12

0 = No

2 = Yes

COB8O01
Onset

/ /

LY
N
O
EW
VI
RE
R
FO

Detailed Child Services Form 2 8

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RELATIONSHIP WITH PROVIDER (FORM 2)

I am now going to read you some statements about your RELATIONSHIPS WITH PROVIDER COB9XYZ 00
experiences with "therapist/clinic." I want you to tell me if Intensity
0 = No
each statement is always true, often true, sometimes true,
rarely true or never true. 2 = Yes

The "health care provider" does a better job helping my ALWAYS/NEVER TRUE COB9I01
child than I can myself. 1 = Always True

LY
Does not have as much time for me as I would like. 2 = Often True

3 = Sometimes True
Does not understand what my child needs.
4 = Rarely True
Criticizes what I do with my child.

N
5 = Never True
Expects too much from my family and me. ALWAYS/NEVER TRUE COB9I02

Accepts what I have to say when I make recommendations. 1 = Always True

O
2 = Often True
Helps me understand what is going on with my child.
3 = Sometimes True
Respects my wishes and experiences.
4 = Rarely True
Shares information with me.
EW 5 = Never True

Treats me as a partner in my child's care. ALWAYS/NEVER TRUE COB9I03

1 = Always True
Does a good job finding programs suitable for my
child. 2 = Often True
VI

Respects our family's beliefs, customs, and the way in 3 = Sometimes True
which we do things in our family. 4 = Rarely True

Shows concerns about our entire family, not just the 5 = Never True
child with special needs. COB9I04
RE

ALWAYS/NEVER TRUE

Points out what my child and family do well. 1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE COB9I05

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COB9I06

1 = Always True

Detailed Child Services Form 2 9

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COB9I07

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE COB9I08
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

ALWAYS/NEVER TRUE COB9I09

1 = Always True

2 = Often True
VI

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COB9I10

RE

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE COB9I11

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COB9I12

1 = Always True

Detailed Child Services Form 2 10

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COB9I13

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE COB9I14
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

OUTCOMES - LESS STRESSED (FORM 2)

PERCEIVED BENEFITS OF TREATMENT. LESS STRESSED COB4I04
Intensity
0 = No
VI

DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS

WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

OUTCOMES - BEHAVIOR IMPROVED (FORM 2)

RE

PERCEIVED BENEFITS OF TREATMENT. YES 2 COB4I01

Intensity
0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.
R

Because of the treatment received with "provider" .....

Has your behavior improved?

FO

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OUTCOMES - RELATIONSHIP IMPROVED

(FORM 2)
PERCEIVED BENEFITS OF TREATMENT. YES 2 COB4I03
Intensity
0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

LY
Have your family relationships improved (less fighting,
more positive interaction, feel better about each
other)?

N
PATIENT SATISFACTION (FORM 2)
INTERVIEWER: ALWAYS ANSWER YES TO ASK PATIENT OPINION COB5XYZ 00
FOLLOWING QUESTIONS. Intensity

O
0 = No

If you needed a "provider" in the future, would you 2 = Yes

return to the same "provider" again?
RETURN TO CLINIC COB5I01
IF NO,

Why not? (Record Verbatim)

EW 0 = No

2 = Yes

RECOMMEND COB5I02
If you were going to recommend a "provider" to a friend,
would you recommend this "provider"? 0 = No
IF NO,
2 = Yes
VI

Why not? (Record Verbatim)

PAYMENT (FORM 2)
RE

Do you know how this was paid for? PAYMENT CPOB3XYZ00

Intensity
0 = No
Did you pay any of the cost yourself?
Did your "parent" pay anything? 2 = Yes

How much have you paid in the last 3 months? FAMILY OUT-OF-POCKET EXPENSE COB3X01
0 = Parent or child paid all of cost of
R

services

1 = Parent or child paid some of cost.

FO

2 = Parent or child paid none of cost.

COB3X02
Frequency

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DETAILED CHILD SERVICES FORM 3

TREATMENT SETTING -
INPATIENT/OUTPATIENT (FORM 3)
Where did you go/whom did you see? TREATMENT SETTING COC0X0Z 00
Intensity
0 = Absent

2 = Present

OVERNIGHT/INPATIENT COC0X99

LY
0 = Absent

1 = Psychiatric hospital

2 = Psychiatric unit in general hospital

N
3 = Drug/Alcohol/Detoxification unit

4 = Medical inpatient unit in hospital

O
5 = Residential Treatment Center

6 = Detention Center/Training School/Jail

7 = Group home/Emergency shelter

8 = Therapeutic Foster Care

EW 9 = Boarding School

OUTPATIENT MENTAL HEALTH COC0X98

TREATMENT

0 = Absent

1 = Partial hospitalization/day program

VI

2 = Drug/Alcohol

3 = Mental health center/Clinic

4 = Communiy health center

RE

5 = Crisis center

6 = In-home counseling/crisis services

7 = Private professional treatment

R

TREATMENT SETTING- FAMILY DOCTOR

(FORM 3)
Did you see a family doctor? FAMILY DOCTOR COC0X95
FO

Intensity
0 = No

2 = Yes

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TREATMENT SETTING - PROFESSIONAL/NON-

PROFESSIONAL HELP (FORM 3)
Where did you go/whom did you see? TREATMENT SETTING COC0X0X 00
Intensity
0 = Absent

2 = Present

OTHER PROFESSIONAL HELP COC0X97

LY
0 = Absent

1 = School guidance counselor/school

psychologist; school social worker

2 = Special class/BEH

N
3 = Social services

4 = Probation officer/juenile correctional

counselor

O
5 = Family doctor/Other MD

6 = Hospital ER

EW 7 = Religious counselor

8 = Other healer/lternative practitioner

9 = Special class/LD or MR

10 = Educational tutoring

11 = School Teacher

12 = School Nurse
VI

OTHER NON-PROFESSIONAL HELP COC0X96

0 = Absent

1 = Crisis hotline
RE

2 = Self-help group (AA, NA, etc)

3 = Adult family member/Relative

4 = Non-professional adult help

5 = Peer help
R
FO

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PROVIDER'S FOCUS OF TREATMENT (FORM 3)

Code here the areas of psychopathology that were a focus ATTENDED TREATMENT SETTING COC0XYZ 00
of treatment provided in this service setting, in the order of Intensity
0 = Absent
their apparent importance. In determining this order,
consider the reason for referral, statements about the aim 2 = Present
of the treatment remembered by the interviewee, and the
FOCUS OF TREATMENT COC0X03
type of treatment provided.
0 = Absent

LY
What were the main reasons that you "went to 1 = School non-attendance
treatment setting"? COC0X04
2 = Separation anxiety
Were there any other reasons? 3 = Worries/anxiety
What were they?
COC0X05

N
4 = Obsessions/compulsions
How often (long) did you go/stay in the last 3 months?
5 = Depression
AVERAGE LENGTH OF EACH SESSION (IN MINUTES) 6 = Mania

O
WITH THAT PARTICULAR PROVIDER.
7 = Physical symptoms
How long was each visit/session? 8 = Food-related behavior

When did you first go there for this current treatment? 9 = Hyperactivity/ADD

Are still going?

EW 10 = Conduct disorder

11 = Alcohol/Drugs
IF CHILD HAS STOPPED ATTENDING TREATMENT
12 = Psychosis
DURING THE LAST 3 MONTHS, CONTINUE.
OTHERWISE, SKIP TO SERVICE CONTACT 13 = Relationships with Parent #1, #2

14 = Relationships with Other Parent #1, #2

VI

When did you stop?

15 = Relationships with other adults
What were the reasons you stopped treatment?
16 = Sibling relationships
CODE 3 REASONS IN ORDER OF APPARENT
17 = Peer relationships
RE

IMPORTANCE
18 = Post-Traumatic Stress

19 = Psychological testing/evaluation

20 = Follow-Up care

21 = Other
R

COC0F01
Frequency
FO

LENGTH OF VISIT (FORM 1) COC0D01

COC0O01
Onset

/ /

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STILL ATTENDING COC6I01

0 = No

2 = Yes

DATE STOPPED WITHIN PRIMARY COC6O01

PERIOD (FORM 1)
/ /
REASON(S) STOPPED COC6X01

LY
1 = Planned termination of treatment

2 = Planned termination of treatment

3 = Child improved so stopped going

N
4 = Parent felt "provider" did not understand
what the problem was

5 = Parent disagreed with "provider" about

O
what should be done

6 = Parent and/or child had a bad

experience with this "provider"
EW 7 = Parent and/or child felt discriminated
against

8 = "Provider" was no longer available

(moved or left setting)

9 = Child refused to go

10 = Insurance/managed care company

limited treatment
VI

11 = Too expensive

12 = Parent or child moved

13 = Other
RE

IF INPATIENT, OUTPATIENT OR
FAMILY DOCTOR/OTHER MD,
CONTINUE. OTHERWISE, SKIP TO
"ANTICIPATED LOSS OF PARENTAL
R

RIGHTS", (PAGE 5).

FO

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FORMAT OF SERVICE CONTACT (FORM 3)

I am going to ask you about the different types of FORMAT OF SERVICE CONTACT COC7X01
treatment that you or family may have received in this Intensity
0 = No
setting
2 = Yes
Did you receive......
ASSESSMENT/EVALUATION/TESTING COC7I01
An assessment/evaluation or psychological testing? 0 = No

LY
Individual therapy? 2 = Yes

INDIVIDUAL THERAPY FOR CHILD COC7I03

Group therapy?
0 = No
Did you or your family receive......

N
2 = Yes
Family therapy, when "provider" meets with parents GROUP THERAPY COC7I04
and children together?
0 = No

O
Counseling for your "parents" by themselves?
2 = Yes
Family support or educational groups, such as group FAMILY THERAPY COC7I07
meetings with other families?
0 = No
Case management, that is someone who helps
coordinate the services you receive?
EW 2 = Yes

COUNSELING FOR PARENT AND/OR COC7I08

Did your "provider"...... PARTNER

0 = No
Contact or work with your school?
2 = Yes
VI

Contact or work with any other services or agencies?

FAMILY GROUP COC7I06
0 = No

2 = Yes
RE

CASE MANAGEMENT COC7I09

0 = No

2 = Yes

CONTACTED SCHOOL COC7I11

R

0 = No

2 = Yes
FO

CONTACTED OTHER SERVICES OR COC7I12

AGENCIES

0 = No

2 = Yes

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PARENTAL INVOLVEMENT (FORM 3)

Did your parents participate in any sessions with you? PARENTAL INVOLVEMENT COC1X01
Intensity
0 = Adequate involvement.
How many?
Did you feel you should be more involved? 2 = Parent feels his/her involvement was
insufficient.
Or less involved?
3 = Parent feels his/her involvement was
too extensive.
CODE NUMBER OF SESSIONS ATTENDED IN LAST 3

LY
MONTHS. COC1F01
Frequency

N
OTHER FAMILY INVOLVEMENT (FORM 3)
Were other family members involved (apart from you OTHER FAMILY INVOLVEMENT COC2X01

O
and your parents)? Intensity
0 = Adequate involvement.

Who? 2 = Parent feels his/her involvement was

Did they participate in any sessions? insufficient.

How many?
Did you feel they should be more involved?
EW 3 = Parent feels his/her involvement was
too extensive.

COC2F01
Or less involved? Frequency
VI
RE
R
FO

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TREATMENT APPROACHES (FORM 3)

Now I want to ask you about what wen on in any of the TREATMENT APPROACHES COC8XYZ 00
treatment sessions you had. Intensity
0 = No

Did your "provider" (or any of your "providers")... 2 = Yes

Have you keep a diary of your behavior? KEEP DIARY COC8I01

0 = No
Help you set up a plan for rewarding your good

LY
behavior? 2 = Yes

REWARDS COC8I02
Set up a behavioral contract?
0 = No
Give you any "homework" to practice?

N
2 = Yes
Suggest using "time-outs"? BEHAVIORAL CONTRACT COC8I03
Teach you ways to manage your behavior? 0 = No

O
Teach you ways to relax? 2 = Yes

"HOMEWORK" COC8I04
Teach you how your thoughts can affect how you feel
and behave? 0 = No

Teach you social skills?

EW 2 = Yes

"TIME - OUTS" COC8I05

Teach you how to deal with depressing or anxious
thoughts? 0 = No

2 = Yes
Was medication prescribed for you?
VI

MANAGE BEHAVIOR COC8I06

Are you still taking it?
0 = No
Are still taking it? 2 = Yes
RE

OFFSET OF MEDICATION. RELAXING COC8I07

0 = No
When did you stop?
2 = Yes

THOUGHTS AFFECTING BEHAVIOR COC8I08

0 = No
R

2 = Yes

SOCIAL SKILLS COC8I09

FO

0 = No

2 = Yes

COPING WITH DEPRESSION COC8I10

0 = No

2 = Yes

MEDICATIONS COC8I11
0 = No

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2 = Yes

STILL TAKING COC8I12

0 = No

2 = Yes

COC8O01
Onset

/ /

LY
N
O
EW
VI
RE
R
FO

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RELATIONSHIP WITH PROVIDER (FORM 3)

I am now going to read you some statements about your RELATIONSHIPS WITH PROVIDER COC9XYZ 00
experiences with "therapist/clinic." I want you to tell me if Intensity
0 = No
each statement is always true, often true, sometimes true,
rarely true or never true. 2 = Yes

The "health care provider" does a better job helping my ALWAYS/NEVER TRUE COC9I01
child than I can myself. 1 = Always True

LY
Does not have as much time for me as I would like. 2 = Often True

3 = Sometimes True
Does not understand what my child needs.
4 = Rarely True
Criticizes what I do with my child.

N
5 = Never True
Expects too much from my family and me. ALWAYS/NEVER TRUE COC9I02

Accepts what I have to say when I make recommendations. 1 = Always True

O
2 = Often True
Helps me understand what is going on with my child.
3 = Sometimes True
Respects my wishes and experiences.
4 = Rarely True
Shares information with me.
EW 5 = Never True

Treats me as a partner in my child's care. ALWAYS/NEVER TRUE COC9I03

1 = Always True
Does a good job finding programs suitable for my
child. 2 = Often True
VI

Respects our family's beliefs, customs, and the way in 3 = Sometimes True
which we do things in our family. 4 = Rarely True

Shows concerns about our entire family, not just the 5 = Never True
child with special needs. COC9I04
RE

ALWAYS/NEVER TRUE

Points out what my child and family do well. 1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE COC9I05

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COC9I06

1 = Always True

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COC9I07

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE COC9I08
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

ALWAYS/NEVER TRUE COC9I09

1 = Always True

2 = Often True
VI

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COC9I10

RE

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True
R

5 = Never True

ALWAYS/NEVER TRUE COC9I11

FO

1 = Always True

2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COC9I12

1 = Always True

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2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

ALWAYS/NEVER TRUE COC9I13

1 = Always True

LY
2 = Often True

3 = Sometimes True

4 = Rarely True

5 = Never True

N
ALWAYS/NEVER TRUE COC9I14
1 = Always True

O
2 = Often True

3 = Sometimes True

4 = Rarely True
EW 5 = Never True

OUTCOMES - LESS STRESSED (FORM 3)

PERCEIVED BENEFITS OF TREATMENT. LESS STRESSED COC4I04
Intensity
0 = No
VI

DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS

WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

Because of the treatment received with "provider"......

RE

OUTCOMES - BEHAVIOR IMPROVED (FORM 3)

PERCEIVED BENEFITS OF TREATMENT. YES 2 COC4I01
Intensity
0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
R

WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes

CODE AS STRUCTURALLY MISSING.
FO

Because of the treatment received with "provider".....

Has your behavior improved?

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OUTCOMES - RELATIONSHIP IMPROVED

(FORM 3)
PERCEIVED BENEFITS OF TREATMENT. YES 2 COC4I03
Intensity
0 = No
DETERMINE IF "NO" MEANS "NO CHANGE" OR "THIS
WAS NEVER A PROBLEM." IF NEVER A PROBLEM, 2 = Yes
CODE AS STRUCTURALLY MISSING.

LY
Have your family relationships improved (less fighting,
more positive interaction, feel better about each
other)?

N
PATIENT SATISFACTION (FORM 3)
INTERVIEWER: ALWAYS ANSWER YES TO ASK PATIENT OPINION COC5XYZ 00
FOLLOWING QUESTIONS. Intensity

O
0 = No

If you needed a "provider" in the future, would you 2 = Yes

return to the same "provider" again?
RETURN TO CLINIC COC5I01
IF NO,

Why not? (Record Verbatim)

EW 0 = No

2 = Yes

RECOMMEND COC5I02
If you were going to recommend a "provider" to a
friend, would you recommend this "provider"? 0 = No

IF NO, 2 = Yes
VI

Why not? (Recoder Verbatim)

PAYMENT (FORM 3)
RE

Do you know how this was paid for? PAYMENT COC3XYZ 00

Intensity
0 = No
Did you pay any of the cost yourself?
Did your "parent" pay anything? 2 = Yes

How much have you paid in the last 3 months? FAMILY OUT-OF-POCKET EXPENSE COC3X01
R

0 = Parent or child paid all of cost of

services

1 = Parent or child paid some of cost.

FO

2 = Parent or child paid none of cost.

COC3X02
Frequency

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ATTITUDES AND BARRIERS TO SERVICES

RECEPTIVITY TO SERVICES
GENERAL RECEPTIVITY
The degree to which an individual thinks that professional GENERAL RECEPTIVITY CPA0I01
services for emotional or behavioral problems are generally Intensity
0 = Sees professional services as an
beneficial and an appropriate response to major problems. appropriate response to major emotional or
behavioral problems for people

LY
When people have a serious emotional or behavioral 1 = Sees professional services as probably
problem, do you think it is a good idea for them to try appropriate for major problems for people
to get help or treatment?
2 = Sees professional services as probably
not appropriate for major problems for
Do you think people like counselors or doctors can people
help with the kinds of emotional and behavioral

N
problems people have? 3 = Sees professional services as definitely
not appropriate for major emotional or
behavioral problems for people

O
EW
VI
RE
R
FO

Attitudes and Barriers to Services 1

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PERCEPTION OF BARRIERS TO SERVICE

Subject's statement that certain circumstances

or feelings influenced his/her decision to seek
treatment for problems or influenced the
response to services.

FEAR, DISLIKE, OR DISTRUST OF

LY
PROFESSIONALS
Concern or discomfort with using services caused by FEAR, DISLIKE, DISTRUST OF CPA1I01
subject's fear, dislike, or distrust of talking with PROFESSIONALS Intensity
professionals. 0 = Absent

N
2 = Present
How do you feel about talking with doctors,
counselors, or other professionals? IF SYMPTOMS CPA1I02
0 = Present but did not keep from getting

O
Have you talked with anyone like that about the kinds of
help
problems we have talked about?
Tell me about the last time. 2 = Present and delayed subject from
What made you uncomfortable? getting some/other particular services in
EW past 3 months
IF SYMPTOMS IN LAST 3 MONTHS, ASK: 3 = Present and stopped subject from
getting some/other particular services
Were there any times in the past 3 months when you
didn't get help because of this feeling about "doctors"? IF SERVICES CPA1I03
0 = Present, but no effect on services
IF SERVICES IN LAST 3 MONTHS, ASK:
2 = Present, and had some effect on
Did this "feeling" make a difference when you got help response to services actually used in past 3
VI

months (missed appointments, not talk

in the past 3 months? freely, not follow recommendations, etc.)

What difference did it make? 3 = Quit getting services

RE
R
FO

Attitudes and Barriers to Services 2

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PREVIOUS NEGATIVE EXPERIENCE

Concern or discomfort with using services caused by PREVIOUS NEGATIVE EXPERIENCE Ever:CPA2E01
subject's previous negative experience with professional(s). Intensity
0 = Absent

Have you ever had a "bad experience/trouble" with a 2 = Present

"professional/provider" that kept you from getting help IF SYMPTOMS CPA2I01
again? Intensity
0 = Present but did not keep from getting

LY
Tell me about it. help

2 = Present and delayed subject from

IF SYMPTOMS IN LAST 3 MONTHS, ASK: getting some/other particular services in
past 3 months
Were there any times in the past 3 months when you
3 = Present and stopped subject from
didn't get help because of "this experience"?

N
getting some/other particular services

IF SERVICES IN LAST 3 MONTHS, ASK: IF SERVICES CPA2I02

O
Did "this experience" make a difference when you got 0 = Present, but no effect on services
help in the past 3 months? 2 = Present, and had some effect on
response to services actually used in past 3
What difference did it make? months (missed appointments, not talk
EW freely, not follow recommendations, etc.)

3 = Quit getting services

SELF-CONCIOUSNESS
Reluctance to use services caused by self-conciousness SELF-CONCIOUSNESS CPA3I01
about admitting having a problem or about seeking help for Intensity
0 = Absent
it. Also inability to talk with anyone about such sensitive
VI

issues. 2 = Present

IF SYMPTOMS CPA3I02
Is it hard for you to talk to others about a problem?
0 = Present but did not keep from getting
RE

Or to ask others for help? help

2 = Present and delayed subject from

Do you feel embarrassed or self-conscious? getting some/other particular services in
past 3 months
IF SYMPTOMS IN LAST 3 MONTHS, ASK:
3 = Present and stopped subject from
getting some/other particular services
Were there any times in the past 3 months when you
R

didn't get help because it would be "embarrassing"? IF SERVICES CPA3I03

IF SERVICES IN LAST 3 MONTHS, ASK: 0 = Present, but no effect on services

FO

2 = Present, and had some effect on

Did this "feeling" make a difference when you got help response to services actually used in past 3
in the past 3 months? months (missed appointments, not talk
freely, not follow recommendations, etc.)
What difference did it make? 3 = Quit getting services

Attitudes and Barriers to Services 3

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ANTICIPATION OF NEGATIVE REACTION

Reluctance to use services caused by anticipation of a ANTICIPATION OF NEGATIVE CPA4I01
negative reaction from family, friends, or others to seeking REACTION Intensity
treatment for an emotional or mental problem. 0 = Absent

2 = Present
Are you concerned about what your family will think
about you getting help? IF SYMPTOMS CPA4I02

LY
Or about what your friends would think? 0 = Present but did not keep from getting
help
Or about what others would think? 2 = Present and delayed subject from
getting some/other particular services in
What do you think they would say? past 3 months

N
3 = Present and stopped subject from
IF SYMPTOMS IN LAST 3 MONTHS, ASK: getting some/other particular services

Were there any times in the past 3 months when you IF SERVICES CPA4I03

O
didn't get help because you were "concerned what
0 = Present, but no effect on services
others would think"?
2 = Present, and had some effect on
IF SERVICES IN LAST 3 MONTHS, ASK: response to services actually used in past 3
months (missed appointments, not talk
freely, not follow recommendations, etc.)
help in the past 3 months?
EW
Did "this concern" make a difference when you got
3 = Quit getting services

What difference did it make?

ANTICIPATION OF OUT OF HOME PLACEMENT

VI

Reluctance to use services caused by fear that subject's ANTICIPATION OF OUT OF HOME CPA5I01
children might be at greater risk of out-of-home placement. PLACEMENT Intensity
0 = Absent
Were you concerned that you might be taken from your
2 = Present
RE

home?
IF SYMPTOMS CPA5I02
Or that you might have to go live somewhere else?
0 = Present but did not keep from getting
help
What did you think might happen?
2 = Present and delayed subject from
IF SYMPTOMS IN LAST 3 MONTHS, ASK: getting some/other particular services in
past 3 months
R

Were there any times in the last 3 months when you

3 = Present and stopped subject from
didn't get help because of "this concern"? getting some/other particular services
FO

IF SERVICES IN LAST 3 MONTHS, ASK: IF SERVICES CPA5103

0 = Present, but no effect on services
Did "this concern" make a difference when you got
help in the past 3 months? 2 = Present, and had some effect on
response to services actually used in past 3
What difference did it make? months (missed appointments, not talk
freely, not follow recommendations, etc.)

3 = Quit getting services

Attitudes and Barriers to Services 4

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ANTICIPATED LOSS OF PARENTAL RIGHTS

Reluctance to use services caused by fear that subject ANTICIPATION OF LOSS OF PARENTAL CPA6I01
might be seen as an unfit parent and lose parental rights. RIGHTS Intensity
0 = Absent
Were you concerned that your parents might not be
2 = Present
allowed to take care of you anymore?
IF SYMPTOMS CPA6I02
What did you think might happen?

LY
0 = Present but did not keep from getting
help
IF SYMPTOMS IN LAST 3 MONTHS, ASK:
2 = Present and delayed subject from
Was there any time in the last 3 months when you getting some/other particular services in
didn't get help because of "this concern"? past 3 months

N
3 = Present and stopped subject from
IF SERVICES IN LAST 3 MONTHS, ASK: getting some/other particular services

Did "this concern" make a difference when you got IF SERVICES CPA6I03

O
help in the past 3 months?
0 = Present, but no effect on services
What difference did it make? 2 = Present, and had some effect on
response to services actually used in past 3
months (missed appointments, not talk
freely, not follow recommendations, etc.)
EW 3 = Quit getting services

INCOMPLETE INFORMATION
Difficulty in getting services caused by lack of information INCOMPLETE INFORMATION CPA7I01
about where to get services or how to arrange them. Intensity
VI

0 = Absent

Did lack of information about who to see make it harder 2 = Present

for you to get services? IF SYMPTOMS CPA7I02
RE

Do you think you need more information about who to 0 = Present but did not keep from getting
see about a problem? help

2 = Present and delayed subject from

How would (did) you try to find out who to see? getting some/other particular services in
Who would (did) you ask about finding the right person? past 3 months
Would (did) your parents know how to find the right 3 = Present and stopped subject from
person? getting some/other particular services
R

IF SYMPTOMS IN LAST 3 MONTHS, ASK: IF SERVICES CPA7I03

0 = Present, but no effect on services
Were there any times in the last 3 months when you
FO

didn't get help because you didn't know who to see 2 = Present, and had some effect on
about the problem? response to services actually used in past 3
months (missed appointments, not talk
freely, not follow recommendations, etc.)
IF SERVICES IN LAST 3 MONTHS, ASK:
3 = Quit getting services
When you got help in the past 3 months, did you have
trouble finding out who to see?

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TIME
Reluctance to use services caused by lack of time to get TIME CPA8I01
treatment or to make arrangements for treatment. Intensity
0 = Absent

Are you concerned about having enough time to get 2 = Present

help? IF SYMPTOMS CPA8I02

Do you have time to go to appointments? 0 = Present but did not keep from getting

LY
Or time to make arrangements? help
How much time would be needed? 2 = Present and delayed subject from
What would you not be able to do? getting some/other particular services in
Would you have to miss school? How much? past 3 months
Would you have to give up a job? 3 = Present and stopped subject from

N
Would you miss out on seeing freinds? getting some/other particular services
Would you have to give up doing things you enjoy?
IF SERVICES CPA8I03
IF SYMPTOMS IN LAST 3 MONTHS, ASK:

O
0 = Present, but no effect on services

Were there any times in the past 3 months when you 2 = Present, and had some effect on
didn't get help because of "the time commitment"? response to services actually used in past 3
months (missed appointments, not talk
freely, not follow recommendations, etc.)
IF SERVICES IN LAST 3 MONTHS, ASK:
EW
Did time make a difference when you got help in the
3 = Quit getting services

past 3 months?
VI
RE
R
FO

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COST
Inability to use services or underutilization of services CONCERN ABOUT COST CPA9I01
caused by perception that services could not be afforded or Intensity
0 = Absent
paid for.
2 = Present
Are you bothered about the cost of getting help? IF SYMPTOMS CPA9I02

What do you think it would cost? 0 = Present but did not keep from getting

LY
How did you find out what it would cost? help

2 = Present and delayed subject from

IF SYMPTOMS IN LAST 3 MONTHS, ASK: getting some/other particular services in
past 3 months
Were there any times in the past 3 months when you
3 = Present and stopped subject from
didn't get help because it would cost too much?

N
getting some/other particular services

IF SERVICES IN LAST 3 MONTHS, ASK: IF SERVICES CPA9I03

O
Did cost make a difference when you got help in the 0 = Present, but no effect on services
past 3 months? 2 = Present, and had some effect on
response to services actually used in past 3
What difference did it make? months (missed appointments, not talk
EW freely, not follow recommendations, etc.)
IF CONCERN ABOUT COST, ASK: 3 = Quit getting services

Was that because your insurance would not cover the INSURANCE CPA9I04
cost?
0 = Insurance covered cost or could afford
co-payment
Would your insurance cover part?
Could you afford the rest? 2 = No insurance or insurance coverage
insufficient
VI
RE
R
FO

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Definitions and questions Coding rules Codes

TRANSPORTATION
Reluctance to use services caused by difficulty getting to PROBLEM WITH TRANSPORTATION CPB0I01
treatment site. Intensity
0 = Absent

Is it difficult for you to get to "treatment" location? 2 = Present

IF SYMPTOMS CPB0I02
How far would you need to go?
What transportation would (do) you need to get there? 0 = Present but did not keep from getting

LY
Is that available? help
Why wouldn't you use it? 2 = Present and delayed subject from
getting some/other particular services in
IF SYMPTOMS IN LAST 3 MONTHS, ASK: past 3 months

3 = Present and stopped subject from

Were there any times in the past 3 months when you

N
getting some/other particular services
didn't get help because you "had no transportation and
couldn't get there"? IF SERVICES CPB0I03

O
0 = Present, but no effect on services
IF SERVICES IN LAST 3 MONTHS, ASK:
2 = Present, and had some effect on
Did transportation make a difference when you got response to services actually used in past 3
help in the past 3 months? months (missed appointments, not talk
EW freely, not follow recommendations, etc.)
What difference did it make? 3 = Quit getting services

BUREAUCRATIC DELAY
This item includes bureaucratic hurdles such as excessive PROBLEM WITH BUREAUCRATIC CPB6I01
pre-visit paperwork or authorizations, difficulty getting an DELAY Intensity
appointment in a timely fashion or being put on a waiting
VI

0 = Absent
list, or offices where the phone is not answered or calls are
not returned. 2 = Present

IF SYMPTOMS CPB6I02
Have there been difficulties getting services because of
RE

0 = Present but did not keep from getting

"the system"? help

Have you had trouble getting through on the phone? 2 = Present and delayed subject from
Were you put on a waiting list? getting some/other particular services in
past 3 months
IF SYMPTOMS IN LAST 3 MONTHS, ASK: 3 = Present and stopped subject from
getting some/other particular services
R

Were there any times in the past 3 months when you

didn't get help because of "bureaucratic delay"? IF SERVICES CPB6I03
0 = Present, but no effect on services
FO

IF SERVICES IN LAST 3 MONTHS, ASK:

2 = Present, and had some effect on
Did bureaucratic delay make a difference when you got response to services actually used in past 3
months (missed appointments, not talk
help in the past 3 months? freely, not follow recommendations, etc.)

3 = Quit getting services

Attitudes and Barriers to Services 8

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Definitions and questions Coding rules Codes

SERVICE NOT AVAILABLE

Non-availability of a particular service desired by a subject PROBLEM WITH AVAILABILITY CPB7I01
(such as counseling or drug rehab) because it does not Intensity
0 = Absent
exist in the area where the subject lives.
2 = Present
Are there particular services you would like to use to IF SYMPTOMS CPB7I02
get help that are not available where you live?
0 = Present but did not keep from getting

LY
What kind of service? help

2 = Present and delayed subject from

IF SYMPTOMS IN LAST 3 MONTHS, ASK: getting some/other particular services in
past 3 months
Were there any times in the past 3 months when you
3 = Present and stopped subject from
didn't get help because that service is not available

N
getting some/other particular services
around here?
IF SERVICES CPB7I03
IF SERVICES IN LAST 3 MONTHS, ASK:

O
0 = Present, but no effect on services
Did availability or existence of services make a 2 = Present, and had some effect on
difference when you got help in the last 3 months? response to services actually used in past 3
months (missed appointments, not talk
What difference did it make? EW freely, not follow recommendations, etc.)

3 = Quit getting services

REFUSAL TO TREAT
Being refused by the service for various reasons: lack of REFUSAL TO TREAT CPB8I01
space/beds, problematic history of subject, fear of liability, Intensity
0 = Absent
etc.
VI

2 = Present
Did any service agency refuse to provide treatment for IF SYMPTOMS CPB8I02
you?
0 = Present but did not keep from getting
RE

What was the reason given? help

What do you think was the reason? 2 = Present and delayed subject from
getting some/other particular services in
IF SYMPTOMS IN LAST 3 MONTHS, ASK: past 3 months

3 = Present and stopped subject from

Were there any times in the past 3 months when you getting some/other particular services
didn't get help because you were refused treatment?
R

IF SERVICES CPB8I03
IF SERVICES IN LAST 3 MONTHS, ASK:
0 = Present, but no effect on services
Did this refusal to treat make a difference when you got
FO

2 = Present, and had some effect on

help in the last 3 months? response to services actually used in past 3
months (missed appointments, not talk
What difference did it make? freely, not follow recommendations, etc.)

3 = Quit getting services

Attitudes and Barriers to Services 9

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Definitions and questions Coding rules Codes

CHILD OR PARENT REFUSES TREATMENT

The subject refused to go for treatment for which s/he was CHILD OR PARENT REFUSES CPB9I01
referred by a professional; or, the spouse/partner refuses to TREATMENT Intensity
allow the subject's participation. 0 = Absent

2 = Present
Have you refused to go to any treatment services?
IF SYMPTOMS CPB9I02
Hase your "parent" refused to allow you to get

LY
treatment? 0 = Present but did not keep from getting
help
What was the reason? 2 = Present and delayed subject from
getting some/other particular services in
IF SYMPTOMS IN LAST 3 MONTHS, ASK: past 3 months

N
3 = Present and stopped subject from
Were there any times in the past 3 months when you getting some/other particular services
didn't get help because you or your "parent" refused
treatment? IF SERVICES CPB9I03

O
0 = Present, but no effect on services
IF SERVICES IN PAST 3 MONTHS, ASK:
2 = Present, and had some effect on
Did your "parent's" refusal to go to treatment make a response to services actually used in past 3
difference in getting help in the last 3 months? months (missed appointments, not talk
freely, not follow recommendations, etc.)
EW
Did your "parent's" refusal make a difference in getting help 3 = Quit getting services
in the last 3 months?
VI
RE
R
FO

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Definitions and questions Coding rules Codes

LANGUAGE
Reluctance to use services caused by lack of professionals LANGUAGES SPOKEN IN THE HOME CPB1I01
who speak the native language of this family. Do not Intensity
0 = English is first language
include a speech defect in a parent or subject whose native
language is English. 1 = English is secong language and other
first language(s) is spoken in the home

What languages are spoken in your home? 2 = Only other language(s), not English,
spoken in the home

LY
Do your parents speak English?
OTHER LANGUAGE(S) CPB1X01
_____________________
IF ENGLISH IS ONLY LANGUAGE, SKIP TO OTHER
BARRIERS. 0 = Absent

2 = Child is so bothered that s/he becomes

Is it hard for you to talk about your problems in English?

N
emotionally upset or physically aggressive
Is it hard for your parents? and/or avoids the situations as much as
possible.
IF SYMPTOMS IN LAST 3 MONTHS, ASK:
CPB2I01

O
LANGUAGE BARRIER
Were there any times in the last 3 months when you 0 = Absent
you didn't go see someone about a problem because
of having to speak English? 2 = Present for spouse/partner but not
EW subject
IF SERVICES IN LAST 3 MONTHS, ASK: 3 = Present for subject

Did having to speak English make a difference when IF SYMPTOMS CPB2I02

you got help in the past 3 months? 0 = Present but did not keep from getting
help
What difference did it make?
2 = Present and delayed subject from
getting some/other particular services in
VI

past 3 months

3 = Present and stopped subject from

getting some/other particular services

IF SERVICES CPB2I03
RE

0 = Present, but no effect on services

2 = Present, and had some effect on

response to services actually used in past 3
months (missed appointments, not talk
freely, not follow recommendations, etc.)

3 = Quit getting services

R
FO

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Definitions and questions Coding rules Codes

OTHER BARRIERS
Reluctance to use services caused by other factors. OTHER BARRIER CPB3I01
Intensity
0 = Absent
Are there other things that you are concerned about in
relation to getting help for your problems? 2 = Present

IF SYMPTOMS CPB3I02
What are they?
Tell me about that. 0 = Present but did not keep from getting

LY
help
IF SYMPTOMS IN LAST 3 MONTHS, ASK: 2 = Present and delayed subject from
getting some/other particular services in
Were there any times in the past 3 months when you past 3 months
didn't get help because of X?
3 = Present and stopped subject from

N
getting some/other particular services
How did it keep him/her from getting help?
IF SERVICES CPB3I03
IF SERVICES IN LAST 3 MONTHS, ASK:

O
0 = Present, but no effect on services
Did X make a difference when you got help in the past 2 = Present, and had some effect on
3 months? response to services actually used in past 3
months (missed appointments, not talk
What difference did it make? EW freely, not follow recommendations, etc.)

3 = Quit getting services

Specify
VI

IF NO CONCERNS OR BARRIERS
IDENTIFIED IN ENTIRE SECTION, SKIP
TO NEXT SECTION.
IF IF CONCERNS OR BARRIERS IN
RE

LAST 3 MONTHS, OTHERWISE..., SKIP

TO END.
R
FO

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Definitions and questions Coding rules Codes

RELATIVE IMPACT OF BARRIERS

Subject's weighting of the relative importance of the BARRIERS REPORTED CPD4X01
barriers to service. Intensity
0 = Absent

You've told me that "barriers" made a difference in the 2 = Present

help you got. RELATIVE IMPACT OF BARRIERS CPB4I01

Which ones bothered you the most? 1 = Fear, dislike, or distrust of professionals

LY
2 = Previous negative experience
Which ones made the most difference in the services you CPB4I02
got? 3 = Self-consciousness

4 = Anticipated negative reaction

CPB4I03

N
7 = Lack Of Information

8 = Time

9 = Cost

O
10 = Problem With Transportation

11 = Language Barrier

12 = Other Barrier
EW 13 = Bureaucratic delay

14 = Service not available

15 = Refusal to treat

16 = Refuses treatment

17 = Anticipated Loss of Own Children

VI

18 = Anticipated Loss Of Parental Rights

RE
R
FO

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Definitions and questions Coding rules Codes

SERVICES AFFECTED
Subject's listing of the providers/treatment settings whose TREATMENT SETTING(S) AFFECTED CPB5X01
services were most affected by the above barriers. Intensity
0 = Absent

Which "services" were affected the most? 2 = Present

TREATMENT SETTING CPB5I01

Who didn't you go to see?
Is there someone you would like to have seen? 1 = Psychiatric Hospital

LY
Or an agency you would have liked to go to for services? 2 = Psychiatric unit in general hospital
CPB5I02
3 = Drug/alcohol/detox unit

4 = Medical inpatient unit in hospital

CPB5I03

N
5 = Residential treatment center

6 = Detention center/training school/jail

7 = Group home/emergency shelter

O
10 = Sheltered living/habilitation/halfway
house

EW 11 = Partial hospitalization/day program

12 = Drug/alcohol clinic

15 = Crisis/Rape Crisis Center

16 = In-home counseling/crisis services

17 = Private professional treatment

21 = College based professional

VI

22 = Professor/Instructor

23 = Marriage Counselor

24 = Work Related Services

RE

25 = Non-professional help at work

26 = Social Services

27 = Probation/Parole Officer

28 = Court Counselor

29 = Family Doctor/Other MD
R

30 = Hospital ER

31 = Vocational Rehab/Sheltered
FO

Workshop/Job Training

32 = Religious Counselor

33 = Other Healer/Alternative Practitioner

34 = Crisis Hotline

35 = Self Help Group

36 = Internet Support Group

37 = Help From Relatives

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38 = Other Non-professional help

39 = Help from friends

LY
N
O
EW
VI
RE
R
FO

Attitudes and Barriers to Services 15