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A-TAC Questionnaire English
Johnny Kerr
2024-09-17T08:21:30+01:00
A-TAC Questionnaire English
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21
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A-TAC
The Autism-Tics, ADHD and other Comorbidities Inventory
This questionnaire is in particular detail focused on a number of abilities and behaviours in children. All children are different from one another. This means that their abilities in various areas as well as their conduct and behaviour vary a great deal.
To gain as complete a picture as possible of your child, we ask you to answer a considerable number of questions.
Naturally, children function in different ways at different ages. State your perception of your child’s functioning as compared to his or her peers.
If your child has had a certain problem or specific characteristic during any period of life, answer the question with “Yes” even if the problem or characteristic is no longer present.
Name of child/adolescent
*
Age of child/adolescent
*
Please enter a number greater than or equal to
0
.
Child's/adolescents's date of birth
*
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Sex
*
Completed by
*
Informant’s relationship to the child/adolescent
*
Date of submission
*
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A. Motor control
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
1. Does he/she have problems coordinating movements smoothly?
*
Yes
Yes, to some extent
No
A1. Is he/she clumsy?
Yes
Yes, to some extent
No
A2. Is he/she fumbling?
Yes
Yes, to some extent
No
A3. Does he/she have balance problems?
Yes
Yes, to some extent
No
A4. Does he/she easily stumble and fall?
Yes
Yes, to some extent
No
A5. Have the peculiarities or problems relating to motor control caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
A6. Do the peculiarities or problems relating to motor control cause him/her significant suffering?
Yes
Yes, to some extent
No
A7. At what age did the peculiarities or problems relating to motor control commence?
Please enter a number greater than or equal to
0
.
A8. Are they still present?
Yes
No
B. Perception
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
2. Does he/she seem disturbed by height differences, such as in connection with climbing stairs etc?
*
Yes
Yes, to some extent
No
3. Does he/she have difficulty judging distance or size?
*
Yes
Yes, to some extent
No
4. Is he/she oversensitive to touch or tight clothing?
*
Yes
Yes, to some extent
No
5. Is he/she particularly sensitive to certain sounds/noise?
*
Yes
Yes, to some extent
No
6. Is he/she particularly sensitive to certain flavours, smells, or consistencies?
*
Yes
Yes, to some extent
No
B1. Does he/she have difficulty comprehending orientation and spatial directions e.g. puts clothes on backwards?
Yes
Yes, to some extent
No
B2. Does he/she often bump into other people?
Yes
Yes, to some extent
No
B3. Does he/she have poor concepts of time?
Yes
Yes, to some extent
No
B4. Does he/she have difficulty imitating other people's movements?
Yes
Yes, to some extent
No
B5. Does he/she have difficulty recognising people?
Yes
Yes, to some extent
No
B6. Have the peculiarities or problems relating to perception caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
B7. Do the peculiarities or problems relating to perception cause him/her significant suffering?
Yes
Yes, to some extent
No
B8. At what age did the peculiarities or problems relating to perception commence?
Please enter a number greater than or equal to
0
.
B9. Are they still present?
Yes
No
C. Concentration and attention
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
7. Does he/she often fail to pay close attention to details or make careless mistakes in schoolwork, or other activities?
*
Yes
Yes, to some extent
No
8. Does he/she often have difficulty sustaining attention in tasks or play activities?
*
Yes
Yes, to some extent
No
9. Does he/she often seem not to listen when spoken to directly?
*
Yes
Yes, to some extent
No
10. Does he/she have difficulty following instructions and finishing tasks?
*
Yes
Yes, to some extent
No
11. Does he/she often have difficulty organising tasks and activities?
*
Yes
Yes, to some extent
No
12. Does he/she often avoid tasks that require sustained mental effort (such as homework)?
*
Yes
Yes, to some extent
No
13. Does he/she often lose things?
*
Yes
Yes, to some extent
No
14. Is he/she easily distracted or disturbed?
*
Yes
Yes, to some extent
No
15. Is he/she often forgetful in daily activities?
*
Yes
Yes, to some extent
No
C1. Does he/she have difficulty getting started on tasks/activities?
Yes
Yes, to some extent
No
C2. Does he/she have difficulty completing tasks/activities?
Yes
Yes, to some extent
No
C3. Have the peculiarities or problems relating to concentration and attention caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
C4. Do the peculiarities or problems relating to concentration and attention cause him/her significant suffering?
Yes
Yes, to some extent
No
C5. At what age did the peculiarities or problems relating to concentration and attention commence?
Please enter a number greater than or equal to
0
.
C6. Are they still present?
Yes
No
D. Impulsiveness and activity
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
16. Does he/she have difficulties keeping his/her hands and feet still or can he/she not stay seated?
*
Yes
Yes, to some extent
No
17. Does he/she get up and move about in class or in other situations when he/she is supposed to remain seated?
*
Yes
Yes, to some extent
No
18. Does he/she often run around or climb excessively compared to peers?
*
Yes
Yes, to some extent
No
19. Does he/she have difficulty playing calmly and quietly?
*
Yes
Yes, to some extent
No
20. Does he/she often act as though he/she had “ants in his/her pants”, i.e. being unable to stay still?
*
Yes
Yes, to some extent
No
21. Does he/she talk constantly?
*
Yes
Yes, to some extent
No
22. Does he/she often blurt out answers to questions before they are completed?
*
Yes
Yes, to some extent
No
23. Does he/she have difficulty waiting for his/her turn?
*
Yes
Yes, to some extent
No
24. Does he/she often interrupt, or intrude on, others?
*
Yes
Yes, to some extent
No
25. Does he/she easily get bored?
*
Yes
Yes, to some extent
No
D1. Is he she unusually intrepid in physically dangerous situations?
Yes
Yes, to some extent
No
D2. Have the peculiarities or problems relating to impulsivness and activity caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
D3. Do the peculiarities or problems relating to impulsivness and activity cause him/her significant suffering?
Yes
Yes, to some extent
No
D4. At what age did the peculiarities or problems relating to impulsivness and activity commence?
Please enter a number greater than or equal to
0
.
D5. Are they still present?
Yes
No
E. Learning
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
26. Has he/she had more difficulties than expected acquiring reading skills?
*
Yes
Yes, to some extent
No
27. Is learning slow and laborious for him/her?
*
Yes
Yes, to some extent
No
28. Does he/she have diffculties with basic maths?
*
Yes
Yes, to some extent
No
E1. Is he/she a slow reader?
Yes
Yes, to some extent
No
E2. Does he/she dislike reading (e.g. does he/she avoid reading books)?
Yes
Yes, to some extent
No
E3. Does he/she have difficulties solving maths problems, which require him/her to read written material?
Yes
Yes, to some extent
No
E4. Does he/she have difficulties understanding or using abstract terms?
Yes
Yes, to some extent
No
E5. Does he/she have difficulties spelling?
Yes
Yes, to some extent
No
E6. Does he/she get special education in school?
Yes
Yes, to some extent
No
E7. Have the peculiarities or problems relating to learning caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
E8. Do the peculiarities or problems relating to learning cause him/her significant suffering?
Yes
Yes, to some extent
No
E9. At what age did the peculiarities or problems relating to learning commence?
Please enter a number greater than or equal to
0
.
E10. Are they still present?
Yes
No
F. Planning and organising tasks
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
29. Does he/she have difficulty shifting plan or strategy when it is required?
*
Yes
Yes, to some extent
No
30. Does he/she have difficulty keeping things in order around him/her?
*
Yes
Yes, to some extent
No
F1. Does he/she have difficulties understanding consequences of his/her own actions?
Yes
Yes, to some extent
No
F2. Is he/she dependent and very much in need of support?
Yes
Yes, to some extent
No
F3. Does he/she find it difficult to take care of his/her personal hygiene, his/her clothes, and the like?
Yes
Yes, to some extent
No
F4. Does he/she have difficullties in postponing rewards until later and finding the meaning in things that are not immediately rewarding?
Yes
Yes, to some extent
No
F5. Does he/she experience simple, everyday activities as tiring or energy consuming?
Yes
Yes, to some extent
No
F6. Have the peculiarities or problems relating to planning and organising tasks caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
F7. Do the peculiarities or problems relating to planning and organising tasks cause him/her significant suffering?
Yes
Yes, to some extent
No
F8. At what age did the peculiarities or problems relating to planning and organising tasks commence?
Please enter a number greater than or equal to
0
.
F9. Are they still present?
Yes
No
G. Memory
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
31. Does he/she have difficulties remembering where he/she put things?
*
Yes
Yes, to some extent
No
32. Does he/she have difficulties remembering long or multiple-step instructions?
*
Yes
Yes, to some extent
No
33. Does he/she have difficulties learning rhymes, songs, multiplication tables etc. by heart?
*
Yes
Yes, to some extent
No
G1. Does he/she have difficulties remembering information about personal data, such as data of birth, home address etc?
Yes
Yes, to some extent
No
G2. Does he/she have difficulties remembering the names of people around him/her?
Yes
Yes, to some extent
No
G3. Does he/she have difficulties remembering the names of week days, months and seasons?
Yes
Yes, to some extent
No
G4. Does he/she have difficulties remembering non-personal facts learned at school (e.g. historic events, chemical formulas etc.)?
Yes
Yes, to some extent
No
G5. Does he/she have difficulty remembering specific events that he/she recently experienced (e.g. what happened during the day or what he/she ate a few hours ago etc.)?
Yes
Yes, to some extent
No
G6. Does he/she have difficulties remembering events that occured some time ago, such as what happened on a trip, what Christmas present he/she got etc.?
Yes
Yes, to some extent
No
G7. Does he/she have difficulties remembering appointments with peers or what homework he/she has?
Yes
Yes, to some extent
No
G8. Does he/she have difficulties learning the rules of new games, sports etc.?
Yes
Yes, to some extent
No
G9. Have the peculiarities or problems relating to memory caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
G10. Do the peculiarities or problems relating to memory cause him/her significant suffering?
Yes
Yes, to some extent
No
G11. At what age did the peculiarities or problems relating to memory commence?
Please enter a number greater than or equal to
0
.
G12. Are they still present?
Yes
No
H. Language
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
34. Was his/her language development delayed, or doesn't he/she speak at all?
*
Yes
Yes, to some extent
No
35. Does he/she have difficulties sustaining a conversation?
*
Yes
Yes, to some extent
No
36. Does he/she like to repeat words and expressions or does he/she use words in a way that other people find strange?
*
Yes
Yes, to some extent
No
37. Does he/she have difficulties with games of make-believe or does he/she imitate others considerably less than other children?
*
Yes
Yes, to some extent
No
38. Does he/she talk in too high a pitch or too quietly?
*
Yes
Yes, to some extent
No
39. Does he/she have difficulties keeping “on track” when telling other people something?
*
Yes
Yes, to some extent
No
H1. Does he/she have difficulties expressing himself/herself in whole sentences?
Yes
Yes, to some extent
No
H2. Does he/she speak in a monotonous or strange voice?
Yes
Yes, to some extent
No
H3. Does he/she have difficulties explaining/recounting his/her experiences to other people?
Yes
Yes, to some extent
No
H4. Does he/she have difficulties explaining what he/she wants?
Yes
Yes, to some extent
No
H5. Does he/she have difficulties speaking fluently, without any pauses?
Yes
Yes, to some extent
No
H6. Does he/she have difficulties pronouncing complex words?
Yes
Yes, to some extent
No
H7. Does he/she explain emotions verbally so that other people have difficulty understanding what he/she means?
Yes
Yes, to some extent
No
H8. Does he/she use strange neologisms, old-fashioned words, or too elegant words?
Yes
Yes, to some extent
No
H9. Does he/she speak so rapidly that it is difficult to comprehend what he/she is saying?
Yes
Yes, to some extent
No
H10. Have the peculiarities or problems relating to language caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
H11. Do the peculiarities or problems relating to language cause him/her significant suffering?
Yes
Yes, to some extent
No
H12. At what age did the peculiarities or problems relating to language commence?
Please enter a number greater than or equal to
0
.
H13. Are they still present?
Yes
No
I. Social interaction
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
40. Does he/she have difficulties expressing emotions and reactions with facial gestures, prosody, or body language?
*
Yes
Yes, to some extent
No
41. Does he/she exhibit considerable difficulties interacting with peers?
*
Yes
Yes, to some extent
No
42. Is he/she uninterested in sharing joy, interests, and activities with others?
*
Yes
Yes, to some extent
No
43. Can he/she only be with other people on his/her terms?
*
Yes
Yes, to some extent
No
44. Does he/she have difficulties behaving as expected by peers?
*
Yes
Yes, to some extent
No
45. Do other people easily influence him/her?
*
Yes
Yes, to some extent
No
I1. Is he/she self-centred?
Yes
Yes, to some extent
No
I2. Is he/she perceived as different, odd, or eccentric by peers?
Yes
Yes, to some extent
No
I3. Does he/she have difficulty understanding other people’s social cues, e.g. facial expressions, gestures, tone of voice, or body language?
Yes
Yes, to some extent
No
I4. Does he/she have difficulty understanding the feelings of other people?
Yes
Yes, to some extent
No
I5. Does he/she have difficulty showing other people respect?
Yes
Yes, to some extent
No
I6. Does he/she get overly excited when there are a lot of people around?
Yes
Yes, to some extent
No
I7. Does he/she often leave in the middle of a conversation, or abruptly change the topic of a conversation?
Yes
Yes, to some extent
No
I8. Does he/she have difficulty realising how to behave in different social situations?
Yes
Yes, to some extent
No
I9. Does he/she inadvertently make a fool of himself/herself or does he/she make embarrassing remarks?
Yes
Yes, to some extent
No
I10. Does he/she often seem to lack common sense?
Yes
Yes, to some extent
No
I11. Does he/she have difficulty with eye contact?
Yes
Yes, to some extent
No
I12. Does he/she think that relationships are not very important or does he/she prefer to be on his/her own?
Yes
Yes, to some extent
No
I13. Is his/her body language awkward, gauche, clumsy, strange or unusual?
Yes
Yes, to some extent
No
I14. Does he/she have difficulty interpreting what is conveyed through eye contact?
Yes
Yes, to some extent
No
I15. Is his/her gaze stiff, strange, peculiar, abnormal or odd?
Yes
Yes, to some extent
No
I16. Have the peculiarities or problems relating to social interaction caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
I17. Do the peculiarities or problems relating to social interaction cause him/her significant suffering?
Yes
Yes, to some extent
No
I18. At what age did the peculiarities or problems relating to social interaction commence?
Please enter a number greater than or equal to
0
.
I19. Are they still present?
Yes
No
J. Flexibilty
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
46. Does he/she get absorbed by his/her interests in such a way as being repetitive or too intense?
*
Yes
Yes, to some extent
No
47. Does he/she get absorbed by routines in such a way as to produce problems for himself/herself or others?
*
Yes
Yes, to some extent
No
48. Has he/she ever engaged in strange hand movements or toe-walking when he/she was happy or upset?
*
Yes
Yes, to some extent
No
49. Does he/she get obsessed with details?
*
Yes
Yes, to some extent
No
50. Does he/she dislike changes in daily routines?
*
Yes
Yes, to some extent
No
J1. Have the peculiarities or problems relating to flexibility caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
J2. Do the peculiarities or problems relating to flexibility cause him/her significant suffering?
Yes
Yes, to some extent
No
J3. At what age did the peculiarities or problems relating to flexibility commence?
Please enter a number greater than or equal to
0
.
J4. Are they still present?
Yes
No
K. Tics
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
51. Has he/she during any period of life made involuntary sounds such as throat clearing, sneezing, swallowing, barking, or shouting?
*
Yes
Yes, to some extent
No
52. Has he/she during any period of life made involuntary facial grimaces or body movements?
*
Yes
Yes, to some extent
No
53. Does he/she make a lot of noise, (e.g. whistle, hum, mumble)?
*
Yes
Yes, to some extent
No
K1. Does he/she curse or use dirty words in an exaggerated way?
Yes
Yes, to some extent
No
K2. Have the peculiarities or problems relating to tics caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
K3. Do the peculiarities or problems relating to tics cause him/her significant suffering?
Yes
Yes, to some extent
No
K4. At what age did the peculiarities or problems relating to tics commence?
Please enter a number greater than or equal to
0
.
K5. Are they still present?
Yes
No
L. Compulsions
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
54. Does he/she have obsessive thoughts, i.e. thoughts that recur over and over again and that he/she cannot stop, for example about dirt, contagion or that something terrible will happen?
*
Yes
Yes, to some extent
No
55. Does he/she have compulsive behaviours such as washing his/her hands, touching things, checking on things, repeating things or procedures, arranging or ordering things, or counting?
*
Yes
Yes, to some extent
No
L1. Have the peculiarities or problems relating to compulsions caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
L2. Do the peculiarities or problems relating to compulsions cause him/her significant suffering?
Yes
Yes, to some extent
No
L3. At what age did the peculiarities or problems relating to compulsions commence?
Please enter a number greater than or equal to
0
.
L4. Are they still present?
Yes
No
M. Eating habits
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
56. Has he/she ever failed to gain enough weight for more than a year or been underweight?
*
Yes
Yes, to some extent
No
57. Has he/she appeared to be fearful of gaining weight or becoming fat?
*
Yes
Yes, to some extent
No
M1. Has he/she dieted hard enough to cause underweight or no weight gain for any length of time?
Yes
Yes, to some extent
No
M2. Has he/she exercised excessively or has he/she been overly interested in his/her physical appearance?
Yes
Yes, to some extent
No
M3. Females only: Has she failed to menstruate for at least 3 months due to weight loss?
Yes
Yes, to some extent
No
M4. Has he/she had periods of overeating followed by vomiting?
Yes
Yes, to some extent
No
M5. Has he/she ever tried to lose weight in spite of already being thin?
Yes
Yes, to some extent
No
M6. Has he/she ever had anorexia nervosa?
Yes
Yes, to some extent
No
M7. Have peculiarities or problems relating to eating caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
M8. Do the peculiarities or problems relating to eating cause him/her significant suffering?
Yes
Yes, to some extent
No
M9. At what age did the peculiarities or problems relating to eating commence?
Please enter a number greater than or equal to
0
.
M10. Are they still present?
Yes
No
N. Separations
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
58. Does he/she have difficulties functioning outside the family home?
*
Yes
Yes, to some extent
No
59. Does he/she often voice fears that family members may die or get hurt?
*
Yes
Yes, to some extent
No
60. Does he/she have an unreasonable fear of being alone or home alone?
*
Yes
Yes, to some extent
No
61. Does he/she have difficulty sleeping if family members are not around?
*
Yes
Yes, to some extent
No
62. Does he/she complain about recurring headaches, bellyaches, nausea or vomiting after being separated from loved ones?
*
Yes
Yes, to some extent
No
N1. Does he/she have difficulty leaving home to go to school for fear of being separated from his/her family?
Yes
Yes, to some extent
No
N2. Does he/she have recurring nightmares about being separated from the family?
Yes
Yes, to some extent
No
N3. Does he/she react unusually strongly when friendships or other close relationships come/about to come, to an end?
Yes
Yes, to some extent
No
N4. Have the peculiarities or problems relating to separation caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
N5. Do the peculiarities or problems relating to separation cause him/her significant suffering?
Yes
Yes, to some extent
No
N6. At what age did the peculiarities or problems relating to separation commence?
Please enter a number greater than or equal to
0
.
N7. Are they still present?
Yes
No
O. & P. Defiance & Conduct
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
63. Has there ever been a time when he/she was so angry that he/she could not be reached?
*
Yes
Yes, to some extent
No
64. Does he/she often argue with adults?
*
Yes
Yes, to some extent
No
65. Does he/she often tease others by deliberately doing things that are perceived as provocative?
*
Yes
Yes, to some extent
No
66. Is he/she easily offended, or disturbed by others?
*
Yes
Yes, to some extent
No
67. Is he/she easily teased?
*
Yes
Yes, to some extent
No
68. Does he/she often lie or cheat?
*
Yes
Yes, to some extent
No
69. Has he/she ever engaged in shoplifting?
*
Yes
Yes, to some extent
No
70. Has he/she ever deliberately been physically cruel to anybody?
*
Yes
Yes, to some extent
No
71. Does he/she often get into fights?
*
Yes
Yes, to some extent
No
72. Does he/she steal things at home or away from home?
*
Yes
Yes, to some extent
No
O1. Does he/she often lose his/her temper?
Yes
Yes, to some extent
No
O2. Does he/she often refuse to follow other directives from adults?
Yes
Yes, to some extent
No
O3. Is he/she often vindictive or cruel?
Yes
Yes, to some extent
No
O4. Does he/she often treat people close to him/her badly or without respect?
Yes
Yes, to some extent
No
O5. Does he/she often blame others for his/her own mistakes?
Yes
Yes, to some extent
No
P1. Does he/she often threaten, harass or humiliate others?
Yes
Yes, to some extent
No
P2. Is he/she cruel to bugs/insects?
Yes
Yes, to some extent
No
P3. Is he/she cruel to other animals?
Yes
Yes, to some extent
No
P4. Has he/she ever started a fire?
Yes
Yes, to some extent
No
P5. Has he/she ever sexually abused other children?
Yes
Yes, to some extent
No
P6. Has he/she ever been detained by the police?
Yes
Yes, to some extent
No
P7. Has he/she ever used a weapon that could cause serious physical harm?
Yes
Yes, to some extent
No
P8. Has he/she ever robbed anyone or else unlawfully acquired other people’s property by means of direct threats?
Yes
Yes, to some extent
No
P9. Has he/she ever purposely attempted to destroy other people’s property?
Yes
Yes, to some extent
No
P10. Has he/she ever broken into someone else’s home, premises or car?
Yes
Yes, to some extent
No
P11. Is he/she often out late at night without consent (beginning before 13 years of age)?
Yes
Yes, to some extent
No
P12. Has he/she ever run away from home and spent the night elsewhere at least twice (or once if it was for an extended period of time)?
Yes
Yes, to some extent
No
P13. Is he/she often skipping school (beginning before 13 years of age)?
Yes
Yes, to some extent
No
OP14. Have the peculiarities or problems relating to defiance/conduct caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
OP15. Do the peculiarities or problems relating to defiance/conduct cause him/her significant suffering?
Yes
Yes, to some extent
No
OP16. At what age did the peculiarities or problems relating to defiance/conduct commence?
Please enter a number greater than or equal to
0
.
OP17. Are they still present?
Yes
No
Q. Anxiety
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
73. Does he/she have panic attacks with sudden strong fear or anxiety?
*
Yes
Yes, to some extent
No
74. Does he/she fear leaving the house alone, being in crowds, waiting in line or going on a bus or train?
*
Yes
Yes, to some extent
No
75. Is he/she often particularly nervous or anxious?
*
Yes
Yes, to some extent
No
Q1. Is he/she extremely shy and reticent?
Yes
Yes, to some extent
No
Q2. Is he/she silent in situations where you are not expected to be silent?
Yes
Yes, to some extent
No
Q3. Is there anything he/she fears doing in front of other people, i.e. talking, eating or writing (excluding presentations of reports)?
Yes
Yes, to some extent
No
Q4. Have the peculiarities or problems relating to anxiety caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
Q5. Do the peculiarities or problems relating to anxiety cause him/her significant suffering?
Yes
Yes, to some extent
No
Q6. At what age did the peculiarities or problems relating to anxiety commence?
Please enter a number greater than or equal to
0
.
Q7. Are they still present?
Yes
No
R. Mood
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
76. Does he/she have poor self-confidence?
*
Yes
Yes, to some extent
No
77. Does he/she often complain about bellyaches, headaches, breathing difficulties or other bodily symptoms?
*
Yes
Yes, to some extent
No
78. Has he/she had recurrent episodes with extremely high activity level, talkativeness and flight of ideas?
*
Yes
Yes, to some extent
No
79. Does he/she have recurrent periods of obvious irritability?
*
Yes
Yes, to some extent
No
80. Does his/her self-confidence vary considerably across different situations?
*
Yes
Yes, to some extent
No
R1. Does he/she often appear to be unhappy, sad, or depressed?
Yes
Yes, to some extent
No
R2. Does he/she often complain about a feeling of loneliness?
Yes
Yes, to some extent
No
R3. Does he/she often express a feeling of being worthless or inferior to peers?
Yes
Yes, to some extent
No
R4. Has there ever been a period when nothing could make him/her feel happy?
Yes
Yes, to some extent
No
R5. Has he/she been thinking of or talked about committing suicide?
Yes
Yes, to some extent
No
R6. Has he/she tried to commit suicide?
Yes
Yes, to some extent
No
R7. Has he/she often had a feeling of emptiness?
Yes
Yes, to some extent
No
R8. Does he/she feel that his/her qualities and talents are ignored by others?
Yes
Yes, to some extent
No
R9. Have peculiarities or problems relating to his/her mood caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
R10. Do the peculiarities or problems relating to his/her mood cause him/her significant suffering?
Yes
Yes, to some extent
No
R11. At what age did the peculiarities or problems relating to his/her mood commence?
Please enter a number greater than or equal to
0
.
R12. Are they still present?
Yes
No
S. Concept of reality
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
81. Has he/she ever had visions or seen things that no one else could see?
*
Yes
Yes, to some extent
No
S1. Has he/she ever perceived himself/herself as being followed or haunted by others even though this has not actually been the case?
Yes
Yes, to some extent
No
S2. Has he/she ever heard voices or sounds, which no one else could hear?
Yes
Yes, to some extent
No
S3. Have the peculiarities or problems relating to concept of reality caused significant impairment in school, among peers or at home?
Yes
Yes, to some extent
No
S4. Do the peculiarities or problems relating to concept of reality cause him/her significant suffering?
Yes
Yes, to some extent
No
S5. At what age did the peculiarities or problems relating to concept of reality commence?
Please enter a number greater than or equal to
0
.
S6. Are they still present?
Yes
No
T. Miscellaneous
The essential aspect of each question is whether the problem/peculiarity has been
pronounced compared to peers during any period of life
82. Does he/she stutter?
*
Yes
Yes, to some extent
No
83. Is he/she or has he/she ever been bullied by other children in school?
*
Yes
Yes, to some extent
No
84. Has he/she ever been severely overweight?
*
Yes
Yes, to some extent
No
85. Does he/she often have sleeping problems?
*
Yes
Yes, to some extent
No
86. Does he/she often have nightmares?
*
Yes
Yes, to some extent
No
87. Does he/she often walk in his/her sleep or have nocturnal attacks when he/she cannot be “reached” or comforted?
*
Yes
Yes, to some extent
No
88. Has he/she ever deliberately hurt himself/herself?
*
Yes
Yes, to some extent
No
89. Has he/she repeatedly and purposely hurt himself/herself?
*
Yes
Yes, to some extent
No
90. Is there anything he/she fears excessively, such as flying, seeing blood, having an injection, heights, cramped rooms, or certain kind of animals or insects?
*
Yes
Yes, to some extent
No
91. Has he/she wet himself/herself during daytime on several occasions after the age of 5?
*
Yes
Yes, to some extent
No
92. Has he/she soiled himself/herself on several occasions after the age of 4 except in connection with gastro-intestinal infection?
*
Yes
Yes, to some extent
No
93. Does he/she smoke?
*
Yes
Yes, to some extent
No
94. Does he/she use any other form of tobacco?
*
Yes
Yes, to some extent
No
95. Has he/she ever used alcohol?
*
Yes
Yes, to some extent
No
96. Has he/she ever had a period after age 5 when he/she only wanted to eat particular types of food?
*
Yes
Yes, to some extent
No
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