[ ] questionnaire-e.doc
Transcript of [ ] questionnaire-e.doc
Attention Deficit Disorder with or without Hyperactivity (ADH/D)
Risk Factor Questionnaire © Poissant, Lecomte, Sylvestre 2001
Epidemiological StudyUniversité du Québec à Montréal
University of Ottawa
General instructions :
1- Carefully READ the written instructions at the start of each section.
2- Reply to ALL the questions in the sections that apply to you.
To begin...
* If you have a child with ADH/D, start at section 1 (p.2)
* If you do NOT have a child with ADH/D, start at section 2 (p.8)
Date (dd/mm/yy): Time:
Location:
You may at any time request assistance by calling Cameron Montgomery (613-562-5800 ext. 4119) or by email: [email protected]
SECTION 1 - Information on a child with ADH/D
* If you have more than one child with ADH/D, begin with the oldest
Reply to each of the 16 questions in this section.Once you have completed section 1, go directly to section 3 and complete an information sheet for each of your children (whether or not they have an ADH/D).
Provide particulars on the child with an ADH/D:
Date of birth of the child (mm/yy):
Age:
Sex: M F
Ranking in the family:
1st 2nd 3rd 4th 5th 6th
Language(s) spoken by the child at home:
French English Spanish Other:
School information:
1. Current school level of your child:
KindergartenElementary 1 2 3 4 5 6Secondary (High School) 7 8 9 10 11 12Other:
2. Has your child repeated one or more of his/her school grades?
Primary: Yes No Secondary: Yes No
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3. Is your child a part of a particular program? (If yes, please indicate which one)
No Yes, Modified/Adapted Program Yes, Individualized Education Plan (IEP) Yes, Action plan
Yes, Outreach program Yes, Integrated Occupational Program (IOP) Yes, Other:
4. In comparison with other children of his/her age (in regular classes), you would say that your child is usually :
Below Average
AverageAbove
AverageVariable **
General school resultsReading abilityWritten expressionHandwriting abilityMathematics and calculation
** Variable: Your child’s performance varies a lot (more than 15 points) from one stage to another.
5. Your child is :
Right handed Left handed Ambidextrous (both left AND right handed)
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Current health status of your child with ADH/D :
6. Has your child been DIAGNOSED with one or more of these disorders?
If yes, please specify the age of the child at the time the evaluation was completed and by whom (write the appropriate letter in the box).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Learning disorder Bipolar disorder (manic-depression) Tourette Syndrome Obsessive-compulsive disorder Other(s):
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7. Does your child receive or has he/she received a form of treatment for his/her disorder? (see question 6)
If yes, which one(s). Please specify the degree of improvement obtained.
Type of treatment NO YESObserved improvement
High Average Weak NoneMedication
Ritalin (methylphenidate)Dexedrine (dextroamphetamine)Wellbutrin (bupropion)Clonidine (catapress)Tofranil (imipramine)Others:
Alternative treatments
DietAcupunctureNaturopathyOsteopathyChiropracticsHomeopathy
Therapy Behavioral modificationIndividual therapy Family therapy
SchoolResource teacherSpeech therapyPsycho-educationSocial worker
Others :
Information on the pregnancy with a child having an ADH/D :
8. Length of the pregnancy : weeks
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9. Difficulties experienced by the mother during the pregnancy with a child having an ADH/D :
Yes No Do not knowBleedingBleeding resulting in bed restNausea (persistent vomiting) beyong the first 3 monthsWeight gain exceeding 25 lbs. (or 11 kg.) Weight gain of less than 15 lbs. (or 7 kg.)High blood pressure Anemia related to the pregnancyToxemiaInfection or illness (specify) : Accidents or injuries (specify) : Family or emotional problems (specify) Others (specify)
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10. Please indicate on the following table the type and average frequency of substances consumed by the mother during her pregnancy with a child having an ADH/D:
Type
Average usage (during a month)
Never1 - 10
times a month
11 - 20 times a month
21 - 30 times a month
Daily(specify how
many each day)
Alcohol (beer, wine, spirits)
Cigarettes Medication (specify) : Opium, heroin, morphine, codeïne
Cocaïne, amphetamines, crack
Marijuana, haschish, huile de haschish
LDS, mescaline, Extasy, PCP
Information on the delivery of a child with ADH/D :
11. Check the type of delivery you had with this child :(If the delivery was natural with the aid of an epidural, please check both Natural AND Anesthesia)
Yes Do not knowNaturalCeasarianAnesthesia (epidural, general )Suction cupObstetrical forcepsOther complications :
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12. Check the elements which describe your baby at birth :
Yes Do not knowBorn with the umbilical cord around the neckInjuries sustained during the birth process (describe) : Breathing difficultiesJaundiceAnemiaCyanosis (turning blue)Fetal distressConvulsionsApplication of oxygenMedications being administeredExtended hospital stay of more than 7 daysSucking difficultiesOther complications (describe) :
13. Length of the labor (from the time of the first contraction) :
hours Do not know
14. Length of the delivery (1st push until actual delivery) :
hours Do not know
15. Apgar Scale : 1 min 5 min Do not know
16. Weight (in pounds or kilos) of the child at birth :
pounds kilos Do not know
Please verify that you have responded to all the questions in section 1.
At any point you may ask for assistance by asking Cameron Montgomery (613-562-5800 ext. 4119) or via email: [email protected]
Please now move on to section 3 (p.15).
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SECTION 2 – Information on the child (the eldest of the family) If you do not have a child with ADH/D
* Start by describing the eldest of the family
Reply to each of the 16 questions in this section.Once you have completed section 2, move on to section 3 and complete an information sheet for each of your other children (those without ADH/D).
Provide particulars on the child:
Date of birth of the child (mm/yy):
Age:
Sex: M F
Ranking in the family:
1st 2nd 3rd 4th 5th 6th
Language(s) spoken by the child at home :
French English Spanish other:
School Information:
1. Current school level of your child:
KindergartenElementary 1 2 3 4 5 6Secondary (High School) 7 8 9 10 11 12Other:
2. Has your child repeated one or more of his/her school grades?
Primary: Yes No Secondary: Yes No
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3. Is your child a part of a particular program? (If yes, please indicate which one)
No Yes, Modified/Adapted Program Yes, Individualized Education Plan (IEP) Yes, Action plan
Yes, Outreach program Yes, Integrated Occupational Program (IOP) Yes, Other:
4. In comparison with other children of his/her age (in regular classes, you would say that your child is usually :
Below Average
AverageAbove
AverageVariable **
General school resultsReading abilityWritten expressionHandwriting abilityMathematics and calculation
** Variable: Your child’s performance varies a lot (more than 15 points) from one stage to another.
5. Your child is :
Right handed Left handed Ambidextrous (both left AND right handed)
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Current health status of your child (oldest in the family) :
6. Has your child been DIAGNOSED with one or more of these disorders?
If yes, please specify the age of the child at the time the evaluation was completed and by whom (write the appropriate letter in the box).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Tourette Syndrome Obsessive-compulsive disorder Other(s):
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7. Does your child receive or has he/she received a form of treatment for his/her disorder(s)? (see question 6)
If yes, which one(s). Please specify the degree of improvement obtained.
Type of treatment NO YESObserved improvement
High Average Weak NoneMedication
Ritalin (methylphenidate)Dexedrine (dextroamphetamine)Wellbutrin (bupropion)Clonidine (catapress)Tofranil (imipramine)Others :
Alternative treatments
DietAcupunctureNaturopathyOsteopathyChiropracticsHomeopathy
Therapy Behavioral modificationIndividual therapy Family therapy
SchoolResource teacherSpeech therapyPsycho-educationSocial worker
Others :
Information on the pregnancy with a child (the oldest of the family) :
8. Length of the pregnancy : weeks
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9. Difficulties experienced by the mother during the pregnancy:
Yes No Do not knowBleedingBleeding resulting in bed restNausea (persistent vomiting) beyong the first 3 monthsWeight gain exceeding 25 lbs. (or 11 kg.) Weight gain of less than 15 lbs. (or 7 kg.)High blood pressure Anemia related to the pregnancyToxemiaInfection or illness (specify) : Accidents or injuries (specify) : Family or emotional problems (specify) Others (specify)
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10. Please indicate on the following table the type and average frequency of substances consumed by the mother during her pregnancy:
Type
Average usage (during a month)
Never1 - 10
times a month
11 - 20 times a month
21 - 30 times a month
Daily(specify how
many each day)
Alcohol (beer, wine, spirits)
Cigarettes Medication (specify) : Opium, heroin, morphine, codeïne
Cocaïne, amphetamines, crack
Marijuana, haschish, huile de haschish
LDS, mescaline, Extasy, PCP
Information on the delivery of a child (oldest in the family) :
11. Check the type of delivery you had with this child :(If the delivery was natural with the aid of an epidural, please check both Natural AND Anesthesia)
Yes Do not knowNaturalCeasarianAnesthesia (epidural, generale )Suction cupObstetrical forcepsOther complications :
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12. Check the elements which describe your baby at birth :
Yes Do not knowBorn with the umbilical cord around the neckInjuries sustained during the birth process (describe) : Breathing difficultiesJaundiceAnemiaCyanosis (turning blue)Fetal distressConvulsionsApplication of oxygenMedications being administeredExtended hospital stay of more than 7 daysSucking difficultiesOther complications (describe) :
13. Length of the labor (from the time of the first contraction) :
hours Do not know
14. Length of the delivery (1st push until actual delivery) :
hours Do not know
15. Apgar Scale : 1 min 5 min Do not know
16. Weight (in pounds or kilos) of the child at birth :
pounds kilos Do not know
Please verify that you have responded to all the questions in section 2.
At any point you may ask for assistance by asking Cameron Montgomery (613-562-5800 ext. 4119) or via email: [email protected]
Please now move on to section 3 (next page).
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 3 – Information regarding the brothers and sisters of the child
Please complete a sheet for EACH of the other children of the family.(If you have 3 other children, you will need to complete 3 sheets)Once all the sheets have been completed, move to section 4 (p.21)
Date of birth (mm/yy): Age: Sex: M F
Ranking in the family: 1st 2nd 3rd 4th 5th 6th
In relation to the first child you described, this child is:
Biological brother/sister (Same biological MOTHER and FATHER)Half brother / half sister
Same biological MOTHER + not same biological FATHERSame biological FATHER + not same biological MOTHER
No biological relationship with the first child (with address received HD) (eg. adoption).
Please indicate if this child has already been given one of the following diagnosis. If yes, indicate his/her age at the time and by whom (use the appropriate letter).
A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)B. Staff at a private clinic (neurologist, clinical psychologist, etc).C. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)D. Other (specify in the space provided below).
Type No Yes
Age of the child
(at the time of the diagnosis)
Stated by(indicate the
corresponding letter)
Learning disorder Anxiety disorders Depression Behavioural (Conduct) disorder Oppositional disorder Phobia (specify type): Bipolar disorder (manic-depression) Attention deficit disorder only (ADD) Hyperactivity/ impulsiveness disorder only Attention deficit and hyperactivity/ impulsiveness (ADH/D) disorder (dual type)
Tourette Syndrome Obsessive-compulsive disorder Other(s):
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SECTION 4 – Information on the parent(s)
Please complete each of the following 10 questions.
Information on the respondent :
Date of birth of the respondent (dd/mm/yy):
Residence postal code:
1. Your relationship with the child (section 1 or 2):
Biological Non-biologicalMother MotherFather FatherOther: Other: (e.g.: grand-parent) (e.g: guardian)
2. Please complete the following table:
Ethnic and cultural originsMOTHER FATHER
Caucasian (white) Caucasian (white)African AfricanAsian AsianHispanic HispanicAmerican-Indian American-IndianOther : Other :
3. Your present civil status:
Maried Separated Common lawSingle Divorced
4. Highest level of education completed:
Elementary College or trade schoolSecondary (high school) University
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5. PRESENT occupation:
Are you presently employed?YES NO
Full timePart timeOn call
How long have you held this position?Less than 6 months6 to 12 months12 to 24 months2 to 5 years5 years or more
Indicate the reason:UnemploymentPregnancyHealth problems (specify) Personal/family reasons (specify) Others (specify)
6. PREVIOUS occupation:
Were you previously employed?YES NO
Full timePart timeOn call
How long have you held this position?Less than 6 months6 to 12 months12 to 24 months2 to 5 years5 years or more
Indicate the reason:UnemploymentPregnancyHealth problems (specify) Personal/family reasons (specify) Others (specify)
7. What is your total annual family income?
Less than $20,000 $20,000 – $40,000 $40,000 – $60,000 $60,000 and more
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8. Check among the following statements the ones that apply to you. Please specify the time, how long it lasted, the seriousness, circumstances, type of problem, frequency, etc.
Applies Specify :
Difficulties with learning to read
Difficulties with mathematics (calculations)
Self expression difficulties ( pronunciation of words, etc)
Behavioural (Conduct) difficulties
Excessively agitated
Repeated school year(s) (reduplication(s))
Traffic accident(s)
History of criminal activity (criminal record)
Move(s) during the last 12 months
Move(s) during the last 5 years
Social isolation
Cardiac problem(s)
Neurological problem(s) Marital problem(s)
Hospitalization(s)
Domestic violence Other problems or difficulties:
None
Medical information on the respondent:
9. have you, now or in the past, been diagnosed for: Type No Yes
DepressionAnxiety disordersObsessive-compulsive disorderPhobia (specify the type) : Attention deficit disorder and hyperactivity/ impulsiveness (ADHD)Attention deficit disorder only (ADD)Hyperactivity and impulsiveness disorder only Behavioral (conduct) disorderBipolar disorder (manic-depression)Alcohol dependence Drug or medication dependenceDelusional (schizophrenia, paranoia, …) disorderOther(s):
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10. Have you already taken or are you presently taking one of the following medications? If yes, indicate the length of treatment.
Type of medication NoYes, for…
Less than 6 months
7 to 23 months
2 to 5 years
6 to10 years
11 years and more
Prozac, Zoloft, Paxil, Serzone or other SSRI’s Tofranil, Tégrétol or other tricyclic antidepressants Ativan, Xanax, Buspar, Valium, Rivotril or other anxiolyticsWellbutrin (bupropion)Ritalin, Dexedrine or other osychostimulantsHaldol, Clozaril, Risperdal, Largactil or other major tranquilizers Lithium, Valpoide acid, Epival or other thymoregulatorsParnate, Nardil or other MAO inhibitors Effexor (venlafaxine)Others :
Please verify that you have properly replied to all the questions in section 4.
At any point you may ask for assistance by asking Cameron Montgomery (613-562-5800 ext. 4119) or via email: [email protected]
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THANK YOU !
You have now completed the questionnaire.The information you have provided is very important for us and ADH/D prevention programs. Be assured that any information provided in this questionnaire will be kept confidential.
We are interested in seeing you again and meeting your children in order to further this research.Please complete the following if you wish to communicate again with us.
I am interested in being informed or in participating in future ADH/D research projects.
NAME:
TELEPHONE: (Home): (Work):
I have a child with ADH/D: YES NO
TO RETURN THIS QUESTIONNAIRE TO THE PRESENT ADMINISTRATOR,SAVE it on your computer and than:By mail : Dr. Cameron Montgomery, P.h.D, Professor, Faculty of Education, University of Ottawa, 145 Jean-Jacques Lussier St., Ottawa (Ontario), K1N 6N5, Canada.By email: [email protected] (Please make note that confidentiality may not be preserved via email)
web site: http://aix1.uottawa.ca/~cmontgom/; (613) 562-5800 (4119)
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