Strengths and Difficulties Questionnaire (4-10)

OMB No: ???: Exp Date: ???

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Strengths and Difficulties Questionnaire

(P4-10)

F or each item, please fill in the circle for ‘Not True,’ ‘Somewhat True,’ or ‘Certainly True.’ It would help us if you answered all items as best as you can even if you are not absolutely certain. Please give your answers on the basis of your child’s behavior over the last six months. Thank you.

	Not True	Somewhat True	Certainly True
Considerate of other people’s feelings	O	O	O
Restless, overactive, cannot stay still for long	O	O	O
Often complains of headaches, stomachaches or sickness	O	O	O
Shares readily with other children, for example toys, treats, pencils	O	O	O
Often loses temper	O	O	O
Rather solitary, prefers to play alone	O	O	O
Generally well behaved, usually does what adults request	O	O	O
Many worries or often seems worried	O	O	O
Helpful if someone is hurt, upset or feeling ill	O	O	O
Constantly fidgeting or squirming	O	O	O
Has at least one good friend	O	O	O
Often fights with other children or bullies them	O	O	O
Often unhappy, depressed or tearful	O	O	O
Generally liked by other children	O	O	O
Easily distracted, concentration wanders	O	O	O
Nervous or clingy in new situations, easily loses confidence	O	O	O
Kind to younger children	O	O	O
Often lies or cheats	O	O	O
Picked on or bullied by other children	O	O	O
Often offers to help others (parents, teachers, other children)	O	O	O
Thinks things out before acting	O	O	O
S Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???). teals from home, school or elsewhere	O	O	O

	Not True	Somewhat True	Certainly True
Gets along better with adults than with other children	O	O	O
Many fears, easily scared	O	O	O
Good attention span, sees chores or homework through to the end	O	O	O

Overall, do you think that your child has difficulties in any of the following areas: emotions, concentration, behavior or being able to get along with other people?	No O	Yes - Minor Difficulties O	Yes - Definite Difficulties O	Yes - Severe Difficulties O
If you have answered "Yes" to #26, please answer the following questions about these difficulties:
How long have these difficulties been present?	Less than a Month O	1-5 Months O	6-12 Months O	Over a Year O
Do the difficulties upset or distress your child?	Not at All O	A Little O	A Medium Amount O	A Great Deal O
Do the difficulties interfere with your child’s everyday life in the following areas?	Not at All	A Little	A Medium Amount	A Great Deal
HOME LIFE	O	O	O	O
FRIENDSHIPS	O	O	O	O
CLASSROOM LEARNING	O	O	O	O
LEISURE ACTIVITIES	O	O	O	O
Do the difficulties put a burden on you or the family as a whole?	O	O	O	O

The End.

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by