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78. Worries that something bad will happen to people he/she is close to.
86. Worries about being separated from loved ones.
95. Avoids school to stay home.
105. Scared to go to sleep without parents being near.
111. Avoids being alone.
118. Has nightmares about being abandoned.
125. Complains of feeling sick before separating from those he/she is close to.
129. Overly upset when leaving someone he/she is close to.
136. Overly upset while away from someone he/she is close to.
140. Is afraid of being away from home.
B. Externalizing Symptoms (31 items; includes subscales for Oppositional Defiant, Conduct Problems, Overt
Hostility, and Relational Aggression)
Response options: 0 = Never or not true; 1 = Sometimes or somewhat true; 2 = Often or very true
i. Oppositional Defiant (9 items)
76. Has temper tantrums or hot temper.
84. Argues a lot with adults.
85. Argues a lot with peers.
94. Defiant, talks back to adults.
110. Blames others for his/her own mistakes.
117. Is easily annoyed by others.
123. Angry and resentful.
130. Gets back at people.
137. Swears or uses obscene language.
ii. Conduct Problems (12 items)
79. Steals; takes things that don't belong to him/her.
87. Lies or cheats.
96. Vandalizes.
101. Sets fires.
106. Cruel to animals.
112. Physically attacks people.
119. Threatens people.
126. Destroys his/her own things.
132. Destroys things belonging to his/her family or other children.
139. Disobedient at school.
145. Cruel, bullies, or mean to others.
152. Uses a weapon when fighting.
iii. Overt Hostility (4 items)
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14i. Diabetes
14j. HIV infection or AIDS
14k. Kidney disease
14l. Leukemia or cancer
14m. Nerve or muscle problems such as cerebral palsy or muscular dystrophy
14n. Repeated, persistent ear infections
14o. Repeated, persistent urinary infections
14p. Repeated, persistent respiratory infections such as colds, bronchitis, or croup
14q. Bad allergies requiring frequent doctor visits and frequent medications.
15. Has your child ever had any other health problems than those already noted? (If yes:) Please describe
the health problem(s).
16. Please indicate below whether your child has had any disorders or problems with learning, hearing,
speech, vision. Place a check in the appropriate column. Has your child had any disorders or
problems with:
Response options: 0 = Never; 1 = Ever but not past year; 2 = Within past year.
16a. Learning
16b. Hearing
16c. Speech
16d. Vision
C. Physical Health Care Utilization (5 items)
8. How many times has your child been seen by his/her primary care provider for a sick visit within the past
year, not including any visits for routine checkups?
9a. How many times has your child been to the Emergency Room within the past year?
18. Please circle whether or not your child receives each of the following services currently or within the
past year.
Response options: 0 = No; 1 = Yes
18b. Speech/Language Therapy
18c. Physical/Occupational Therapy
20. Please think about the past year. Has your child taken any prescription or non-prescription medications
on a DAILY basis for more than a month at a time?
Response options: 0 = No; 1 = Yes
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If excluded from the Mental Health Externalizing Symptoms scale, the Overt Hostility and Relational Aggression
subscales can be used in the Social Functioning domain.
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23. During the current or most recent school year, did your child belong to any clubs or groups with adult
leadership, such as Scouts, Brownies, or any religious or community programs? Please do not include any
groups or activities already answered in Questions 21 and 22. (If yes:) To how many such clubs or groups
did he or she belong? During the current or most recent school year, how many times a week did your child
attend meetings of these clubs or groups?
Response options: 0 = Less than once a week; 1 = 1-3 times a week; 2 = 4 or more times a week
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