Informations Sur Le (S) Parent (S)

1

Return this filled-out questionnaire by mail to :

Prof. Hélène Poissant, Ph.D

Université du Québec à Montréal, DSÉ

C.P. 8888, Succ. Centre-Ville

Montréal (Qué), Canada, H3C 3P8

Or by e-mail at

For information by phone: 1-514-987-3000 (# 3028)

ADH/D (Attention Deficit Disorder with or without Hyperactivity)

RISK FACTOR QUESTIONNAIRE

Epidemiological Study - UQAM

DATE : ______

DD-MM-YYY

TIME :______

LOCATION:______

© Poissant, Lecomte, Sylvestre 2001

General instructions:

1)Carefully READ the written instructions at the start of each section.

2) Reply to ALLthe questions in the sections that apply to you.

To begin …

If you have a child with ADHD, start at section 1 (p.3)

If you do NOT have a child with ADHD, start at section 2 (p.12)

SECTION 1

If you have a child with ADHD

(If you have more than one child with ADHD, begin with the oldest)

Reply to each of the 16 questions in section 1.

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 ADHD)

You may at any time request assistance by calling 1-514-987-3000 (# 3028)

Section 1: Information on a child with an ADHD

Provide particulars on the child with an ADHD (no 1)

Date of birth of the child (mm/yy) : ______Age: ______

Sex: MF

Ranking in the family : 1st 2nd 3rd 4th 5th 6th

Language(s) spoken by the child at home: : French EnglishSpanish Other ______

School information

1. Circle the current school level of you child:

Kindergarten

Elementary 1 2 3 4 5 6

Secondary (High School) 7 8 9 10 1112

Other (indicate): ______

2. Has your child repeated one or more of his/her school grades ?

Primary YES NO

SecondaryYES NO

3. Is your child a part of a particular program (if yes, please indicate which one)

No Yes Modified/Adapted Program

Individualized Program Plan (IPP)

Action Plan

Outreach Program

Integrated Occupational Program (IOP)

Other (specify) ______

1. In comparison with other children of his/her age (in regular classes), would you say that your child is usually:

General school results

Handwriting ability

Mathematics and calculations

** 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)

Current health status of your child with ADHD

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 (insert the appropriate letter in the box).

1. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)
2. Staff at a private clinic (neurologist, clinical psychologist, etc)
3. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)

D. Other (specify in the space provided below)

Hyperactivity/ impulsiveness disorder only

Depression

1. 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.

Medication

Ritalin (methylphenidate)

Alternative treatments

Diet

Homeopathy

Therapy

Behavioural modifications

Information on the pregnancy with a child having an ADHD

1. Length of the pregnancy: ______weeks

9. Difficulties experienced by the mother during the pregnancy with a child having an ADHD (check  )

1. Please indicate on the following table the type and average frequency of substances consumed by the mother during herpregnancy with a child having an ADHD

Opium, heroin, morphine, codeïne

Information on the delivery of a child with ADHD

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.

1. Check () the elements which describe your baby at birth.

1. Length of the labor (from the time of the first contraction): ______hours Do not know

1. 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: ______lbs OR______kilos Do not know

Please verify that you have responded to all the questions in section 1 and that you have asked all the necessary questions of the research assistants before moving to section 3 (p. 21)

You can ask for assistance at any time by calling 1-514-987-3000 (# 3028)

Instruction:

Please now move on to section 3 (p. 21)

SECTION 2

If you do not have a child with ADHD

(if you have more than one child without ADHD, start with the eldest)

Instructions:

Please reply to all of the 16 questions of section 2 . Start by describing the eldest of the family.

Once section 2 has been done, move on to section 3 and complete an information sheet for each of your other children (those without ADHD).

Section 2: Information on the child ( the eldest in the family)

Provide particulars on the child:

Date of birth of the child (mm/yy): ______Age: ______

Sex: M F

Language(s) spoken by the child at home : French EnglishSpanish Other ______

School information

1. Circle the current school level your child is attending:

Kindergarten

Elementary 123456

Secondary (High School) 7 8 9 10 1112

2. Has your child repeated one or more of his/her school grade(s) ?

Elementary Yes No

Secondary (High School) Yes No

3. Is your child a part of a particular program (if yes, please indicate which one)

No Yes Modified/Adapted Program

Individualized Program Plan (IPP)

Action Plan

Outreach Program

Integrated Occupational Program (IOP)

Other (specify) ______

1. In comparison with other children of his/her age (in regular classes), would you say that your child is usually:

General school results

Handwriting ability

Mathematics and Calculations

** Variable: the performance of your child varies a lot (more than 15 points) from one stage to another

5. Your child is: Right handed Left handed Ambidextrous (right AND left handed)

Present health of your child (oldest in the family)

6. Has your child received a DIAGNOSIS for 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? (Insert the appropriate letter in the box).

A. Staff in a hospital setting (family doctor, psychiatrist, neurologist, pediatrician, etc.)

1. Staff at a private clinic (neurologist, clinical psychologist, etc.)

1. Staff in a school environment (teacher, resource teacher, school psychologist, etc.)
2. Other (specify in the space provided)

Depression

Hyperactivity/ impulsiveness disorder only

1. Does your child receive or has he/she received any form of treatment for his/her disorder(s) ? ( see question 6)?

If yes, which one(s). Please specify the quality of the results that were obtained.

Medication

Ritalin (methylphenidate)

Alternative medicine

Homeopathy

Therapy

Behaviour modifications

Information on the pregnancy with a child ( the oldest of the family )

1. Length of the pregnancy: ______weeks

1. Difficulties experienced by the mother during this pregnancy (check )

1. Please indicate on the following table the type and average frequency of substances consumed by the mother during her pregnancy with this child.

Information on the birth delivery of the child (oldest in the family)

11. Check () the type of delivery you had for this child.

(if the delivery was natural with the aid of an epidural, please check both Natural AND Anesthesia)

12. Check () the elements which describe your baby at birth.

1. Length of the labour (from the time of the first contraction): ______hours Do not know

1. Length of the delivery (1st push until actual delivery): ______hours Do not know

15. Agpar scale ______1 min.______5 min. Do not know

16. Weight (in pounds or in kilos) of the child at birth: ______lbs OR ______kilos Do not know

Please verify that you have responded to all the questions in section 2 and that you have asked all the necessary questions of the research assistant(s) before moving on to section 3.

At any point you may ask for assistance by calling 1-514-987-3000 (# 3028)

Instructions

Now please move on to SECTION 3 (p. 21)

SECTION 3:

For all respondents

Information regarding the brothers and sisters of the child

Instructions:

Please complete a sheet for EACH of the other children of the family (eg. If you have 3 other children, you will need to complete three sheets).

Once all the sheets have been completed, move to section 4 and reply to the 10 questions

Sex: F M Date of birth (mm/yy) ______Age: ______

Order in the family: 1 2 3 4 5 6

In relation to the first child whom you described, this child is:

Biological brother/ sister (Same biological MOTHER and FATHER )

Half brother/half sister: Same biological MOTHER + not the same biological FATHER

Same biological FATHER + not the same biological MOTHER.

No biological relationship with the first child with ADHD (ex. adoption)

Please indicate if this child has already received one of the following diagnosis: If yes, indicate by whom (use the appropriate letter ) ?

1. Hospital staff ( includes family doctor, psychiatrist, neurologist, pediatrist, etc.)

1. Staff at a private clinic (neurologist, clinical psychologist, etc)
2. Staff at an educational institution (teacher, resource teacher, school psychologist, etc.)
3. Other (detail your case)

Depression

Hyperactivity/ impulsiveness disorder only

Attention deficit and hyperactivity/impulsiveness (ADHD) disorder (dual type)

Sex: F MDate of birth (mm/yy) ______Age:______

Order in the family: 1 2 3 4 5 6

In relation to the first child whom you described, this child is

Biological brother/sister (same biological MOTHER and FATHER)

Half brother/ half sister : Same biological MOTHER + not the same biological FATHER)

Same biological FATHER + not the 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 by whom (use the appropriate letter):

1. Hospital staff ( includes family doctor, psychiatrist, neurologist, pediatrist, etc.)

1. Staff at a private clinic (neurologist, clinical psychologist, etc)
2. Staff at an educational institution (teacher, resource teacher, school psychologist, etc.)
3. Other (detail your case)

Depression

Behavioural (Conduct) disorder

Hyperactivity/ impulsiveness disorder only

Attention deficit and hyperactivity/ impulsiveness (ADHD) disorder (dual type)

Sex: F MDate of Birth (mm/yy) ______Age:______

Order in the family: 1 2 3 4 5 6

In relation to the first child whom you described, this child is:

Biological brother/ sister (same biological MOTHER and FATHER)

Half brother/ half sister: Same biological MOTHER + not the same biological FATHER

Same biological FATHER + not the same biological MOTHER

No biological relationship with the first child with ADHD (eg. adoption)

Please indicate if this child has already received on of the following following diagnosis: If yes, indicate by whom (use the appropriate letter):

A. Hospital staff (includes family doctor, psychiatrist, neurologist, pediatrist, etc.)

1. Staff at a private clinic (neurologist, clinical psychologist, etc.)

1. Staff at an educational institution (teacher, resource teacher, school psychologist, etc.)
2. Other (detail your case)

Depression

Hyperactivity/ impulsiveness disorder only

Attention deficit and hyperactivity/ impulsiveness ADHD) disorder only(dual type)

Tourette Syndrome

Sex: F MDate of Birth (mm/yy) ______Age: ______

Order in the family: 1 2 3 4 5 6

In relation to the first child whom you described, this child is:

Biological brother/ sister (same biological MOTHER and FATHER)

Half brother/ half sister Same biological MOTHER + not the same biological FATHER

Same biological FATHER + not the same biological MOTHER

No biological relationship with the first child with AD/HD (eg. adoption)

Please indicate if this child has already received one of the following diagnosis: If yes, indicate by whom (use the appropriate letter):

1. Hospital staff (includes family doctor, psychiatrist, neurologist, pediatrist, etc).

1. Staff at a private clinic (neurologist, clinical psychologist, etc.)
2. Staff at an educational institution (teacher, resource teacher, school psychologist, etc.)
3. Other (detail your case)

Depression

Hyperactivity/ impulsiveness disorder only

Attention deficit and hyperactivity/ impulsiveness (ADHD) disorder (dual type)

Sex: F MDate of Birth (mm/yy) ______Age: ______

Order in the family: 1 2 3 4 5 6

In relation to the first child whom you described, this child is:

Biological brother/ sister (same bioligical MOTHER and FATHER)

Half brother/ half sister Same biological MOTHER + not the same biological FATHER

Same biological FATHER + not the same biological MOTHER

No biological relationship with the first child with AD/HD (eg. adoption)

Please indicate if this child has already received one of the following diagnosis: If yes, indicate by whom (use the appropriate letter):

1. Hospital staff (includes family doctor, psychiatrist, neurologist, pediatrist, etc.)

1. Staff at a private clinic (neurologist, clinical psychologist, etc.)
2. Staff at an educational institution (teacher, resource teacher, school psychologist, etc.)
3. Other (detail your case)

Depression

Hyperactivity/ impulsiveness disorder only