piacentiniTG14app.111_124
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Page 112
Current Symptoms Self-Report Form
Week of:
Instructions: Please check the response next to each item that best describes your behavior during the past week.
Children’s Yale-Brown OC Scale (CY-BOCS) Self-Report Symptom Checklist
Name of Child:
1
Never or
Date: Rarely
Informant: Often
Sometimes
Very Often
This questionnaire can be completed by the child/adolescent, parents, or both working together.
We
are attention
interestedtoindetails
getting
most
accurate information possible. There are no right or wrong
Fail to give
close
or the
make
careless
answers.
Please just answer the best you can. Thank you.
mistakes in
my work
Please check all COMPULSIVE SYMPTOMS that you have noticed during the past week.
2
Fidget with hands or feet or squirm in seat
3
Have diffidoes
cultynot
sustaining
my attention
in tasksare
or typically done to reduce fear of distress associated with
make sense.
Compulsions
fun activities
obsessive thoughts.
4
Leave my seat in situations in which seating is
Washing/Cleaning Compulsions
expected
5
Don’t listen when terrupted,
spoken to directly
needs to wash hands in particular order of steps)
6
Feel restless
7
Don’t follow through on instructions and fail to
Excessive cleaning of items (e.g., clothes, faucets, floors or important objects)
finish work
8
Have difficulty engaging
leisure
activities
or door;
doing refusing to shake hands; asking family members to refoot toin
flush
toilet
or open
fun things quietly move insecticides, garbage)
9
Other washing/cleaning
Have difficulty organizing
tasks and activitiescompulsions (Describe)
COMPULSIONS are things you feel compelled to do even though you may know the behavior
Excessive or ritualized hand washing (e.g., takes long time to wash, needs to restart if inExcessive or ritualized showering, bathing, tooth brushing, grooming, toilet routine
(see hand washing)
Other measures to prevent or remove contact with contaminants (e.g., using towel or
10
Feel “on the go” or “driven by a motor”
11
Avoid, dislike,
or amCompulsions
reluctant to engage in work that
Checking
requires sustained mental effort
Checking locks, toys, schoolbooks/items, and so on
12
Talk excessively Checking associated with getting washed, dressed, or undressed
13
Checking
that
did not/will not harm others (e.g., checking that nobody’s been hurt,
Lose things necessary
for tasks
or activities
14
Blurt out answers before questions have been
Checking that did not/will not harm self (e.g., looking for injuries or bleeding after
completed
15
Am easily distracted
Checking that nothing terrible did/will happen (e.g., searching the newspaper or televi-
16
Have difficulty awaiting turn
17
Am forgetful in daily
activities
lations,
homework)
18
Checking
Interrupt or intrude
on otherstied to health worries (e.g., seeking reassurance about having an illness, re-
asking for reassurance, or telephoning to make sure that everything is alright)
handling sharp or breakable objects, asking for reassurance that everything is alright)
sion for news about catastrophes)
Checking that did not make a mistake (e.g., while reading, writing, doing simple calcu-
peatedly measuring pulse, checking for body odors or ugly features)
From R. A. Barkley & K. R. Murphy
Attention-Defi
cit Hyperactivity
Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.
Other(1998),
checking
compulsions
(Describe)
Reprinted with permission.
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Current Symptoms Self-Report Form
Week of:
Instructions: Please check the response next to each item that best describes your behavior during the past week.
Repeating Compulsions
1
Never or
Rarely
Sometimes
Often
Very Often
Rereading, erasing, or rewriting (e.g., taking hours to read a few pages or write a few
because
over not understanding or needing letters to be perfect)
Fail to give close sentences
attention to
details of
or concern
make careless
mistakes in my work
Needing to repeat routine activities (e.g., getting up and down from a chair or going in and
out of a doorway, turning the light switch or TV on and off a specific number of times)
2
Fidget with hands or feet or squirm in seat
3
Have difficulty sustaining my attention in tasks or
fun activities
4
Leave myCounting
seat in situations
in which seating is
Compulsions
expected
5
or spoken)
Don’t listen whenread
spoken
to directly
6
Feel restless
Arranging/Symmetry
7
Arranging/ordering
(e.g.,failspends
hours straightening paper and pens on a desktop or
Don’t follow through
on instructions and
to
books in a bookcase, becomes very upset if order is disturbed)
finish work
8
Symmetry/evening
up (e.g.,
Have difficulty engaging
in leisure activities
or arranges
doing things or own self so that two or more sides are
“even”
or
symmetrical)
fun things quietly
9
Have difficulty organizing tasks and activities
Other repeating compulsions (Describe)
Counts objects (e.g., floor tiles, CDs or books on a shelf, his/her own steps, or words
Other arranging compulsions (Describe)
10
Feel “on the go” or “driven by a motor”
11
Hoarding/Saving
Compulsion
not count
Avoid, dislike,
or am reluctant
to engage(do
in work
that saving sentimental or needed objects)
requires sustainedDifficulty
mental effthrowing
ort
things away; saving bits of paper, string, old newspapers, notes,
12
Talk excessively or garbage
13
Lose things necessary
forhoarding/saving
tasks or activitiescompulsions (Describe)
Other
14
15
Blurt out answers before questions have been
completed
Excessive Games/Superstitious Behaviors (must be associated with anxiety, not just a game)
Am easily distracted
16
Have difficulty awaiting
ject/selfturn
a certain number to times to avoid something bad happening, not leaving
17
Am forgetful in daily activities
18
Rituals Involving Other Persons
Interrupt or intrude on others
cans, paper towels, wrappers and empty bottles; may pick up useless objects from street
Behaviors such as not stepping on cracks or lines on floor/sidewalk, touching an obhome on the th of the month)
Needing to involve another person (usually a parent) in rituals (e.g., excessive asking for
reassurance,
parent Disorder:
to answer
the same
question,
making
parent
wash
From R. A. Barkley & K. R. Murphy
(1998), repeatedly
Attention-Defiasking
cit Hyperactivity
A clinical
workbook
(2nd ed.).
New York:
Guilford
Press.
Reprinted with permission.
excessively)
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Current Symptoms Self-Report Form
Week of:
Instructions: Please check the response next to each item that best describes your behavior during the past week.
Children’s Yale-Brown OC Scale (CY-BOCS) Self-Report Symptom Checklist continued
Miscellaneous Compulsions
1
Never or
Rarely
Sometimes
Often
Very Often
Excessive telling, asking, or confessing (e.g., confessing repeatedly for minor or imagined transgressions,
askingcareless
for reassurance)
Fail to give close attention
to details or make
mistakes in my work
Measures (not checking) to prevent harm to self or others or some other terrible conse-
quences (e.g., avoids sharp or breakable objects, knives, or scissors)
2
Fidget with hands or feet or squirm in seat
3
Have difficulty sustaining
attention
in tasks
eating; my
eating
according
to aorstrict ritual)
fun activities
4
jects, or other
people,
perhaps
to prevent a bad occurrence)
Leave my seat in situations
in which
seating
is
expected
Excessive list making
5
Needing
do things (e.g., touch or arrange) until it feels “just right”
Don’t listen when spoken
toto
directly
6
Feel restless
7
Don’t follow through on instructions and fail to
finish work
8
Pleaseengaging
check all
SYMPTOMS
that you have noticed during the past week.
Have difficulty
in OBSESSIVE
leisure activities
or doing
fun thingsOBSESSIONS
quietly
are intrusive, recurrent, and distressing thoughts, sensations, urges, or images
9
Have difficulty organizing tasks and activities
Ritualized eating behaviors (e.g., arranging food, knife, fork in a particular order before
Excessive touching, tapping, rubbing (e.g., repeatedly touching particular surfaces, ob-
Avoiding saying certain words (e.g., goodnight or goodbye, person’s name, bad event)
Other (Describe)
10
11
that you may experience. They are typically frightening and may be either realistic or unrealistic
in nature.
Feel “on the go” or “driven by a motor”
Contamination Obsessions
Avoid, dislike, or am
reluctant
to engage
in dirt,
workgerms,
that certain illnesses (e.g., from door handles, other
Excessive
concern
with
requires sustained mental
eff
ort
people)
12
Talk excessively
13
Lose things necessary for tasks or activities
14
stances)
Blurt out answers before
questions have been
completed
Excessive concern with contamination from household items (e.g., cleaners, solvents)
15
Am easily distracted
Excessive concern about contamination from touching animals/insects
16
Excessively
Have difficulty awaiting
turn bothered by sticky substances or residues (e.g., adhesive tape, syrup)
17
Am forgetful in daily activities
18
Concerned
Interrupt or intrude
on others will get others ill by spreading contaminant
Excessive concern/disgust with bodily waste or secretions (e.g., urine, feces, semen,
sweat)
Excessive concern with environmental contaminants (e.g., asbestos or radioactive sub-
Concerned will get ill as a result of being contaminated by something (e.g., germs, animals, cleaners)
Other washing/cleaning obsessions (Describe)
From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.
Reprinted with permission.
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Current Symptoms Self-Report Form
Week of:
Instructions: Please check the response next to each item that best describes your behavior during the past week.
Aggressive Obsessions
Never or
Rarely
Sometimes
Often
Very Often
Fear might harm self (e.g., using knives or other sharp objects)
1
Fail to give close attention to details or make careless
Fear might harm others (e.g., fear of pushing someone in front of a train, hurting somemistakes in my work
one’s feelings, causing harm by giving wrong advice)
2
Fidget with handsFear
or feet
or squirm
in will
seat happen to self
something
bad
3
Have difficulty sustaining
my attention
in tasks
or to others
Fear something
bad will
happen
fun activities
4
ing images)
Leave my seat in situations
in which seating is
expected
Fear of blurting out obscenities or insults (e.g., in public situations like church, school)
5
Don’t listen whenFear
spoken
willtoactdirectly
on unwanted impulses (e.g., punch or stab a friend, drive a car into a tree)
6
Feel restless
7
Don’t follow through on instructions and fail to
Fear will be responsible for terrible event (e.g., fire or burglary because didn’t check
finish work
8
Have difficulty engaging
in leisure activities
or (Describe)
doing
Other aggressive
obsessions
fun things quietly
9
Have difficulty organizing tasks and activities
Violent or horrific images (e.g., images of murders, dismembered bodies, other disgust-
Fear will steal things against his or her will (e.g., accidentally “cheating” cashier or
shoplifting something)
locks)
10
Feel “on Hoarding/Saving
the go” or “driven Obsessions
by a motor”
11
abouttothrowing
things because he or she might need them in
Avoid, dislike, or Worries
am reluctant
engage in away
work unimportant
that
the
future,
urges
to
pick
up
and
collect
useless
things
requires sustained mental effort
12
Health-Related Obsessions
Talk excessively
13
Excessive
concern
with illness or disease (e.g., worries that he or she might have an illLose things necessary
for tasks
or activities
14
Blurt out answersabout
beforevomiting)
questions have been
completed
ness like cancer, heart disease, or AIDS despite reassurance from doctors; concerns
15
Excessive concern with body part or aspect of appearance (e.g., worries that his or her
face, ears, nose, arms, legs, or other body part is disgusting or ugly)
Am easily distracted
16
Have difficulty awaiting turn
17
Religious/Moral
Obsessions
Am forgetful
in daily activities
18
Interrupt or intrude
on thoughts,
others
mous
saying blasphemous things, or being punished for these things)
Other health-related obsessions (Describe)
Overly concerned with offending God or other religious objects (e.g., having blaspheExcessive
concern
with right/wrong,
moralityA clinical
(e.g., worries
always
doing
“the Press.
From R. A. Barkley & K. R. Murphy
(1998),
Attention-Defi
cit Hyperactivity Disorder:
workbook about
(2nd ed.).
New York:
Guilford
Reprinted with permission.
right thing,” worries about having told a lie or having cheated someone)
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Current Symptoms Self-Report Form
Week of:
Instructions: Please check the response next to each item that best describes your behavior during the past week.
Children’s Yale-Brown OC Scale (CY-BOCS) Self-Report Symptom Checklist continued
Other religious obsessions (Describe) Never or
Rarely
Sometimes
Often
Very Often
1
Fail to give close attention to details or make careless
mistakes inMagical
my work
Obsessions
2
Has
lucky/unlucky
numbers, colors, words, or gives special meaning to certain numbers,
Fidget with hands or
feet
or squirm in seat
colors, or words (e.g., red is a bad color because once had a bad thought while wearing
3
4
Have difficulty sustaining
my attention in tasks or
red shirt)
fun activities
Sexual Obsessions
Leave my seat in situations in which seating is
Forbidden or upsetting sexual thoughts, images, or impulses (e.g., unwanted images of
expected
violent sexual behavior toward others, or unwanted sexual urges toward family members
5
Don’t listen when spoken
to directly
or friends)
6
Feel restless
7
Don’t follow through on instructions and fail to
Other sexual obsessions (Describe)
finish work
8
9
Obsessions about sexual orientation (e.g., that he or she may be gay or may become gay
when there is no basis for these thoughts
Have difficulty engaging in leisure activities or doing
fun things quietly
Miscellaneous Compulsions
Have difficulty organizing tasks and activities
Fear of doing something embarrassing (e.g., appearing foolish, burping, having “bath-
10
accident”)
Feel “on the go” orroom
“driven
by a motor”
11
The
need totoknow
orin
remember
Avoid, dislike, or am
reluctant
engage
work thatthings (e.g., insignificant things like license plate numbers,
bumper
stickers,
T-shirt
slogans)
requires sustained mental effort
12
Talk excessively
13
Lose things necessary
activities
Fearforoftasks
not or
saying
the right thing (e.g., fear of having said something wrong or not
14
Blurt out answers before questions have been
Intrusive (nonviolent) images (e.g., random, unwanted images that come into his or her
completed
15
Am easily distracted
16
or herturn
mind that can’t stop; bothered by low sounds like clock ticking or people talking)
Have difficulty awaiting
17
Uncomfortable
sense of incompleteness or emptiness unless things done “just right”
Am forgetful in daily
activities
18
Interrupt or intrude on others
Fear of saying certain things (e.g., because of superstitious fears, fear of saying “thirteen”)
using “perfect” word)
mind)
Intrusive sounds, words, music, or numbers (e.g., hearing words, songs, or music in his
Other obsessions (Describe)
From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.
Adapted from Goodman, W. K., Price, L. H., Rasmussen, S. A. et al. (). The Yale-Brown Obsessive–Compulsive
Reprinted with permission.
Scale. Arch Gen Psychiatry, , –.
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