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BITSEA-Parent English
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*
" indicates required fields
Parent Form
Child's Name
*
First
Last
Sex
*
Boy
Girl
Child's Date of Birth
*
MM slash DD slash YYYY
Parent/Guardian's name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Was your child born prematurely?
*
No
Yes
If yes, what was the expected date of birth.
MM slash DD slash YYYY
Instructions: Many statements describe normal feelings and behaviors, but some describe feelings and behaviors that may be problems. Please respond to every item. Please select the ONE response that best describes your child's behavior in the LAST MONTH.
1. Shows pleasure when he or she succeeds (for example, claps for self).
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
2. Gets hurt so often that you can't take your eyes off him or her.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
3. Seems nervous, tense, or fearful.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
4. Is restless and can't sit still.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
5. Follows rules.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
6. Wakes up at night and needs help to fall asleep again.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
7. Cries or has a tantrum until he or she is exhausted.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
8. Is afraid of certain places, animals or things.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
What is he or she afraid of?
9. Has less fun than other children.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
10. Looks for you (or other parent) when upset.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
11. Cries or hangs onto you when you try to leave.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
12. Worries a lot or is very serious.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
13. Looks right at you when you say his or her name.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
14. Does not react when hurt.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
15. Is affectionate with loved ones.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
16. Won't touch some objects because of how they feel.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
17. Has trouble falling asleep or staying asleep.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
18. Runs away in public places.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
19. Plays well with other children (not including brother/sister).(Select N if there is no contact with other children)
*
N
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
20. Can pay attention for a long time (other than when watching TV).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
21. Has trouble adjusting to changes.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
22. Tries to help when someone is hurt (for example, gives a toy).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
23. Often gets very upset.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
24. Gags or chokes on food
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
25. Imitates playful sounds when you ask him or her to.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
26. Refuses to eat.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
27. Hits, shoves, kicks, or bites children (not including brother/sister).( Select N if there is no contact with other children)
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N
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
28. Is destructive. Breaks or ruins things on purpose.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
29. Points to show you something far away.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
30. Hits, bites, or kicks you (or other parent).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
31. Hugs or feeds dolls or stuffed animals.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
32. Seems very unhappy, sad, depressed, or withdrawn.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
33. Purposely tries to hurt you (or other parent)
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
34. When upset, gets very still, freezes, or doesn't move.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
The following statements describe feelings and behaviors that can be problems for young children. Some of the descriptions may be a bit hard to understand, especially if you have not seen the behavior in your child. Please do your best to respond to all statements.
35. Puts things in a special order over and over and gets upset if he or she is interrupted.
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
36. Repeats the same action or phrase over and over without enjoyment
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
Please give an example:
37. Repeats a particular movement over and over without enjoyment (like rocking, spinning).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
Please give an example:
38. Spaces out. Is totally unaware of what's happening around him or her
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Not true/Rarely
Somewhat true/Sometimes
Very true/Often
39. Does not make eye contact.
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
40. Avoids physical contact
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
41. Hurts self on purpose (for example, bangs his or her head).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
Please describe:
42. Eats or drinks things that are not edible (like paper or paint).
*
Not true/Rarely
Somewhat true/Sometimes
Very true/Often
Please describe:
A. How worried are you about your child's behavior, emotions, or relationships?
*
Not at all worried
A little worried
Worried
Very worried
B. How worried are you about your child's language development?
*
Not at all worried
A little worried
Worried
Very worried
The Problem Total
Calculated- do not edit
The Competence Total
Calculated- do not edit
