Behavioral Inventory for Children 6-18 years old

(CBCL) 1

Name and surname of the child:

Sex: ⎕ Boy ⎕ Girl ⎕ Boy ⎕ Girl Age:..................years Date of birth: ......................... / ..... / ............
Type of School: ⎕ Private ⎕Official ⎕ ⎕ Does not attend school.
Grade level:
School Type . Since when?...........................................
REASON: ⎕Expulsion ⎕Change of Residence
⎕Requires Special Education ⎕Financial Problems
⎕Doesn't want to.

This questionnaire was answered by: Father: ...............................................................................................................................

Mother: .............................................................................................................................
Others: ..............................................................................................................................

Parents' usual job, even if they are not working now

Father's job: ......................................................... Job of the mother: .................................... Date of birth: ................... / .... / .......

PLEASE CHECK THAT YOU HAVE ANSWERED ALL THE QUESTIONS.

I. List the three sports Compared to other children your age, Compared to other children your age,
what your child does most (e.g. swimming, how much time do you spend on each of how well do you practice these sports?
baseball, skating, biking, basketball, fishing, these sports?
etc.)

⎕ None
a) I do Less Same More I do not Worst Same Best
b) not
I do Less Same More know
I do not Worst Same Best
c) not
I do Less Same More know
I do not Worst Same Best
not know
II. What are your child's favorite activities, Compared to other children your age, Compared to other children his/her age,
games, or hobbies other than sports? E.g. how much time do you spend on each of how does he/she do in these activities?
reading, playing the piano, crafts, these activities?
mechanics, playing with dolls, etc. (Does not
include listening to the radio or watching
TV).
⎕ None
a) I do not Less Same More I do not Worst Same Best
know
I do not Less know
I do not
b) Same More Worst Same Best
c) know
I do not Less Same More know
I do not Worst Same Best
know know
Compared to other children of the same age how active is he/she in each of the
III. What organizations, teams, clubs or groups?
groups does your child belong to?
⎕ None
a) I do not know Less Same More
b) I do not know Less Same More
c) I do not know Less Same More
 Behavioral Inventory for Children 6-18 years old (CBCL) 2

IV. Name some type of chores or tasks your Compared to children your age, how do you perform these tasks?
child does at home (picking up his/her
room, setting the table, picking up things,
etc.).
⎕ None
a) I do not know Less Same More
b) I do not know Less Same More
c) I do not know Less Same More

V. 1. How many close friends does your child have? (Does not include siblings)
⎕ None ⎕ O ne ⎕ Two or three ⎕ Four or more
2. How many times do you play with them per week?
⎕ Less than one ⎕ 1-2 times ⎕ 3 or more times

VI. If you compare your child to other children of his/her age, how would you say your child behaves? Worst Same
Best
a) With their siblings: ........................................... ......................................................... .........................................................
b) With other children: .................................. ......................................................... .........................................................
c) With their parents: .................................. ......................................................... .........................................................
d) When playing alone: .................................. ......................................................... .........................................................

VII. 1. School performance level:

# Does not attend school Failing Below average Average Above Average
a) Spanish: .................................. ................................................. ................................................. ..................................................
b) Mathematics: .................................. ................................................. ................................................. ..................................................
c) Social Sciences: .................................. ................................................. ................................................. ..................................................
d) History .................................. ................................................. ................................................. ..................................................
e) Cs. Natural: .................................. ................................................. ................................................. ..................................................
f) ................................................... ........................................................................... ...........................................................................
g) ................................................... ........................................................................... ...........................................................................

2. Does your child attend any special classes or schools? ⎕ No..........................................⎕ Yes Class type:
3. Has your child repeated a grade?
⎕ No ⎕ Yes Course and reason: ........................................................................................
4. Has your child had any problems worth mentioning at school?
⎕ No ⎕ Yes Describe: .............................................................................................................
When did they start and how long did they last? ..............................................................................
5. Does your child have any type of illness, physical problem or mental disorder? ⎕No ⎕ Yes Describe:
6. What worries you most about your child? …………………………………………………………………………………………………

VIII. On the following pages, you will find different adjectives about your child's behavior. Each of these statements attempts to
describe your child's behavior in the past six months and at the present time.
To do this you must put a Z or a circle around each of the following ratings:
0: When you do not believe the statement is appropriate for your child or the behavior never appears.
1: When this behavior is true, or when it happens sometimes.
2: When such behavior is very certain, it either occurs very frequently or many times.
 Behavioral Inventory for Children 6-18 years old (CBCL) 3

PLEASE READ ALL THE QUESTIONS AND ANSWER EACH AND EVERY ONE OF THEM.
001. He acts as if he were much younger than his age. 0 1 2
002. Drinks alcoholic beverages without parental permission. Specify: ........................................................................... 0 1 2
003. Argues a lot 0 1 2
004. Leaves unfinished what he/she starts 0 1 2
005. Enjoy very few things 0 1 2
006. Poops outside the toilet bowl (on clothes, floor, etc.). 0 1 2
007. He bluffs. Likes to show off 0 1 2
008. Cannot concentrate, cannot be attentive for long. 0 1 2

009. You can't get certain ideas out of your head, manias, obsessions. Specify: .................................................
0 1 2
010. Cannot sit still; is fidgety or hyperactive 0 1 2
011. Is overly dependent on or attached to adults
0 1 2
012. Complains of feeling lonely 0 1 2
013. You are confused, or seem as if you are in the clouds. 0 1 2
014. Cry a lot 0 1 2
015. It is cruel to animals 0 1 2
016. You are cruel, abusive, or mean to others. 0 1 2
017. Lost in his thoughts, he daydreams 0 1 2
018. Intentionally harms self, has made a suicide attempt, etc. 0 1 2
019. Demands a lot of attention 0 1 2
020. Breaks or destroys your things, toys 0 1 2
021. Breaks or smashes other people's things or toys. 0 1 2
022. Does not obey at home 0 1 2
023. Does not obey at school 0 1 2
024. Does not eat well 0 1 2
025. Does not get along with other children. 0 1 2
026. You do not seem to feel guilty after misbehaving 0 1 2
027. Easily jealous 0 1 2

028. Break the rules at home, school or anywhere else

0 1 2
029. Has a fear of certain animals, places or situations (except school). Specify: ...................................................
0 1 2
030. You are afraid to go to school 0 1 2
031. You are afraid of doing or thinking something bad 0 1 2
032. You feel you must be perfect 0 1 2
033. Feels or complains that no one loves him/her. 0 1 2
034. You think you are being persecuted by someone, you feel that others want to harm you. 0 1 2
035. You feel less or think you are worthless 0 1 2
Behavioral Inventory for Children 6-18 years old
(CBCL) 4

036. Accidentally injured very often, prone to accidents. 0 1 2

037. Gets into fights a lot 0 1 2
038. Others often make fun of him/her. 0 1 2
039. Hangs out with kids/youth who get into trouble 0 1 2
040. He hears things that do not exist, for example voices. Specify: .................................................................... 0 1 2
041. You are very impulsive, act without thinking 0 1 2
042. Prefer to be alone rather than with other people 0 1 2
043. Is a liar 0 1 2
044. Nail biting 0 1 2
045. You are nervous, look tense 0 1 2
046. You have nervous gestures or movements, tics. Describe: .......................................................................... 0 1 2
047. You have nightmares 0 1 2
048. Other children/youth don't like you 0 1 2
049. You suffer from constipation 0 1 2
050. You are too fearful 0 1 2
051. It gets dizzy 0 1 2
052. Feeling too guilty 0 1 2
053. Eats too much 0 1 2
054. You feel very tired, with no reason to be tired. 0 1 2
055. She is too heavy for her age 0 1 2
056. You have physical problems with no known medical cause:
a) Pain. Specify: ............................................................................................................................ 0 1 2
b) Headache 0 1 2
c) Nausea, urge to vomit 0 1 2
d) Eye problems (does not include wearing glasses). Describe:
0 1 2
e) Rash or other skin problems 0 1 2
f) Stomachaches 0 1 2
g) Vomiting 0 1 2

h) Others. Describe: .....................................................................................................................................................

0 1 2
057. Physically attacks other people 0 1 2
058. Pokes finger in nose, scratches skin or other body parts. Describe: 0 1 2

059. Play with your sexual parts in public 0 1 2

060. He plays a lot with his genitals, masturbates a lot. 0 1 2
061. Your school work is weak 0 1 2
062. It is clumsy, with poor coordination 0 1 2
063. Prefers to play with children older than him/her. 0 1 2
064. Prefers to play with children younger than him/her. 0 1 2
Behavioral Inventory for Children 6-18 years old
(CBCL) 5

065. Refuses to speak outside the family 0 1 2

066. He repeats some acts successively, compulsively. Describe: 0 1 2

067. Runaway from home 0 1 2

068. Shout a lot 0 1 2
069. Secretive, keeps things to him/herself 0 1 2
070. It sees things that do not exist. Describe: .................................................................................... 0 1 2
071. You are embarrassed, embarrassed easily 0 1 2
072. Burning things 0 1 2
073. She has sexual problems. Describe: ....................................................................................................... 0 1 2
074. You like to attract attention or be funny. 0 1 2
075. Too shy or withdrawn 0 1 2
076. Sleeps less than most children his/her age 0 1 2
077. Sleeps more than most children his age, during the day and/or night. Describe:

0 1 2
078. Inattentive or easily distracted 0 1 2
079. Has speech or language problems. Describe:
0 1 2
080. He looks blankly, he looks into the void. 0 1 2
081. Home burglary 0 1 2
082. Stealing away from home 0 1 2
083. Stores things you don't need. Describe: ................................................................................................... 0 1 2
084. Odd or strange behavior. Describe: .................................................................................................................... 0 1 2
085. You have strange or bizarre ideas. Describe: ................................................................................................. 0 1 2

086. You are stubborn, moody, or irritable. 0 1 2

087. Your mood or feelings change from one moment to the next 0 1 2
088. Puts on a grim face 0 1 2
089. You are suspicious, mistrustful, distrustful, suspicious of 0 1 2
090. You use profanity or swear words 0 1 2
091. He talks about wanting to kill himself. 0 1 2
092. Talks or gets up or walks when asleep. Describe: ............................................................................................... 0 1 2
093. Talks too much 0 1 2
094. He makes fun of others a lot. 0 1 2
095. Has a lot of temper tantrums, bad temper 0 1 2
096. You think about sexual things a lot 0 1 2
097. Threatening others 0 1 2
098. Thumb sucking 0 1 2
099. Smoke, chew or inhale tobacco 0 1 2
100. Does not sleep well. Describe: ...........................................................................................................................
0 1 2
15.1.1. Child Behavior Inventory
Child Behavior Checklist (CBCL) 1
8

101. Truant from school, no reason. 0 1 2

102. Is inactive, sluggish, lacks energy 0 1 2
103. You are unhappy, sad, or depressed. 0 1 2
104. Is louder than usual 0 1 2
105. Uses drugs. Describe: ............................................................................................................. 0 1 2
106. Commits acts of vandalism, destroys public things 0 1 2
107. Urinates on clothes during the day 0 1 2
108. Bedwetting 0 1 2
109. Complains a lot 0 1 2
110. Wishes to be of the opposite sex 0 1 2
111. Does not socialize with other children, does not have any friends 0 1 2
112. Cares a lot 0 1 2

Please describe any problems your child has that are not listed:

0 1 2

PLEASE DO NOT FORGET TO REVIEW THE ENTIRE QUESTIONNAIRE ONCE YOU HAVE COMPLETED IT. ANSWER ALL
QUESTIONS.

THANK YOU FOR YOUR COOPERATION.