1. Informed Consent

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Principal Investigator:
Wendy D’Andrea, Ph.D.

The purpose of this study is to survey clinicians who work with children and adolescents in order to evaluate proposed diagnostic criteria for Developmental Trauma Disorder.

The Following Procedures will be Involved: We will ask you to participate in an evaluation where you will fill out two (2) brief questionnaires for various child and adolescent patients that you currently work with. You may fill out the questionnaires for as many patients as you choose. The first questionnaire involves a checklist that lists twenty (20) types of traumatic events that your patient may have experienced. We will ask you to indicate if your patient has experienced or witnessed each traumatic event listed. For traumas that you endorse, we will ask you for the ages or age range that your patient has experienced the trauma during. The second questionnaire is a checklist consisting of ninety-seven (97) psychiatric symptoms. We will ask you to indicate the presence or absence of each symptom listed. The surveys may be filled out on paper or online via the website https://www.surveymonkey.com/s/5CWT5XD. It will take approximately 10 minutes to fill out both questionnaires for each patient you choose to report on.

Expected Duration of Participation: Your participation will be limited to the amount of time necessary to complete the questionnaires, which will take approximately 10 minutes per case. You may fill out the questionnaires for as many patients as you like.

The Potential Risks or Discomforts to you are: Some clinicians may feel uncomfortable answering questions about types of violence or abuse their patients may have been exposed to. The principal investigator takes no responsibility for the disclosure of abuse information, and will under no circumstances report any disclosed abuse. No identifying information (name, address) will be collected for the patients you report data on, so we will have no way of identifying your patients.

The Potential Benefits to You or to Others are: You are not expected to receive any direct benefit as a result of participating in this research. We hope that the information we obtain from this study will help improve our understanding of the various traumas that children and adolescents experience, and help identify associated symptoms. The results of this research will be used to support the validation of a new proposed psychiatric diagnosis, Developmental Trauma Disorder. We expect results to be available by August, 2011. We will post results on our website, https://sites.google.com/site/nssrtraumalab/home

Participating in this research is voluntary.

Reimbursement: There will be no reimbursement or compensation for participating in this study.

Confidentiality: All information obtained from you will not be identified with your name; your responses will be linked with a coded number. We will only retain your name to indicate informed consent, and this file will be kept separate from all survey responses. All data will be stored in password-protected computer files in a secure research lab that requires key-card entry for access. Any publications resulting from this study will not identify you.

Termination of your Participation: Your decision to take part in this study is voluntary. You have the right to decide not to participate. Should you agree to participate in this research, you may change your mind at any time and withdraw from the study.

General Conditions and Other Information:
1. If you would like to discuss your rights as a research subject and/or your participation in this study with an institutional representative who is not part of this study, you may contact: Madeline Bohm, IRB Coordinator, 212.229.5727, ext. 3102.
2. If you have any questions about the study, you may call Wendy D’Andrea, Ph.D., Principal Investigator, at 212-229-5727, ext. 3257, or email dandreaw@newschool.edu.

* Patient Consent to Research Participation:

I have read the consent form, understood the purpose of the following questionnaires, and voluntarily consent to participate in this research study.

Please type your name below, which will serve as your electronic signature and indicate your consent.