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Lurie Children’s Primary Care – Town & Country Pediatrics 1460 N. Halsted Street, Suite 402, Chicago, Illinois, 60642 312.227.2800 312.227.9551 Fax [email protected] 6374 N. Lincoln Ave, Suite 204, Chicago, Illinois, 60659 312.227.2860 312.227.9557 Fax [email protected] 2601 Compass Drive, Suite 120, Glenview, Illinois 60026 312.227.2850 312.227.9555 Fax [email protected]
RE: ______________________________ Dear Teacher: The parents of one of your students are seeking to have their child evaluated by our office for a health concern. As part of our evaluation process, we ask that both the child’s parents and teacher complete a set of behavioral rating scales. This information is important for the diagnosis and treatment of your student. Your time and cooperation in this matter is greatly appreciated. Attached please find the following forms: School Questionnaire Vanderbilt Assessment Scale – Teacher Informant Generally, the teacher who spends the most time with the child should complete the teacher rating scales. However, if the child has more than one primary teacher, it would be useful for us to obtain a separate set of rating scales from each teacher. If more than ones set of rating scales is required, please have the parent contact me directly and I will forward additional rating scales as needed. Please fill out the form as completely as possible. If you do not know the answer to a question, please write “Don’t Know,” so that we can be sure that the item was simply overlooked. Some of the questions in the rating scales may seem redundant. This is necessary to ensure that we obtain accurate diagnostic information. We ask that you complete these forms as soon as possible. These forms can be returned to us in the pre-addressed envelope provided to you, or mailed directly to 2601 Compass Drive, Suite 120, Glenview, IL 60026. They also may returned to Connie Collins via fax at 312-227-9555. Thank you for your assistance and cooperation in completion of these forms. If you have any questions, please contact Connie Collins at [email protected] or 312-227-2854. If you would like to share additional information for the evaluation and treatment of the child, you may contact our psychologist, Dr. Devin Carey, at [email protected] or 312-227-2812. Sincerely, Lurie Children’s Primary Care-Town & Country Pediatrics
Roshani Anandappa, MD Jennifer Bergquist, MD Lee Budin, MD Danielle Smith Cherian, MD Diane DiMaggio, MD Leslie Dion, MD David Drelicharz, MD Irene Freeman, MD Diane Holmes, MD Youn J. (Jenny) Hong, MD Barbara N. Johnston, MD Mona Kansagra, MD Emily Lieberman, MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin, MD Julia G. Ray, MD Rachel Saccaro, DO Julie I. Selig, MD Kori Summers, MD Hilary Vallorano, MD Maria Carmen Del Cid, CPNP Julianne Bertalmio, CPNP Jennifer Gill, CPNP Jennifer B. Hartman, CPNP Marianne Miller, CPNP Kathleen Schmiege, CPNP Devin Carey, Ph.D. Sr. Director Donald J. Camp
Date:
Lurie Children’s Primary Care-Town & Country Pediatrics School Questionnaire
Student’s Name: ____________________Grade:___ School: __________________ Your name: _______________________ Your position: ______________________ 1. How long have you known this student: 0-4 months 5-8 months > 12 months 2. Please rate the student’s attendance:
Poor (misses 5+ Fair (misses 3-4 Good (misses 1-2 Excellent (misses <1 day/month) day/month) day/month) day/month)
3. How many teachers does this student have? ______ 4. Do you see this student as having an academic, attentional, or behavioral difficulty?
yes no Please describe:__________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. Overall, is this student: below grade level at grade level above grade level 6. Please list the academic areas where this student has difficulty: _________________________ ____________________________________________________________________________________________________________________________________________________________ 7. Does this student have an IEP? yes no If yes, please provide If yes, under what category?_______________________________________________________ 8. Does this student have a 504 plan? yes no If yes, please provide 9. Does this student have a behavior support plan? yes no If yes, please provide 10. Has the student had any cognitive or academic testing? yes no If yes, please provide 11. Please check all school modifications that have been made (check all that apply) Shortened day Exempt from exams Tutor Less homework More time for exams/assignments Educational Assistant Preferential seating Fully self-contained classroom School counseling Speech therapy Occupational therapy Physical therapy Resource classes (please list subjects_____________________________________________) Social skills assistance (please describe: __________________________________________) Help with organizational skills (please describe: ____________________________________) Other: _____________________________________________________________________ 12. Have you noticed any difficulty focusing/staying on task? yes no Please describe: _______________________________________________________________ ______________________________________________________________________________ 13. Have you noticed any difficulty with memory and learning? yes no Please describe: _____________________________________________________________ ______________________________________________________________________________ 14. Please comment on this student’s classroom behavior, work habits, and relationship with teacher: __________________________________________________________________ ____________________________________________________________________________ 15. Please comment on this student’s socialization with peers (popularity, sensitivity, bullying, friendships): ___________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
Please use back of this form to describe any additional concerns. Thank you very much!
CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION
ASSESSMENT AND DIAGNOSIS Page 1 of 3
Symptoms Never Occasionally Often VeryOften
1. Failstogiveattentiontodetailsormakescarelessmistakesinschoolwork
2. Hasdifficultysustainingattentiontotasksoractivities
3. Doesnotseemtolistenwhenspokentodirectly
4. Doesnotfollowthroughoninstructionsandfailstofinishschoolwork (notduetooppositionalbehaviororfailuretounderstand)
5. Hasdifficultyorganizingtasksandactivities
6. Avoids,dislikes,orisreluctanttoengageintasksthatrequiresustained mentaleffort
7. Losesthingsnecessaryfortasksoractivities(schoolassignments, pencils,books)
8. Iseasilydistractedbyextraneousstimuli
9. Isforgetfulindailyactivities
10. Fidgetswithhandsorfeetorsquirmsinseat
11. Leavesseatinclassroomorinothersituationsinwhichremaining seatedisexpected
12. Runsaboutorclimbsexcessivelyinsituationsinwhichremaining seatedisexpected
13. Hasdifficultyplayingorengaginginleisureactivitiesquietly
14. Is“onthego”oroftenactsasif“drivenbyamotor”
15. Talksexcessively
16. Blurtsoutanswersbeforequestionshavebeencompleted
17. Hasdifficultywaitinginline
18. Interruptsorintrudesinonothers(eg,buttsintoconversations/games)
NICHQ Vanderbilt Assessment Scale: Teacher InformantChild’sName:
Child’sDateofBirth:
Teacher’sName:
Today’sDate:
ClassTime:
ClassName/Period:
GradeLevel:
Directions:Eachratingshouldbeconsideredinthecontextofwhatisappropriatefortheageofthechildyouareratingandshouldreflectthatchild’sbehaviorsincethebeginningoftheschoolyear.Pleaseindicatethenumberofweeksormonthsyouhavebeenabletoevaluatethebehaviors:.
ForOfficeUseOnly
__________/9
ForOfficeUseOnly
__________/9
NICHQ Vanderbilt Assessment Scale: Teacher Informant
ASSESSMENT AND DIAGNOSIS Page 2 of 3
Symptoms(continued) Never Occasionally Often VeryOften
19. Losestemper
20. Activitydefiesorrefusestocomplywithadults’requestsorrules
21. Isangryorresentful
22. Isspitefulandvindictive
23. Bullies,threatens,orintimidatesothers
24. Initiatesphysicalfights
25. Liestoobtaingoodsforfavorsortoavoidobligations(eg,“cons”others)
26. Isphysicallycrueltopeople
27. Hasstolenitemsofnontrivialvalue
28. Deliberatelydestroysothers’property
29. Isfearful,anxious,orworried
30. Isself-consciousoreasilyembarrassed
31. Isafraidtotrynewthingsforfearofmakingmistakes
32. Feelsworthlessorinferior
33. Blamesselfforproblems;feelsguilty
34. Feelslonely,unwanted,orunloved;complainsthat“nooneloveshimorher”
35. Issad,unhappy,ordepressed
Somewhat Above ofa AcademicPerformance Excellent Average Average Problem Problematic
36. Reading
37. Mathematics
38. Writtenexpression
Somewhat Above ofa ClassroomBehavioralPerformance Excellent Average Average Problem Problematic
39. Relationshipwithpeers
40. Followingdirections
41. Disruptingclass
42. Assignmentcompletion
43. Organizationalskills
Comments:
Pleasereturnthisformto:
Mailingaddress:
Faxnumber:
ForOfficeUseOnly
__________/10
ForOfficeUseOnly
__________/7
ForOfficeUseOnly
5s:_________/3
ForOfficeUseOnly
4s:_________/3
ForOfficeUseOnly
5s:_________/5
ForOfficeUseOnly
4s:_________/5
NICHQ Vanderbilt Assessment Scale: Teacher Informant
ASSESSMENT AND DIAGNOSIS Page 3 of 3
Therecommendationsinthispublicationdonotindicateanexclusivecourseoftreatmentorserveasastandardofmedicalcare.Variations,takingintoaccountindividualcircumstances,maybeappropriate.OriginaldocumentincludedaspartofCaring for Children With ADHD: A Resource Toolkit for Clinicians, 2ndEdition.Copyright©2012AmericanAcademyofPediatrics.AllRightsReserved.TheAmericanAcademyofPediatricsdoesnotrevieworendorseanymodificationsmadetothisdocumentandinnoeventshalltheAAPbeliableforanysuchchanges.
AdaptedfromtheVanderbiltRatingScalesdevelopedbyMarkL.Wolraich,MD.
ForOfficeUseOnly
Totalnumberofquestionsscored2or3inquestions1––9:_____________
Totalnumberofquestionsscored2or3inquestions10–—18:_____________
Totalnumberofquestionsscored2or3inquestions19–—28:_____________
Totalnumberofquestionsscored2or3inquestions29–—35:_____________
Totalnumberofquestionsscored4inquestions36–—38:_____________
Totalnumberofquestionsscored5inquestions36–—38:_____________
Totalnumberofquestionsscored4inquestions39–—43:_____________
Totalnumberofquestionsscored5inquestions39–—43:_____________
