Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
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]
Dear Parent: As part of our evaluation process, we ask that the child’s parents complete a set of behavioral rating scales. This information is important for the diagnosis and treatment of your child. Your time and cooperation in this matter is greatly appreciated. Attached please find the following form: Vanderbilt Assessment Scale – Parent Informant Please fill out the forms 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, as any delay in receiving the forms also may delay your child’s appointment. 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 your 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
CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION
ASSESSMENT AND DIAGNOSIS Page 1 of 4
Symptoms Never Occasionally Often VeryOften
1. Doesnotpayattentiontodetailsormakescarelessmistakeswith, forexample,homework
2. Hasdifficultykeepingattentiontowhatneedstobedone
3. Doesnotseemtolistenwhenspokentodirectly
4. Doesnotfollowthroughwhengivendirectionsandfailstofinishactivities (notduetorefusalorfailuretounderstand)
5. Hasdifficultyorganizingtasksandactivities
6. Avoids,dislikes,ordoesnotwanttostarttasksthatrequireongoing mentaleffort
7. Losesthingsnecessaryfortasksoractivities(toys,assignments, pencils,books)
8. Iseasilydistractedbynoisesorotherstimuli
9. Isforgetfulindailyactivities
10. Fidgetswithhandsorfeetorsquirmsinseat
11. Leavesseatwhenremainingseatedisexpected
12. Runsaboutorclimbstoomuchwhenremainingseatedisexpected
13. Hasdifficultyplayingorbeginningquietplayactivities
14. Is“onthego”oroftenactsasif“drivenbyamotor”
15. Talkstoomuch
16. Blurtsoutanswersbeforequestionshavebeencompleted
17. Hasdifficultywaitinghisorherturn
18. Interruptsorintrudesinonothers’conversationsand/oractivities
NICHQ Vanderbilt Assessment Scale: Parent InformantToday’sDate:
Child’sName:
Child’sDateofBirth:
Parent’sName:
Parent’sPhoneNumber:
Directions:Eachratingshouldbeconsideredinthecontextofwhatisappropriatefortheageofyourchild.Whencompletingthisform,pleasethinkaboutyourchild’sbehaviorsinthepast6months.
Isthisevaluationbasedonatimewhenthechild
wasonmedication wasnotonmedication notsure?
ForOfficeUseOnly
__________/9
ForOfficeUseOnly
__________/9
NICHQ Vanderbilt Assessment Scale: Parent Informant
ASSESSMENT AND DIAGNOSIS Page 2 of 4
Symptoms(continued) Never Occasionally Often VeryOften
19. Argueswithadults
20. Losestemper
21. Activelydefiesorrefusestogoalongwithadults’requestsorrules
22. Deliberatelyannoyspeople
23. Blamesothersforhisorhermistakesormisbehaviors
24. Istouchyoreasilyannoyedbyothers
25. Isangryorresentful
26. Isspitefulandwantstogeteven
27. Bullies,threatens,orintimidatesothers
28. Startsphysicalfights
29. Liestogetoutoftroubleortoavoidobligations(ie,“cons”others)
30. Istruantfromschool(skipsschool)withoutpermission
31. Isphysicallycrueltopeople
32. Hasstolenthingsthathavevalue
33. Deliberatelydestroysothers’property
34. Hasusedaweaponthatcancauseseriousharm(bat,knife,brick,gun)
35. Isphysicallycrueltoanimals
36. Hasdeliberatelysetfirestocausedamage
37. Hasbrokenintosomeoneelse’shome,business,orcar
38. Hasstayedoutatnightwithoutpermission
39. Hasrunawayfromhomeovernight
40. Hasforcedsomeoneintosexualactivity
41. Isfearful,anxious,orworried
42. Isafraidtotrynewthingsforfearofmakingmistakes
43. Feelsworthlessorinferior
44. Blamesselfforproblems,feelsguilty
45. Feelslonely,unwanted,orunloved;complainsthat“nooneloveshimorher”
46. Issad,unhappy,ordepressed
47. Isself-consciousoreasilyembarrassed
Somewhat Above ofa Performance Excellent Average Average Problem Problematic
48. Reading
49. Writing
50. Mathematics
51. Relationshipwithparents
52. Relationshipwithsiblings
53. Relationshipwithpeers
54. Participationinorganizedactivities(eg,teams)
ForOfficeUseOnly
__________/8
ForOfficeUseOnly
__________/14
ForOfficeUseOnly
__________/7
ForOfficeUseOnly
5s:_________/4
ForOfficeUseOnly
5s:_________/3
ForOfficeUseOnly
4s:_________/4
ForOfficeUseOnly
4s:_________/3
NICHQ Vanderbilt Assessment Scale: Parent Informant
ASSESSMENT AND DIAGNOSIS Page 3 of 4
OtherConditions
TicBehaviors:Tothebestofyourknowledge,pleaseindicateifthischilddisplaysthefollowingbehaviors:
1. MotorTics:Rapid,repetitivemovementssuchaseyeblinking,grimacing,nosetwitching,headjerks,shouldershrugs,armjerks, bodyjerks,orrapidkicks.
Noticspresent. Yes,theyoccurnearlyeverydaybutgounnoticedbymostpeople. Yes,noticeableticsoccurnearlyeveryday.
2. Phonic(Vocal)Tics:Repetitivenoisesincludingbutnotlimitedtothroatclearing,coughing,whistling,sniffing,snorting,screeching, barking,grunting,orrepetitionofwordsorshortphrases.
Noticspresent. Yes,theyoccurnearlyeverydaybutgounnoticedbymostpeople. Yes,noticeableticsoccurnearlyeveryday.
3. IfYESto1or2,dotheseticsinterferewiththechild’sactivities(likereading,writing,walking,talking,oreating)? No Yes
PreviousDiagnosisandTreatment:Tothebestofyourknowledge,pleaseanswerthefollowingquestions:
1. HasyourchildbeendiagnosedwithaticdisorderorTourettesyndrome? No Yes
2. IsyourchildonmedicationforaticdisorderorTourettesyndrome? No Yes
3. Hasyourchildbeendiagnosedwithdepression? No Yes
4. Isyourchildonmedicationfordepression? No Yes
5. Hasyourchildbeendiagnosedwithananxietydisorder? No Yes
6. Isyourchildonmedicationforananxietydisorder? No Yes
7. Hasyourchildbeendiagnosedwithalearningorlanguagedisorder? No Yes
Comments:
NICHQ Vanderbilt Assessment Scale: Parent Informant
ASSESSMENT AND DIAGNOSIS Page 4 of 4
Therecommendationsinthispublicationdonotindicateanexclusivecourseoftreatmentorserveasastandardofmedicalcare.Variations,takingintoaccountindividualcircumstances,maybeappropriate.OriginaldocumentincludedaspartofCaring for Children With ADHD: A Resource Toolkit for Clinicians, 2ndEdition.Copyright©2012AmericanAcademyofPediatrics.AllRightsReserved.TheAmericanAcademyofPediatricsdoesnotrevieworendorseanymodificationsmadetothisdocumentandinnoeventshalltheAAPbeliableforanysuchchanges.
ForOfficeUseOnly
Totalnumberofquestionsscored2or3inquestions1––9:_____________
Totalnumberofquestionsscored2or3inquestions10–—18:_____________
Totalnumberofquestionsscored2or3inquestions19–—26:_____________
Totalnumberofquestionsscored2or3inquestions27–—40:_____________
Totalnumberofquestionsscored2or3inquestions41–—47:_____________
Totalnumberofquestionsscored4inquestions48–—50:_____________
Totalnumberofquestionsscored5inquestions48–—50:_____________
Totalnumberofquestionsscored4inquestions51–—54:_____________
Totalnumberofquestionsscored5inquestions51–—54:_____________
AdaptedfromtheVanderbiltRatingScalesdevelopedbyMarkL.Wolraich,MD.