Complete Parent Packet

Douglas R. Coombs, MD 520 East Medical Drive #301 Bountiful, Utah 84010 Phone (801)292-1464 Fax (801)292-1465

Date__________________ Dear Parent/Guardian, This ADHD evaluation includes information from school as well as home. Please fill out the the following home screening scales and return them to our office one week before your office visit. Attached, please find: Structured Parent Interview Vanderbilt Parent Assessment Scale Home Symptom Screening Scale Depression Scale for Children Screen for Child Anxiety (CHILD) Screen for Child Anxiety (PARENT) Please complete these forms as soon as you can find time to do so thoroughly. If there is additional information that you consider pertinent, please provide this on an additional sheet or call us at the office. As soon as you have completed the forms, please either mail them, fax them, or return them in person one week before your office visit. Please bring a quiet toy or activity for your child to play with during the consultation process of the exam. ***Not all insurances will cover the cost of reviewing, scoring or interpreting this packet. You will be responsible for any costs not covered by your insurance plan*** Sincerely,

Douglas R. Coombs, MD, FAAP Lisa Sharp, RN, FNP, BC Gina M. Capps, RN, CPNP Stacey A. Bushell, MSN, CPNP Kim Webb, RN, CPNP Brian J. Holdstock, MSN, CFNP

STRUCTURED PARENT INTERVIEW __________________________________________________________________________________________ Pateint Name Grade Age Date __________________________________________________________________________________________ Form Completed By Relationship ______________________________________________________________________________________ School Name/ Contact School Phone # School Fax # __________________________________________________________________________________________ Parents or legal guardians should complete the following questionnaire. This feedback will provide valuable information to the school regarding your child and his/her current school-related difficulties. All information will be kept confidential. If you do not wish to respond to an item on the interview form, just write "no response" in the space provided or out to the side. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION ONE - FAMILY INFORMATION Mother's name _________________________________

Father's name _______________________________

Marital status of child's parents: [ ] Unmarried [ ] Married [ ] Separated [ ] Divorced (for how long?)____________ [ ] Remarried (name of step parents)_________________________________________ Number of sibling residing in the home: Name___________________________________________________ Name___________________________________________________ Name___________________________________________________ Name___________________________________________________ Name___________________________________________________ Name___________________________________________________ Name___________________________________________________

Age____________ Age____________ Age____________ Age____________ Age____________ Age____________ Age____________

SECTION TWO - PREGNANCY / DELIVERY General health during pregnancy: [ ] Excellent [ ] Good

[ ] Poor (please explain)____________________________________________

During your pregnancy, indicate if you often used: [ ] Cigarettes [ ] Alcohol [ ] Other drugs

[ ] None of the above

Pregnancy was: [ ] Without complications [ ] With complications (please explain)______________________ __________________________________________________________________________________________ Delivery was: [ ] Without complications

[ ] Induced

[ ] C-Section [ ] Other ________________________

Infants health at birth was: [ ] Excellent [ ] Good [ ] Poor (please explain) ______________________________ __________________________________________________________________________________________

SECTION THREE - CHILD'S DEVELOPMENTAL HISTORY Please place a mark through the box if your child had difficulty in any of these areas during the first three years of life: [ ] Poor eye contact [ ] Didn't get along well with peers [ ] Overly fearful [ ] Colicky / irritable [ ] Difficulty adjusting to schedules (eating, sleeping, etc.) [ ] Difficult to comfort [ ] Sleep problems [ ] Resisted affection from others [ ] Overactive [ ] Threw tantrums [ ] Resisted changes in schedules [ ] Accident prone [ ] Stubborn Overall, as a toddler, I would describe my child's temperament as (check one): [ ] Extremely difficult [ ] Difficult [ ] Average

[ ] Very easy

Indicate the age at which your child developed the following skills: _____Crawling _____Toilet training _____Riding a bike _____Getting dressed without help _____Walking _____First words _____Ability to complete simple chores independently SECTION FOUR - CHILD'S MEDICAL HISTORY Family physician ____________________________________________ Phone # _______________________ Please place a mark through the box if your child has had any of the following medical conditions: [ ] Asthma _________________________ [ ] Chronic ear infections ____________________________ [ ] Allergies ________________________ [ ] Hearing loss ____________________________________ [ ] Bedwetting ______________________ [ ] Vision problems _________________________________ [ ] Diabetes ________________________ [ ] Poor motor coordination __________________________ [ ] Seizure disorder __________________ [ ] Sleep problems__________________________________ [ ] Surgeries (for what?) __________________________ [ ] Appetite problems (under / over eats) ________________________________ [ ] Head trauma_____________________ [ ] Serious injuries (broken bones, stitches, etc) ___________________________ Overall, I would describe my child's current level of health as being:

[ ] Excellent [ ] Good

[ ] Poor

My child is currently taking the following medications: Name of medication ______________________________ For what condition? ____________________ Name of medication ______________________________ For what condition? ____________________ Name of medication ______________________________ For what condition? ____________________ Name of medication ______________________________ For what condition? ____________________ Name of medication ______________________________ For what condition? ____________________ Name of medication ______________________________ For what condition? ____________________ SECTION FIVE - FAMILY HISTORY Please check the box if either of the child's biological parents have experienced any of the following conditions: [ ] Attention Deficit / Hyperactivity Disorder [ ] Obsessive-compulsive disorder [ ] Learning disablities / Academic underachievement [ ] Autism / Asperger's syndrome [ ] Communication disorders / disablities [ ] Tourette's syndrome [ ] Depression [ ] Substance abuse [ ] Anxiety disorder(s) [ ] Criminal misconduct

Please check the box if any of the child's biological siblings have experienced any of the following conditions: [ ] Attention Deficit / Hyperactivity Disorder [ ] Obsessive-compulsive disorder [ ] Learning disablities / Academic underachievement [ ] Autism / Asperger's syndrome [ ] Communication disorders / disablities [ ] Tourette's syndrome [ ] Depression [ ] Substance abuse [ ] Anxiety disorder(s) [ ] Criminal misconduct SECTION SIX - CHILD'S EDUCATIONAL HISTORY Please list any previous schools your child has attended: Name of school ________________________________________City___________________________ Name of school ________________________________________City___________________________ Name of school ________________________________________City___________________________ Name of school ________________________________________City___________________________ Name of school ________________________________________City___________________________ Please place a mark through the box if the item is true about your child. If unsure about an item, leave it blank. [ ] My child has been previously evaluated for school-related problems ___________________________ [ ] My child has had to repeat a grade ______________________________________________________ [ ] My child has difficulty learning academic material _________________________________________ [ ] My child has difficulty following school rules _____________________________________________ [ ] My child has difficulty forming friendships at school _______________________________________ [ ] My child resists going to school and/or complains about disliking school _______________________ [ ] My child has received counseling at school _______________________________________________ [ ] My child is or has been in special education ("resource") _______________________________________ [ ] My child has (or has had) a 504 plan ____________________________________________________ [ ] My child has a medical condition that may affect his/her ability to succeed at school - please describe: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please describe any additional information about your child's school history that you feel might be helpful __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ SECTION SEVEN - CURRENT BEHAVIORAL CONCERNS Please check the boxes that describe a current concern that you have about your child: Behavior [ ] Overactive / always on the go [ ] Impulsive - acts without thinking about behavioral consequences [ ] Distractible - shifts focus from one activity to another [ ] Difficulty complying to rules and expectations [ ] Talks too much - interrupts others

[ ] Can't play quietly [ ] Doesn't complete tasks or chores [ ] Disorganized - frequently loses things [ ] Forgetful - has trouble following directions [ ] Impatient - difficult waiting for turns

Compliance to Rules and Social Norms [ ] Refuses to comply with adults and rules [ ] Argues with adults [ ] Throws tantrums [ ] Seems angry / vindictive

[ ] Destroys property [ ] Dishonest - lies, cheats, steals [ ] Bullies - threatens others [ ] Physically aggressive toward others - gets in fights

General Mood [ ] Cries often or without apparent reason [ ] Loss of appetite [ ] Irritable / Moody [ ] Excessive fatigue / Loss of energy [ ] Complains of having no friends [ ] Doesn't seem to enjoy activities that used to be fun [ ] Complains about feeling unloved [ ] Expresses suicidal thoughts ("I don't want to live") [ ] Can't sleep at night / sleeps too much during the day Anxiety Level [ ] Worries excessively (e.g., sickness, weather, safety, school) [ ] Difficulty separating from parents [ ] Difficulty sleeping [ ] Difficulty concentrating [ ] Doesn't seem to enjoy activities that used to be fun [ ] Restless / Easily agitated [ ] Expresses suicidal thoughts ("I don't want to live anymore") [ ] Loss of energy / Easily fatigued [ ] Complains of headaches, stomachaches, nausea when not appearing sick Peer Relationships [ ] Complains that "nobody likes me" [ ] Bossy - has to have own way [ ] Doesn't follow rules when playing games [ ] Sore loser [ ] Argues and fights with peers

[ ] Has difficulty sharing and cooperating with others [ ] Teases others [ ] Bullies others [ ] Doesn't show concern for the welfare of others

School Performance [ ] Academic deficits - not learning as quickly as classmates [ ] Behavior problem - disruptive / does not follow rules [ ] Fails to complete classwork and homework [ ] Resists going to school

[ ] Low test scores [ ] Excessive absences / tardiness [ ] Social problems - has few friends at school

SECTION EIGHT - ADDITIONAL INFORMATION Please use the lines below to indicate your child's individual strengths and positive personality characteristics: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Please use the lines below to provide additional information about your child that may be of importance to the school: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Thank you for providing this information. When you have completed the questionnaire(s), please return them to our office at least one week prior to your scheduled appointment. If you have any questions, please contact our office at (801) 292-1464.

NICHQ Vanderbilt Assessment Scale—Parent Informant NICHQ Vanderbilt Assessment Scale—PARENT Informant

Today’s Date: __________ Child’s Name: _________________________________ Date of Birth: ___________ Parent’s Name: _______________________________________ Parent’s Phone Number: __________________ Direction: Each rating should be considered in the context of what is appropriate for the age of your child When completing this form, please think about your child’s behaviors in the past 6 months. Is this evaluation based on a time when the child: [ ] was on medication [ ] was not on medication [ ] not sure? Symptoms

Never

Occasionally

1. Does not pay attention to details or makes careless mistakes 0 with, for example, homework 2. Has difficulty keeping attention to what needs to be done 0 3. Does not seem to listen when spoken to directly 0 4. Does not follow through when given directions and fails to finish activities 0 (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities 0 6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 or books) 8. Is easily distracted by noises or other stimuli 0 9. Is forgetful in daily activities 0 10. Fidgets with hands or feet or squirms in seat 0 11. Leaves seat when remaining seated is expected 0 12. Runs about or climbs too much when remaining seated is expected 0 13. Has difficulty playing or beginning quiet play activities 0 14. Is “on the go” or often acts as if “driven by a motor” 0 15. Talks too much 0 16. Blurts out answers before questions have been completed 0 17. Has difficulty waiting his or her turn 0 18. Interrupts or intrudes in on others’ conversations and/or activities 0 19. Argues with adults 0 20. Loses temper 0 21. Actively defies or refuses to go along with adults’ requests or rules 0 22. Deliberately annoys people 0 23. Blames others for his or her mistakes or misbehaviors 0 24. Is touchy or easily annoyed by others 0 25. Is angry or resentful 0 26. Is spiteful and wants to get even 0 27. Bullies, threatens, or intimidates others 0 28. Starts physical fights 0 29. Lies to get out of trouble or to avoid obligations (ie, “cons” others) 0 30. Is truant from school (skips school) without permission 0 31. Is physically cruel to people 0 32. Has stolen things that have value 0

Often

Very Often

1

2

3

1 1 1

2 2 2

3 3 3

1 1

2 2

3 3

1

2

3

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances. Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD. Revised – 1102

HE0350

Symptoms

Never

33. Deliberately destroys others’ property 34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 35. Is physically cruel to animals 36. Has deliberately set fires to cause damage 37. Has broken into someone else’s home, business, or car 38. Has stayed out at night without permission 39. Has run away from home overnight 40. Has forced someone into sexual activity 41. Is fearful, anxious, or worried 42. Is afraid to try new things for fear of making mistakes 43. Feels worthless or inferior 44. Blames self for problems, feels guilty 45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 46. Is sad, unhappy, or depressed 47. Is self-conscious or easily embarrassed

Performance

48. Overall school performance 49. Reading 50. Writing 51. Mathematics 52. Relationship with parents 53. Relationship with siblings 54. Relationship with peers 55. Participation in organized activities (eg, teams) Comments:

Occasionally

Often

0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

0 0

1 1

2 2

3 3

Excellent

Above Average

Average

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3

Very Often

Somewhat of a Problem Problematic

4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5

__________________________________________________________________________________________________ For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: ______________________________ Total number of questions scored 2 or 3 in questions 10–18: ____________________________ Total Symptom Score for questions 1–18:___________________________________________ Total number of questions scored 2 or 3 in questions 19–26: ____________________________ Total number of questions scored 2 or 3 in questions 27–40: ____________________________ Total number of questions scored 2 or 3 in questions 41–47: ____________________________ Total number of questions scored 4 or 5 in questions 48–55:_____________________________ Average Performance Score:______________________________________________________ 3 NICHQ Vanderbilt Assessment Scale—PARENT Informant, continued The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances. Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD. 11-19/Rev1102

HE0350

Home Symptom / Impairment Screening Scale TOM SCREME SYMP ENING SCALE

____________________________________________________________________________________________________________

Name

Grade

Age

Date

_________________________________________________________________________________________________ Form Completed By Relationship _________________________________________________________________________________________________ School Name/Contact School Phone # School Fax # Home Symptom Screening Scale The HOME SYMPTOM SCREENING SCALE should be completed by the child's parent / legal guardian. This scale will provide a preliminary assessment of your child's ADHD symptoms. Please rate each behavior according to the degree of problem the student is currently experiencing at home. When complete, add the ratings for each domain. Then add the three domain scores to obtain a to tal scale score. After t reatment is ini tiated, the scale should be administered again to determine t reatment effects on level of symptoms.

BEHAVIOR DOMAINS

No Problems =0

Mild Problem =1

Mod. Problem =2

Severe Problem =3

Is easily distracted Distractibility

Has difficulty following directions Has difficulty sustaining attention Shifts from one activity to another Does not seem to listen Loses materials DOMAIN SCORE___________

Impulsivity

Has difficulty waiting for turns Engages in dangerous activities Interrupts or intrudes Blurts out answers to questions DOMAIN SCORE___________

Hyperactivity

Fidgets or squirms in a chair Has difficulty playing quietly Talks excessively DOMAIN SCORE___________ TOTAL SCALE SCORE____________ (Add 3 Domain Scores) .

Home Impairment Scale The HOME IMPAIRMENT SCALE should be completed by the child's parent / legal guardian. It will provide a preliminary measure of the child's level of impairment. When complete, add the ratings for each domain. Then add the four domain scores to obtain a to tal scale score. The domain and to tal scale scores provide a baseline estimate of the child's degree of impairment at home. After t reatment is ini tiated, the scale should be administered again to determine t reatment effects on level of impairment.

BEHAVIOR DOMAINS

No Problems =0

Mild Problem =1

Mod. Problem =2

Severe Problem =3

Home Responsibilities

Performs chores Does homework Takes care of personal property Meets time demands Follow directions Practices lessons (dance, music...) Is self-reliant DOMAIN SCORE___________

Follows home rules Controls anger Home Behavior

Respect for authority figures Respect for home property Uses inappropriate language Is dishonest (steals, lies, cheats) Problems with police Traffic tickets/accidents Substance abuse DOMAIN SCORE___________

Relates well to others Social Relationships

Cooperates in groups/games Teases others Is teased by others Withdrawn from classmates Aggressive toward other children Respect for others' property Respect for others' feelings DOMAIN SCORE___________

Has sleeping problems Complains of aches and pains Wets the bed Emotional Domain

Doesn't seem to enjoy anything Cries for no apparent reason Appears agitated/irritable Stays inside too much Is excessively fearful/anxious Talks about (or does) running away Talks about/has attempted suicide Feels unliked or unloved DOMAIN SCORE___________ TOTAL SCALE SCORE____________ (Add 4 Domain Scores) .

Note: Some students display symptoms of ADHD without experiencing impairment. To receive a diagnosis of ADHD, there must be impairment in two or more settings (school, home, and/or work). This scale assesses impairment in one domain only.

Screen for Child Anxiety Related Disorders (SCARED) Parent Version—Pg. 1 of 2 (To be filled out by the PARENT) Name:______________________________________ Date:_______________________________________ Directions: Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child. 0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

1. When my child feels frightened, it is hard for him/her to breathe.

O

O

O

2. My child gets headaches when he/she is at school.

O

O

O

3. My child doesn’t like to be with people he/she doesn’t know well.

O

O

O

4. My child gets scared if he/she sleeps away from home.

O

O

O

5. My child worries about other people liking him/her.

O

O

O

6. When my child gets frightened, he/she feels like passing out.

O

O

O

7. My child is nervous.

O

O

O

8. My child follows me wherever I go.

O

O

O

9. People tell me that my child looks nervous.

O

O

O

10. My child feels nervous with people he/she doesn’t know well.

O

O

O

11. My child gets stomachaches at school.

O

O

O

12. When my child gets frightened, he/she feels like he/she is going crazy.

O

O

O

13. My child worries about sleeping alone.

O

O

O

14. My child worries about being as good as other kids.

O

O

O

15. When he/she gets frightened, he/she feels like things are not real.

O

O

O

16. My child has nightmares about something bad happening to his/her parents.

O

O

O

17. My child worries about going to school.

O

O

O

18. When my child gets frightened, his/her heart beats fast.

O

O

O

19. He/she gets shaky.

O

O

O

20. My child has nightmares about something bad happening to him/her.

O

O

O

21. My child worries about things working out for him/her.

O

O

O

22. When my child gets frightened, he/she sweats a lot.

O

O

O

23. My child is a worrier.

O

O

O

24. My child gets really frightened for no reason at all.

O

O

O

25. My child is afraid to be alone in the house.

O

O

O

Screen for Child Anxiety Related Disorders (SCARED) Parent Version—Pg. 2 of 2 (To be filled out by the PARENT) 0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

26. It is hard for my child to talk with people he/she doesn’t know well.

O

O

O

27. When my child gets frightened, he/she feels like he/she is choking.

O

O

O

28. People tell me that my child worries too much.

O

O

O

29. My child doesn’t like to be away from his/her family.

O

O

O

30. My child is afraid of having anxiety (or panic) attacks.

O

O

O

31. My child worries that something bad might happen to his/her parents.

O

O

O

32. My child feels shy with people he/she doesn’t know well.

O

O

O

33. My child worries about what is going to happen in the future.

O

O

O

34. When my child gets frightened, he/she feels like throwing up.

O

O

O

35. My child worries about how well he/she does things.

O

O

O

36. My child is scared to go to school.

O

O

O

37. My child worries about things that have already happened.

O

O

O

38. When my child gets frightened, he/she feels dizzy.

O

O

O

39. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport.)

O

O

O

40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn’t know well.

O

O

O

41. My child is shy.

O

O

O

SCORING: A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific. A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms. A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder. A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder. A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance. Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pgh. (10/95). E-mail: [email protected]

Screen for Child Anxiety Related Disorders (SCARED) Child Version—Pg. 1 of 2 (To be filled out by the CHILD) Name:________________________________________ Date:_________________________________________ Directions: Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for you. Then for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months. 0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

1. When I feel frightened, it is hard to breathe.

O

O

O

2. I get headaches when I am at school.

O

O

O

3. I don’t like to be with people I don’t know well.

O

O

O

4. I get scared if I sleep away from home.

O

O

O

5. I worry about other people liking me.

O

O

O

6. When I get frightened, I feel like passing out.

O

O

O

7. I am nervous.

O

O

O

8. I follow my mother or father wherever they go.

O

O

O

9. People tell me that I look nervous.

O

O

O

10. I feel nervous with people I don’t know well.

O

O

O

11. I get stomachaches at school.

O

O

O

12. When I get frightened, I feel like I am going crazy.

O

O

O

13. I worry about sleeping alone.

O

O

O

14. I worry about being as good as other kids.

O

O

O

15. When I get frightened, I feel like things are not real.

O

O

O

16. I have nightmares about something bad happening to my parents.

O

O

O

17. I worry about going to school.

O

O

O

18. When I get frightened, my heart beats fast.

O

O

O

19. I get shaky.

O

O

O

20. I have nightmares about something bad happening to me.

O

O

O

21. I worry about things working out for me.

O

O

O

22. When I get frightened, I sweat a lot.

O

O

O

23. I am a worrier.

O

O

O

24. I get really frightened for no reason at all.

O

O

O

25. I am afraid to be alone in the house.

O

O

O

26. It is hard for me to talk with people I don’t know well.

O

O

O

27. When I get frightened, I feel like I am choking.

O

O

O

Screen for Child Anxiety Related Disorders (SCARED) Child Version—Pg. 2 of 2 (To be filled out by the CHILD)

0 Not True or Hardly Ever True

1 Somewhat True or Sometimes True

2 Very True or Often True

28. People tell me that I worry too much.

O

O

O

29. I don’t like to be away from my family.

O

O

O

30. I am afraid of having anxiety (or panic) attacks.

O

O

O

31. I worry that something bad might happen to my parents.

O

O

O

32. I feel shy with people I don’t know well.

O

O

O

33. I worry about what is going to happen in the future.

O

O

O

34. When I get frightened, I feel like throwing up.

O

O

O

35. I worry about how well I do things.

O

O

O

36. I am scared to go to school.

O

O

O

37. I worry about things that have already happened.

O

O

O

38. When I get frightened, I feel dizzy.

O

O

O

39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport.)

O

O

O

40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well.

O

O

O

41. I am shy.

O

O

O

SCORING: A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific. A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms. A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder. A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder. A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance. *For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions. Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pgh. (10/95). E-mail: [email protected]

Center for Epidemiological Studies Depression Scale for Children (CES-DC)

Number ________________ Score __________________

Name _____________________________ INSTRUCTIONS Below is a list of the ways you might have felt or acted. Please check how much you have felt this way during the past week. DURING THE PAST WEEK

Not At All

A Little

Some

A Lot

1. I was bothered by things that usually don’t bother me.

_____

_____

_____

_____

2. I did not feel like eating, I wasn’t very hungry.

_____

_____

_____

_____

3. I wasn’t able to feel happy, even when my family or

_____

_____

_____

_____

4. I felt like I was just as good as other kids.

_____

_____

_____

_____

5. I felt like I couldn’t pay attention to what I was doing.

_____

_____

_____

_____

Not At All

A Little

Some

A Lot

6. I felt down and unhappy.

_____

_____

_____

_____

7. I felt like I was too tired to do things.

_____

_____

_____

_____

8. I felt like something good was going to happen.

_____

_____

_____

_____

9. I felt like things I did before didn’t work out right.

_____

_____

_____

_____

10. I felt scared.

_____

_____

_____

_____

Not At All

A Little

Some

A Lot

11. I didn’t sleep as well as I usually sleep.

_____

_____

_____

_____

12. I was happy.

_____

_____

_____

_____

13. I was more quiet than usual.

_____

_____

_____

_____

14. I felt lonely, like I didn’t have any friends.

_____

_____

_____

_____

15. I felt like kids I know were not friendly or that

_____

_____

_____

_____

Not At All

A Little

Some

A Lot

16. I had a good time.

_____

_____

_____

_____

17. I felt like crying.

_____

_____

_____

_____

18. I felt sad.

_____

_____

_____

_____

19. I felt people didn’t like me.

_____

_____

_____

_____

_____

_____

_____

_____

friends tried to help me feel better.

DURING THE PAST WEEK

DURING THE PAST WEEK

they didn’t want to be with me. DURING THE PAST WEEK

20. It was hard to get started doing things.

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