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  • Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,
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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] 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

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Page 1: Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,

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

mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
Page 2: Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,

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

Page 3: Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,

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

Page 4: Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,

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:

Page 5: Parent Informant - Lurie Children's Hospital · Barbara N. Johnston, MD Mona Kansagra, MD , MD Damian McGee, MD Emelie Medalle, MD Meg M. Nally, MD Ellen Papacek, MD Kenneth S. Polin,

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.


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