past medical history - university of arizona · tired severe worsening moderate worsening mild...

Autoimmune Encephalopathy Clinic Intake Form

Today’s date Name of the person filling out this form Phone Number

/ /

CHILD INFORMATION

Child’s Name (last, first, middle) Birth date: Sex: Race/Ethnicity (check all that apply):

/ / Male Female

White Hispanic, any race American Indian/Alaska Native Asian Black or African American Native Hawaiian/Pacific Islander

PAST MEDICAL HISTORY

Has your child been diagnosed with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) OR Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) OR Autoimmune Encephalopathy (AE) by another physician?

Yes No

If yes, please let us know who diagnosed your child and when. Physician name: Date / / We would like to know specific information about each episode of PANS your child has experienced. Specifically we would like to know about the symptoms and experiences during the initial episode and how they are feeling currently (in the past two weeks).

Onset Initial episode Past Two weeks

Is your child currently experiencing symptoms? Yes No

What was the date of the illness? / / / /

What was the infection?

Strep mycoplasma influenza Other Unknown

Strep mycoplasma influenza Other Unknown

What was the date of initial symptom onset? / / / /

Did your child appear sick?

Sore throat Persistent cough Fever Positive evidence of infection only

No, but positive evidence of illness in a close friend/ relative

No appearance of illness

Sore throat Persistent cough Fever Positive evidence of infection only

No, but positive evidence of illness in a close friend/ relative

No appearance of illness

How long did it take for your child to show their first symptom after becoming ill? (please specify)

Hours Days Weeks

Hours Days Weeks

How long did it take for your child to hit the maximum symptoms experienced following the first symptom you noticed?

Hours Days Weeks

Hours Days Weeks

How many separate episodes has your child have that lasted at least a week? episodes

Do symptoms worsen 1-3 days before or after infections Before After Both Before After Both

Are symptoms usually worse or does your child’s function decline during infections Severe worsening Moderate worsening Mild worsening No worsening

Severe worsening Moderate worsening Mild worsening No worsening

Explain:

Are symptoms usually worse or does your child’s function decline during stress Severe worsening Moderate worsening Mild worsening No worsening


Explain:

Are symptoms usually worse or does your child’s function decline when he/she is tired



Explain:

Do symptoms increase without an apparent cause Yes No Yes No

HEALTH HISTORY

These are some symptoms that may be relevant to your child’s problems or some that might not seem relevant at all. However, to ensure that we don’t miss anything, it is important to ask all of these questions. We would like to know about these symptoms for the following time periods:

1) Symptoms that were present before at any time before your child first developed symptoms 2) Symptoms that were present during the initial episode – the first time they became ill 3) How has your child been feeling, thinking, and acting within the past two weeks

BEHAVIORS Before initial episode Initial episode Past Two Weeks

Did your child have any behaviors that were potentially harmful or life threatening to themselves or others?

Child Family Others Child Family Others Child Family Others

If others, who: Does your child exhibit any behaviors or describe thoughts that you think might be symptoms of obsessive compulsive disorder?

Yes No Yes No Yes No

Explain:

SEPARATION ANXIETY Before initial episode Initial episode Past Two Weeks

Have you noticed an increase in your child’s difficulty separating from you? Yes No Yes No Yes No

FOOD INTAKE Before initial episode Initial episode Past Two weeks

Have you ever been concerned about your child’s eating or drinking? Yes No Yes No Yes No

Please describe the concerns

Has your child been diagnosed with or prescribed any of the following by a physician:

Abnormal weight loss Any nutritional deficiency Enteral feeding/nutritional supplements Hospitalization due to any of the above



SLEEP Before initial episode At initial episode Past Two Weeks

How many hours a night does your child sleep Hours Hours Hours

Where does your child sleep? (Check all that apply) Own bed Shared bed Own room Shared room Other (Couch, floor etc.)

Own bed Shared bed Own room Shared room Other (Couch, floor etc.)

Own bed Shared bed Own room Shared room Other (Couch, floor etc.)

If shared or other, please describe:

What time do they normally go to bed on school nights?

What time do they normally wake up on school days?

What time do they normally go to bed on weekend nights? What time do they normally wake up on weekend days?

Does your child have any trouble sleeping? Falling asleep Staying asleep Falling asleep Staying asleep Falling asleep Staying asleep

If yes, please describe:

Does your child have any trouble waking up? Yes No Yes No Yes No


How many days a week does your child take a nap? 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Is there a TV or other electronic device in your child’s room?

TV Computer Tablet/Phone



Does your child have fears of going to bed or bedtime rituals and routines that seem inappropriate for his or her age?


Does your child have nightmares? Yes No Yes No Yes No

URINARY SYMPTOMS Before initial episode Initial episode Past Two Weeks

Does your child have any wetting accidents Yes No Yes No Yes No

If yes, how many accidents are typical in a week: # a week # a week # a week

Please check when wetting accidents occur: Day Night Both Day Night Both Day Night Both

Do you or your child feel like he/she has to urinate more often than usual? Yes No Yes No Yes No

MOVEMENTS Before initial episode Initial episode Past Two weeks

Has your child exhibited any strange or unusual hand or finger movements (e.g. dance-like movements of hands or arms, piano playing like finger movements)?


Have you noticed any issues in your child’s walk (e.g. pigeon toe walking)? Yes No Yes No Yes No

Has your child exhibited any strange or unusual arm movements like stiffness or positioning in strange angles?


Please describe any strange movements:

Are you concerned your child may have tics? A tic is a nonvoluntary body movement or vocal sound that is made repeatedly, rapidly, and suddenly. It has a stereotyped but nonrhythmic character.


SENSORY DEFENSIVENESS Before initial episode Initial episode Past Two Weeks

Have you noticed that your child reacts to tags, labels, or certain kinds of materials Yes No Yes No Yes No


EMOTIONAL LABILITY Before initial episode Initial episode Past Two weeks

Have you ever had concerns over any of the following in your child (select all that apply):

Moodiness Irritability Mood swings Oppositional/Defiant Depressed or numb




Please describe if your child experienced any stressors in weeks or months prior to an episode:

IMPULSIVITY

Does your child have a diagnosis of ADHD?

Yes No No but I am concerned about these

types of issues

If yes, when was your child diagnosed / /

TREATING PHYSICIAN INFORMATION

Provider Name 1: Location (Address) Phone Fax Provider Specialty: Primary Care (PCP) Is your PCP willing to work in consultation with our team regarding the management of your child’s condition? Yes No

Please enter in any other provides your child sees for his or her condition (e.g. neurology, psychology, immunology, psychiatry) Provider Name 2: Location (Address) Phone Fax Provider Specialty: Provider Name 3: Location (Address) Phone Fax Provider Specialty: Provider Name 4: Location (Address) Phone Fax Provider Specialty: Provider Name 5: Location (Address) Phone Fax Provider Specialty:

MEDICATIONS

Please include all prescribed medications, such as antibiotics, psychiatric and behavioral medications, recent infusions (e.g., IVIG or steroids) and steroids, over-the-counter medications (e.g., nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen or naproxen), creams, supplements, vitamins, herbal remedies, hormones, or other over-the-counter products.

MEDICATION NAME DOSAGE FREQUENCY START DATE

Leave blank if current

END DATE ORDERING PHYSICIAN

If discontinued please indicate why

Was it effective?

/ / / /

No Somewhat Moderately Completely

/ / / /


/ / / /


/ / / /


/ / / /


/ / / /


THERAPIES AND INTERVENTIONS

Please include all any types of therapies your child may have tried (e.g. physical, occupational, speech, counseling, ERP, HRT, ACT, ABA) and any parent trainings or interventions you may have participated in.

THERAPY / INTERVENTION NAME DOSAGE FREQUENCY

START DATE

Leave blank if current

END DATE ORDERING PHYSICIAN

If discontinued please indicate why

Was it effective?

/ / / /


/ / / /


/ / / /


/ / / /


HOSPITALIZATIONS AND PROCEDURES

Has your child ever been hospitalized for any of the following?

If yes, how long were they hospitalized?

Please, describe: If more than one hospitalization please describe

Medical reasons

Psychiatric reasons

Treatment or surgery Has your child had any of the following tests? When was it performed? Why was it performed?

IQ or neuropsychological

Brain Magnetic Resonance Imaging (MRI)

Electroencephalogram (EEG)

Lumbar puncture (LP)

SOCIAL INFORMATION

What is your child’s current grade level? Does your family attend religious services? Is your child involved in community activities?

Yes No Yes No Does your child have any supports? If yes, please describe: If yes, please describe:

IEP 504 Other supports Name and location of school

Please mark if any of the following life events have happened to your child within TWO YEARS of initial onset (Check all that apply):

Moving to a new home Change to a new school Parents fighting Parents separated Parents divorced New stepmother/stepfather Mother or father lost a job Mother or father started new job Change in parent’s financial status Increased absence of a parent Parent in trouble with the law Parent went to jail Serious illness or injury in the family Death of a family member

Child had major personal injury/illness New brother or sister Trouble with brother or sister More arguments with parents Less arguments with parents Boyfriend/girlfriend/friend having operation Became pregnant/girlfriend became pregnant Death of a friend Loss of a pet Got a new pet Got own car Breaking up with boyfriend/girlfriend Making up with boyfriend/girlfriend Losing a close friend

Got a new job Lost a job Special recognition for good grades Made honor role Joined a new club Making an athletic or other team Failed to make an athletic or other team Trouble with teacher Trouble with classmates Making failing grades in school classes Failed a grade/got put back a grade Skipped a grade/got put ahead a grade Got suspended from school Got into trouble with police Got put into detention/jail

Does your child have any severe problem behaviors? If yes, please describe:

Yes No

PERFORMANCE Before initial episode Initial episode Past Two weeks

How was your child functioning in all areas of life (family, friends, school, and activities)?

Not functioning at all Severely impaired in most to all areas Moderately impaired in most to all areas Slightly impaired in most to all areas Able to participate in all areas and activities of life



How much school did your child miss on average days days days

Have you noticed difficulty in your child’s performance at school Yes No Yes No Yes No

If yes, in which subjects

Reading Writing Math Other:__________



Has your child ever experienced a loss of skills? Yes No Yes No Yes No

If yes what skills?

Learning ability Language Social Skills Handwriting/fine motor Coordination/gross motor Other



Have you noticed a change in your child’s interactions with friends Yes No Yes No

Have you noticed a change in your child’s participation in activities Yes No Yes No

Have you noticed a change in your child’s handwriting

Harder to read Takes longer to write Seems difficult for him/her

Harder to read Takes longer to write Seems difficult for him/her

DEVELOPMENTAL HISTORY

BIRTH

What was your child’s birth weight? What was your child’s birth length? What was your child’s gestational age in weeks? Did you have any problems with birth? Did your child require a NICU stay? Yes No Yes No Was your child: Late Full-term Early If yes, describe: If yes, for how long: Was there maternal exposure to any of the following during pregnancy? What type of delivery did you have?

Infections Maternal alcohol use Illness Maternal recreational drug use Smoking Maternal caffeine consumption

Vaginal – Spontaneous Vaginal – Forceps Vaginal – Vacuum assisted Cesarean (C-Section)

DEVELOPMENT

Are your child’s immunizations up to date? Has your child had any immunization reactions? Does your child have allergies to food, medications, or environment?

Yes No Yes No Yes No If no, describe:

If yes, describe:

If yes, describe:

Do you feel like your child is sick more frequently than his/her siblings or peers?

Has your child started to show changes associated with puberty (i.e. armpit or pubic hair; girls – breast changes, boys–voice changes)?

Have you ever noticed your child had dilated pupils or a “deer in the headlights” look?

Yes No Yes No Yes No If yes, describe:

YOUR CHILD’S STORY

Please describe your child’s initial onset of AE: Please describe your child’s most distressing symptoms from your point of view or your child’s point of view: From your point of view, select the your child’s THREE most distressing symptoms from the following list:

Rage/Aggression Irritability Food Avoidance Hoarding Compulsions Separation Anxiety Anxiety Moodiness Obsessions Depression Oppositional Behaviors Pain Hyperactivity/Impulsivity Memory Problems Developmental Regression Sleep Disturbance Urinary changes / wetting Sensory Sensitivities Hallucinations Tics Suicidal thoughts Paranoid thoughts School Performance Decline Mood swings

What would you like to accomplish at your visit with the team:

Is there anything different or strange about your child’s onset or course of illness that wasn’t in this questionnaire or anything else you would like us to know?

PARENT AND CAREGIVER INFORMATION

What is your name (last, first, middle) Birth date: Sex: Relationship to child: Race/Ethnicity (check all that apply):

Male Female

Biological parent Grandparent Step parent Foster parent Adoptive parent Other legal guardian

White American Indian/Alaska Native Asian Black or African American Hispanic, any race Native Hawaiian/Pacific Islander

Primary phone: Primary phone type Alternate phone: Alternate phone type Home Work Cell Home Work Cell Email Address: Marital Status Level of Education Current employment status (check all that apply)

Married/Common Law Not Married, Living Together Separated Divorced/Annulled Widowed Never Married, Living single

6th grade 7th – 9th grade Some high school High school graduate/GED Some college or technical Bachelor’s degree Graduate school or degree

Working Full Time Unemployed, Looking for Work Working Part Time Unemployed, Not Looking for Work Homemaker Student – Full Time Disabled Student – Part Time Retired Other

Your Profession: If respondent is not biological mother

What is your child’s biological mother’s name (last, first, middle) Biological mother’s birth date: Biological mother’s phone: Biological mother’s phone type Biological mother’s race/Ethnicity (check all that apply):

Home Work Cell White American Indian/Alaska Native Asian Black or African American Hispanic, any race Native Hawaiian/Pacific Islander

Biological mother’s marital Status Biological mother’s Level of Education Biological mother’s current employment status (check all that apply)




Biological mother’s profession: If respondent is not biological father

What is your child’s biological father’s name (last, first, middle) Biological father’s birth date: Biological father’s phone: Biological father’s phone type Biological father’s race/Ethnicity (check all that apply):

Home Work Cell White American Indian/Alaska Native Asian Black or African American Hispanic, any race Native Hawaiian/Pacific Islander

Biological father’s marital Status Biological father’s Level of Education Biological father’s current employment status (check all that apply)




Biological father’s profession:

FAMILY HISTORY

Please indicate presence of diagnosis in your child and all family members for any of the following and use initial to indicate which family member Use initial for family member and specify condition.

CONDITION/SYMPTOM

Age of onset If

diagnosed in your child

WHICH FAMILY MEMBERS ARE DIAGNOSED WITH CONDITION?

Immediate Maternal (Mom’s side) Paternal (Dad’s side)

F – Father M – Mother B – Brother S – Sister

GF–grandfather GM –grandmother U –uncle A –aunt H –½ sibling C –1st cousin GG –great-grandparent D – other distant relative

GF–grandfather GM –grandmother U –uncle A –aunt H –½ sibling C –1st cousin GG –great-grandparent D – other distant relative

EXAMPLE 9y M-Kawasaki GM, C, A – Crohns U, GM - Celiac

Systemic autoimmune disease Lupus; Kawasaki’s disease; Addison’s disease; Type 1 diabetes; Crohn’s disease; Sjogren’s syndrome; celiac disease/gluten intolerance; psoriasis; myasthenia gravis; multiple sclerosis; Hashimoto/Grave’s disease; etc…

History of recurrent/chronic infections Ear infections, respiratory tract (URI), pneumonia, urinary tract (UTI), bronchitis, tonsillitis/ pharyngitis, gastroenteritis; etc…

Allergies/Allergic Rhinitis/Asthma

Developmental Delays Speech delay; motor delay; delayed milestones; etc…

Anxiety and Mood Disorders generalized anxiety disorder (GAD); separation; social phobia); depression; bipolar or manic depression; rages/anger issues; aggressive disorder or oppositional defiant disorder (ODD); etc…

Eating Disorders anorexia nervosa, bulimia; avoidant/restrictive eating; etc…

Obsessions and Compulsions obsessions, compulsions, obsessive compulsive (OCD), trichotillomania; skin picking; hoarding; etc…

Psychotic and personality disorders schizophrenia; any personality disorders; etc…

Neurodevelopmental Disorders autism; learning disabilities; intellectual disabilities; attention deficit hyperactivity disorder (ADD/ADHD); etc…

Movement related behavioral disorders Tourette’s syndrome; chronic tic disorder; provisional or transient tic disorder; Sydenham chorea;etc…

Excessive alcohol use or alcoholism

Fevers acute rheumatic fever; rheumatic heart disease; Recurrent fever syndrome; etc…

Other

https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

HOUSEHOLD INFORMATION

We would like to know about where your child lives. First we will ask about your child’s PRIMARY household, which is where she/he lives 50% of the time or more. Street Address: Apartment/Suite: City: State: ZIP Code:

Which of the following best describes your child’s current housing situation? Owned single/multiple family home Subsidized housing (e.g. HUD) Shelter

Rented single/multiple family home Boarding school Residential treatment

Rented apartment Group home Homeless

What is the primary language spoken in the home? Who lives in the home with your child?

Person Relationship Age

Does your child spend at least 25% of his/her time in any other residence? Yes No Street Address: Apartment/Suite: City: State: ZIP Code:

Which of the following best describes your child’s other housing situation? Owned single/multiple family home Subsidized housing (e.g. HUD) Shelter

Rented single/multiple family home Boarding school Residential treatment

Rented apartment Group home Homeless

What is the primary language spoken in that home? Who lives in that home with your child?

Person Relationship Age

Screen for Child Anxiety Related Disorders (SCARED) PARENT Version—Page 1 of 2 (to be filled out by the PARENT)

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 Pittsburgh (October, 1995). E-mail: [email protected]

See: Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–6.

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 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 PN

2. My child gets headaches when he/she am at school. O O O SH

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

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

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

6. When my child gets frightened, he/she fells like passing out. O O O PN

7. My child is nervous. O O O GD

8. My child follows me wherever I go. O O O SP

9. People tell me that my child looks nervous. O O O PN

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

11. My child gets stomachaches at school. O O O SH

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

13. My child worries about sleeping alone. O O O SP

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

15. When my child gets frightened, he/she feels like things are not real. O O O PN

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

17. My child worries about going to school. O O O SH

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

19. He/she child gets shaky. O O O PN

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

Screen for Child Anxiety Related Disorders (SCARED) PARENT Version—Page 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

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

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

23. My child is a worrier. O O O GD

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

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

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

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

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

29. My child doesn't like to be away from his/her family. O O O SP

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

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

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

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

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

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

36. My child is scared to go to school. O O O SH

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

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

39. My child feels nervous when he/she is with other children or adultsand 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 SC

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

41. My child is shy. O O O SC

SCORING: A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific. TOTAL = 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. PN = A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. GD = A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety SOC. SP = A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder. SC = A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance. SH =

The SCARED is available at no cost at www.wpic.pitt.edu/research under tools and assessments, or at www.pediatric bipolar.pitt.edu under instruments.

March 27, 2012

NICHQ Vanderbilt Assessment Scale—PARENT Informant

Today’s Date: ___________ Child’s Name: _____________________________________________ Date of Birth: ________________

Parent’s Name: _____________________________________________ Parent’s Phone Number: _____________________________

Directions: 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 Often Very Often

1. Does not pay attention to details or makes careless mistakes 0 1 2 3

with, for example, homework

2. Has difficulty keeping attention to what needs to be done 0 1 2 3

3. Does not seem to listen when spoken to directly 0 1 2 3

4. Does not follow through when given directions and fails to finish activities 0 1 2 3

(not due to refusal or failure to understand)

5. Has difficulty organizing tasks and activities 0 1 2 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 1 2 3

mental effort

7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 1 2 3

or books)

8. Is easily distracted by noises or other stimuli 0 1 2 3

9. Is forgetful in daily activities 0 1 2 3

10. Fidgets with hands or feet or squirms in seat 0 1 2 3

11. Leaves seat when remaining seated is expected 0 1 2 3

12. Runs about or climbs too much when remaining seated is expected 0 1 2 3

13. Has difficulty playing or beginning quiet play activities 0 1 2 3

14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3

15. Talks too much 0 1 2 3

16. Blurts out answers before questions have been completed 0 1 2 3

17. Has difficulty waiting his or her turn 0 1 2 3

18. Interrupts or intrudes in on others’ conversations and/or activities 0 1 2 3

19. Argues with adults 0 1 2 3

20. Loses temper 0 1 2 3

21. Actively defies or refuses to go along with adults’ requests or rules 0 1 2 3

22. Deliberately annoys people 0 1 2 3

23. Blames others for his or her mistakes or misbehaviors 0 1 2 3

24. Is touchy or easily annoyed by others 0 1 2 3

25. Is angry or resentful 0 1 2 3

26. Is spiteful and wants to get even 0 1 2 3

27. Bullies, threatens, or intimidates others 0 1 2 3

28. Starts physical fights 0 1 2 3

29. Lies to get out of trouble or to avoid obligations (ie,“cons” others) 0 1 2 3

30. Is truant from school (skips school) without permission 0 1 2 3

31. Is physically cruel to people 0 1 2 3

32. Has stolen things that have value 0 1 2 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

Symptoms (continued) Never Occasionally Often Very Often33. Deliberately destroys others’ property 0 1 2 3

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0 1 2 3

35. Is physically cruel to animals 0 1 2 3

36. Has deliberately set fires to cause damage 0 1 2 3

37. Has broken into someone else’s home, business, or car 0 1 2 3

38. Has stayed out at night without permission 0 1 2 3

39. Has run away from home overnight 0 1 2 3

40. Has forced someone into sexual activity 0 1 2 3

41. Is fearful, anxious, or worried 0 1 2 3

42. Is afraid to try new things for fear of making mistakes 0 1 2 3

43. Feels worthless or inferior 0 1 2 3

44. Blames self for problems, feels guilty 0 1 2 3

45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3

46. Is sad, unhappy, or depressed 0 1 2 3

47. Is self-conscious or easily embarrassed 0 1 2 3

SomewhatAbove of a

Performance Excellent Average Average Problem Problematic

48. Overall school performance 1 2 3 4 5

49. Reading 1 2 3 4 5

50. Writing 1 2 3 4 5

51. Mathematics 1 2 3 4 5

52. Relationship with parents 1 2 3 4 5

53. Relationship with siblings 1 2 3 4 5

54. Relationship with peers 1 2 3 4 5

55. Participation in organized activities (eg, teams) 1 2 3 4 5

Comments:

NICHQ Vanderbilt Assessment Scale—PARENT Informant

Today’s Date: ___________ Child’s Name: _____________________________________________ Date of Birth: ________________

Parent’s Name: _____________________________________________ Parent’s Phone Number: _____________________________

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 4 or 5 in questions 48–55: ____________________________________________________________

Average Performance Score: ______________________________________________

DBT2007

DIRECTIONS: Fill in the circle on the scale below each question that best describes your child's mood in the past 3 months.

1. Suddenly starts to cry for little or no apparent reason, more so than other children his/ her age.

2. It is hard to tell what will set him/ her off into a blow-up of temper.

3. Suddenly becomes tense or anxious.

4. Has bursts of being overly affectionate for little reason, hugging or kissing more than you would expect.

5. Suddenly loses interest in what he/ she is doing.

6. It is hard to tell what mood he/ she will be in.

7. Suddenly loses his/ her temper (may yell, cuss, or throw something) when you would not expect.

RELATIONSHIP TO CHILD: Mother Father Other, specify:

8. Has bursts of increased talking.

9. Complains of short periods when he/ she feels shaky or his/ her heart is pounding, or he/ she has difficulty breathing (not due to asthma or another medical problem).

CHILDREN'S AFFECTIVE LABILITY SCALE (CALS)Parent Form for children 6-17 years old

Never orrarely

occurs

1-3 timesduring the

month

1-3times aweek

4-6times aweek

1 or moretimes a

day

16. Suddenly appears sad, depressed, and down in the dumps for no apparent reason.

17. Has bursts of being nervous or fidgety.

18. Has bursts of crabbiness or irritability.

19. Suddenly is overly familiar with people he/ she barely knows.

20. Appears very angry (yells, uses abusive language) in response to a simple request.

15. Suddenly starts to laugh about something that most people do not think is very funny.

10. It is hard to tell what will set him/ her off crying.

12. Does an activity and then suddenly stops and says he/ she is tired.

13. You never know when he/ she is going to blow up.

14. Has periods of time when he/ she talks about the same thing over and over.

ID: DATE: / /

11. Has bursts of silliness for little or no apparent reason.

Visit: Initial 3 Month 6 Month 9 Month 12 Month 64822

Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS) - Parent Strongly

Disagree Disagree Slightly

Disagree Slightly Agree Agree

Strongly Agree

1 My child is a picky eater

2 My child dislikes most of the foods that

other people eat

3 My child’s list of foods that he/she likes

and will eat is shorter than the list of foods

he/she won't eat

4 My child is not very interested in eating;

he/she seems to have a smaller appetite

than other people

5 My child has to push him/herself to eat

regular meals throughout the day, or to eat

a large enough amount of food at meals

6 Even when my child is eating a food

he/she really likes, it is hard for him/her to

eat a large enough volume at meals

7 My child avoids or puts off eating because

he/she is afraid of GI discomfort, choking,

or vomiting

8 My child restricts him/herself to certain

foods because he/she is afraid that other

foods will cause GI discomfort, choking,

or vomiting

9 My child eats small portions because

he/she is afraid of GI discomfort, choking,

or vomiting

Zickgraf, Hana F., and Jordan M. Ellis. "Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns." Appetite 123 (2018): 32-42.

CHALLENGING BEHAVIOR

Patient Name: __________________________ Date of Birth: ___________________

1. Record each problem behavior the individual displays and describe it specifically. Include any damage

resulting from the problem behavior either to the individual or others. Please rank in order of concern.

Behavior Description

a.

b.

c.

2. Estimate the severity of the problem behavior of greatest concern (circle one).

Moderate Severe Life-threatening

3. Has the individual ever been sent to the hospital to treat an injury resulting from the behavior or to

develop a treatment plan for the behavior?

Yes No Describe:

5. In what settings do these behaviors occur?

7. Estimate the current frequency of the problem behavior(s). _______________________________ ______

8. How long has the individual been engaging in the problem behavior(s)? __________________________

9. When is the problem behavior(s) likely to occur (circle all that apply)?

a. When individual is left alone or unattended.

b. When lots of people are around.

c. When demands are placed on the individual.

d. Mealtimes, dressing or bathing (circle).

e. Time of day:

g. Other:

10. Are there any occasions when the problem behavior(s) rarely or never occurs?

11. a. How do people (staff, parents, etc.) typically respond when the individual engages in the problem

behavior(s)? (If a formal program is currently being conducted, refer to it here and send a copy.

b. How long has the program been in place?

12. Estimate the general trend of the problem behavior(s) during the past year (circle one).

a. Increasing (behavior getting worse).

b. Decreasing (behavior getting better).

c. Stable (about the same).

13. Does the individual display aggressive behavior toward staff or peers? If yes, explain: _______________

Please Complete

Today’s Date: ____________________________ Parent’s Name:__________________________________

Child’s Name: ____________________________ Parent’s Date of Birth: ____________________________

Child’s Date of Birth: _______________________ Parent’s Gender: ________________________________

Parent’s Last Grade Completed in School: ____________

Race or Ethnic Identity: (Please circle all that apply)

Hispanic White/Non-Hispanic Black/Non-Hispanic Other/Non-Hispanic Please read the questions below. We want to know the TOTAL number of times you answer YES, but we don’t need to know which questions you answered YES to. Each time you answer YES, place a line through one of the circles below. When the questionnaire is complete, count up the number of circles you have crossed out.

While YOU were growing up, during your first 18 years of life:

1. Were your parents ever separated or divorced?

2. Was anyone you lived with depressed or mentally ill, or did they attempt suicide?

3. Did you live with anyone who was a problem drinker, alcoholic or used street drugs?

4. Did anyone you lived with go to prison?

5. Was your mother or step-mother pushed, grabbed, slapped, kicked, bitten, hit with a fist or something

hard, had something thrown at her, repeatedly hit for at least a few minutes, or ever threatened or

hurt by a knife or a gun?

6. While you were growing up, did you sometimes not have enough to eat, wear dirty clothes, not have

anyone take you to the doctor, or were your parents too drunk or high to take care of you?

7. Did a parent or adult in your home swear at you, insult you, or put you down or act in a way that made

you afraid you might be physically hurt?

8. Did a parent or other adult in your home push, grab, slap, or throw something at you, or ever hit you

so hard that you had marks or were injured?

9. Did a parent, adult, or someone at least 5 years older than you ever touch you sexually or try to make

you touch them sexually?

10. While you were growing up, did you feel as if there was NO ONE who made you feel special or loved, or

that your family was NOT a source of strength, support and protection for you?

○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Total Number of Parent “YES” Answers Here: __________

Please read the questions below. We want to know the TOTAL number of times you answer YES, but we don’t need to know which questions you answered YES to. Each time you answer YES, place a line through one of the circles below. When the questionnaire is complete, count up the number of circles you have crossed out.

Since your CHILD was born: 1. Have you and your partner separated or divorced?

2. Has your child lived with anyone who was depressed or mentally ill, or who attempted suicide?

3. Has your child lived with anyone who was a problem drinker or used street drugs?

4. Has your child lived with anyone who has been to prison?

5. Has your child ever witnessed anyone in the home (parents or adults) push, grab, slap, or throw things at

each other and/or witnessed anyone kick, bite, hit with a fist, or hit each other with something hard, or ever

witness people threatening each other with a weapon, such as a knife or a gun?

6. Since your child was born, have there been times when your child has not had enough to eat, has not had

anyone take him/her to the doctor, or have any of his/her caregivers been too drunk or high to take care of

him/her?

7. Since your child was born, has a parent or other adult in your home sworn at, insulted, or put your child

down or acted in a way that made your child afraid that he/she might be physically hurt?

8. Did a parent or other adult in your home push, grab, slap, or throw something at your child, or ever hit

him/her so hard that she /he had marks or was injured?

9. Did a parent, adult, or someone at least 5 years older than your child ever touch your child sexually or try to

make your child touch them sexually?

10. Since your child was born, do you feel as if there has NOT been anyone in his/her family who makes

him/her feel special, or that you or his other caregivers have NOT been able to be a source of strength,

support or protection for your child?

○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Total Number of Child “YES” Answers Here: __________

past medical history - university of arizona · tired severe worsening moderate worsening mild...

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