ADHD Initial Consultation Letter

Transcription

1 ADHD Initial Consultation Letter Dear Parent, Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 8% of children and youth. The term includes patients with ADHD as well as those with ADD (Attention Deficit Disorder). Symptoms can include inattention, hyperactivity, and/or impulsivity out of the normal range for a child s age. Children with ADHD have problems that interfere with their ability to lead normal lives at both home and school. Because the symptoms of ADHD can be confused with learning disorders and other psychological disorders like depression, anxiety, oppositional defiant disorder and conduct disorder, it is important to do an evaluation to make sure the patient is properly diagnosed. This evaluation can be either a psychological-educational evaluation performed by the school system or a private psychologist or a screening tool, like the Vanderbilt Form, which is a screening tool used by pediatricians. If you or your child s teacher have concerns of ADHD, it is important that your pediatrician assess the child further to make a proper diagnosis and offer suggestions on treatment strategies if is determined any are needed. Because this is a time consuming process, you will need to schedule a separate consultation to discuss your concerns with your child s regular pediatrician. In order to make the visit as efficient as possible for you and for your medical provider, we request the following information be submitted to our office one week prior to your consultation:. A copy of any psychoeducational evaluations done by a licensed psychologist or the school system 2. Completion of the NICHQ Vanderbilt Assessment Scale: Parental Informant form by one or both parents (located on our website). Completion of at least 2 NICHQ Vanderbilt Assessment Scale: Teacher Informant forms by teachers who know your child s academic abilities and behaviors (located on our website) 4. Completion of the ADHD Rating Scale IV (with adolescent prompts) for patients aged years and above (each of the 8 headings has specific questions listed below it that must be individually answered). This is not available online and may only be picked up at our office. 5. Copies of any IEP (Individualized Education Plan) or 54 Plans already in place at school. 6. Completion of the Oberlin Road Pediatrics ADHD Screening Form (located on our website). It is important to note that diagnosing a patient with ADHD requires a great amount of background information. As this is considered a chronic illness, patients diagnosed with ADHD will be required to follow up at our office at certain designated time intervals (within 4 weeks of starting medication and at a minimum of 2 additional times within the first months of diagnosis). It can take a number of months for the physician, family, and patient to evaluate the effects of medication(s) and behavioral intervention strategies before arriving at a successful therapeutic outcome. Additionally, the medication s side effects as well as the effects on the patient s vital signs (weight, height, blood pressure, and heart rate) must all be monitored closely until the patient is stabilized on the medication. We appreciate your patience in this process as we strive to deliver the best medical care possible. If you have any questions, please feel free to call our office. If we do not receive your paperwork in sufficient time prior to the appointment, you may be asked to reschedule. Thank you in advance for your cooperation. Sincerely, Physicians of Oberlin Road Pediatrics

2 D 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? S~toms Never Occasionall_l. Does not pay attention to details or makes careless mistakes with, for example, homework Has difficulty keeping attention to what needs to be done Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) ~- Has difficulty organizing tasks and activities 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) - _: 8_. _ Is easily distracted by noises or other stimuli _9_._Is forgetful in daily activities ~. Fidgets with hands or feet or squirms il seat!_. Leaves seat when remaining seated is expected 2. Runs about or climbs too much when remaining seated is expected ~_'-Ias difficulty playing or beginning quiet play activities 4. Is "on the go" or often acts as if "driven by a motor" Talks too much o ~:Slurts out answers_~efore que~tions have been completed _o 7. Has difficulty waitin~ his or her turn _o l_i)._interrupts or intrudes in on others' conversations and/ or activities 9. Argues with adults - 2. Loses temper 2. Actively defies or reflses to go along with adults' requests or rules _ 22. Deliberately annoys people 2. Blames others for his or her mistakes or misbehaviors 24. Is tmkhy or easily_annoyed by others o 25. Is angry or resent~ul _o (>. Is spiteful and wants to get even o 27. Bullies, threatens, or intimidates others 28. Starts physical fights ~- Lies to get out of trouble or to avoid obligations (ie, "cons" others). Is truant from school (skips school) without permission ~physically cruel to people o 2. Has stolen things that have value Often Ver_l Often ~ -- The information contained in fhis 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. DEDICATED TO THE HEALTH OF ALL CHILDREN'" Copyright 22 and National Initiative for Children's Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised- 2 NICH();

3 ~~-~ ~~. ~- ~ D NICHQ Vanderbilt Assessment Scale-PARENT Informant, continued Today's Date: Child's Name: Date of Birth: Parent's Name: Parent's Phone Number: Symptoms (continued) Never Occasionally ~_pelibera!ely_ (}estr()_y~ ot~ers' p~operty ~ 4. Has used a weapon that can cause serious harm (bat, knife, brick, gun) ~--~-~ Is physically cruel to animals _2~_I:I_~~ ~lib~rately s~t ~res to c~~~~!~<l_g~ 7. Has broken into someone else's home, business, or car ~-- 8. Has stayed out at night without permission 9. Has run away from home overnight 4. Has forced someone into sexual activity - 4. Is fearful, anxious, or worried 42. Is afraid to try new thing~[or fe(lr_()f_ila~ing mistake_s 4. Feels worthless or inferior Blames self for problems, feelsglgty- ~ ~ --~~el~j(:mely,unwanted, or unloved; complains that "no one loves him or her" ~ 46. Is sad, unhappy, ()r depres_sed 47. Is self-conscious or easily embarrassed Above Performance Excellent 48. Overall school performance ~ 49. Reading 2Q. \IV'~i!i~- - ~ 5. Mathematics -~ 52. Relationship with parents Relationship with si~lings ~ 54. Relationship with peers Participation in organized activities (eg, teams) Often Very Often Somewhat ofa Problem Problematic -~-- Comments: For Office Use Only Total number of questions scored 2 or in questions -9: Total number of questions scored 2 or in questions -8: Total Symptom Score for questions -8: Total number of questions scored 2 or in questions 9-26: Total number of questions scored 2 or in questions 27-4: Total number of questions scored 2 or in questions 4-47: Total number of questions scored 4 or 5 in questions 48-55: Performance Score: DEDICATED TO THE HEALTH OF ALL CHILDREN"' NICH(l McNei Consumer & Specii;/ty P/Jdtma<eurtcals

4 D 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? S~toms Never Occasionall_l. Does not pay attention to details or makes careless mistakes with, for example, homework Has difficulty keeping attention to what needs to be done Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) ~- Has difficulty organizing tasks and activities 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) - _: 8_. _ Is easily distracted by noises or other stimuli _9_._Is forgetful in daily activities ~. Fidgets with hands or feet or squirms il seat!_. Leaves seat when remaining seated is expected 2. Runs about or climbs too much when remaining seated is expected ~_'-Ias difficulty playing or beginning quiet play activities 4. Is "on the go" or often acts as if "driven by a motor" Talks too much o ~:Slurts out answers_~efore que~tions have been completed _o 7. Has difficulty waitin~ his or her turn _o l_i)._interrupts or intrudes in on others' conversations and/ or activities 9. Argues with adults - 2. Loses temper 2. Actively defies or reflses to go along with adults' requests or rules _ 22. Deliberately annoys people 2. Blames others for his or her mistakes or misbehaviors 24. Is tmkhy or easily_annoyed by others o 25. Is angry or resent~ul _o (>. Is spiteful and wants to get even o 27. Bullies, threatens, or intimidates others 28. Starts physical fights ~- Lies to get out of trouble or to avoid obligations (ie, "cons" others). Is truant from school (skips school) without permission ~physically cruel to people o 2. Has stolen things that have value Often Ver_l Often ~ -- The information contained in fhis 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. DEDICATED TO THE HEALTH OF ALL CHILDREN'" Copyright 22 and National Initiative for Children's Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised- 2 NICH();

5 ~~-~ ~~. ~- ~ D NICHQ Vanderbilt Assessment Scale-PARENT Informant, continued Today's Date: Child's Name: Date of Birth: Parent's Name: Parent's Phone Number: Symptoms (continued) Never Occasionally ~_pelibera!ely_ (}estr()_y~ ot~ers' p~operty ~ 4. Has used a weapon that can cause serious harm (bat, knife, brick, gun) ~--~-~ Is physically cruel to animals _2~_I:I_~~ ~lib~rately s~t ~res to c~~~~!~<l_g~ 7. Has broken into someone else's home, business, or car ~-- 8. Has stayed out at night without permission 9. Has run away from home overnight 4. Has forced someone into sexual activity - 4. Is fearful, anxious, or worried 42. Is afraid to try new thing~[or fe(lr_()f_ila~ing mistake_s 4. Feels worthless or inferior Blames self for problems, feelsglgty- ~ ~ --~~el~j(:mely,unwanted, or unloved; complains that "no one loves him or her" ~ 46. Is sad, unhappy, ()r depres_sed 47. Is self-conscious or easily embarrassed Above Performance Excellent 48. Overall school performance ~ 49. Reading 2Q. \IV'~i!i~- - ~ 5. Mathematics -~ 52. Relationship with parents Relationship with si~lings ~ 54. Relationship with peers Participation in organized activities (eg, teams) Often Very Often Somewhat ofa Problem Problematic -~-- Comments: For Office Use Only Total number of questions scored 2 or in questions -9: Total number of questions scored 2 or in questions -8: Total Symptom Score for questions -8: Total number of questions scored 2 or in questions 9-26: Total number of questions scored 2 or in questions 27-4: Total number of questions scored 2 or in questions 4-47: Total number of questions scored 4 or 5 in questions 48-55: Performance Score: DEDICATED TO THE HEALTH OF ALL CHILDREN"' NICH(l McNei Consumer & Specii;/ty P/Jdtma<eurtcals

6 --~- -- ~--~ ~-- ~ ~-- -~ - ~~-- ~~--~ ~ D4 NICHQ Vanderbilt Assessment Scale-TEACHER Informant Teacher's Name: Class Time: Class Name/Period: Today's Date: Child's Name: Grade Level:-- Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors:. Is this evaluation based on a time when the child D was on medication D was not on medication D not sure? Symptoms Never Occasionally Often Very Often ~. _Fails to ~ive attention to details or makes careless mistakes in schoolwork~ --~~ ~~ _2. Has difficulty sustaining attention to tasks or activities~--~ ~ ~ ~- 2 - ~ ~--~--~~ ~-- ~ _. Doesnot seem to l~sten when spoken to directly ~--~~--~--~ --~~-- 2 ~ ~-- 4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand) - - _ 5. I:!as difficulty organizing tasks and activities ~~--~~-- --~ 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort ~-- --~ ~ --~ --~--~~--~ ~-- ~--~ ~--~-- 7. Loses things necessary for tasks or activities (school assignments, pencils, or books) ~s _easily_distracted by extraneous stimul_i ~--~ --~~-- o_ ~-- ~~--~ 2_ ~--~~- -~forgetful in daily activities ~~--~ -- ~ ~~--~ ~-- o -- ~ 2_ -- ~--. Fidgets with hands or feet or squirms in seat ~ ~--~--~--~~~--~ 2 ~ ~-. Leaves seat in classroom or in other situations in which remaining seated is expected ~--~~ ~-- ~ _ 2. Runs about or climbs excessively in situations in which remaining seated is expected ~ ~ ~~-~~--~- ~--~ --~~-- :2. Has difficulty playing or engaging inleisure activities quietlr 4. Is "on the go" or often acts as if "driven by a motor_" --~ --~-- ~--~ -~~-2--~-- ~ o ~_2_ ~~--~~-- _ 5. Talksexcessive_lr ~--~ ~ ~ Blurts out answers before questions have been completed --~ ~ ~-- 2 ~-- ~- o ~2_ --~~-~ 2._Has difficultyw~iting in line_~-~-- --~~ --~ ~ ~Interrupts orintrudes on others (eg, butts into conversations/games) ~ ~-- ~--2 ~ 2_.Losestemper --~ ~-- ~~-~-~~--_2 ~-- 2. Actively defies or refuse~ to comply with adult's requests or rule_s _ ~ --~--~~ ~ 2 ~ ~._Is angry or resentful ~ ~--~ --~ 2 _E.. Is spiteful and vindictive~--~--~~-- ~-~--~-~~2 ~~- 2. Bullies, threatens, or intimidates others ~ Initiates physical fights ~--~~- ~-- --~ o ~~ ~ 2 ~ _ 25. Lies to obtain goods for favors or to avoid obligations ( eg, "cons" others) --~-- --~--~ ~~--2- ~-- ~~ 26. Is physically cruel to people ~ ~ ~ ~ ~ 27. Has stolen items of nontrivial value 2? ~~~ -~-- ~~~ ~~-- ~-- --~ Deliberately destroys others' proper_!r ~-- ~~--~ ~ --~--2--~ ~ _ 29. Is fearful, anxious, or worried ~~~-~-- --~--~--~--~~ - -~- ~. Is self-conscious or easily embarrasse_c! --~--~ ~ --~ 2 ~~--~~-. Is afraid to try new things for fear of making mistakes The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. DEDICATED TO THE HEALTH OF ALL CHILDREN'" Copyright 22 and National Initiative for Children's Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 2 NICH(}

7 D4 NICHQ Vanderbilt Assessment Scale-TEACHER Informant, continued Teacher's Name: Class Time: Class Name/Period: Today's Date: Child's Name: Grade Level: Symptoms (continued) Never Occasionally 2. Feels worthless or inferior. Blames self for problems; fe~ls guilty o ~:_ ~eels lonely, unwan~e_d, or unloved; complains that "no one loves him or her" 5. Is sad, unhappy, or depressed Performance Academic Performance 6. Reading 7. Mathematics 8. Written expression Classroom Behavioral Performance Excellent 2 -~- 2 2 Excellent Above Above Often Very Often Somewhat of a Problem Problematic Somewhat ofa Problem Problematic 9. Relationship with~p'--e_e_r_s 2 _io :_~ollowing directions 2 _ 4_L_Disrupting class Assignment completion 4. Organizational skills Comments: Please return this form to: Mailing address: Fax number: For Office Use Only Total number of questions scored 2 or in questions -9: Total number of questions scored 2 or in questions -8: Total Symptom Score for questions -8: Total number of questions scored 2 or in questions 9-28: Total number of questions scored 2 or in questions 29-5: Total number of questions scored 4 or 5 in questions 6-4: Performance Score: DEDICATED TO THE HEALTH OF ALL CHILDRENrn NICHQ

8 --~- -- ~--~ ~-- ~ ~-- -~ - ~~-- ~~--~ ~ D4 NICHQ Vanderbilt Assessment Scale-TEACHER Informant Teacher's Name: Class Time: Class Name/Period: Today's Date: Child's Name: Grade Level:-- Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors:. Is this evaluation based on a time when the child D was on medication D was not on medication D not sure? Symptoms Never Occasionally Often Very Often ~. _Fails to ~ive attention to details or makes careless mistakes in schoolwork~ --~~ ~~ _2. Has difficulty sustaining attention to tasks or activities~--~ ~ ~ ~- 2 - ~ ~--~--~~ ~-- ~ _. Doesnot seem to l~sten when spoken to directly ~--~~--~--~ --~~-- 2 ~ ~-- 4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand) - - _ 5. I:!as difficulty organizing tasks and activities ~~--~~-- --~ 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort ~-- --~ ~ --~ --~--~~--~ ~-- ~--~ ~--~-- 7. Loses things necessary for tasks or activities (school assignments, pencils, or books) ~s _easily_distracted by extraneous stimul_i ~--~ --~~-- o_ ~-- ~~--~ 2_ ~--~~- -~forgetful in daily activities ~~--~ -- ~ ~~--~ ~-- o -- ~ 2_ -- ~--. Fidgets with hands or feet or squirms in seat ~ ~--~--~--~~~--~ 2 ~ ~-. Leaves seat in classroom or in other situations in which remaining seated is expected ~--~~ ~-- ~ _ 2. Runs about or climbs excessively in situations in which remaining seated is expected ~ ~ ~~-~~--~- ~--~ --~~-- :2. Has difficulty playing or engaging inleisure activities quietlr 4. Is "on the go" or often acts as if "driven by a motor_" --~ --~-- ~--~ -~~-2--~-- ~ o ~_2_ ~~--~~-- _ 5. Talksexcessive_lr ~--~ ~ ~ Blurts out answers before questions have been completed --~ ~ ~-- 2 ~-- ~- o ~2_ --~~-~ 2._Has difficultyw~iting in line_~-~-- --~~ --~ ~ ~Interrupts orintrudes on others (eg, butts into conversations/games) ~ ~-- ~--2 ~ 2_.Losestemper --~ ~-- ~~-~-~~--_2 ~-- 2. Actively defies or refuse~ to comply with adult's requests or rule_s _ ~ --~--~~ ~ 2 ~ ~._Is angry or resentful ~ ~--~ --~ 2 _E.. Is spiteful and vindictive~--~--~~-- ~-~--~-~~2 ~~- 2. Bullies, threatens, or intimidates others ~ Initiates physical fights ~--~~- ~-- --~ o ~~ ~ 2 ~ _ 25. Lies to obtain goods for favors or to avoid obligations ( eg, "cons" others) --~-- --~--~ ~~--2- ~-- ~~ 26. Is physically cruel to people ~ ~ ~ ~ ~ 27. Has stolen items of nontrivial value 2? ~~~ -~-- ~~~ ~~-- ~-- --~ Deliberately destroys others' proper_!r ~-- ~~--~ ~ --~--2--~ ~ _ 29. Is fearful, anxious, or worried ~~~-~-- --~--~--~--~~ - -~- ~. Is self-conscious or easily embarrasse_c! --~--~ ~ --~ 2 ~~--~~-. Is afraid to try new things for fear of making mistakes The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. DEDICATED TO THE HEALTH OF ALL CHILDREN'" Copyright 22 and National Initiative for Children's Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 2 NICH(}

9 D4 NICHQ Vanderbilt Assessment Scale-TEACHER Informant, continued Teacher's Name: Class Time: Class Name/Period: Today's Date: Child's Name: Grade Level: Symptoms (continued) Never Occasionally 2. Feels worthless or inferior. Blames self for problems; fe~ls guilty o ~:_ ~eels lonely, unwan~e_d, or unloved; complains that "no one loves him or her" 5. Is sad, unhappy, or depressed Performance Academic Performance 6. Reading 7. Mathematics 8. Written expression Classroom Behavioral Performance Excellent 2 -~- 2 2 Excellent Above Above Often Very Often Somewhat of a Problem Problematic Somewhat ofa Problem Problematic 9. Relationship with~p'--e_e_r_s 2 _io :_~ollowing directions 2 _ 4_L_Disrupting class Assignment completion 4. Organizational skills Comments: Please return this form to: Mailing address: Fax number: For Office Use Only Total number of questions scored 2 or in questions -9: Total number of questions scored 2 or in questions -8: Total Symptom Score for questions -8: Total number of questions scored 2 or in questions 9-28: Total number of questions scored 2 or in questions 29-5: Total number of questions scored 4 or 5 in questions 6-4: Performance Score: DEDICATED TO THE HEALTH OF ALL CHILDRENrn NICHQ

10 Oberlin Road Pediatrics ADHD Screening Tool Patient name: Date of birth: Current school/grade: Teacher name/number: Counselor name/number: Chief concerns from parent (please complete below items): Age of onset Frequency of concerns Duration of problem behaviors Situation in which behaviors increase or decrease Previous treatment and results Family s understanding of issues Current Medications Over The Counter: Prescription: Supplements: Significant Past Medical History: Birth history: Prematurity? No Yes (if so, what gestation: ) Neonatal problems (hospitalized in NICU or Special Care, any infections, or any ventilator use?) No Yes (if yes, please explain): Head trauma: No Yes (if yes, please explain):

11 Health History: Check or circle any applicable conditions General Enlargement of adenoids/tonsils asthma allergies obesity iron deficiency Cardiac high blood pressure heart murmur (other than innocent or functional murmur ) other heart problems rheumatic fever chest pain or palpitations Stressors (such as: family stress and problematic relationships that may contribute to patient s overall functioning, parental tension, drug abuse in a family member, bullying, social pressures, etc). If any, please explain: Developmental/behavioral history (explain any abnormalities): School history Any school failure or need to repeat a grade? Yes No Any concern of learning disability? Yes No Any problems with performance on standardized tests? Yes No Any psychological-educational testing done previously? Yes No Is there an IEP or 54 plan in place at school? Yes No Any detentions, suspensions, or expulsions? Yes No

12 Has patient received any prior counseling? Yes No Family history (circle all applicable conditions) Cardiac: arrhythmia, sudden death in family member <5 yrs of age, cardiomyopathy, Wolf- Parkinson-White Syndrome, prolonged QT syndrome, short QT syndrome, Brugada syndrome Neurologic: Restless leg syndrome/periodic limb movement disorder, developmental delay/learning disability Medical syndrome (like Marfan Syndrome): Psychiatric: ADHD, mood disorders, anxiety, bipolar, tobacco or substance use School problems: (Any family members with school problems?) Review of Systems of patient: Cardiac: Chest pain or shortness of breath with exercise Fainting/dizziness with exercise unexplained or noticeable change in exercise tolerance palpitations Psychiatric: Anxiety Depression Oppositional-Defiant Disorder Conduct Disorder Disruptive behaviors Suicidal thoughts/actions Delusions Mood instability Substance use (cigarettes/alcohol/drugs/prescription meds) Neurologic: Seizure Restless Leg Syndrome/Periodic Limb Movement Disorder (urge to move legs at night) Tics Learning difficulties Sleep history: Problem with sleep onset/maintaining sleep/awakening early Snoring Apnea (pause in breathing) Restless sleep Daytime sleepiness Sleep hygiene: inconsistent bedtimes and waketimes absence of bedtime routine electronics in bedroom caffeine use Other: lead exposure