2538 Davidsonville Road <> Gambrills, Maryland <> Telephone

Transcription

1 2538 Davidsonville Road <> Gambrills, Maryland <> Telephone You may be scheduled to meet with Dr. Schneider to discuss your child s behavior and /or school difficulties. Dr. Schneider has expertise in the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (A.D.H.D.). In many pediatric offices these problems are, simply, referred to mental health professionals. Insurance carriers frequently do not recognize the time and effort necessary to adequately diagnose, educate about and treat this disorder. In addition to time spent reviewing reports from parents and teachers Dr Schneider(s) will spend 1 ½ -2 hours discussing the disorder and the treatment options. The charge for these services is between $ Insurance carriers may reimburse these services at a much lower rate. We cannot provide these services at that reduced rate. If you choose to proceed with the consultation with Dr. Schneider(s) you should understand that you must be responsible for the difference. If you cannot agree to this, then we would be glad to provide you a list of mental health professionals who could help in the assessment. I understand that I will be (Parents name) financially responsible for the charges for this consultative service provided by Dr. Schneider. Signature Date Please return all paper work to the office at least one week prior to your appointment.

2 Patient Information Name DOB Age y m Address_ Home Phone ( ) Work ( ) Cell ( ) GRADE School_ Primary Teacher Guidance Counselor Principal_ Math Teacher Science Teacher LA Soc.St. Language Mother s Name_ Address Father s Name_ Address_ Briefly, state your concerns

3 TEACHER BEHAVIORAL RATING SCALE Teacher Subject Date Child s Name: Age: Grade: Not at Just a Pretty Very all little much much 1. Fails to pay attention to details or makes careless mistakes. 2. Has difficulty sustaining attention to tasks or play. 3. Often does not seem to listen Has difficulty following instructions Has difficulty organizing tasks and activities Avoids or strongly dislikes tasks (schoolwork or homework) that requires mental effort. 7. Often loses things necessary for tasks Is easily distracted Often is forgetful in daily activities Often fidgets or squirms in seat Has difficulty remaining seated Often runs and climbs excessively when not appropriate. 13. Has difficulty playing quietly Is on the go or acts as driven by a motor Often talks excessively Often blurts out answers Has difficulty waiting turn Often interrupts or intrudes Please give a brief narrative on this child s learning style. (Use other side).

4 Note: The Teacher Behavioral Rating Scales on the previous page or available as a download from our website ( is for your child s teacher. If your child has more than 1 teacher you can make copies and distribute. We need scales only from teachers of primary subjects. Behavioral Evaluation Screening Questionnaire 1. Developmental Factors A. Prenatal factors How was your health during pregnancy? How old were you when your child was born Good Fair Poor Did you use any of the following substances during pregnancy? Beer or wine Liquor Marijuana Other illicit drugs Coffee Tobacco products B. Perinatal History Did you have toxemia? Was your child premature If so, how many weeks _ Was delivery Vaginal? Caesarian section? Breech? Forceps? Induced? What was your child birth weight Do you know the APGAR score? Was your child jaundiced? _lbs oz _1min 5min Did (s) he require phototherapy C. Postnatal and Infancy Were there feeding problems in infancy? Was your child colicky? Were there early infancy sleep problems? Were there problems with your infant s responsiveness (alertness)? Was your child an easy baby? How would you rate your baby s activity level? Active Average Less active Not active

5 D. Developmental Milestones At what age did (s) he sit up? 3-6m 7-12m >12m At what age did (s)he walk 6-12m 13-18m >18m At what age did (s)he speak single words? 9-13m 14-18m 19-24m 25-36m 37-48m At what age did he string 2 or more words together? 9-13m 14-18m 19-24m 25-36m 37-48m At what age was (s)he toilet trained? 1-2y 2-3y 3-4y >5y E. Family History Is there a family history of ADHD? If so, who?_ Is there a family history of learning disabilities? Is there a family history of anxiety disorder? Is there a family history of depression? Is there a family history of bipolar or manic/depressive disorder? Is there a family history of sudden unexplained death? Does either parent think they exhibit(ed) symptoms of ADHD? Did either parent struggle with learning or behavior in school? F. Medical History Is there a problem with hearing? Is there a problem with Vision? Is your child clumsy? Is there a problem with fine motor coordination? Is there a problem with speech? Is your child accident prone? Broken bones or Stitches Don t know DK Are there any chronic health conditions? If Yes, specify

6 Which of the following conditions has your child had? Seizures Celiac disease Thyroid disease Asthma Diabetes Autism Cerebral Palsy Tonsillitis Sleep Apnea Is there any suspicion of alcohol or drug use? Is there suspicion or history of physical/sexual abuse? Does your child have difficulty falling asleep? Is your child a restless sleeper? Does you child snore? Does your child have difficulty with bladder control? If yes.. day? night? Is there a problem with bowel control? Is there a problem with appetite control? G. Treatment History Has the child ever been treated with medication for this problem? If so, which medications? Has your child ever had any of the following therapies for this problem? Individual psychotherapy Group therapy Family Therapy Residential Therapy Natural Supplements Occupational therapy Sensory integration therapy Optometric therapy Chiropractic therapy H. School History Please summarize your child s progress (academic, behavioral, social) within each of these grade levels. Preschool Kindergarten Grades 1-3 Grades 4-5

7 Grades 6-8 Grades 9-12 Has your child ever been: Suspended from school Expelled Retained in a grade Have ther been any other interventions? Behavior modification program Daily/weekly reports Tutoring I. Current Behavioral Concerns What strategies have been utilized to deal with behavioral problems? Have any of the following stress events occurred in the last 2 years? Verbal reprimands Time out Loss of privilege Rewards Physical punishment Parents divorce/separation Family illness Death in family Parent changed/lost jobs Changed schools Family moved Financial problems Which of the following are considered to be significant? Fidgets Can t remain seated Inappropriately runs or climbs Trouble playing quietly Always on the go Talks excessively Interrupts or intrudes on others Can t wait turn Blurts out answers to questions HA/Imp Total Difficulty sustaining attention Can t stay on task Doesn t appear to listen Does not complete work or chores Disorganized Forgetful Distracted easily Loses things Avoids tasks requiring sustained attention Inattention Total When did these problems begin (specify age)?

8 Which of the following are considered significant? Loses temper easily Often argues with adults Actively defies or refuses adult requests or rules Deliberately does things to annoy other people Blames others for own mistakes Often touchy or easily annoyed Often angry or resentful Spiteful or vindictive Uses foul language ODD total Which of the following are considered to be significant? Stolen Run away from home at least twice Lies often Deliberate fire-setting Often truant (skips school) Breaking and entering Destruction of others property Cruel to animals Forced someone to have sex Used a weapon Physical fights Cruel to people Conduct disorder total Which of the following are considered to be significant? Unrealistic or persistent worry about possible harm to family member Unrealistic or persistent worry that a calamitous event will separate child from family Persistent or frequent school refusal Refusal to sleep alone Refusal to be alone Nightmares Unreal complaints about aches or pains Distress in anticipation of separation Distress after separated from family member Separation Anxiety Total Which of the following are considered to be significant? Unrealistic worry about future events Unrealistic concern about appropriateness of past behaviors Unrealistic concerns about competence Somatic complaints (physical complaints..aches,pains) Marked self-consciousness Excessive need for reassurance Inability to relax Anxiety Total

9 Which of the following are considered to be significant? Depressed or irritable mood most of day, nearly every day Diminished pleasure in activities Decrease or increase in appetite with weight loss/gain Insomnia or hypersomnia (sleep too much) most days Agitated or lethargic Fatigue or low energy Feelings of worthlessness or excessive inappropriate guilt Diminished ability to concentrate Suicidal thoughts or attempts Depressive episode Total Which of the following are considered to be significant? Depressed or irritable mood most of the day >1 year Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self esteem Difficulty making decisions Feeling hopeless Never without symptoms for >2months over past year Dysthymia Total Has the child exhibited any of the following symptoms? Stereotyped mannerisms or repetitive movements Odd postures Excessive reaction to noise Fails to react to loud noise Overreacts to touch Sensitive to the feel of clothes, tags or jewelry Compulsive rituals Motor tics Vocal tics or noises

10 NICHQ Vanderbilt Assessment Scale-Parent Informant 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 behavior in the last 6 months. Symptoms Never Occasionally Often Very Often 1.Does not pay attention to detail or makes careless mistakes, 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 lack of understanding) Has difficulty organizing tasks and activities Avoids, dislikes or does not want to start tasks that require ongoing mental effort Loses things necessary for tasks or activities (toys, assignments, pencils, books, etc.) Is easily distracted by noise or other stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs around or climbs too much Has difficulty playing quietly Is on the go or acts as if driven by a motor Talks too much Blurts out answers before questions have been completed Has difficulty waiting own turn Interrupts or intrudes on others Argues with adults Loses temper Actively defies or refuses to go along with adults requests or rules Deliberately annoys people Blames others for his or her mistakes or misbehavior Is touchy or easily annoyed by others Is angry or resentful Is spiteful and wants to get even Bullies, threatens or intimidates others Starts physical fights Lies to get out of trouble or to avoid obligations Is truant from school (skips school) Is physically cruel to people Has stolen things of value Deliberately destroys others property Has used a weapon for harm Is physically cruel to animals Has deliberately set fires to cause damage Has broken into to someone else s home, car or business Has stayed out all night without permission Has run away from home overnight Has forced someone into sexual activity

11 Symptoms (continued) Never Occasionally Often Very Often 41 Is fearful, anxious or worried Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely or unwanted or unloved.; complains that no one loves him or her Is sad, unhappy or depressed Is self conscious or easily embarrassed Performance Excellent Above Avg Average Somewhat of Problematic a Problem 48 Overall school performance Reading Writing Math Relationship with parents Relationship with siblings Relationship with peers Participation in organized activities

12 Children s Atypical Development Scale (CADS) 0 = not true 1= sometimes true 2 = often true Misses the point or main idea in conversation Rambling speech one idea is not connected to the next Refers to self in third person (uses own name rather than I or me Makes odd noises or talks in odd voices Obsessive interest in narrow or atypical topic (e.g. death, anatomy, fantasy characters) Makes irrelevant comments Insists on sticking to unusual routines Lacks interest in toys or uses toys in an unusual manner Strong attachment to inanimate objects Unusual aversion to objects or situations (e.g. will not wear certain materials or walk up certain stairways) Engages in repetitive or stereotypical behaviors (e.g. shakes or flaps hands) Extreme reactions to minor inconveniences or irritations Difficulty with dealing with change in daily schedule or routine Marked lack of concern for appearance Lacks social discretion (e.g. comments on others behavior in public without concern for their reaction or feelings Acts as if people were not in the same room Poor judge of other people s reactions or feelings Reveals overly personal detail to strangers or acquaintances Lacks interest in peers Makes poor eye contact with others Does not appreciate personal space (e.g. stands too close) Mood changes quickly without apparent reason Describes the details of an event yet misses the meaning or importance of it Sits, stands or walks in odd postures Attributes meaning to events that are simply a coincidence Believes others are talking about him/her when others are speaking softly among themselves