BEHAVIORAL INTERVIEW Ken Tellerman M.D.
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1 BEHAVIORAL INTERVIEW Ken Tellerman M.D. Name: Age: Birthdate: Date of Evaluation: School: Grade: Number of classmates Informant(s): Counseling Time: What are your major concerns?
2 BEHAVIORAL INVENTORY: (Common behavioral clusters) Attention Deficit Hyperactivity Disorder Attention span/ daydreams Distractibility Difficulty following directions/ not listening well Hyperactivity/ fidgety/ talks excessively Impulsivity (not waiting turn, butts in, blurts out answers) Organization (space/time/planning) loses things/ notebook/bedroom Inconsistency of performance Oppositional Defiant/quarrelsome/angry Temper tantrums Doesn t listen/uncooperative Conduct Disorder Lying Stealing/shoplifting/ violation of rules/ law Destructive behaviors (i.e. careless/ intentional) Truancy Aggressive behavior/ Bullying Animal cruelty/ Fire setting Acute Stressors (moves, new sibling, new job, illness, death, divorce, separation, bullying) Depression Sadness/ moodiness/ irritability Appetite change Activity (hyperactivity, psychomotor retardation/ impaired concentration) Sleep disturbance (sleeps too much/ insomnia/day-night reversal) Suicidal ideation/ prior attempts Risk taking behaviors (substance abuse, sexual promiscuity, runaway, driving while impaired) Bipolar Disorder Cycles of mania/ agitation/ non- stop talk/ cycles of depression/insomnia Anxiety Worries a lot/ nervous/ high strung/ perfectionistic Separation anxiety/ school refusal Phobias /social anxiety Obsessive/compulsive (repeated rituals/ thoughts) Panic attacks Somatic symptoms (headaches, abdominal pain, sleep problems)
3 Global Developmental Delay/ Autism/ PDD/ Asperger s Rocking/ Head banging/ Eye contact/ Stereotypic behaviors ( hand flapping/ twirling)/ ritualistic behaviors Language problems / pragmatics/ socialization delays Temperament/ Sensory Processing Intense/negative/moody/rigid/trouble with transitions/ slow to warm up Over-reacts to sensory stimulation (sounds, noise, smells, clothing, food, visual stimuli, malls, crowds, etc.) Elimination Disorders Enuresis Encopresis Sleep Trouble falling asleep/ insomnia/ excessive / day-night reversal Snoring/ obstructive sleep apnea Eating Disorders (anorexia/ bulimia) Substance Abuse (drugs/ alcohol) Other School / Grade/ (learning difficulty/ behavior problems/ prior grades/ homework psycho-educational testing/ resource help) Prior Evaluations:
4 PAST MEDICAL HISTORY: Perinatal: (pregnancy/ birth hx/ neonatal hx) Developmental milestones: Sat alone Crawled Walked Talked (first words) Talked (short sentences) Toilet trained Was development different from other siblings or children? Gross/ Fine motor skills (clumsy/ tie shoes/ buttoning/ handwriting) Past Medical Health: Medical (seizures/ head injury/ lead toxicity/ hearing or vision problems) Surgical Hospitalization Trauma Allergies Medications Immunizations Complementary medicine Cardiac history (structural problems/ murmurs/ chest pain/ dizziness/ syncope/ SOB/ arrhythmias/ palpitations) Tics (motor/vocal (grunting, sniffing, coughing) Obstructive sleep apnea/ snoring Seizures (staring episodes) Other
5 FAMILY HISTORY: A. Mother 1. Age 2. State of health 3. Education (grade completed) 4. Learning/behavior problems in school 5. Occupation B. Father 1. Age 2. State of health 3. Education (grade completed) 4. Learning/behavior problems in school 5. Occupation C. Siblings 1. Age 2. State of health 3. School performance/behaviors D. Anyone in family with: 1. Learning problems 2. Hyperactivity or attention problems 3. Emotional problems (depression/ suicide, anxiety, bipolar disorder, schizophrenia, substance abuse) 4. Autism/ PDD/ Asperger s 4. Tourette Syndrome/tics 5. Cardiac problems (arrythmias/ sudden deaths/ cardiomyopathy) 6. Other
6 SOCIAL HISTORY: Who does child live at home with? Are there any family problems? (marital, financial, substance abuse, domestic violence, communication between family members) How does child get along with: Parents/ step-parents/ grandparents? (parents work together on discipline?) Siblings? Peers? (bossy, aggressive, annoying, shy or withdrawn, bullying- victim or perpetrator? inappropriately touches others/ poor boundaries ) (plays with children same age younger older?) (acts own age younger older) Media (computers, video games, TV, cell phones) Driving?
7 What are your child s strengths? What does your child do well? What do you like about your child? What do you think is going on? Do you feel your child s problems are primarily: Learning difficulty Attention/hyperactivity Emotional Family problems Teacher/child (personality conflict, poor teaching) Other Additional concerns? Anything not yet discussed? What are your thoughts about medication? What have you read or heard? DIAGNOSIS:
8 RECOMMENDATIONS: Educational Accomodations (preferential seating/break material into subunits/extra time/decrease work load/repeat directions/organizational assistance/ allow out of seat) 504 plan letter tutor resource help daily report card/ other (speech/ OT/ PT) Psychosocial psychoeducational testing counseling behavior plan other Social social skills group peer activities (sports/clubs/scouts groups/camp/volunteering) other Medical comorbidities/other medical conditions medication psychiatry referral Followup Miscellaneous Recommendations/ Books/Websites/ Support groups (e.g. CHADD)
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