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Diagnostic Screening Survey

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Diagnostic Screening Survey
 
The Diagnostic Screening Survey was designed by Dr. Brian Richardson to aid in the identification of interrelated conditions which can cause, imitate, and/or impact the behavioral expression of childhood attention problems.  It consolidates various other diagnostic checklists found in other published sources, including Healing ADD by Dr. Daniel Amen, Parent Stress Index, Stanley Turecki's Temperament checklist, Childhood Bipolar checklist by Papados, Sensory Integration Disorder checklist by Kranowicz, and others.  The DSS is for parents to fill out, but does not itself diagnose any condition.  A diagnosis of ADD requires consideration of much more data, and can include test results from behavior checklists filled out my teachers, continous performance tests, QEEG tests, and others.  The DSS examines the typical and atypical signs and symptoms of Attention Deficit Disorder, with or without Hyperactivity.  In addition, the DSS helps to identify the particular subtype of ADD that your child may have, as have been described by Daniel Amen in his book, Healing ADD.  The DSS helps to screen for various childhood behavior problems, explores that possible biological, social, and familial sources of the attention problem, screens for excess parental stress and parenting conflicts (which can impact effective treatment of ADD), screens for biological temperament influences on attention and behavior, screens for mood and anxiety disorders, sensory integration disorders, and learning disabilities.  The DSS also attempts to gauge social consequences of the attention and behavior problems and categorize any social skill problems that may exist.
 
                                                                                                                     
 
Please print a copy of the DSS in order to fill it out.  Please circle the number that best describes your child's behavior.  Some questions will be repeated because of overlapping symptoms of the interrelated conditions being examined.
Key: 0 = Never or Rarely
        1 = Sometimes
        2 = Often
        3 = Very Often
Scoring: Traits that occur "often" or "very often" are, depending upon the age of the child, usually significant.  Score each "often" and "very often" as a single (1) diagnostic sign and add each of the diagnostic signs and put the totals in the appropriate spaces.  Significance thresholds are listed in bold-face type.
                                                                                                                      
 
Diagnostic Screening Survey
 
ADD - Inattentive Type - Executive Function Deficit
 
1. Has difficulty sustaining attention in tasks or play                       0  1  2  3
2. Makes careless mistakes and has poor attention to detail                0  1  2  3
3. Has difficulty staying organized (bedroom, desk, locker, book bag)
     or organizing tasks, chores, or games                                           0  1  2  3
4. Hates homework, skips doing it if possible, or does it carelessly
     and in a slipshod manner                                                              0  1  2  3
5. Has a tendency to lose things                                                        0  1  2  3
6. Is forgetful                                                                                    0  1  2  3
 
1-6  ADD-Inattentive - Executive Function Deficit                      4                   
 
ADD- Inattentive - Auditory Processing Problems
 
7.Easily distracted by other things going on in the room                      0  1  2  3
8. Procrastinates - has difficulty following through when told what to do   0  1  2  3
9. Has trouble listening when others are talking                                     0  1  2  3
10. Does not seem to listen when spoken to directly                             0  1  2  3
 
7-10 ADD Auditory Processing Problems                                 2                    
 
1-10 ADD - Inattentive Type                                                     6                    
 
ADD- Prefrontal Cortex System Dysfunction
 
1. Excessive daydreaming                                                                  0  1  2  3
2. Complains of being bored                                                               0  1  2  3
3. Appears apathetic and unmotivated                                                 0  1  2  3
4. Is tired, sluggish, or slow moving                                                     0  1  2  3
5. Appears spacey or internally preoccupied                                        0  1  2  3
 
1-5 ADD- Prefrontal Cortex System Dysfunction                      3                     
 
ADD - Hyperactive/Impulsive Type
 
1. Is restless or hyperactive                                                                0  1  2  3
2. Has trouble sitting still, especially in school                                     0  1  2  3
3. Is fidgety, in constant motion with hands, body, or feet                     0  1  2  3
4. Is noisy, has a hard time being quiet                                               0  1  2  3
5. Acts as if being "driven by a motor"                                                 0  1  2  3
6. Talks excessively                                                                          0  1  2  3
7. Is impulsive, doesn't think through what to say or do ahead of time    0  1  2  3
8. Has difficulty waiting for his or her turn                                            0  1  2  3
9. Interrupts or intrudes on others                                                       0  1  2  3
 
1-9 ADD - Hyperactive/Impulsive Type                                 6                      
 
ADHD - Combined Type - If Inattentive and Hyperactive/Impulsive Types are both present.
 
ADD - Overfocused/Cingulate System Subtype
 
1. Worries excessively or senselessly                                              0  1  2  3
2. Is super-organized                                                                      0  1  2  3
3. Is oppositional and argumentative                                                 0  1  2  3
4. Strong tendency to get locked ino negative thoughts; has the        
     same thoughts over and over again (obsessive)                             0  1  2  3
5. Has a tendency towards compulsive behavior (has rituals,
     or redoes things needlessly)                                                       0  1  2  3
6. Has an intense dislike of change                                                  0  1  2  3
7. Has a tendency to hold grudges                                                   0  1  2  3
8. Has trouble shifting attention from subject to subject                      0  1  2  3
9. Has difficulties seeing options in situations                                    0  1  2  3
10. Has tendency to hold on to own opinion and not listen to others      0  1  2  3
11. Has a tendency to get locked into a course of action, even if it is
     not good for the child                                                                  0  1  2  3
12. Needs to have things done in a certain way or the child becomes  0  1  2  3
     very upset (explosive)                                                                 0  1  2  3
13. Others complain that the child worries too much                          0  1  2  3
 
1-13  ADD- Overfocused/Cingulate System Subtype              6                    
 
ADD - Temporal Lobe/Explosive Subtype
 
1. Has periods of quick temper, child rages with little provocation        0  1  2  3
2. Misinterprets comments as negative even when they are not           0  1  2  3
3. Irritability tends to build to an emotional meltdown, which eventually
     recedes; the child is often tired after the meltdown is over              0  1  2  3
4. Has periods of spaciness or confusion                                          0  1  2  3
5. Has periods of fear and/or panic for not specific reason                   0  1  2  3
6. Perceives visual changes, such as shadows/auras around objects
     or objects changing shapes                                                         0  1  2  3
7. Has periods of deja vu (strange feelings of having been somewhere
     or done something before)                                                           0  1  2  3
8. Feels acutely sensitive to others' comments or scrutiny; or is
     mildly paranoid                                                                           0  1  2  3
9. Has headaches or stomachaches of uncertain origin                       0  1  2  3
10. Has a history of any head injury or a family history of violence        0  1  2  3
11. Has dark thoughts (either morbid, homicidal, or suicidal) or
     violent fantasies                                                                          0  1  2  3
12. Has periods of forgetfulness or memory problems                          0  1  2  3
13. Has a short fuse; periods of extreme irritability                              0  1  2  3
 
1-13  ADD - Temporal Lobe/Explosive Subtype                        6                   
 
ADD -Depressive/Limbic System Subtype
 
1. Is moody                                                                                      0  1  2  3
2. Is negative                                                                                    0  1  2  3
3. Has low energy                                                                             0  1  2  3
4. Is frequently irritable                                                                      0  1  2  3
5. Has a tendency to be socially isolated                                           0  1  2  3
6. Has feelings of hopelessness, helplessness, and needless guilt       0  1  2  3
7. Has lowered interest in things that are usually considered fun          0  1  2  3
8. Undergoes sleep changes (too much or too little)                            0  1  2  3
9. Has chronic low self esteem                                                          No   Yes
 
1-9 ADD - Depressive Limbic System Subtype                       6                      
 
ADD - "Ring of Fire" Subtype
 
1. Is angry and aggressive                                                                   0  1  2  3
2. Is excessively sensitive to noise, light, clothes, or touch                    0  1  2  3
3. Undergoes frequent or cyclic mood changes (highs and lows)            0  1  2  3
4. Is inflexible and rigid in his or her thinking                                         0  1  2  3
5. Demands to have his or her own way, even when told NO many times 0  1  2  3
6. Has periods of mean, nasty, or insensitive behavior                            0  1  2  3
7. Has periods of increased talkativeness                                             0  1  2  3
8. Has periods of increased impulsivity                                                 0  1  2  3
9. Displays unpredictable behavior                                                       0  1  2  3
10. Thinks in grandiose, expansive and unrealistic ways                        0  1  2  3
11. Talks fast                                                                                     0  1  2  3
12. Says that their thoughts are going "fast" or are "racing"                   No    Yes
13. Appears anxious or fearful                                                              0  1  2  3
14. There are few periods where the above criteria are not present and
      things seem normal (this sign excludes Bipolar Disorder)                 No   Yes
 
1-14 ADD - "Ring of Fire" Subtype                                           8                    
 
ADD - Biological factors that can cause or influence ADHD or ADD
 
1. Is there a genetic history of ADD or ADHD in the child's blood
     relatives?                                                                                       No Yes
2. Does the child thrash around in bed all night? (Restless Leg
     Syndrome)                                                                                      No Yes
3. Does the child snore or gasp for breath at night? (Sleep Apnea)           No  Yes
4. Does the child have any history of head injury? (TBI)                           No  Yes
5. Is there a historyof a lack of oxygen in womb or during birth? (anoxia)   No  Yes
6. Has child suffered a birth trauma? (e.g. forceps delivery)                      No  Yes
7. Has the child suffered a drowning accident and survived? (anoxia)         No  Yes
8. Has the child suffered from encephalitis or meningitis? (brain trauma)   No  Yes
9. Was the child exposed to drugs, alcohol, or nicotine in the womb?       No  Yes
10. Has the child diagnosed with overactive or underactive thyroid gland?  No  Yes
11. Has the child been diagnosed with any endocrine disorder?               No  Yes
12. Does the child take asthma medications? (epinephrine)                     No  Yes
13. Has the child started puberty yet?                                                   No  Yes
     If yes, have the signs of ADD gotten worse since the start of puberty? No  Yes
14. For girls, do the symptoms get worse prior to the start of menses?     No  Yes
15. Is it possible that the child is abusing drugs or alcohol?                     No  Yes
16. Has the child had a positive drug screen?                                         No  Yes
17. Does the child have a diet that low in protein?                                   No  Yes
     A diet that is high in sugar and simple carbohydrates?                       No  Yes
18. Is the child sedentary and gets little exercise?                                  No  Yes
19. Has the child been exposed to lead or other toxic heavy metals?        No  Yes
20. Does the child have any history of seizures?                                     No  Yes
21. Is there a history of chronic ear infections and tubes placed in ears?   No  Yes
22. Is there a history of speech delay or other developmental delay?        No  Yes
 
ADD - Psychological factors that contribute to or influence ADHD behaviors
 
1. Has the child suffered early neglect?                                                  No  Yes
2. Has the child suffered physical or sexual abuse?                                No  Yes
3. Does the child engage in negative self-talk?                                        No  Yes
4. Has the child grown discouraged about school?                                  No  Yes
5. Has there been a divorce that might be affecting the child's mood?       No  Yes
6. If there is a step-parent, does the child deny their authority to tell them
     what to do?                                                                                    No  Yes
7. Is the child alienated from a parent separated from the family?             No  Yes
8. Is the family in a financial crunch now?                                              No  Yes
9. Is the child physically handicapped?                                                  No  Yes
10. Is there drug or alcohol abuse in the home?                                      No  Yes
11. Did the child's mother give birth as a teenager?                                 No  Yes
12. Is the child spending too much time watching TV, playing video games
     or surfing the internet?                                                                     No  Yes
     a. Daily hours watching TV (write number)                                                       
 
     b. Daily hours surfing the internet or on MySpace                                         
 
     c. Daily hours playing video games                                                              
13. Child has a recent history of increased stress                                   No  Yes
14. Child has a problem adjusting to a new life situation                          No  Yes
15. Child has been traumatized                                                             No  Yes
 
Possible Childhood Signs of Stress
 
15. Child wakes up with nightmares more than twice per month               No  Yes
16. Child wets the bed more than twice a week for more than 2 weeks     No  Yes
17. Child has tics - sudden, rapid, non-rhythmic movements or noises     No  Yes
18. Child is significantly distressed by phobias or irrational fears             No  Yes
19. Child stutters                                                                                 No  Yes
 
Parental Stress   (for parents only)                                  Circle MOM   or    DAD
 
1. I feel depressed most of the day, nearly every day (sad, hopeless)   False  True
2. I have greatly diminished zest for living - It's hard to get interested in
     anything.                                                                                   False  True
3. Things which used to give me pleasure no longer do.                      False  True
4. Being a parent is harder than I ever imagined.                                False  True
5. I have little appetite lately                                                             False  True
6. I find it ver difficult to sleep restfully                                               False  True
7. I am tired when I get out of bed                                                       0  1  2  3
8. I feel wound up and restless and can't relax                                      0  1  2  3
9. I do not enjoy being a parent                                                           0  1  2  3
10. I am tired and fatigued nearly every day                                       False  True
11. I feel like I only make my child's problems worse                          False  True
12. I never seem to be able to get what I want since I became a parentFalse  True
13. I can't seem to concentrate on anything lately                              False  True
14. I often feel guilty about how I parent my child                                False  True
15. I can't seem to make decisions lately                                          False  True
16. When my child misbehaves, I feel responsible as if I didn't do
     something right                                                                          False  True
17. My child seeks a lot of physical affection, and I sometimes
     wonder if we may be too close                                                     False  True
18. I sometimes feel my child has taken over my life                          False  True
 
Parental Discord   (for parents only)                                  Circle   MOM  or  DAD
 
1. My spouse and I often disagree about discipline                                 No  Yes
2. I am afraid that my spouse is too harsh or rough with punishing child   No  Yes 
3. There are times when I feel out of control when my child misbehaves    No  Yes
4. My spouse and I argue in front of the children                                     No  Yes
5. Our child has witnessed a parent hitting the other parent or sibling       No  Yes
6. I wish my spouse would discipline child more firmly and consistently   No  Yes
7. I wish my spouse would just try to understand our child's feelings more
    rather than just punishing                                                                 No  Yes
8. My spouse and I disagree about spanking                                         No  Yes
 
The Family Functioning Inventory
(From The ADD Book by Sears and Thompson)
 

BUILDERS

3

2

1

0

 X

0

1

2

3

BREAKERS

Positive Actions

 

 

 

 

 X

 

 

 

 

Negative Actions

1. Peaceful – You anticipate and plan for problems

 

 

 

 

 X

 

 

 

 

Chaotic- Nothing is  planned, each problem is a new crisis

 2. Organized - You have a family calender, a method to handle messages, etc.

 

 

 

 

 X

 

 

 

 

 Unorganized - You fly by the seat of your pants - no one is sure of anything

3. Responsive - You join together to find solutions to meat each others needs long-term 

 

 

 

 

 X

 

 

 

 

 Reactive - You make knee-jerk responses to problems and live "in the moment" 

4. Supportive - You help everyone win and do their best 

 

 

 

 

 X

 

 

 

 

Competitive - You are concerned about the individual winning, being the best 

 5. Rewarding - Family members praise one another

 

 

 

 

 X

 

 

 

 

 Denigrating - Family members put each other down

 6. Protecting - You are careful with one another's vulnerable spots

 

 

 

 

 X

 

 

 

 

Attacking - You lask out at each other's vulnerable spots

7. Trusting - You trust each other's motives 

 

 

 

 

 X

 

 

 

 

 Suspicious - You are suspicious of each other's motives

 8. Open - You listen and use open-ended questions to help solve problems

 

 

 

 

 X

 

 

 

 

 Closed Communication - You confront, judge, command, moralize, criticize, and analyze

 9. Nurturing - You encourage the individual growth of each person

 

 

 

 

 X

 

 

 

 

 Constricting - You insist that others behave as you do.  You discourage individualism

 Other

 

 

 

 

 X

 

 

 

 

 Other

 

POSITIVE Communication

3

2

1

0

 X

0

1

2

3

NEGATIVE Communication

Positive Actions

 

 

 

 

 X

 

 

 

 

Negative Actions

1. Clear - "That door slamming scored me"

 

 

 

 

 X

 

 

 

 

Confusing - "Why are you always so wild?"

 2. Direct - "Tom, I get angry when you don't listen to me."

 

 

 

 

 X

 

 

 

 

Indirect - "He slammed the door Is he mad at someone?"

3. Immediate - "Come here and pick up the coat you just dropped, please."

 

 

 

 

 X

 

 

 

 

 Delayed - "We can't rely on you; lst week you kept us waiting."

4. Complete - "Dad, I need the care tonight.  I said I'd drive us to the movie."

 

 

 

 

 X

 

 

 

 

Incomplete - "I have to have the car tonight."

 5. Flexible - You are willing to discuss issues and make adjustments

 

 

 

 

 X

 

 

 

 

 Rigid "If you are living under my roof, you follow my rules."

 6. Reflective - "Let's discuss consequences"

 

 

 

 

 X

 

 

 

 

Impulsive - "You're grounded for a month"

7.Accepting - "I know that hurts when they won't play with you."

 

 

 

 

 X

 

 

 

 

 Nonaccepting - "Don't be a crybaby."

 Other

Try rating other characteristics that apply to your family

 

 

 

 

 X

 

 

 

 

Other

 POSITIVES

Column Scores

 

 

 

 

 X

 

 

 

 

 NEGATIVES

Column Scores

 TOTAL POSITIVE SCORE

 

 

 

 

 X

 

 

 

 

 TOTAL NEGATIVE SCORE

 
     Behavior Disorders
 
Oppositional Defiant Disorder (ODD)
 
1.My child loses his or her temper                                                      0  1  2  3
2. Argues with adults                                                                         0  1  2  3
3. Actively defies or refuses to comply with adult requests or rules        0  1  2  3
4. Deliberately annoys people                                                             0  1  2  3
5. Blames others for his or her mistakes or misbehavior                        0  1  2  3
6. Is touchy or easily annoyed by others                                              0  1  2  3
7. Is angry or resentful                                                                        0  1  2  3
8. Is spiteful or vindictive (seeks revenge)                                             0  1  2  3
9. Refuses to do what he or she is asked upon the first request or
     order from an adult                                                                        0  1  2  3
 
1-9  Oppositional Defiant Disorder                                          6                    
 
Conduct Disorder
 
1. Bullies, threatens,  or intimidates others                                           0  1  2  3
2. Starts fights                                                                                   0  1  2  3
3. Has used a weapon that could cause a serious injury (bat, brick,
     bottle, knife, gun, etc.)                                                                   0  1  2  3
4. Has been physically cruel to animals                                               0  1  2  3
5. Has been physically cruel to people                                                 0  1  2  3
6. Has forced someone into sexual activity or has had sex with a child
     5 or more years younger than he or she                                          0  1  2  3
7. Has deliberately set fires                                                                 0  1  2  3
8. Has broken into someone's home, car, store, or building                    0  1  2  3
9. Lies to obtain goods or favor, or to avoid obligations                           0  1  2  3
10. Has stolen items of value without confronting the victims                  0  1  2  3
11. Stays out all night without permission                                             0  1  2  3
12. Has run away from home overnight more than once                          No  Yes
13. Is truant at school, beginning before the age of 13                            No  Yes
 
1-13 Conduct Disorder                                                             3                    
      (In order to qualify for a CD diagnosis, three of the above infractions
      must have occurred in the last year and at least 1 in the last 6 months)
 
Difficult Temperament  
 
Temperament, based on the ideas of Stanley Turecki and Ainsley, are biologically based factors that influence the development of personality and are observable from the first few months of life.  Once particular temperament, Poor Adaptability, plays a role in the development of the Explosive Child syndrome, which looks like oppositional behavior, but must be managed very differently than ODD to be successful.
 
Temperament - Initial Withdrawal
 
1. Doesn't like new situations - new places,, people, food or clothes      0  1  2  3
2. Holds back and protests by clinging when exposed to new situation  0  1  2  3
3. May have tantrums if forced to go forward in new situations               0  1  2  3
 
1-3  Temperament - Initial Withdrawal                                    2                    
 
Temperament - Irregularity
 
1. Unpredictable - can't predict when the child will be hungry or tired      0  1  2  3
2. Moods change suddenly                                                                0  1  2  3
3. Conflicts arise over meals or bedtimes                                            0  1  2  3
4. Wakes up at night (poor sleep regulation)                                        0  1  2  3
 
1-4 Temperament - Irregularity                                                 2                   
 
Temperament - High Intensity
 
1. My child is loud, whether miserable, angry or happy                          0  1  2  3
 
1. Temperament - High Intensity                                               1                   
 
Temperament - Poorly Adaptable
 
1. Has trouble with transition or change, of activity or routine                  0  1  2  3
2. Goes on and on for something that he or she wants                           0  1  2  3
3. Is very persistent if he or she really likes an activity                           0  1  2  3
4. Stubborn - tantrums are long and hard to stop                                   0  1  2  3
5. Gets used to things and then refuses to give them up                        0  1  2  3
6. Has unusual preferences for food or clothes                                      No  Yes
 
1-6  Temperament - Poorly Adaptable                                        4                 
 
Low Frustration Tolerance - "Explosive Child" syndrome
                         (includes Poorly Adaptable characteristics)
7. Becomes easily enraged if things don't go his or her way                   0  1  2  3
8. Becomes extremely disrespectful or destructive when frustrated or
     thwarted                                                                                       0  1  2  3
9. Insists on having things done in a certain way or certain order            0  1  2  3
10. Expresses self in black-and-white terms, using words like "never,"
      "hate," "always," etc.                                                                   0  1  2  3
11. Applies rigid, inflexible rules to complex situations (e.g., "We
     always go out for recess at 10:30.  I don't care if there is an
     assembly, I am going out for recess!")                                            0  1  2  3
12. Continues to have meltdowns  in response to rules even though
     the child is adequately motivated to comply with firm and
     consistently-applied consequences                                                No  Yes
13. Explosive episodes have an "out-of-the-blue" quality.  A good mood
     can dissolve immediately with a trivial frustration                              No  Yes
14. Is more apt to become frustrated when hungry or tired                      No  Yes
 
1-14 Low Frustration Tolerance - Explosive Child syndrome    6                  
 
Mood Disorders and Anxiety
 
Mood Instability - Pediatric Bipolar Disorder (from The Bipolar Child by Papados, etal)
 
1. Mood and activity levels vary dramatically, has rapid, wide swings of  
     emotion, arousal, excitability and activity (Mania)                             0  1  2  3
2. Episodes of elated mood (silly, giddy, goofy), euphoria or irritability    0  1  2  3
3. Sometimes so talkative that others can hardly get a word in              0  1  2  3
4. Child says their thoughts are racing; they jump from topic to topic     0  1  2  3
5. Antidepressants can cause the moods to cycle more rapidly             0  1  2  3
6. Has periods of depressed mood (e.g. fatigue, lethargy, slowed speech
     increased appetite or sleep, loss of interest)                                    0  1  2  3
7. Has grandiose "larger than life" sense of self-importance                    0  1  2  3
8. May only need 3-5 hours of sleep, or 10+ hours when depressed        0  1  2  3
9. Has a history of Night Terrors (child wakes screaming after 2-3 hours
     is very difficult to soothe, and doesn't even realize you are there)        No  Yes
10. Has extremely morbid Nightmares, with images of gore, devils          No  Yes
11. Has a history of bedwetting (eneuresis)                                           No  Yes
12. Has a history of other sleep problems (i.e. sleepwalking, states of
     confusion or disorientation when awoken) (Parasomnias)                   No  Yes
13. Engages in high-risk behavior (extreme sports, promiscuous sex,
     daredevil acts)                                                                               No  Yes
14. Binges on massive amounts of food; vomits or uses diuretics or 
      laxatives to avoid weight gain (Bulimia)                                            No  Yes
15. Has conduct problems, trouble with the law (Conduct Disorder)          No  Yes
16. Has problems with transitions of activity, persons, or place               0  1  2  3
17. Has significant symptoms of Explosive Child syndrome                     No  Yes
18. Temper tantrums are accompanied by swearing, destruction, or
     threats of violence                                                                          0  1  2  3
19. Easily startled and aroused by new, unwanted, or unexpected
     stimuli                                                                                           No  Yes
20. Is bothered by the sounds of ticking clocks, vacuum cleaners,
     thunder, over-sensitive to light, (Low Sensory Threshold)                    No  Yes
21. Hates wearing clothes, may prefer being naked - clothes feel "too
     hot" or "scratchy" (Low Tactile Threshold)                                        No  Yes
22. Has tics - sudden, rapid, non-rhythmic movements or noises             No  Yes
23. Has significant problems with attention (see ADD, ADHD)                 No  Yes
24. Excessively fearful in social situations, can be painfully shy              0  1  2  3
25. Overreacts to stress dramatically                                                    No  Yes
26. History of refusing to go to school                                                   No  Yes
27. Unusual fears (phobias), may take exaggerated risks to cover up
     these fears                                                                                     No  Yes
28. Recurrent obsessions; repeated compulsive actions (see OCD)         No  Yes
29. Family history of mood disorders and alcoholism, usually on both
     sides of family                                                                               No  Yes
 
1-29 Pediatric Bipolar Disorder                                             15-18                  
 
Obsessive Compulsive Disorder (OCD)
 
1. Can't seem to get certain thought or worries out of head                      No  Yes
2. Gets angry or upset if things aren't ordered exactly as he or she likes  No  Yes
3. May tantrum if activities don't go exactly as they expect                     No  Yes
4. Worries so much about doing things just right that often the task
    never gets done (Perfectionism)                                                        No  Yes
5. Repeats certain actions to avoid imagined danger to self or others       No  Yes
6. Has problems throwing anything away (Hoarding)                               No  Yes
7. Washes hands or bathes excessively; overly fearful of germs              No  Yes
8. Has significant signs of Overfocused/Cingulate ADD Subtype             No  Yes
 
1-8 Obsessive-Compulsive Disorder                                           4                 
 
Pediatric Depression
 
1. Has become more of a loner recently                                               No  Yes
2. Acts tired, bored, or depleted                                                          0  1  2  3
3. Acts more impulsively, unpredictably, or irrationally lately                  No  Yes
4. More irritable lately, now trivial things throw him or her into rages       No  Yes
5. Appears more stoic, hard, and "shut down." doesn't cry                    No  Yes
6. If the child cries, it lasts a long time and doesn't relieve mood            No  Yes
7. Focuses more on their failures than their successes                         No  Yes
8. Blames self for things that aren't his or her fault                                No  Yes
9. Talks about themselves negatively                                                   No  Yes
10. Talks or preoccupied with death or suicide, or jokes about it             No  Yes
11. More preoccupied with her weight lately, thinks she fat                    No  Yes
12. Acting "wilder" lately; fighting, rebellious, out of control                    No  Yes
13. Acts silly or outrageous as a cover for sadness                               No  Yes
14. Strenuously avoids the help of others                                             No  Yes
15. Has more difficulty with school lately                                              No  Yes
 
1-15 Pediatric Depression                                                       6                   
 
Social Phobia
 
1. Fearful in social situations to the point of isolation from peers             No  Yes
2. Painfully shy                                                                                  No  Yes
3. Exposure to a feared social situation inevitably prvokes anxiety,
     causing crying, tantrums, or panic                                                  No  Yes
4. Has refused to go to school                                                             No  Yes
5. Refuses to play with neighborhood peers                                          0  1  2  3
6. Never speaks up in class, even if the child knows the answers           No  Yes
7. Shows marked distress when separating from a parent (mother)         No  Yes
8. Has stomach aches prior to school and social events, and uses
    these maladies to excuse self from social events or obligations          No  Yes
 
1-8  Social Phobia                                                                   5