PARENTS QUESTINONNAIRE
MATHERS CLINIC LLC.
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654
Fax: (815) 397 2712
Name of child:___________________ Gender:______ Age:___ Grade:_____Date: ____________
Completed by: _________________________ 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 behavior in the past 6 months.
Is this evaluation based on a time the child __ was on medication __ was not on medication __ not sure?
Never
Occasionally
Often
Very
Often
0
1
2
3
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 on instructions and fails to finish schoolwork, chores, or duties
0
1
2
3
5. Has difficulty organizing tasks and activities
0
1
2
3
Symptoms
1.
Does not pay close attention to details or makes careless mistakes with, for example,
homework
6.
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework)
0
1
2
3
7.
Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
0
1
2
3
8. Is distracted by extraneous 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 in classroom or in other situations in which remaining seated is expected
0
1
2
3
12. Runs about or climbs excessively in situations in which remaining seated is expected
0
1
2
3
13. Has difficulty playing or engaging in leisure activities quietly
0
1
2
3
14. Is "on the go" or often acts as if "driven by a motor"
0
1
2
3
15. Talks excessively
0
1
2
3
16. Blurts out answers before questions have been completed
0
1
2
3
17. Has difficulty waiting in line
0
1
2
3
18. Interrupts or intrudes on others (e.g., butts into conversations/games)
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 adult 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 (i.e., "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
33. 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
Performance
.. Academic Performance
Excellent
Above
Average
Average
Somewhat
of a
Problematic
Problem
48.
Reading
1
2
3
4
5
49.
Mathematics
1
2
3
4
5
50.
Written expression
1
2
3
4
5
.
Classroom Behavioral Performance
Excellent
Above
Average
Average
51.
Relationship with peers
1
2
3
4
5
52.
Following directions
1
2
3
4
5
53.
Disrupting class
1
2
3
4
5
54.
Assignment completion
1
2
3
4
5
55.
Organizational skills
1
2
3
4
5
Somewhat
of a
Problematic
Problem
For Office Use Only
Total number of items scored 2 or 3 in items 1-9: _____ (ADHD, predominantly inattentive type—6 or more symptoms)
Total number of items scored 2 or 3 in items 10-18:_____ (ADHD, predominantly hyperactive-impulsive type—6 or more
symptoms)
Total number of items scored 2 or 3 for items 1-18:_____ (ADHD, combined type—6 or more symptoms of both types)
Total number of items scored 2 or 3 in items 19-26:_____ (oppositional defiant disorder screen—4 or more symptoms)
Total number of items scored 2 or 3 in items 27-40:_____ (conduct disorder screen—3 or more symptoms)
Total number of items scored 2 or 3 in items 41-47:_____ (anxiety/depression screen—3 or more symptoms)
Scoring Instructions for the Vanderbilt Assessment Scale—Parent Informant
The Vanderbilt Assessment Scale has two components: symptom assessment and impairment of performance.
For the ADHD screen, the symptoms assessment component screens for symptoms that meet the criteria for both inattentive
(items 1-9) and hyperactive-impulsive ADHD (items 10-18). To meet DSM-IV criteria for the diagnosis of ADHD, one must have at
least 6 responses of "Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive or 9 hyperactive-impulsive items, or both
and a score of 4 or 5 on any of the Performance items (48-55). There is a place to record the number of symptoms that meet
these criteria in each subgroup.
The Vanderbilt Assessment Scale also contains items that screen for 3 other co-morbidities: oppositional defiant disorder,
conduct disorder, and anxiety/depression.
For the oppositional defiant disorder screen there must be a score of 2 or 3 on 4 of the 8 items (19-26) on the subscale and a
score of 4 or 5 on any of the Performance items (48-55).
For the conduct disorder screen there must be a score of 2 or 3 on 3 out of the 14 items (27-40) on this subscale and a score of
4 or 5 on any of the Performance items (48-55).
For the anxiety/depression screen there must be a score of 2 or 3 on 3 of the 7 items (41-47) and a score of 4 or 5 on any of the
Performance items 48-55).
The Vanderbilt Assessment Scale should NOT be used alone to make a diagnosis. The practitioner must consider information
from other sources.
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised-1102.
TEACHERS QUESTIONNAIRE
MATHERS CLINIC LLC.
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654
Fax: (815) 397 2712
Name of student:___________________ Gender:______ Age:___ Grade:_____Date: ____________
Completed by: _________________________ Teacher's Phone Number: ______________________
Directions: Each rating should be considered in the context of what is appropriate for the age of the child
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 the child __ was on medication __ was not on medication __ not sure?
Never
Occasionally
Often
Very
Often
1. Fails to give attention to details or makes careless mistakes in schoolwork
0
1
2
3
2. Has difficulty sustaining attention to tasks or activities
0
1
2
3
3. Does not seem to listen when spoken to directly
0
1
2
3
0
1
2
3
5. Has difficulty organizing tasks and activities
0
1
2
3
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
0
1
2
3
Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
or books)
0
1
2
3
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 in classroom or in other situations in which remaining seated is expected
0
1
2
3
12. Runs about or climbs excessively in situations in which remaining seated is expected
0
1
2
3
13. Has difficulty playing or engaging in leisure activities quietly
0
1
2
3
14. Is "on the go" or often acts as if "driven by a motor"
0
1
2
3
Symptoms
4.
7.
Does not follow through on instructions and fails to finish schoolwork
(not due to refusal or failure to understand)
15. Talks excessively
0
1
2
3
16. Blurts out answers before questions have been completed
0
1
2
3
17. Has difficulty waiting in line
0
1
2
3
18. Interrupts or intrudes on others (e.g., butts into conversations/games)
0
1
2
3
19. Loses temper
0
1
2
3
20. Actively defies or refuses to comply with adults' requests or rules
0
1
2
3
21. Is angry or resentful
0
1
2
3
22. Is spiteful and vindictive
0
1
2
3
23. Bullies, threatens, or intimidates others
0
1
2
3
24. Initiates physical fights
0
1
2
3
25. Lies to obtain goods for favors or to avoid obligations (e.g., "cons" others)
0
1
2
3
26. Is physically cruel to people
0
1
2
3
27. Has stolen items of nontrivial value
0
1
2
3
28. Deliberately destroys others' property
0
1
2
3
29. Is fearful, anxious, or worried
0
1
2
3
30. Is self-conscious or easily embarrassed
0
1
2
3
31. Is afraid to try new things for fear of making mistakes
0
1
2
3
32. Feels worthless or inferior
0
1
2
3
33. Blames self for problems; feels guilty
0
1
2
3
34. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
0
1
2
3
35. Is sad, unhappy, or depressed
0
1
2
3
..
Performance
Academic Performance
36. Reading
Excellent
Above
Average
Average
1
2
3
Somewhat
of a
Problematic
Problem
4
5
37. Mathematics
1
2
3
4
5
38. Written expression
1
2
3
4
5
Excellent
Above
Average
Average
39. Relationship with peers
1
2
3
4
5
40. Following directions
1
2
3
4
5
41. Disrupting class
1
2
3
4
5
42. Assignment completion
1
2
3
4
5
43. Organizational skills
1
2
3
4
5
.
Classroom Behavioral Performance
Somewhat
of a
Problematic
Problem
Comments:
For Office Use Only
Total number of items scored 2 or 3 in items 1-9: _______ (ADHD, predominantly inattentive type—6 or more symptoms)
Total number of items scored 2 or 3 in items 10-18:_______ (ADHD, predominantly hyperactive-impulsive type—6 or more
symptoms)
Total number of items scored 2 or 3 for items 1-18:_______ (ADHD, combined type—6 or more symptoms of both types)
Total number of items scored 2 or 3 in items 19-28:_______ (oppositional and conduct disorder screen—3 or more symptoms)
Total number of items scored 2 or 3 in items 29-35:_______ (anxiety/depression screen—3 or more symptoms)
Total number of items scored 2 or 3 in items 36-43:_______ (academic and classroom behavior symptoms)
Scoring Instructions for the Vanderbilt Assessment Scale—Teacher Informant
The Vanderbilt Assessment Scale has two components: symptom assessment and impairment of performance.
For the ADHD screen, the symptoms assessment component screens for symptoms that meet the criteria for both inattentive (items 1-9)
and hyperactive-impulsive ADHD (items 10-18). To meet DSM-IV criteria for the diagnosis of ADHD, one must have at least 6 responses of
"Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive or 9 hyperactive-impulsive items, or both and a score of 4 or 5 on any of
the Performance items (36-43). There is a place to record the number of symptoms that meet these criteria in each subgroup.
The Vanderbilt Assessment Scale also contains items that screen for 3 other co-morbidities: oppositional defiant disorder (items 19-22),
conduct disorder (items 23-28), and anxiety/depression (items29-35).
To screen for oppositional defiant disorder/conduct disorder one must have at least 3 responses of "Often" or "Very Often" on items 1928 and a score of 4 or 5 on any of the Performance items (36-43).
To screen for anxiety/depression one must have at least 3 responses of "Often" or "Very Often" on items 29-35 and a score of 4 or 5 on
any of the Performance items 36-43.
MATHERS CLINIC
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654 Fax: (815) 397 2712
SNAP-IV-C Rating Scale
Child's name:________________________ Gender:_____ Age:______ Grade:_____Date: ____________
Ethnicity (check one which best applies) African-American Asian Caucasian Hispanic Other _____________
Completed by:______________________ Type of Class ___________________ Class Size: ___________
For each of the 80 items, check the column which best describes this child.
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
1. activities
2.
3.
4.
5.
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g.,
6. schoolwork or homework)
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
Often is distracted by extraneous stimuli
Often is forgetful in daily activities
Often has difficulty maintaining alertness, orienting to requests, or executing directions
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate
Often has difficulty playing or engaging in leisure activities quietly
Often is "on the go" or often acts as if "driven by a motor"
Often talks excessively
Often blurts out answers before questions have been completed
Just a
Little
Not at all
Items
Quite a
Bit
Very
Much
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18.
19
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
Often has difficulty awaiting turn
Often interrupts or intrudes on others (e.g., butts into conversations/games)
Often has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home
Often loses temper
Often argues with adults
Often actively defies or refuses adult requests or rules
Often deliberately does things that annoy other people
Often blames others for his or her mistakes or misbehavior
Often touchy or easily annoyed by others
Often is angry and resentful
Often is spiteful or vindictive
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Often is negative, defiant, disobedient, or hostile toward authority figures
Often teases other children and interferes with their activities
Often is aggressive to other children (e.g., picks fights or bullies)
Often is destructive with property of others (e.g., vandalism)
Often is deceitful (e.g., steals, lies, forges, copies the work of others, or "cons")
Often and seriously violates rules (e.g., is truant, runs away, or completely ignores class rules)
Has persistent pattern of violating the basic rights of others or major societal norms
Has episodes of failure to resist aggressive impulses (to assault others or to destroy property)
Has motor or verbal tics (sudden, rapid, recurrent, non-rhythmic motor or verbal activity)
Has repetitive motor behavior (e.g., hand waving, body rocking, or picking at skin)
Has obsessions (a persistent and intrusive inappropriate ideas, thoughts, or impulses)
Has compulsions (repetitive behaviors or mental acts to reduce anxiety or distress)
Often is restless or seems keyed up or on edge
Often is easily fatigued
Often has difficulty concentrating (mind goes blank)
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
Often is irritable
Often has muscle tension
Often has excessive anxiety and worry (e.g., apprehensive expectations)
Often has daytime sleepiness (unintended sleeping in inappropriate situations)
Often has excessive emotionality and attention-seeking behavior
Often has need for undue admiration, grandiose behavior, or lack of empathy
Often has instability in relationships with others, reactive mood, and impulsivity
Sometimes, for at least a week, has inflated self-esteem or grandiosity
Sometimes, for at least a week, is more talkative than usual or seems pressured to keep talking
Sometimes, for at least a week, has flight of ideas or says that thoughts are racing
Sometimes, for at least a week, has elevated, expansive or euphoric mood
Sometimes, for at least a week, is excessively involved in pleasurable but risky activities
Sometimes, for at least 2 weeks, has depressed mood (sad, hopeless, discouraged)
Sometimes, for at least 2 weeks, has irritable or cranky mood (not just when frustrated)
Sometimes, for at least 2 weeks, has markedly diminished interest or pleasure in most activities
Sometimes, for at least 2 weeks, has psychomotor agitation (even more active than usual)
Sometimes, for at least 2 weeks, has psychomotor retardation (slowed down in most activities)
Sometimes, for at least 2 weeks, is fatigued or has loss of energy
Sometimes, for at least 2 weeks, has feelings of worthlessness or excessive, inappropriate guilt
Sometimes, for at least 2 weeks, has diminished ability to think or concentrate
Chronic low self-esteem most of the time for at least a year
Chronic poor concentration or difficulty making decisions most of the time for at least a year
Chronic feelings of hopelessness most of the time for at least a year
Currently is hyper vigilant (overly watchful or alert) or has exaggerated startle response
Currently is irritable, has anger outbursts, or has difficulty concentrating
Currently has an emotional (e.g., nervous, worried, hopeless, tearful) response to stress
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70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
Currently has a behavioral (e.g., fighting, vandalism, truancy) response to stress
Has difficulty getting started on classroom assignments
Has difficulty staying on task for an entire classroom period
Has problems in completion of work on classroom assignments
Has problems in accuracy or neatness of written work in the classroom
Has difficulty attending to a group classroom activity or discussion
Has difficulty making transitions to the next topic or classroom period
Has problems in interactions with peers in the classroom
Has problems in interactions with staff (teacher or aide)
Has difficulty remaining quiet according to classroom rules
Has difficulty staying seated according to classroom rules
Sections below to be completed by health care provider.
The following are items that make up various subscales. First four rows provide the cutoffs for ADHD and
ODD subscales. See instructions below for further information.
Average score for ADHD-Inattention (items 1-9)
Average score for ADHD-Hyperactivity-Impulsivity (items 11-19)
Average score for ADHD-Combined type (items 1-9 and 11-19)
Average score for Oppositional Items (sum of items 21-28)
Conduct Disorder (items 31, 32, 33, 34, and 35)
Intermittent Explosive Disorder (item 36)
Stereotypic Movement Disorder (item 38)
Obsessive-Compulsive Disorder (items 39 and 40)
Generalized Anxiety Disorder (items 41, 42, 43, 44, 45 and 46)
Narcolepsy (item 47)
Histrionic Personality Disorder (item 48)
Narcissistic Personality Disorder (item 49)
Borderline Personality Disorder (item 50)
Manic Episode (items 51, 52, 53, 54 and 55)
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Average
Sum of
Teacher
Rating Per
Items for
5%
Item for
Each Scale
Cutoff
Each Scale
Parent
5%
Cutoff
______ .______
2.56
1.78
.______ .______
1.78
1.44
.______ .______
2.00
1.67
.______ .______
1.38
1.88
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
.______ .______ .
.
Dysthymic Disorder (items 64, 65, and 66)
Posttraumatic Stress Disorder (items 67 and 68)
Adjustment Disorder (items 69 and 70)
SKAMP Rating Scale (classroom manifestations of core ADHD symptoms) (items 71-80)
.______ .______ .
.
______ .______ .
.
______ .______ .
.
______ .______
The SNAP-IV-C Rating Scale is a revision of the Swanson, Nolan and Pelham (SNAP) Questionnaire (Swanson et al, 1983). The items from the DSM-IV
(1994) criteria for ADHD are included for the two subsets of symptoms: inattention (items # 1-9) and hyperactivity/impulsivity (items # 11-18). Also. Items are
included from the DSM-IV criteria for Oppositional Defiant Disorder (items # 21-28) since it often is present in children with ADHD. Items have been added to
summarize the Inattention domain (# 10) and the Hyperactivity/Impulsivity domain (# 20) of ADHD. Two other items were added: an item from DSM-III-R (#
29) that was not included in the DSM-IV list for ODD, and an item to summarize the ODD domain (# 30).
The 4-point response is scored 0-3 (Not at All=0, Just A Little=1, Quite a Bit=2, and Very Much=3). Subscale scores for the ADHD and ODD subscales on
the SNAP-IV are calculated by summing the scores on the items in the specific subset (e.g., Inattention) and dividing by the number of items in the subset
(e.g., 9). The score for any subset is expressed as the Average Rating-Per-Item. The 5% cutoff scores for teachers and parents are provided. Compare the
Average Rating Per Item score to the cut off score to determine if the score falls within the top 5% of extreme scores.
Finally, the SNAP-IV-C includes the 10 items (# 69-78) of the Swanson, Kotkin, Agler, MyInn, and Pelham (SKAMP) Rating Scale. These items are
classroom manifestations of inattention, hyperactivity, and impulsivity (i.e., getting started, staying on task, interactions with others, completing work, and
shifting activities). The SKAMP may be used to estimate severity of impairment in the classroom.
Adapted from the SNAP-IV-C Rating Scale by James Swanson, UCI, Irvine, CA.
MATHERS CLINIC LLC
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654
Fax: (815) 397 2712
ADHD Symptom Checklist—Child and Adolescent Version
Child's Name: ________________________________ Age: ____
Grade: ______________ Gender: _______
Completed by: ________________________________ Relationship to child: _______________ Date: ________
Check the box that describes this child's behavior at home (if you are the child's parent) or at school (if you are the child's teacher) over the past
six months.
Inattention Symptoms
Not at Just a
Often
all
little
Very
Often
1. fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities
.
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.
2. has difficulty sustaining attention in tasks or play activities
.
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4. does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (not due to oppositional behavior or failure to understand instructions)
.
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.
5. has difficulty organizing tasks and activities
.
.
.
.
6. avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g.,
schoolwork or homework)
.
.
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.
7. loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or
tools)
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8. is easily distracted by extraneous stimuli
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12. runs about or climbs excessively in situations in which it is inappropriate
(in adolescents may be feelings of restlessness)
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13. has difficulty playing or engaging in leisure activities quietly
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3. does not seem to listen when spoken to directly
9. is forgetful in daily activities
Hyperactivity Symptoms
10. fidgets with hands or feet or squirms in seat
11. leaves seat in classroom or in situations in which remaining seated is expected
14. is “on the go” or often acts as if “driven by a motor”
15. talks excessively
Impulsivity Symptoms
16. blurts out answers before questions have been completed
17. has difficulty awaiting turn
18. interrupts or intrudes on others (e.g., butts into conversations or games)
At what age did these symptoms first appear? Or when did you notice them?
Do these symptoms impair the child’s functioning in two or more settings? (Yes, No, DK)
Where is their impairment? Home? School? Work? (list all)
Scoring Instructions for the ADHD Symptom Checklist
To meet DSM-IV criteria for ADHD, one must have at least 6 responses of "Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive items
(1-9) or 9 hyperactive-impulsive items (10-18), or both. In addition, symptoms must have occurred in childhood, they must impair the child's
functioning in two or more settings and they must not be primarily due to any other factors or conditions.
MATHERS CLINIC
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654
Fax: (815) 397 2712
Childhood Disorders Checklist
Child's name: _________________________ Age: _____ Grade: _________ Gender: ____ Date ____________
Completed by: ____________________________ Relationship to child: _______________________________
Below are lists of behaviors or reactions that describe disorders that may be seen in children and adolescents.
Read each list and check the box to the left of the item to indicate whether your child has displayed any of these
behaviors or reactions during the period noted for each list.
A. Oppositional Defiant Disorder List
Indicate if your child has displayed any of the behaviors listed below within the past six months.
.
Often loses temper
.
Often argues with adults
.
Often defies or refuses to do what you tell him/her
.
Often does things to deliberately annoy others
.
Often blames others for his/her own mistakes or misbehavior
.
Often is touchy or is easily annoyed by others
.
Often is angry or resentful
.
Often takes anger out on others or tries to get even
Does your child show four or more of these behaviors?
Have these behaviors been exhibited for at least the past six months?
At what age did these behaviors first cause problems for your child?
______ (yrs)
Have these behaviors been the cause of problems for your child in any of the following areas?
___Home ___School ___Workplace ___Community
B. Conduct Disorder List
Indicate if your child has displayed any of the behaviors listed below within the past six months.
.
Often bullies, threatens, or intimidates others
.
Often starts physical fights
..
Has used a weapon when fighting (bat, brick, bottle, etc.)
.
Has been physically cruel to people
.
Has stolen things from others using physical force
.
Has stolen things when others were not looking
.
Has forced someone into sexual activity
.
Has destroyed others’ property (other than by fire setting)
.
Has broken into someone else’s house, building, or car
.
Has not come home overnight at least twice while living in parent’s home, foster care, or group home? If so, how many times?
.
Is often truant from school? Did this occur before age 13? _____
If so, at what age? ____ (yrs)
Does your child show three or more of the above behaviors?
Have three of these behaviors occurred during the past 12 months?
Has at least one of these behaviors occurred during the past six months?
Did any of these behaviors occur prior to age ten years?
Have these characteristics been the cause of problems for your child in any of the following
areas? ___Home ___School ___Workplace ___Community
C. Attention-Deficit/Hyperactivity Disorder List
Indicate if your child has displayed any of the behaviors listed below within the past six months.
Inattention List
.
Often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
.
Often has difficulty sustaining attention in tasks or play activities
.
Often does not seem to listen when spoken to directly
.
Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (not due to oppositional behavior or failure to
understand instructions)
.
Often has difficulty organizing tasks and activities
.
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
.
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
.
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Hyperactivity-Impulsivity List
.
Often fidgets with hands or feet or squirms in seat
.
Often leaves seat in classroom or in other situations in which remaining seated is expected
.
Often runs about or climbs excessively in situations in which it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
.
Often has difficulty playing or engaging in leisure activities quietly
.
Is often “on the go” or often acts as if “driven by a motor”
.
Often talks excessively
.
Often blurts out answers before questions have been completed
.
Often has difficulty awaiting turn
.
Often interrupts or intrudes on others (e.g., butts into conversations or games)
.
Does your child show six or more of the behaviors on the inattention list?
.
Does your child show six or more of the behaviors on the hyperactive-impulsive list?
At what age did these behaviors first cause problems for this child? ______yrs of age
Have these behaviors existed for at least the past six months? _____ Yes _____ No
Have these behaviors been the cause of problems for your child in any of the following areas?
___Home ___ School ___Workplace ___Community
D. Learning Problems List or Academic Skills Disorder List
Indicate if your child has displayed any of the following problems in learning or academic performance compared to other children of his or her age or
grade level.
.
Recognizing unfamiliar words when reading
.
Comprehending the meaning of what he/she reads
.
Spelling
.
Expressing ideas in writing
.
Expressing ideas orally
.
Memory
.
Handwriting
.
Arithmetic computation
.
Arithmetic problem solving (word problems)
.
Organizing work and homework
.
Completing homework on his/her own and in a timely manner
.
Excessive absences from school
.
Little effort made to achieve up to his/her potential
E. Asperger’s Disorder List
Indicate if your child has exhibited any of the following patterns of behavior.
Problems in social interaction as manifested by at least two of the following:
.
Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze,
facial expression, body postures, gestures to regulate social interaction
.
Failure to develop peer relationships appropriate to developmental level
.
Marked impairment in the ability to express pleasure at other people’s happiness
.
Lack of social or emotional reciprocity
In addition, which of the following patterns of behavior are exhibited?
.
Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities
.
Lack of any significant delay in language
Lack of any significant delay in cognitive development. Has age-appropriate self-help skills,
adaptive behavior and curiosity about the environment
F. Tourette’s Disorder List
Indicate whether your child has exhibited the following tics. A tic is an involuntary, sudden,
rapid, recurrent, non-rhythmic, motor movement or vocalization.
.
Both multiple motor and one or more vocal tics (not necessarily at the same time)
.
The tics occur many times a day (usually in bouts), nearly every day or intermittently
throughout a period of more than one year and never stop for more than two months at a time
Describe the tic(s)
G. Chronic Motor or Vocal Tic Disorder List
Indicate whether your child has exhibited the following tics.
.
Either vocal or motor tics but not both
.
The tics occur many times a day (usually in bouts), nearly every day or intermittently throughout
a period of more than one year and never stop for more than two months at a time
Describe the tic(s)
H. Transient Tic Disorder List
Indicate whether your child has exhibited the following tics.
.
Single or multiple motor or vocal tics
.
The tics occur many times a day, nearly every day for at least four weeks, for no longer than
12 consecutive months
Describe the tic(s)
I. Specific Phobia List
Indicate whether your child has exhibited each of the behaviors in this list within the past six months.
.
Persistent, excessive and unreasonable fear triggered by the presence of, or the anticipation
of, a specific object or situation. For example, in response to, or anticipation of, certain
animals, heights, being in the dark, receiving an injection, seeing blood, etc.
.
Exposure to the feared situation or object almost always produces immediate anxiety. In
children this may be expressed by crying, tantrums, freezing, or clinging
.
The fearful situation or object is avoided or else endured with extreme anxiety or distress
Avoidance or anxious anticipation or distress in the feared situation interferes significantly with the
child’s normal routine and affects academic functioning, social activities, or relationships with others
Has this fearful or anxious reaction to a situation or object persisted for at least the past 6 months?
Describe the specific situation or object that your child exhibits anxiety to.
J. Separation Anxiety List
Indicate whether your child has exhibited each of the behaviors in this list.
.
Persistent and excessive worry about losing a major attachment figure (e.g., parent,
grandparent, guardian) or of possible harm befalling a major attachment figure
.
Extreme worry that something will occur that will lead to separation from a major attachment
figure (e.g., getting lost or being kidnapped)
.
Persistent reluctance or refusal to go to school or elsewhere due to fear of separation
.
Persistent reluctance to be alone or without major attachment figures at home or in other settings
.
Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
.
Re-occurring nightmares having to do with the theme of separation
.
Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, or vomiting) when separated from a major attachment figure
or when separation is anticipated
.
Re-occurring distress when separation from home or major attachment figures takes place or is anticipated
K. Generalized Anxiety Disorder List
Indicate whether your child has exhibited any of the following behaviors or reactions.
.
Excessive anxiety and worry occurring more often than not for at least six months
.
Child finds it difficult to control the worry
Anxiety and worry are associated with at least three of the following six symptoms:
.
Restlessness or feeling keyed up or on edge
.
Being easily fatigued
.
Trouble with concentration
.
Irritability
.
Muscle tension
.
Trouble falling asleep or staying asleep or restless sleep
L. Obsessive Compulsive Disorder List
Indicate whether your child has exhibited any of the following obsessions or compulsions.
Obsessions
.
Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and
inappropriate and cause marked anxiety and distress
.
The thoughts, impulses or images are not simply excessive worries about real-life problems
.
The child attempts to ignore or suppress these thoughts or impulses or to “neutralize” them
with some other thought or action
.
The child recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind
Compulsions
.
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the child feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
.
The behaviors or mental acts have the goal of preventing or reducing distress or preventing
some dreaded event or situation; however, these acts are not connected in a realistic way with
what they are designed to neutralize or prevent, or are clearly excessive
Does the child realize that the obsessions or compulsions are excessive or unreasonable?
Do the obsessions or compulsions cause marked distress; are they time-consuming; or do they significantly interfere with the person’s normal routine
or social relationships with others?
M. Dysthymic Disorder List
Indicate whether your child has exhibited any of the following reactions.
.
Exhibits depressed mood or irritability for most of the day, for more days than not, for at least one year
Presence, while depressed, of at least three of the following:
.
Low self-esteem, low self-confidence, or feelings of inadequacy
.
Feelings of pessimism, hopelessness, or despair
.
General loss of interest or pleasure in activities that others of his/her age enjoy
.
Little interest in social activities
.
Persistent state of fatigue or tiredness
.
Feelings of guilt, brooding about the past
.
Subjective feelings of irritability or excessive anger
.
Decreased activity, drive, or productivity
.
Difficulty concentrating, poor memory, or indecisiveness
If your child has exhibited signs of depressed mood, has this created distress for your child or
impairment in any of the following areas?
Home
School
Workplace
Community
N. Major Depressive Disorder List
Indicate whether your child has exhibited any of the following reactions for at least a two-week period of time.
.
Depressed or irritable mood most of the day, nearly every day, as indicated by complaints of
feeling sad or appears to be sad or irritable.
.
Diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
.
Significant weight loss or weight gain when not dieting
.
Trouble falling asleep or staying asleep, or excessive sleeping
.
Agitated or lethargic (slow moving) nearly every day
.
Fatigue or loss of energy nearly every day
.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
.
Diminished ability to concentrate or cannot make a decision nearly every day
.
Repeated thoughts of death (not just fear of dying), repeated suicidal thoughts without a
specific plan or with a plan
O. Bipolar Disorder: Manic Episode List
Indicate if your child has ever experienced the following reactions for a period of time that lasted at least one week.
.
Mood was abnormally and persistently elevated (he/she felt abnormally happy, giddy, ecstatic)
.
Mood was abnormally and persistently expansive (he/she felt able to accomplish everything
he/she decided to do and had no limits on his/her abilities to accomplish things)
.
Mood was abnormally and persistently irritable (he/she was very touchy, easily given to
outbursts of anger or temper, easily annoyed by minor events or by others, or abnormally cranky
If your child exhibited any of the above during the week or more that your child showed this abnormal and persistent mood, mark which of the
following behaviors were exhibited?
...
Inflated self-esteem or grandiosity
.
Decreased need for sleep (e.g., feels rested after only three hours of sleep)
.
More talkative than usual or pressure to keep talking
.
Thoughts seem to be racing
.
Easily distracted (i.e., attention drawn away by unimportant external stimuli)
.
Increased goal-directed activity; he/she became unusually focused and productive toward one or more tasks
.
.
.
Becomes highly involved in pleasurable activities without regard for negative consequences (e.g., spending excessively, taking risks, etc.)
Were at least three of the behaviors listed above present?
Was this disturbance in your child’s mood significant enough to cause marked impairment in social relationships, academic performance, or other
important activities?
.
.
Did your child’s abnormal mood result in him/her being hospitalized?
Did your child have hallucinations or bizarre ideas or feel or act paranoid?
Explain in more detail.
MATHERS CLINIC LLC.
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654
Fax: (815) 397 2712
Child and Adolescent Developmental History Form
INSTRUCTIONS:
Please complete the following information about your child and family. If any questions do not apply to your child,
simply write “DNA” (does not apply) in the space provided or leave the space blank. It is best if this form is completed
by all parents or primary caretakers. This information will be helpful to your child’s doctor or other professionals
to better understand your child and your family.
Child’s name: ________________________ Informant: __________________ Date: ______________
Address: ________________________________________________________________________
Informant’s relationship to child: _________________________________________________________
Child’s age: __________________
Child’s date of birth: _____________
Gender: _____________
School: __________________________ Grade: ________ Phone # of school: ____________________
Current teacher(s):
____________________________
_________________________
_____________________________
_________________________
_____________________________
_________________________
I. Family Composition
Is this child your: biological child, adopted child or foster child? _______________
Other? _______________
With whom does this child live? _________________________________________________________________
Who has legal custody of this child? _____________________________________________________________
Names and ages of this child’s brothers and sisters or other children in the family:
_____________________________
_________________________
_____________________________
_________________________
_____________________________
________________________
II. Current Concerns
What are you most concerned about regarding your child that has led you to complete this history form?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
III. Developmental and Medical Information
Pregnancy
Indicate any complications during pregnancy.
_____ Excessive vomiting. Was hospitalization required? _________________________________________________
_____ Excessive staining/blood loss? Any infection(s)? Specify ____________________________________________
_____ Toxemia? Other illnesses? ___________________________________________________________________
_____ Smoking during pregnancy? # cigarettes smoked per day ___________________________________________
_____ Alcohol consumption during pregnancy (if beyond an occasional drink)? _______________________________
_____ Other drug use during pregnancy? ______________________________________________________________
Delivery
Type of labor: _____ Spontaneous
Type of delivery: _____ Normal
_____ Induced Duration (hours) _______________
_____ Breech
_____ Caesarean
Complications: _____ Cord around neck _____ Hemorrhage
_____ Infant injured during delivery
Other: __________________________________________________________________________________________
Birth weight: __________ lbs. __________ oz.
Post Delivery Period
_____ Jaundice _____ Cyanosis (turned blue) _____ Incubator care
Infection (specify) ______________________________________________________________________________
Infancy Period
Were any of the following presents to a significant degree during the first few years of life? If so, describe:
_____ Did not enjoy cuddling_____________________________________________________________________
_____ Was not calmed by being held or stroked _____________________________________________________
_____ Difficult to comfort _______________________________________________________________________
_____ Colic _________________________________________________________________________________
_____ Excessive restlessness ___________________________________________________________________
_____ Excessively irritable _____________________________________________________________________
_____ Diminished sleep _______________________________________________________________________
_____ Frequent head banging ___________________________________________________________________
_____ Difficulty nursing ________________________________________________________________________
_____ Constantly into everything ________________________________________________________________
Developmental Milestones
Indicate below whether this child achieved the following developmental milestones at a normal age,
early, or later than others his/her age.
Smiled: _____ early _____ normal age _____ later than normal
Sat without support: _____ early _____ normal age _____ later than normal
Crawled: _____ early _____ normal age _____ later than normal
Stood without support: _____ early _____ normal age _____ later than normal
Spoke first words:
_____early
_____normal age _____ later than normal
Said phrases: _____ early _____ normal age _____ later than normal
Said sentences: _____ early _____ normal age _____ later than normal
Bladder trained, all day: _____ early _____ normal age _____ later than normal
Bladder trained, at night: _____ early _____ normal age _____ later than normal
Bowel trained: _____ early _____ normal age _____ later than normal
Rode tricycle: _____ early _____ normal age _____ later than normal
Rode bicycle (without training wheels): _____ early _____ normal age _____ later than normal
Buttoned clothing: _____ early _____ normal age _____ later than normal
Tied shoelaces: _____ early _____ normal age _____ later than normal
Named colors: _____ early _____ normal age _____ later than normal
Recited alphabet in order: _____ early _____ normal age _____ later than normal
Began to read: _____ early _____ normal age _____ later than normal
Medical History
If your child’s medical history includes any of the following, please note the age when the incident
or illness occurred and any other pertinent information.
Childhood diseases (age and complications if any) ____________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Operations ____________________________________________________________________________________
Hospitalizations ________________________________________________________________________________
Head injuries __________________________________________________________________________________
Convulsions with fever _____________________________
without fever ________________________________
Coma ________________________________________________________________________________________
Vision problems ________________________________ Hearing problems ________________________________
Allergies or asthma _____________________________________________________________________________
Poisoning _____________________________________ Sleep problems _________________________________
Appetite ______________________________________
Growth problems ________________________________
Other medical information that is relevant _____________________________________________________________
_______________________________________________________________________________________________
Height ______
Weight ______
Present illnesses for which the child is being treated:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Psychotropic medications (stimulants, medications for ADHD, mood, anxiety medications) child has been taking
or is currently taking. Include name of medication and dosing.
a. current medications:____________________________________________________________________________
b. previous medications: ___________________________________________________________________________
Describe any benefit from these medications or adverse effects:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Has your child ever received treatment by a mental health professional? If so, who provided this
treatment, when, and what was the purpose of the treatment?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
IV. Family Information
Use the checklists below to describe any family history of psychiatric and learning problems
(in child’s parents, grandparents, or siblings).
Aggressiveness, defiance: ___not a problem ___a problem (specify who)___________________________________
Difficulties with attention/hyperactivity as a child: ___not a problem ___a problem (specify who)_________________
Learning problems: ___not a problem ___a problem (specify who)_________________________________________
Failed to graduate from high school: ___not a problem ___a problem (specify who)___________________________
Mental retardation: ___not a problem ___a problem (specify who)_________________________________________
Psychosis or schizophrenia: ___not a problem ___a problem (specify who)_________________________________
Depression: ___not a problem ___a problem (specify who)______________________________________________
Anxiety: ___not a problem ___a problem (specify who)_________________________________________________
Tics or Tourette’s syndrome: ___not a problem ___a problem (specify who)________________________________
Alcohol abuse/substance abuse: ___not a problem ___a problem (specify who)_____________________________
Antisocial behavior (assaults, thefts, etc.): ___not a problem ___a problem (specify who)_____________________
Arrests: ___not a problem ___a problem (specify who)___________________________________________________
Physical abuse/sexual abuse: ___not a problem ___a problem (specify who)________________________________
V. School Information
List the name of each school your child has attended from preschool on.
kg__________________________________ 7th _______________________________
1st_________________________________ 8th________________________________
2nd ________________________________ 9th _______________________________
3rd _________________________________ 10th _______________________________
4th_________________________________ 11th _______________________________
5th_________________________________ 12th________________________________
6th_________________________________ After 12th____________________________
In general, describe your child's performance during elementary school. Go grade by grade, if necessary,
and list any outstanding strengths or problems.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Describe your child's performance during middle school and high school. Again, go grade by grade, if
necessary, and list any outstanding strengths or problems.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Has your child ever had to repeat a grade? ________________ If so, which grade? _________________________
Has your child ever received special education services? __________ If so, what grades? ___________________
Does your child currently have an IEP from his/her school? _____________________________________________
Does your child currently have a 504 Plan at school? __________________________________________________
Describe the main focus of your child’s IEP or 504 Plan (note accommodations your child is currently receiving).
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Indicate if your child’s teacher(s) describe any of the following as significant classroom problems.
____ Doesn’t sit still in his or her seat
____ Frequently gets up and walks around the classroom
____ Shouts out. Does not wait his/her turn to be called on
____ Does not cooperate well in group activities
____ Typically does better in a one to one relationship
____ Does not respect the rights of others
____ Does not pay attention during lessons
____ Fails to finish assigned class work
____ Fails to finish assigned homework
____ Bullies other children
____ Is not sought out by others to play or work together
____ Describe any problems your child may have in school with learning.
____ Describe any problems your child may have with homework (e.g., forgets, does not return it to school, etc.)
VI. Child Management Techniques
When your child is disruptive or misbehaves, what steps are you likely to take to deal with the problem and
how well do they work?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Describe any differences or similarities between each parent's management styles in handling disruptive behavior.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Describe what steps you might take to improve your management style in handling disruptive behavior.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
VII. Strengths and Accomplishments
We realize that we have focused largely on problems that your child may be having. However, we are
also quite interested in understanding your child’s strengths, talents, skills, and accomplishments.
Please use the space below to describe these assets and use additional pages if necessary.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
MATHERS CLINIC LLC
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654Fax: (815) 397 2712
Novotni Social Skills Checklist—Self-Report
Name:___________________________________________
Age:________
Date:_______________________
TRAITS: How many of the following traits of highly likeable people are descriptive of you? Circle all that apply. Put a
check by the ones you would like to work on.
sincere
honest
understanding
loyal
responsible
friendly
truthful
trustworthy
intelligent
warm
unselfish
trustful
thoughtful
considerate
reliable
kind
humorous
cheerful
Not a
Problem
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SKILLS: Use the following checklist to identify strengths as well as areas to work on.
I. BASIC Manners: The ability to do the following in social interactions.
Use mannerly words like please, thank you, and you’re welcome
Express appreciation
Receive compliments without discounting
Give compliments regularly to others
Apologize
Accept the apology of others
Introduce yourself
Introduce others
Use appropriate greetings
Use appropriate ending comments
Phone manners
Mealtime behaviors (follow lead of host/hostess, chew with mouth closed, not open
Ask to have items passed, use napkins, elbows off the table, ask to be excused
Making others feel comfortable in your home—hosting
Offer to help others
II. VERBAL COMMUNICATION SKILLS: In conversation with others the ability to:
Join a conversation without disruption
Check—repeat what you heard and ask if you heard it right
Identify and reflect content of conversation—tracking
Identify and reflect feelings of others
Reflect content + feelings in conversations
Use minimal encouragers to let others know you are following the conversation
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Use open questions to keep conversations going
Ask for help when needed or desired
III.NONVERBAL COMMUNICATION SKILLS: Looking attentive when listening. When talking with others do you:
Keep an open posture
Face the person
Lean forward
Maintain appropriate eye contact
Look relaxed
IV.COMMUNICATION ROADBLOCKS
Miss pieces of information—”blinks”
Use closed or naked questions
Voice too loud or too soft
Speak too quickly
Interrupt others
Too quiet—rarely speaking in conversations
Talk excessively
Order or boss others
Criticize—judge or evaluate others
Minimize or not be considerate
V.ORGANIZATIONAL SKILLS—TRUSTWORTHY
Difficulty with deadlines
Difficulty being on time for meetings and appointments
Difficulty remembering special occasions
Too organized, rigid
Difficulty managing money, bills, bank accounts, etc.
Difficulty organizing your stuff
Do what you agree to do
Finish projects
VI.SELF CONTROL
Take turns/wait
Ability to handle
Effectively manage conflict, negotiate, and compromise
Effectively manage anger
Refrain from aggressive behavior
Assertiveness
Impulsive spending
Impulsive decision-making
Filter thoughts avoiding impulsive words—blurting out things that hurt people
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Inappropriate touching of others
Difficulty relaxing
Excessive physical activity (trouble staying seated, fidgeting, feeling restless)
VII. KNOWLEDGE
Understand attribution theory’s role in social relationships
Understand the importance of social exchange theory—give and take in relationships
Understand the subtle cues that you give others with your body language
Ability to pick up the subtext—socially perceptive
Understand context
VIII. RELATIONSHIPS
Sensitive to the needs of others
Patient
Creative
Fun to be with
Flexible—able to go with the flow
Respect boundaries of others
Treat others with respect
Tolerance to differences of others
Initiate invitations to others
Difficulty with intimacy
Have at least three close friends
IX.SELF CARE
Ability to nurture yourself
Appearance—clean, neat, and appropriate for situations
Ability to identify and express your feelings
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Self-esteem
Participate in support groups
Sense of humor
Positive outlook—hope
SKILL AREAS TO WORK ON: Check the box to the left of each skill area that you want to work on.
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Basic Manners
Verbal Communication Skills
Nonverbal Communication Skills
Communication Roadblocks
Organizational Skills
Self-control
Knowledge
Relationships
MATHERS CLINIC LLC.
Novotni Social Skills Checklist-Observer Version
Name of Rater:________________________ Name of Person Rated: ____________________Date:____________
TRAITS: How many of the following traits of highly likeable people are descriptive of the person being rated? Circle all that apply. Put a check
by the ones you would like to see him/her work on.
sincere
honest
understanding
loyal
responsible
friendly
truthful
trustworthy
intelligent
warm
unselfish
trustful
thoughtful
considerate
reliable
kind
humorous
cheerful
Not a
Problem
Needs
Improvement
SKILLS: Use the following checklist to identify strengths as well as
areas to work on that you have observed. Leave blank if not observed.
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I. Basic Manners: The ability to do the following in social interactions.
Uses mannerly words like please, thank you, and you’re welcome
Expresses appreciation
Receives compliments without discounting
Gives compliments regularly to others
Apologizes
Accepts the apology of others
Introduces him/herself
Introduces others
Uses appropriate greetings
Uses appropriate ending comments
Phone manners
Mealtime behaviors (follows lead of host/hostess, chews with mouth closed not open)
Asks to have items passed, use napkins, elbows off the table, ask to be excused
Makes others feel comfortable in their home—hosting
Offers to help others
II. VERBAL COMMUNICATION SKILLS: In conversation with others the ability to:
Joins a conversation without disruption
Checks—repeats what they heard and asks if they heard it right
Identifies and reflects content of conversation—tracking
Identifies and reflects feelings of others
Reflects content + feelings in conversations
Uses minimal encouragers to let others know they are following the conversation
Uses open questions to keep conversations going
Asks for help when needed or desired
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III.NONVERBAL COMMUNICATION SKILLS: Looking attentive when
listening. When talking with others do you:
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Keeps an open posture
Faces the person
Leans forward
Maintains appropriate eye contact
Looks relaxed
IV.COMMUNICATION ROADBLOCKS
Misses pieces of information—”blinks”
Uses closed or naked questions
Voice too loud or too soft
Speaks too quickly
Interrupts others
Too quiet—rarely speaking in conversations
Talks excessively
Orders or bosses others
Criticizes—judges or evaluates others
Minimizes or is not considerate
V.ORGANIZATIONAL SKILLS—TRUSTWORTHY
Difficulty with deadlines
Difficulty being on time for meetings and appointments
Difficulty remembering special occasions
Too organized, rigid
Difficulty managing money, bills, bank accounts, etc.
Difficulty organizing their stuff
Does what they agree to do
Finishes projects
VI.SELF CONTROL
Take turns/wait
Ability to handle
Effectively manage conflict, negotiate and compromise
Effectively manage anger
Refrains from aggressive behavior
Assertiveness
Impulsive spending
Impulsive decision-making
Filters thoughts avoiding impulsive words—blurting things that hurt people
Inappropriate touch of others
Difficulty relaxing
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Excessive physical activity (trouble staying seated, fidget, feeling restless)
VII. KNOWLEDGE
Understands attribution theory’s role in social relationships
Understands the importance of social exchange theory—give and take in relationships
Understands the subtle cues that they give others with their body language
Ability to pick up the subtext—socially perceptive
Understands context
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VIII. RELATIONSHIPS
Sensitive to the needs of other
Patient
Creative
Fun to be with
Flexible—able to go with the flow
Respects boundaries of others
Treats others with respect
Tolerance to differences of others
Initiates invitations to others
Difficulty with intimacy
Has at least three close friends
IX.SELF CARE
Ability to nurture themselves
Appearance—clean, neat, and appropriate for situations
Ability to identify and express their feelings
Self-esteem
Participates in support groups
Sense of humor
Positive outlook—hope
SKILL AREAS TO WORK ON: Check the box to the left of each skill area that you think is important
for this person to work on.
Basic Manners
Verbal Communication Skills
Nonverbal Communication Skills
Communication Roadblocks
Organizational Skills
Self-control
Knowledge
Relationships
Self-care
MATHERS CLINIC LLC.
6180 e. State St.,
Rockford, IL.61108
Phone: (815) 397 7654Fax: (815) 397 2712
Weekly ADHD Monitoring Form
Child's name: _____________________________
Teacher:_______________________
Date:______________
Teacher: Please answer the items below on your observations of this child during the past week. Note that for
items 1-12, high scores indicate problems while for items 13-15, low scores indicate problems.
Not at
all
Just a
little
Often
Very
Often
1. fidgets with hands or feet and squirms in seat
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2. difficulty remaining seated
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3. difficulty awaiting turn
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4. always "up and on the go" or acts as if "driven by a motor"
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5. talks excessively
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6. interrupts or intrudes on others
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7. easily distracted
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8. fails to finish assigned tasks
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9. difficulty sustaining attention
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10. careless or messy work
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11. does not seem to listen when spoken to
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12. difficulty following directions
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13. follows class rules
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14. gets along with peers
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15. seems happy and in a good mood
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Weekly ADHD Monitoring Form
16. Indicate how the behaviors rated on the other side compared during the morning and afternoon times during the prior week by checking one of the
choices below. (Note: If you only have this child in class during morning or afternoon this does not apply)
___morning better than afternoon ___no
clear difference ___afternoon better than morning
17. Indicate the approximate percentage of assigned class work that this child completed during the past week:
___________________________________________________________________________________
0%
20%
40%
60%
80%
100%
18. The general quality of work completed by this child this week was:
___ very poor
___poor
___satisfactory
___good
___very good
19. If the quality of this child's work varied significantly between subjects, please indicate this below.
20. Did this child turn in all assigned homework? If not, please indicate the assignments that were missing.
21. Please include any other comments or observations that you believe are important.
MATHERS CLINIC LLC
6180 E. State St.,
Rockford, IL.61108
Phone: (815) 397 7654 Fax: (815) 397 2712
ADHD MONITORING SYSTEM
A Systematic Guide to Monitoring School Progress for Children with ADHD
David L. Rabiner, Ph.D.
Welcome to the ADHD Monitoring System
One of the most important things you can do to help promote your child’s healthy development is to carefully
monitor how he or she is doing at school. The ADHD Monitoring System will help make it easy for you to do
this. By using this program, you will be able to carefully track how your child is doing in school, and will be
alerted to when any adjustments or modifications to your child’s treatment need to be discussed with your
child’s doctor.
This packet contains a sample monitoring form and the instructions you need to interpret the information this
form provides. You may make as many copies of this form as you need for your own use. Thus, you will be
able to use this program to monitor and track your child’s progress over the entire course of his or her
schooling. It is recommended that you make a number of copies and give them to your child’s teacher so they
are readily available for him or her to complete. If your child has multiple teachers, copies should be provided
to each of them.
In my own experience, I have found that this program works best with elementary school children who have
only a single teacher. This program can also be quite helpful for children who are in middle school or high
school, although teachers in these grades may not spend enough time with a student to provide ratings that are
as reliable. You will have to see how this works in your own situation.
I want to stress that by using this program to keep careful track of how your child is performing at school, you
will be in excellent position to help promote your child’s success. Many times in my own practice, I have spoken
with parents who are frustrated by the lack of communication from their child’s teacher, and with not learning
about problems until weeks after they begin. Using this system will prevent this from happening to you, and will
provide you and your child’s physician with information that can be essential in planning and modifying your
child’s treatment.
Instructions for Using the ADHD Monitoring System
The ADHD Monitoring System provides an easy and systematic way to monitor how a child with ADHD is doing
each week at school in several important areas. By using this system you will be alerted to difficulties that may
develop so that adjustments to your child’s treatment can be made in a timely manner. The program will also
help you to evaluate the effectiveness of any such adjustments that are made. Guidelines for using this
program effectively are presented below.
For this system to be of the greatest benefit to your child, the cooperation and support of your child’s teacher is
ESSENTIAL.
You will be asking your child’s teacher to complete the weekly rating form contained in this packet at the end of
each week, and should provide the teacher with a sufficient number of copies. Completing this form should not
require more than 10-15 minutes of the teacher’s time, and you should discuss this with him or her to make
sure the teacher understands the importance of the information they will be providing. Rather than just having
your child gives the forms to the teacher along with a note, it is suggested that you discuss this with the teacher
on the phone or in person.
The teacher needs to understand that the information he or she provides will help to determine when any
changes/additions to treatment need to be made, and that without this input, it will be extremely difficult to know
how well your child’s ADHD symptoms are being managed.
NOTE: If your child has multiple teachers, you can provide copies to each teacher who spends a significant
amount of time with your child each week.
In discussing this program with the teacher, be sure that arrangements are clearly made to insure that you will
be getting the completed form each week. The information won’t do you or your child any good if it sits in the
classroom for weeks before you receive it.
What Information is Provided?
The ADHD Monitoring System is designed to provide you with information on:
• how well your child’s ADHD symptoms are being managed;
• your child’s behavioral, social, and emotional functioning at school;
• your child’s weekly academic performance.
Please refer to the Weekly Monitoring Form when reviewing the information below.
How well are ADHD symptoms being managed?
Questions 1-12 deal specifically with symptoms of ADHD. Items 1-6 ask for teacher ratings of
hyperactive/impulsive symptoms and items 7-12 provide information on inattentive symptoms.
For children without ADHD, the vast majority of the ratings on these items will be either 0 or 1. For a child with
ADHD whose symptoms are being managed effectively—via medication or some other means—you would also
expect to see a majority of 0’s and 1’s being circled.
NOTE: Not all children with ADHD display both inattentive symptoms and hyperactive/impulsive symptoms. For
example, children diagnosed with ADHD Predominantly Inattentive Type display primarily problems with
attention (i.e. items 7-12) and do not show many of the hyperactive/impulsive characteristics (i.e. items 1-6).
Conversely, children with ADHD, Predominantly Hyperactive/Impulsive Type show the reverse pattern. Thus,
should your child have one of these subtypes of ADHD, rather than the Combined subtype in which both sets
of symptoms are present, you would look specifically at the appropriate symptom group to determine how well
the difficulties are being managed.
Behavioral, social, and emotional functioning
Items 13-15 provide a simple screening for behavioral, social, or emotional difficulties. In addition to seeing
mostly low scores for items 1-12, you want to see high scores (i.e. 3’s or 4’s) for these items. If your child
receives low scores (i.e. 0’s or 1’s) on any or all of these items, you will want to contact the teacher to obtain
more detailed information about the difficulties that were observed.
NOTE: It is important to emphasize that these items provide only a simple screen for behavioral, social, and
emotional difficulties and are not intended to provide a comprehensive assessment. Although teachers are
generally in an excellent position to comment on how a child is following classroom rules (i.e. item 13), they
can be less aware of how a child is doing socially (i.e. item 14) or how a child is feeling (i.e. item 15). Thus your
child’s teacher may report that your child is doing well in these areas when this is not necessarily the case.
Learning about these areas in a comprehensive way requires feedback from your child as well.
Academic performance
The reverse side of the rating form provides important information on your child’s academic performance during
the prior school week. Information is provided on the amount of assigned work completed, the general quality
of the work completed (and whether this varies by subject), and also alerts you to homework assignments that
may not have been turned in. Obviously, the ideal is for your child to be completing all assigned work, for it to
be of good to very good quality, and for no homework assignments to have been missing.
Suggested guidelines for using the information
The information contained in the weekly monitoring form is designed to provide you and your child’s physician
with the data you need to make informed decisions about the effectiveness of your child’s treatment and when
any treatment modifications appear necessary.
In reviewing this data, it is important to stress that any child can have an occasional bad week. If your child has
been doing well, and then has a week where the teacher’s ratings indicate difficulties in one or more areas, this
should not necessarily cause alarm nor indicate the need for treatment changes. In general, treatment
modifications for a child who has been doing well would not be suggested unless the problems persist for
several weeks in succession. (When this occurs, changes in the child’s environment that may be related to a
sudden increase in difficulties also need to be considered.) You should also consider modifying treatment if
troublesome weeks start to occur with increased frequency (i.e. instead of one bad week every couple of
months you start to see several bad weeks each month).
With this important caution in mind, a simple and reasonable framework for evaluating the information
contained in the Weekly Monitoring Form is to consider the ADHD symptom ratings (i.e. items 1-12) and the
other information separately. When done in this way, several different combinations are possible. These are
discussed below.
Everything going well
This is what you hope to see each week. In this scenario, ratings of ADHD symptoms (items 1-12) are primarily
or exclusively 0’s and 1’s, ratings for items 12-15 indicate that your child is following rules, getting along with
peers, and appearing happy. In addition, academic ratings would show that your child is completing all or
almost all assigned work and the work is of good quality.
When this is the case, it indicates that your child is doing a great job at school, and that whatever treatments
and/or support are in place are working well. No changes or adjustments are indicated.
Everything going poorly
At the other extreme is a situation where nothing is going well. Ratings of ADHD symptoms are high, problems
with behavior, peer relations, and/or mood are also evident, and both the quantity and quality of assigned work
being completed is problematic.
In almost all cases, this indicates a situation where changes and adjustments (i.e. to medication, behavioral
plan, etc.) need to be implemented. The only exception would be if, as noted above, your child has been doing
consistently well and then has a bad week. If this is the case, it is still important to speak with your child and his
or her teacher to try and learn what may have accounted for the difficult week. Should things get back to
normal the following week, there is probably no need to change anything. If the difficulties persist, however, it
will be important to consider modifications that may be necessary. Consulting with your child’s physician and/or
a child mental health professional about the most appropriate steps to pursue is strongly recommended.
ADHD symptoms under control, but problems with behavior, peer relations, mood, or academics.
This would be indicated when ratings of ADHD symptoms on items 1-12 are fine (i.e. mostly 0’s and 1’s) but
problems are indicated in one or more of these other areas. When ADHD symptom ratings are low, these other
problems are unlikely to be direct results of ADHD, but may reflect additional difficulties. Such difficulties can
occur for a variety of reasons and it is very important to learn what factors are contributing to the difficulties
your child is having. Once again, consulting with your child’s physician and/or a child mental health
professional is recommended.
NOTE: When children are in middle school or high school and have multiple teachers, teachers often do not
spend enough time with the child to observe problems with regards to ADHD symptoms. In these grades, it is
more common for ADHD symptom ratings to look okay, but for the difficulties to show up in academic
performance and/or behavior. It is important to be aware of this because the teachers’ ratings may suggest that
primary ADHD symptoms are being managed well when this is not the case. If this is true, efforts to manage
the inattentive and/or hyperactive/impulsive symptoms more effectively will often be an important first step to
take.
Other areas look good but ratings of ADHD symptoms are high.
This would be indicated when ratings on items 1-12 include multiple 2’s and 3’s but significant problems with
behavior, peer relations, mood, or academics are reported. This is probably the most unusual combination
because when a child’s ADHD symptoms are not being managed well, significant problems in behavioral,
emotional, social, and/or academic functioning are usually also evident.
Should this pattern persist for more than one week, some adjustment in the treatment being used to manage
primary ADHD symptoms is likely to be necessary (i.e. medication adjustment, revising behavior plan). Of
course, if a child continues to do well academically, socially, and behaviorally at school, despite high levels of
ADHD symptoms, it may not be necessary to change anything. Generally, however, one would expect
problems in these areas to emerge if ADHD symptoms are not being managed well for a sustained period.
Again consulting with your child’s physician is strongly recommended.
NOTE: The first question on side 2 of the Weekly Monitoring Form asks for the teacher’s impression of how
morning and afternoon periods compared. If your child is taking medication, and is receiving a longer acting
stimulant or is taking a second dose during the day at school, morning and afternoon behavior would not be
expected to differ.
If your child is receiving only a single dose in the morning, however, and the teacher’s ratings indicate that
mornings are consistently better than the afternoons, it may indicate that the medication is wearing off during
the day and that a single dose is not sufficient. If this pattern emerges in the teacher’s ratings, you should
discuss this issue with your child’s physician.
There can be other reasons, of course, for why a child’s behavior and schoolwork can vary between mornings
and afternoon. For example, it may be that the type of classes and/or activities are consistently different during
these periods, and your child has a much easier time with one set of activities/classes than the other. Once
again, the important task will be to try and learn why your child is having a harder time with one part of the day
than the other, and then determine what type(s) of assistance may be necessary to help with the more difficult
time.
How to Reevaluate a Child’s Need for Medication
If your child is taking medication as part of his or her treatment, it is important to be aware that a child’s need
for medication can change over time. Because of this, it is generally recommended that this be reevaluated on
an annual basis. This should be done at a time when a child’s symptoms appear to be under good control, and
things have been stable and going reasonably well for a sustained period. It should not be done at the very
beginning of a new school year because children generally require a month or so to settle in to a new
classroom. In addition, the teacher needs some time to get to know your child.
To use the monitoring program to reevaluate your child’s need for medication, you simply need to pick a week
where your child does not receive any medication for the week, and then compare the teacher’s ratings for this
week with the ratings your child had been receiving when on medication. (Note: Prior to doing this it is
important that you discuss this with your child’s physician.)
For children who continue to require medication, you would expect to see a clear increase in ADHD symptom
ratings (i.e. instead of mostly 0’s and 1’s you would see more 2’s and 3’s for the week without medication).
Problems with following class rules may be reported and the amount and quality of assigned work completed
would also be expected to show a decline.
NOTE: When you do this reevaluation, it is generally better if your child’s teacher does not know that your child
is not receiving medication during the week. This is because if the teacher is aware of this, he or she may
“expect” to see problems, and have a hard time providing objective ratings as a result.
If your child is not receiving a second dose during the school day, keeping the teacher “blind” to the medication
holiday is not a problem. (Just ask your child not to tell the teacher that he or she is not getting medication that
week. Alternatively, you can speak with your child’s doctor about using a “placebo”—i.e. something that looks
like medication but is really not—for this week.) If your child receives a second dose during the day, however, it
can be a good idea for this dose to continue during the reevaluation week. In this case, the teacher should be
instructed to base the ratings for this week during the morning periods only—the time when your child would
not be on the medication.
IMPORTANT: If your child appears to do quite well during the week without medication (i.e. no clear change in
the ratings provided by the teacher), he or she may not need to continue taking it. This decision should be
made in consultation with your child’s physician and it is recommended that you do not discontinue medication
or change the dose that your child receives without the doctor’s approval.
Even if you and your child’s physician elect to discontinue medication because your child did well without it, it is
very important to continue to use the Weekly Monitoring Form to keep careful track of how your child is doing
each week. It is not uncommon, for example, for a child to do fairly well during a one-week break from
medication, but to have a difficult time sustaining this good performance. Thus, do not be surprised if you see
symptoms reemerge after a short period of time. Should this occur, it may be necessary to resume medication
that your child had been taking and this should be discussed with your child’s physician. The important point is
that a single good week without medication in no way means that medication may not be necessary again at
some point later on and that carefully monitoring how your child does on a weekly basis is essential.
Conclusion
I hope that the instructions above have provided you with a good understanding about how to use the ADHD
Monitoring System to carefully follow how your child is performing at school. If you enlist the cooperation of
your child’s teacher(s), and use this program as outlined above, you will be in a much better position to make
well informed decisions about the effectiveness of your child’s treatment, and to know when changes and
adjustments are indicated.
The ADHD Monitoring System by David Rabiner, Ph.D.