@PsychCorp. BROWN Attention-Deficit Disorder Bit Sut- Fae Pe Leal a FR 7 et PEARSONIntroduction Recognizing Attention-Deficit/ Hyperactivity Disorder During the past decade, AD/HD has been recognized as a valid disorder that significantly impairs at least 3 to 7% of children and adolescents (DSM-IV-TR; American Psychiatric Association, 2001). The large body of scientific research on AD/HD and the validity of the disorder has been acknowledged by governmental and scientific organizations, including the American Academy of Pediatrics (2000), the American Medical Association (Goldman, Genel, Bezman, & Slanetz, 1998), the American Academy of Child and Adolescent Psychiatry (1997), the National Institutes of Health (2000), and the U.S. Surgeon General (2000). School surveys completed by teachers have shown that 8 to 119 of students show enough impairment from AD/HD symptoms to warrant further diagnostic evaluation (Wolraich, Hannah, Pinnock, Baumgaertel, & Brown, 1996; Gaub & Carlson, 1997b), Although boys outnumber girls by a 3:1 ratio, research has shown that females can be just as impaired by this disorder (Biederman, Faraone, Mick, et al., 1999; Biederman, Mick, & Faraone, 2000), and in many cases, may be more impaired than males with AD/HD (Gaub & Carlson, 1997; Rucklidge & Tannock, 2001), Research has shown that children with AD/HD tend to have a variety of problems with learning disorders, being inconsistent or unmotivated in their learning, developing age-appropriate self-care and self-control, sleep patterns, accidental injuries, increased driving risks and motor vehicle accidents, adaptive relationships with peers and adults, and an elevated high school dropout rate (Barkley, 1998). ‘The variety of problems associated with AD/HD reflects the complex nature of the disorder, Fortunately, more than 75% of children with AD/HD can be helped by appropriate accommoda- tions and treatment (Greenhill, Halperin, & Abikoff, 1999). To accurately identify children with AD/HD requires careful screening followed by comprehensive evaluation and diagnosis. A New Understanding of AD/HD and Impaired Executive Functions Scientific understanding of Attention-Deficit/Hyperactivity Disorder (AD/HD) has evolved considerably over the past ten years. It was once seen as essentially a distuptive behavior disorder accompanied by problems in paying attention. There is now considerable evidence to indicate that AD/HD is a developmental disorder that is usually inherited, and is a result of impaired functioning of certain neurotransmitter networks in the brain, resulting in impaired executive functions (Barkley, 1997, 1998, 2000; Brown, 1995, 1999, 2000; Castellanos, 1999; Denckla, 2000; Douglas, 1999; Ernst, Zametkin, Matochik, et al., 1999; Solanto, Arnsten, & Castellanos, 2001; Tannock & Schachar, 1996). Executive functions of the brain are cognitive functions that activate, integrate, and control other functions of the mind. They operate like the conductor of an orchestra who selects the piece to be played and then organizes the musicians—starting, integrating, and stopping theiri in and out as needed to play their , and fading various players in a n 0 pl playing, Keeping them i ee ancions are not working effectively, the individual, vet st eng iis, Wan experience significant problems in many aspects of learning, getting despite str can rokk done, social functioning, and self-esteem. ¢ associated with AD/HD encompass a wide range of cognitive Prectfons. Individuals diagnosed with AD/HD typically have inattention difficulties such 7 ae problems with listening attentively, organizing their work, sustaining effort for tasks, sereening out distractions, keeping track of assignments and belongings, anc cae forgetful. sein daly activites. Many individuals also have significant problems remembering what they rave read or recalling what they have learned. These difficulties may or may not be accompa. nied by hyperactivity or behavior problems. students with executive function impairments associated with AD/HD are usually puzzling to teachers and parents. Often parents and teachers will ask, “If you can pay attention so well when you are doing whatever interests you, why can’t you put that same attention and effort into your schoolwork and homework?” These children tend to show little impairment in func. tions associated with AD/HD when they're involved in activities that interest them (e.g,, certain sports, video games, arts, music, mechanical tasks, computer activities). Yet, for most other tasks, especially schoolwork and homework, students with AD/HD tend to display marked impair. ments and extreme inconsistency in their functioning, even when they want very much to do well, Because students with AD/HD can show very good ability to sustain attention in tasks that especially interest them, their problem may appear to be a simple matter of lacking sufficient motivation. AD/HD often appears to be a problem of insufficient willpower, but it is not. Prevalence of AD/HD Although everyone may experience AD/HD impairment symptoms occasionally, most people do not experience sufficient impairment to warrant an AD/HD diagnosis. Approximately 3 to 7% of children younger than 18 years old meet the full diagnostic criteria for one of the three types of AD/HD described by the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV; APA, 1994) while a significant number of children manifest sub-threshold AD/HD, having significant impairment from AD/HD symptoms that do not meet full DSM-IV criteria (Scahill, Schwab-Stone, Merikangas, et al., 1999). Among males and females, about 70% of those who meet full diagnostic criteria for AD/HD in childhood continue to experience signit- icant AD/HD impairments into adulthood (Biederman, Faraone, Mick, et al., 1999; Millstein, Wilens, Biederman, & Spencer, 1997). Delay in identification and treatment can significantly impair development of important academic skills and cause damage to self-esteem that can have long-lasting effects. AD/HD Impairments Emerging at Various Ages Although most individuals with AD/HD are probably born with vulnerability to this disorder, AD/HD symptoms do not always emerge in early child! i ‘i hood. S e fi ns, © self-control of body movements and actions, dev furng eal childhood hi : : develop rapidly during early childhood, while cues ait functions donot appea unt later childhood or adolescence (Levin, ian et al., 1991; Lin, Hsiao, & Chen, 1999; is whose AD/HD impairments include signif ; Weyandt & Willis, 1994). For those wh hildren with AD/HD ate very restless and hyperactive during ‘nantly inattentive type are often not Willcutt, et al., 1999), Denttty school years, junior high, or high school (McBurnett, Pll functioning escalate — adolescence, demands for self-management in academic and SO") for the first time, ', causing some individuals’ AD/HD impairments to become aP?™" Chapter 7AD/HD Executive Function Impairments and Learning Problems Executive function impairments of AD/HD can have significant impact on learning and academic achievement, even when no specific learning disorder is present. Attention problems at an early age play an important role in reading and math difficulties. Kindergarten children lentified by their teachers as having significant problems with inattention were retested in Sth grade and found to be three times more likely than peers without inattention problems to have significant impairment in reading achievement (Rabiner & Coie, 2000). Likewise, elementary school students with AD/HD and no learning disorder were significantly slower and less accu- rate in solving math problems. In calculating, they made six times as many errors as their peers (Benedetto-Nasho & Tannock, 1999). Specific learning disabilities are much more common among students with AD/HD than in the general population (Tannock & Brown, 2000). A study by Dickerson Mayes, Calhoun, and Crowell (2000) showed that among referred children diagnosed with AD/HD, 27% had a learning disorder in reading, 31% had a learning disorder in math, and 65% had a learning disorder in written expression. Conversely, incidence of AD/HD is markedly elevated among children diagnosed with specific learning disorders when compared to the general population. Among boys diagnosed with Reading Disorder, 60% met DSM-IV criteria for inattention symptoms of AD/HD; among girls diagnosed with Reading Disorder the comparable figure was 24% (Willcutt & Pennington, 2000). If a child with a specific learning disorder also has an untreated AD/HD impairment, that student's ability to benefit from special education services for the learning disorder is likely to be severely compromised. AD/HD Executive Function Impairments and Problems in Social Behavior Executive function impairments associated with AD/HD typically impact the individual's academic functioning and social functioning. Greene, Biederman, Faraone, et al., (2001) reported that samples of both boys and girls with AD/HD showed significant impairments in social func- tioning relative to their peers without AD/HD symptoms. Cadesky, Mota, and Schachar (2000), and Norvilitis, Casey, Broolier, and Bonello (2000) demonstrated that children with AD/HD show impairments in their ability to monitor and correctly interpret emotions in themselves and others. Melnick and Hinshaw (1996) have shown that some AD/HD children annoy peers or elicit rejection from peers because of chronic difficulties in modulating their emotions and actions in changing social situations. These impairments in assessing and regulating n can have significant negative effects on social interactions and relationships with emot peers and adults, Henker and Whalen (1999) reviewed research on children with AD/HD in school and peer settings. They described three problematic social behavior patterns that emerge from research ‘on children diagnosed with AD/HD. One pattern, identified as “aggressive/assertive,” is char- acterized by oppositional behavior with adults and contentious or disruptive interaction with peers, Another pattern, “active/maladroit,” is seen in children who actively seek and enjoy interaction with peers, but are often rejected because they are too intense or too insensitive to the needs and behaviors of others. The third pattern describes children, often shy and seeming not to enjoy social contact with peers, who tend to avoid social participation, preferring isolated activities or interaction with adults, AD/HD-related executive function impairments, character- ized by any of these three subtypes, can cause considerable difficulty in social interactions with peers and adults in school and in a variety of other environments. IntroductionAD/HD Executive Function Impairments and Problems in Family Contexts 7 Because AD/HD is a highly familial disorder, it is not uncommon we Sacer aes to have a parent, sibling, or other close relative who also has See ete ae Gon is not specific as to subtype (Faraone, Biederman, & Friedman, ean: os ey, ie uy 2 Hour, et al,, 2000). A parent with Predominantly Inattentive Type Al Le is eos 4 ter with Combined Type AD/HD. One child in a family may have Combined Typé ile another has Predominantly Hyperactive-Impulsive Type. Regardless of subtype, when one or more members ofa family have AD/HD, oa stresses ate likely to arise as family members respond to many day-to-day difficulties that often emerge from AD/HD executive function impairments. At the least, a child with AD/HD is likely to require more intensive support and supervision from parents than most other children of the same age. Settling into bed at night, getting up and off to school in the morning, managing meals, getting homework and chores completed, managing routine conflicts with siblings and playmates, and numerous other household routines are often especially problematic for families where one or more members has AD/HD impairments. Some families affected by AD/HD function quite well most of the time while other affected families are severely dysfunctional. Henker and Whalen (1999) have reviewed research on this topic and concluded that AD/HD imposes more than the usual challenges for caregivers, while children with AD/HD tend to be more vulnerable to negative environmental influences (eg, family stresses) Emotional and/or Behavioral Disorders Complicating AD/HD Studies of children and adolescents with AD/HD have consistently demonstrated that more than 50% of individuals diagnosed with this disorder have other problems that meet diagnostic criteria for one or more other psychiatric disorders (Brown, 2000; Jensen, Martin, & Cantwell, 1997; Pliszka, Carlson, & Swanson, 1999). These studies show not only that it is possible for someone to have AD/HD with an anxiety disorder or AD/HD with a depressive disorder, but that research shows that persons diagnosed with AD/HD are two to five times more likely to have one or more additional psychiatric diagnoses at some fe point in th 5. Fe le, while about 5% of children in the general A en ; ul i population have a diagnosable anxiety disorder, = ea chien with ADYD meet criteria for this diagnosis (Tannock, 2000) Similarly high rates of comorbidity have b in h oe Try, have been reported for almost every other psychiatric disorder among a - dlagnosis of AD/HD and executive function impairments associated with is not simple. When this as thought to i , simple. When t involve eractive beha and difficulty in listening, diagnosis was often made from ADIND syraptonc at ae completed by teachers and parents, possibly supplemented by classroom Onna of ' to evaluation is not sufficient to assess AD/HD as it is now ent requires . pulse tad apie eee ‘uires a more comprehensive assessment with more ‘The Brown i . thi nav meee aa Forms provide instruments and procedures that incorporate of the mind. The scales can be used to aa aiek Cevelopmental impairment of executive functions and behavioral problems often associated ony tins Of a wide range of cognitive, emotional, Brown ADD Diegneate Foe asociated with executive function impaitments of AD/HD. The and related problems, within ghej ene Sttucture for a comprehensive assessment of AD/HD oo ae {he sales may be integrated with 1Q index scores, standa‘d- provides a system for assessing possible ea aie other rating scale scores, The form als° VHD and specific learning disorders. Chapter 1Purpose and Development of the Brown ADD Scales Impetus for the development of the Brown ADD Scales began a decade ago in clinical conver- sations with students, ages 12 through 18 years, who were chronic underachievers in school despite high IQs and strong wishes to do well in school. Many of these students met DSM-III (APA, 1980) diagnostic criteria for AD/HD without hyperactivity and responded well to conven- tional stimulant treatment for AD/HD. These students also had a number of symptoms in common that were not included among the recognized symptoms of AD/HD: difficulties in Setting started and sustaining effort for work-related tasks, problems with required reading, and problems with working memory. Evaluation and treatment of adults with similar symp- toms led to the development of a similar scale for adults. After a series of research studies that refined and validated these items for clinical use, the Brown Attention Deficit Disorder Scales® for Adolescents and Adults were published in 1996, Since publication of the original scales, additional studies have been conducted to develop new versions for use with children ages 3-12 years. These new scales are designed to assess the same wide range of AD/HD-related executive func- tion impairments, but in age-appropriate terms for children. The new Brown ADD Scales for Children may be used to assess impairments in monitoring and self-regulating action as well as for hyperactive and impulsive behavior. ‘The Brown ADD Scales are instruments designed to elicit parent and teacher observations of symptoms in 3- to 12-year-olds and to elicit self-report from children ages 8 years and older that may indicate impairment in executive functions related to Attention-Deficit/Hyperactivity Disorders. The scales provide descriptions of interrelated cognitive, affective, and behavioral symptoms often characteristic of persons diagnosed with Attention-Deficit/Hyperactivity Disorders. The profile of AD/HD symptoms these clients experience suggest that developmental impairments of executive functions are considerably broader and more complex than indicated by the current diagnostic criteria for AD/HD. Evaluating Clusters of Executive Function Impairments Items on the Brown ADD Scales for Children are grouped into six clusters, each representing an underlying aspect of AD/HD. These clusters have been renamed to reflect the most recent conceptualizations of aspects of AD/HD. Each is a grouping of related functions, some of which can overlap with items in other clusters. Despite this overlapping, the cluster groupings provide a way of organizing observations about an individual’s functioning that can be clinically useful for assessment and treatment. These clusters address a range of symptoms beyond the diagnostic criteria for AD/HD in the DSM-IV (APA, 1994) to assess for executive function impairments often associated with AD/HD. Clusters are similar across the age groups, but specific items within each cluster are worded with language and examples appropriate to each age group. Note that Clusters 1-S in this version represent the same constructs as Clusters 1-5 in the Brown ADD Scales for Adolescents and Adults (Brown, 1996). Cluster 6 has been added to the children’s version of the scales. Cluster 1: Organizing, Prioritizing, and Activating to Work. Items in this cluster address excessive difficulties a child may have in getting organized and getting started on work-like tasks (i,, activities not usually chosen for pleasure). For younger children these tasks mainly include following directions and completing daily routines such as getting dressed, picking up toys, etc. For older children, items address difficulties in organizing homework and getting started on assignments. Adolescent items inquire about excessive procrastination, difficulty in prioritizing and completing assignments, etc. along with undue problems in waking up and self-activating for daily routines. Cluster 2: Focusing, Sustaining, and Shifting Attention to Tasks. These items query a child’s chronic problems in sustaining attention and focus for tasks, or in shifting attention as needed from one focus to another. For younger children, items address excessive need for adults to ask the child to stop and listen, problems in listening to stories when being read to, and difficulties wucsnion [3]in making transitions from one activity to another. For older children, ante questions about excessive distractibility and difficulty in grasping the main idea when tying to read ‘Adolescents are queried about excessive daydreaming and the need to re-read texts in order to understand required readings. Cluster 3: Regulating Alertness, Sustaining Effort, and Processing Speed. This cluster addresses a child’s problems in staying alert and in sustaining sufficient effort for work-related tasks, It also addresses slow processing of information, inadequate task completion, and inconsistent performance. For younger children, this includes the need for excessive prodding to eat meals. and to get ready for bed, and giving up too quickly when trying a learn a new task. For older children items include difficulty in completing tasks within allotted time and needing reminders to complete assignments. Adolescents are asked about problems with daytime drowsiness, not completing assignments on time, and chronic underachievement. Cluster 4: Managing Frustration and Modulating Emotions. Items in this cluster address the extent to which a child's difficulties with regulating emotional reactions such that frustrations, worries, anger, hurt feelings, sadness, etc., take over too much of what the child is thinking or doing. Items address frustrations with excessive irritability, feelings hurt too easily, work disrupted by excessive worries, or getting overly discouraged and depressed. Cluster 5: Utilizing Working Memory and Accessing Recall. These items query a child’s forget- fulness in daily routines and problems in recall of learned material. For younger children, items assess difficulties in remembering directions, in remembering daily routines, and problems in recalling basic learning. Older children are queried about difficulties following through on intended actions, losing track of belongings, and problems in memorizing vocabulary or math facts. Adolescents are asked about problems in keeping track of assignments and chronic diff- culty in recalling learned material Executive Functions Assessed for Impairment With the Brown ADD Scales for Children of the same age, tho ADIHD us ugh they vary in degree of difficulty with each cluster sually hay i impairmentsin Caster acu ial Six clusters Predominantly Inattentive TPE Many activities of daily lite include integrated functioning ee aa Diagram of the Six Clusters ine ton KDD Scales fr Adolescents and Ad lt ults 195 {=| Genet (1996) include only Clusters 1 though 5.Cluster 6: Monitoring and Self-Regulating Action. Items in this cluster address problems the child may have in sizing up situations to recognize what should be done and in self-regulating actions to do what is appropriate. For younger children this includes butting in or interrupting others and having much more difficulty in waiting for things than do most others of the same age. Older children are queried about doing too much teasing or arguing after being asked to stop, grabbing things or starting actions without waiting for permission or directions, doing things too fast, and not slowing down enough to write letters or numbers carefully. The Brown ADD Scales for Children and Adolescents The Brown ADD Scales for Children and Adolescents can be used for initial screening of chil- dren and adolescents suspected of having an Attention-Deficit/Hyperactivity Disorder and as a comprehensive diagnostic assessment tool in a battery of assessment instruments. The scales address a variety of AD/HD-related cognitive impairments and symptoms beyond the DSM-IV criteria, The test results can be combined with data from clinical interviews, an analysis of 1Q subtest patterns and additional measures to determine whether a child meets diagnostic criteria for AD/HD and to aid in the development of appropriate interventions. The Diagnostic Form for Children and the Diagnostic Form for Adolescents provide a complete set of protocols and ician in making a comprehensive diagnostic evaluation of AD/HD. forms to assist the ‘The Brown ADD Scales also can be used to evaluate which AD/HD symptoms are responding to medication or other interventions and which are not. The information obtained from repeated administrations can be useful in titrating medication doses and in suggesting when additional assessments or treatments may be indicated for non-responsive AD/HD symptoms. ‘The Brown ADD Scales for Children and Adolescents starter kit includes the following components for evaluating AD/HD impairments and related executive functions: @ this Examiner’s Manual, the Parent Report Ready Score* Form, the Teacher Report Ready Score Form, Ha Self-Report Ready Score® Form for ages 8-12, and the Diagnostic Form. The scales are also useful as components of comprehensive assessments for diagnosis of possible comorbidities and as tools to monitor responses to treatment. The Brown ADD Scales for Children are designed for evaluating children in two age groups: ages 3-7 years and ages 8-12 years, The Brown ADD Scales for Adolescents are designed for assessing individuals ages 12-18 years. Students who are 12 years old may be assessed with the version for ages 8-12 years or the adolescent version of the Brown ADD Scales for Adolescents and Adults. The children’s version is usually recommended for this age. Using the Ready Score Forms The version for children ages 3-7 years includes a Parent and a Teacher Form. The Brown ADD Scales for Children ages 8-12 years includes a Self-Report Form for the child, a Parent Form, and a Teacher Form. The Brown ADD Scales for Adolescents is available in one format designed to elicit both self-report and parent report. All of these are in Ready Score format for easy scoring and analysis. ‘The Ready Score format indicates whether the level of symptomatic impairment reported is within the range usually associated with an AD/HD diagnosis. Cumulative percentages Introductionfive or six clusters of is reporting on each of the impairment the individual is repo naa ow mach ee pen sane ea ADIRD aeiora be used in screening to determine which individuals sh a ful these measures ¢ assessment for AD/HD. Using the Diagnostic Forms for Children and Adolescents Assessment of Attention-Deficit/ Hyperactivity Disorder is not a simple Process Thee no sing test adequate to make this dlagnosis. Executive function oes erying this oe ferent sub-functions. are very complex, each involving many dif fi 8 requires a comprehensive evaluation that integrates different types of Conn information to determine whether a given individual meets diagnostic criteria and has sufficient impairment to warrant an AD/HD diagnosis ‘The seven sections of the Brown ADD Diagnostic Form for Children and the Diagnostic Form for Adolescents provide formats for documenting a comprehensive evaluation for AD/HD and related executive function impairments in children ages 3-12 years and adolescents 12-18 years, ‘The Diagnostic Forms also include guidelines for adapting these formats according to develop- ‘mental level. (Note: The Brown ADD Diagnostic Form does not include the Ready Score forms, but is used in conjunction with the Ready Score forms.) Clinical Interview With Child and Parents A well-conducted, semi-structured clinical interview with the child/adolescent and parents is usually the most sensitive measure for assessing adaptive strengths and AD/HD impairments, This form provides a structure to guide clinicians in eliciting and recording essential information from the child and parents about past and current functioning in school, home and social rela- tionships, and other factors that may impact diagnosis, B. Brown ADD Scales Threshold Interpretation and Cluster Scores Graphs The Diagnostic Form for Children enables you to compare Cluster and Total Scores across multiple raters for an individual child. The form shows levels of impairment reported by each rater for each of six clusters of symptoms. Differences across settings can be noted for further evaluation. Total Scores may be used as threshold indicators of meeting AD/HD diagnostic Criteria, ‘ius form can also be used to monitor symptom changes observed during treatment by (8-12 years), parents, and teachers. The Diagnostic Form for Adolescents summarizes the Self-Report. C. Multi-Rater Evaluation Form for D: Diagnostic Criteria All 18 symptoms of AD/HD in the DSM-IV are each symptom as present or absent, as reporte; form provides a summary of observed symptor whether DSM-IV diagnostic criteria have beer SM-IV AD/HD listed on this form. Spaces are provided to rate ‘d by the child, the parents, and the clinician. This ms to be used with other information to determine n met for AD/HD in any of the three subtypes. D. Screener for Other Learning and Psychiatric Disorders Fifty percent of persons with It p the clinician identify additional disorders, such as disorders of reading, math, or written exp, s ression, as well as disorders of coordination, sleep, anxiety, mood, behavior and many other psy Chapter 1 chiatric problems,E. Examiner's Worksheet for Comparing Psychoeducational Test Scores The usual full-scale, verbal, and performance IQ scores cannot make or contraindicate a diagnosis, of AD/HD. Yet research with the Brown ADD Scales and other studies indicates that index scores from the Wechsler Intelligence Scale for Children*-Third Edition (WISC-III; Wechsler, 1991) or the Wechsler Adult Intelligence Scale*-Third Edition (WAIS-III; Wechsler, 1997) may be used as indicators of executive function impairments associated with AD/HD. The Examiner's Worksheet provides a format for comparing IQ index scores, verbal memory test scores, and academic achievement test scores to identify discrepancies that may indicate a co-existing, specific learning disorder. F. Display of Psychoeducational Test Scores This form provides clear, easy-to-understand graphs to show parents, teachers, and students how the student's specific IQ index scores, verbal memory scores, and academic achievement test scores are positioned relative to each other on a normal distribution. The format makes it easy to recognize discrepancies that suggest impaired executive function impairments related to AD/HD and/or specific learning disorders. The integrated format can be useful in explaining how individual strengths and impairments are demonstrated in scores on these different stan- dardized tests. G. Summary of Diagnostic Data and Impressions ‘This summary sheet provides an integrated format for summarizing information from each aspect of a comprehensive evaluation for AD/HD and related problems. The information is formatted so that the clinician can review all the elements required for DSM-IV diagnosis of AD/HD and determine whether full diagnostic criteria have been met. Items include not only the official requirements for DSM-IV diagnosis, but also spaces for information and scores from other measures that may be useful (e.g., the verbal memory test, TOVA, CPT, or other computer- ized measures). Space is provided for recording diagnosis of AD/HD subtypes, level of severity, possible comorbid disorders, and comments and plans for intervention and follow-up. As AD/HD impairments are being reconceptualized as more cognitive than behavioral in nature and often comorbid with other psychiatric disorders, careful diagnosis requires broader and more subtle instruments, more sophisticated clinical skills, and closer collaboration between medical and psychological specialists. A comprehensive diagnostic evaluation for AD/HD in a child or adolescent requires a semi-structured cl al interview with the child/adolescent and parents; an assessment of self-report, parent reports, and teacher reports using full DSM-IV AD/HD criteria; a screening for comorbid psychiatric and learning disorders; an analysis of subtest index score data from a full 1Q test; an evaluation of verbal memory; and an integration and weighting of all relevant data to make a diagnosis as to presence or absence of AD/HD and comorbid disorders, Accurate dlagnosis requires interpretation and differential weighting of a variety of psycho- logical and psychiatric data. Professionals with graduate training in psychological assessment can administer the Brown ADD Scales as a screener to identify persons who should veceive a comprehensive evaluation for definitive diagnosis of AD/HD, as an important element of a ‘comprehensive evalu: e n for AD/HD, and to monitor the effectiveness of ongoing treatment, 4 Somprchensive diagnostic evaluation for AD/HD should be done by a mental health profes. sional with relevant gra : 7 : iduate-level education and training in differential diagnosis using the DSM-IV, and who has experience in assessment and treatment of AD/HD. rnntesn [7]Conceptual Assumptions of the Brown ADD Scales Chapter 1 ‘The Brown ADD Scales are used to assess symptoms of AD/HD SE ie eet diagnostic system of the American Psychiatric Association (DSM-IV-1 roa aacaiiments aeoclsied include a numberof ather symptoms characteristic of executive function ipaltan soe with AD/HD that ae supported by research, but not yet incorporated into the DSN AV diag nostic criteria. The Brown ADD Scales are built on several basic assumptions about the nature of AD/HD summarized in the following paragraphs. AD/HD Impairments Are Dimensional Disorders Items on the Brown ADD Scales delineate problems that occur from time to time for virtu- ally everyone. The scales distinguish between persons who have AD/HD and those who do not have AD/HD by determining the frequency and intensity with which they experience problems that are symptomatic of AD/HD. For example, most people have difficulty remembering what they have just read if they are tired when reading. Many people with AD/HD have difficulties ‘with recall almost any time they read, regardless of how well rested they may be. By employing dimensional scoring and using a clinical cut score for total scores, the Brown ADD Scales allow for dimensional variations in the symptoms being evaluated. ADJHD is a dimensional, not a categorical, diagnosis. Levels of severity range from “slightly worse than what almost everyone experiences” to “very severely impairing, much worse than most people ever have.” Blacker and Tsuang (1992) and Achenbach (1991) have noted problems with any psychological diagnosis that works only with categorical distinctions and does not allow for dimensional variation. AD/HD Symptoms May Vary According to Task and Context Some items on the Brown ADD Scale vary according to context (e.g., home, Persons with AD/HD report that they have chronic and severe problems in sustaining concentra. tion and effort for most work-related tasks, yet they are able to concentrate very well for specific tasks that interest them, such as playing video games, engaging in sports, drawving, making ‘music, or using a computer (Brown, 1995, 1999, 2000), school, work). Many ‘The scoring system of the Brown ADD Scales allows for contextual variability that do not occur consistently and by including some items that differentiate between work- related or assigned tasks and self-selected pleasurable tasks (eg, items that specifically ask about Problems in reading that is required rather than self-selected for interest and pleasure). For many Persons with AD/HD, this task differentials significant, The Brown ADD Scales are based on the assumption that some ofthe impairments of AD/HD depend upon the nature ofthe task and/or the context in which the task is given. by rating problems Hyperactivity /Impul Element in AD/HD The DSM-IV, departing from the Diagnostic and Statistical Manual of Mental Disorders-Thj Edition-Revised (DSM-III-R; American Psychiatric Association, i987), Soin oe symptoms of Hyperactivity/Impulsivity are not essential for making the diagsoee ct te Deficit/Hyperacivty Disorder (American Psychiatric Association, 1994), Accoieg a entom™ criteria, AD/HD symptoms may be classified as Predominat “ording to DSM-IV intly Inattentive Ty Hyperactive-Impulsve Type, ot Combined Type, DSMIV requites ne nee ees eedominantly ; no sympt : activity/Impulsivty for making an AD/HD diagnosis. Ths approach sop cre ae studies documenting the validity ofthese subtypes (Lahey, Schaughency, Hynel Coe oe Nieves, 1987; Lahey, Pelham, Schaughency, eta, 1988; Lahey & Carlom, 1991; Meda ae ity is Not an EssentialPfiffner, Willcutt, et al., 1999; Neuman, Todd, Heath, et al., 1999), (Note: The terms ADD and AD/HD are used interchangeably in this manual to refer to any of the three subtypes of Attention-Deficit/Hyperactivity Disorder in DSM-IV: Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, and Combined Type.) ‘The Brown ADD Scales take this point of view one step further by assuming that the central impairment of any AD/HD type is not disruptive behavior or failure of inhibition, but impair- ment in a variety of executive functions, Data to support this point of view are reported in the psychometric section of this manual. From this perspective, AD/HD with Hyperactivity/ Impulsivity is merely one particular type of AD/HD. Although this point of view is contrary to the conceptual framework of some researchers, it is finding increasing acceptance and support from others (Brown, 1999, 2000; Douglas, 1999). Conceptual Assumptions Underlying the Brown ADD Scales Diagnostic Forms ‘The Diagnostic Form for Children and the Diagnostic Form for Adolescents-Revised provides a comprehensive approach to assessment of AD/HD and related problems. This approach is based ‘on several basic assumptions about assessment for AD/HD. Assumption 1; DSM-IV diagnostic criteria for AD/HD are a necessary, but not complete, basis for diagnostic evaluation of AD/HD and related executive function impairments. AD/HD symptoms may vary considerably from one context or setting to another. Adequate evaluation requires queries to determine specific tasks and settings where AD/HD symptoms are present or absent. Moreover, DSM-IV diagnostic criteria do not yet reflect some of the executive function impairments that have been found important in AD/HD, e.g., problems with self-regulation of emotion, difficulties in regulating alertness and processing speed, or problems in getting started on work tasks. This wider range of symptoms associated with AD/HD impairments needs to be queried in evaluations. DSM-IV criteria alone are not enough. ‘Assumption 2: Detailed self-report data about a variety of possible AD/HD impairments is essential for assessment of AD/HD. Self-report information is important because many symptoms of executive function impairments associated with AD/HD are not directly observable. It is especially important to include self-report data in assessment of AD/HD impairments in any child old enough to provide the necessary information. The Brown ADD Scales provide forms to élicit self-report data from children 8 years and older. The Brown ADD Diagnostic Form utilizes and integrates self-report information for an AD/HD assessment. Self-report can be an invaluable source of information about medical or psychological problems. Jackson (1992) cautioned evaluators about the risk of error in merely “looking at” patients and the data about them, rather than asking them about themselves and their experiences. He pointed out that a clinician’s eliciting and listening carefully to patients’ descriptions of their symptoms may yield valuable information about the complexities of their disorders; informa- tion that may not be revealed if the evaluator narrows the focus of assessment to what is readily visible and easily categorized or measured Research indicates that in children and adolescents, some symptoms may be more accessible by self-report than by ratings from outside evaluators, even if they are parents or teachers (Melnick & Hinshaw, 1996; Robin, 1994). Several epidemiological studies have shown that parents report depression and anxiety in their children less often than the children report it in themselves (Angold & Costello, 1993; Bird, Gould, & Staghezza, 1993). The Brown ADD Diagnostic Forms utilize self-report data derived from the Brown ADD Scales and from a semi-structured clinical interview with the child and parents to develop understanding of executive function impair ments that may be problematic in academic, social, and family functioning.HD impairments observed jety of possible AD/ wvaviders 5 ‘essential for assessment of AD/HD ‘a children and adolescents. Some appro: Al as ly on very brief D/HD assessment rely on ‘ents. Some approaches to A\ a rating scales completed by teachers and parents to diagnose presence OF absence of AD/HD. 8 5 i i HD, more detailed i jirments associated with AD/HD, s executive function impairments ¢ oe To ade sof cds functioning needed 0 suppleness ‘The Brown ADD Scales for Children provide separate agespecl ee information from parents and teachers about many aspects of the to AD/HD diagnosis. and parents Often ratings of a child’s AD/HD impairments differ considerably eee ae aL ‘This may be due to differences in task demands and in how the child funcONs © A settings observed by teachers and parents. To capture these differences, reports om No parents and teachers about a child's AD/HD and executive function impairmen’* Ut ule helpful, Mota and Schachar (2000) have shown that despite differences, when diagnol oon the basis of symptoms of AD/HD most related to impairment, agreement between parents and teachers is three times higher. The Brown ADD Diagnostic Form for Children provides a format for comparing similarities and differences in parents’ and teachers’ reports to the student's self-report data. data o1 stion 3: Detailed report Asari teachers, and oer cae P Assumption 4: 1Q index scores are valuable in evaluation for AD/HD. AD/HD has been found to occur in persons at every level of intelligence and there is some evidence to suggest that 1Q scores of persons with AD/HD are normally distributed (Kaplan, et al., 2000), although overall Verbal 1Q, Performance 1Q, and Full Scale 1Q scores are not useful for diagnosis of AD/HD. Standardized 1Q tests can provide a structured way to assess relevant areas of cognitive functioning. ‘Some subtests of IQ tests, such as WISC-III and WAIS-III, are quite sensitive to impairments of attention, working memory, processing speed, and other aspects of executive functions. Other subtests are not so affected by AD/HD related impairments. For this reason, some WISC- TIL and WAIS-IIl index scores comprised of subtests more sensitive to AD/HD impairments may be compared with index scores for subtests not known to be sensitive to AD/HD impairments, to examine the icepances in scores as clinical indicators of AD/HD. Useulnes of : such comparisons has been described by Brown (1996), Schwean and Saklofske (1998); Dickerson Mayes, Calhoun, i : a Coanaia Crowell (1998), Kaufman and Lichtenberger, (1999), and Mayes, Calhoun, The Brown ADD Diagnostic Form suggests comparison of the individual’ H index score and Perceptual Organization index ee ee ee : d score with his or her scores on bot! from Distractibility (WISC-II}) or Working Memory (WAIS-IIl) Index score and re Processing, = Speed Index score. Chapter 4 of this manual includes descriptic vl ions of methods for whether differences between these scores are significant or not, aa ‘Assumption 5: Verbal working memory measures can be useful j impairments. Working memory is recognized as an important as i is often impaired in AD/HD (Barkley, 1997; Pennington, Bennett MeAtcen & Hoon oe Verbal working memory impairments have been found in children and adolescents man AD/HD (Chang, Klorman, Shaywiz, etal, 1999; Seidman, Biederman, Faraone, etal vo 1997). Most of these studies have used list-learning or paited-associate leatning tava tenn au arming tasks to evaluate in assessment for AD/HD The Brown ADD Diagnostic Forms utilize scores from a briet st ‘ verbal working memory impairments in children and tice with ADIH. Re nen 3 to 16 years, the age-appropriate story memory items from the Children's Memory sae eg Cohen, 1997) are recommenced, Story memory items from the Logical Memony f sinc ces the Wechsler Memory Scale-Third Edition (WMS-I; Wechsler, 1997) are reconreg ne eo with adolescents 16 years and older. ended for use“These measures of verbal working memory from the CMS and WMS-III are recommended because they are brief and easy to administer and score, and because they are more ecologically valid. List-learning and paired-associate learning tasks involve multiple presentations of simple verbal stimuli. Story memory tasks of the CMS and WMS-III involve more active processing of more complex information than list-learning or paired-associate learning tasks (Bradley, 2000). The story memory tasks also provide only one repetition of each story, more closely resembling many daily activities in home and schoo! where children and adolescents with AD/HD are often forgetful. ‘Assumption 6: Screening for learning disorders and possible comorbid psychiatric disorders is essential to adequate assessment for AD/HD. Children and adolescents with AD/HD are two to five times more likely to suffer from a specific learning disorder or another psychiatric disorder (mood, anxiety, behavior, etc.) than are children in the general population Brown, 2000; Pliszka, Carlson, & Swanson, 199). Because of this high rate of comorbidity, comprehensive assessment for AD/HD requires at least screening for other learning and psychi- atric disorders. ‘The Brown ADD Diagnostic Form includes specific probes for use in the semi-structured clinical interview to query for indicators of other learning or psychiatric disorders commonly associated with AD/HD. It also includes the recommendation that any student evaluated for possible AD/HD should be screened for possible learning disorders in reading, math, and written expression. The Brown ADD Diagnostic Form contains a Summary Display of Psychoeducational Measures for noting IQ index scores, verbal memory scores, and academic achievement test scores so that significant discrepancies can be discussed with the student, parent(s), and teacher(s).Administering and Scoring the Ready Score® Forms Administering the Ready Score Forms for Children Ages 3-7 Years The Parent Form The Brown ADD Scale for Children, ages 3 through 7 years, includes a Parent and a Teacher Ready Score form. The Parent Form is for recording information from the parent or other primary caretaker. The Teacher Form is for recording information from the child’s teacher or daycare provider. The preferred mode of administering the Parent Form is to interview the child’s parent(s) in a relaxed setting, This may be done in a private meeting with the parents or it can be done while the child is playing in the same room. If the child is listening and wishes to comment on any: of the items being discussed, note any of the child’s comments that might be useful; however, the Parent Form is designed to elicit and score responses from the parent about the child. Prior to administering the scale to the parent(s), start by saying: ¥’m going to read a list of problems that children have sometimes. After I read each one, please tell me how much that item has been a problem with your child over the past 6 months. Score each item as 0, 1, 2, or 3. If it’s never a problem, say 0. If it’s a problem once a week or less, say 1. If it happens about twice a week, say 2. If it happens almost every day, say 3. Administering the Parent Form in an interview enables you to monitor the parent’s under- standing of each item and, if necessary, clarify the questions. As parents respond to various questions, they may offer comments or anecdotal examples that can help you gain a clearer picture of the child's functioning and their reactions to it. The Teacher Form ‘The Teacher Form is for recording information from a nursery school or classroom teacher, daycare provider, or other caretaker outside the immediate family. If a child is in school and in an after-school or daycare setting, it is helpful to have his or her primary teacher and at least one childcare worker in the daycare setting complete a Teacher Form. The teacher or caretaker may add comments on the back of the form or on a separate page. You also may use the Teacher Form in a direct interview format. This may yield additional anecdotal information that could be helpful, but it is not necessary for the validity of the report. Administering Forms for Ages 8-12 Years ‘The Teacher, Parent, and Self-Report Forms comprise the Brown ADD Scales for Children ages 8-12 years. All three forms have very similar items, but each form is worded and normed specifically for the intended rater. Inside each form is a space for compiling scoring information. 15The Parent and Self-Report Forms ildret 12 years can be administered separately, er ete te roa pe) complete thet for before the iesew seton, Tiss especially helpful if two Parents are feneitana ae child, but only one is available to attend the ce eer When ae Parent Form is completed, itis important for you to have ie oy a oe with the parent(s) to elicit any questions they may have about speci for examples related to their responses. You may administer the Parent and Self-Report Forms individually or simultaneously a a interview with the child and parents. The conjoint administration enables you oo tion from both child and parents while gaining the opportunity to see how eacl nei iets others scoring on each item. However, norms are based on separate administrations to paren and child, and not collaborative responses. Therefore, T scores are valid only if parent and child have not influenced each other's responses, Individual Administration Before you begin, give the child and each parent a Copy of the response sheet provided at the end of this manual, As you administer the forms, you may child, Begin the interview by saying something like this to the child: Let’s do a couple for brush your teeth?” F your teeth almost everyday, ¥€ you probably brush et. You might say 1 if you forgot to brush your teeth only once or twi /ou brushed whole week, you would answer 2. if Ke cath you eon oe a Let’s do another one, < . 'chool?” You might say, “0, Never.” Some F : ae if they ride the bus, but er chron might say. Idren might say, "2, twice a be for you? if tis an almost every d lay problem, (Point to each response on the child’s sheet as you read.) For these questions we are {YOU to think about yoy in school since you started this grade. (IF eae than 5 to 6 months, Bers, like, “ls this a or is it a 22" ala i a 7 s thinking of. And remember, there arena Fight or wrong. answers on this. Just say how you think t is for you, Conjoint Administration tn the joint interview, ead aloud the question on the chiles form, and after the child has responded, elicit a response from the paren tem on the Parent Form, Parents usually can respond tothe oven Chapter 2 clicit the child’s response, (3) for the corresponding Ng read from the child'sform, but if they need clarification, You can read the phrasing of the corresponding item on the Parent Form aloud. If the Parent Form is administered to parents when the child is not present, each item should be read directly from the Parent Form. If the child is being interviewed conjointly with one or both parents, Say to the child: After you have given me your number for each item, 1am going to ask your Mom (and/or Pad) to tell me what score they would give for that problem, They will use the same 0.1.2.3, but they will be thinking about what they have seen with their own eyes, and what you have told them, and what your teachers have told them al n bout you. Don’t worry if your parents give a different number from yours. We don’t have to decide who is right. Il just write down both numbers. Now | am going to read this list of problems to you one at a time. After I read each one I will stop and ask you to tell me 0-1. 2 or 3 to say how much that problem is a problem for you. You can look at the paper I just gave you to help you remember what each number means. Alter all the parties seem to understand these directions, read the first item on the Self-Report Form aloud and then ask the student to score it with a number from 0 to 3. Mark the student’s Tesponse on the Self-Report Form in the row beside that item by circling the number beneath the column that tells how much the stucent believes that feeling or behavior has been a Problem in the past 6 months. After recording the student's score, ask the parent(s) how they want to score that item. Then record the parent’s response on the Parent Ready Score form (Parent Form) in the row beside that item by circling the number under the appropriate column, Daring the conjoint session, alternate between the Self-Report and Parent Forms as you elicit Tesponses from both the child and the parent(s), During the administration, if a parent speaks before the student answers or tries to get the student to modify an answer, you should interrupt and clarify that the student is being asked to sive an answer on his own, after which the parent will be asked to respond. This is important in that norms are based on individual administration of the (child’s) Self-Report, You may need to clarify some items during administration. If a student doesn’t seem to under- stand a particular item, paraphrase or give some examples to help them understand. For example, for Item 8, you might say, “This means that you might remember one or two little things that happened in the story, but you're not quite sure what the whole story was about.” lem 23 includes two parts that sometimes confuse a student. Tell the student to say the appro- priate number if either aspect is true. For item 26 you might cl: by saying: This is asking you if someone is bothering you or doing things that make you angry, can you usually say or do something to get them to quit it? I it’s hard for you to tell someone to quit bothering you, say 2 or 3; if t's not too hard for you to tell someone to quit bothering you, say 0 or 1. For item 36 clarification you might state: This means, if you think your teacher would say, “Oh, he cares a lot about trying to do good work,” say 0 or 1. But, if you think your teacher would say “Oh, he doesn’t care very much at all about trying to do good work,” then say 2 or 3. This is not about how much you really are about your work; itis about what you believe your teacher thinks about how much you care about doing good work. One particular comment that many children make as they are deciding how to score an item is “It all depends on whether it is something that interests me.” When a child appeats to be strug- sling with this dilemma, you might say, “Answer according to how you usually respond when it is just regular, not when it is something in which you have an especially strong interest.” In addi n to formal responses to items, a child’s incidental comments, anecdotal examples, and affective responses (e.g., laughter, sarcasm, embarrassment, resentment, rolled eyes) can. ‘Administering and Scoring the Ready Score? Formsi i ADD Scales for Children in a non- i information, If you are using the Brown AD for C n ; te anal ciation you may find it helpful to pause briefly and inquire oe interesting annem or to listen to a brief anecdote offered by the seuent ot Lia ae a a i les for Children for resé 4 a response. If you are using the Brown ADD Scal } ses, should not comin or make queries until after the full instrument has been administered. Administering all items of the Brown ADD Scales for Children usually takes 10 to 15 minutes. The time will vary according to how many responses you choose to query and how much you encourage the rater to elaborate. ‘PARENT FORM is Name ate see "Ro Cn his: ence Ci is cass Same ee ote — * even Com TT Figure 2.1 Examples of Parent, Teacher, for Ages 8-12 Years and Self-Report Ready Score Forms The Teacher Form You may use the Teacher Form in a direct interview or give it to the teacher(s) to complete and return later. The teacher who has the most contact with the child should complete the Teacher Form. If the child has more than one teacher, you may want to have the others complete and return the form as well. This enables you to examine the consistency of responses among teachers.ROVE] 12-18 Years Name DoB 1D Se aoe eee Sea Dee EEE ieee iiealal Sex [Male [1 Female Home Address City State Zip. Phone. Mother Father Primary language spoken at home. Adolescent lives with: [Mother (Father OBoth Other Evaluator Date of Evaluation ff his Diagnostic Form includes probes and forms for integrating clinical information for evaluating an adolescent 12- to 18-year-old) who may have AD/HD, executive function impairments, and related problems. Full directions or administration and interpretation of the Diagnostic Form for Adolescents-Revised are included in the manual for he Brown ADD Scales for Children and Adolescents (2001). This form may also be used with the manual for the Browit ADD Scales for Adolescents and Adults (1996). A. Clinical Interview With Adolescent and Parents B. Brown ADD Scales Threshold Interpretation and Cluster Scores Graphs C. Multi-Rater Evaluation for DSM-IV AD/HD Diagnostic Criteria D. Screener for other Learning and Psychiatric Disorders E, Examiner's Worksheet for Comparing Psychoeducational Test Scores F. Display of Psychoeducational Test Scores G. Summary of Diagnostic Data and Impressions paiag a Sanaa Serco RONEN Ackaeiad TAAASON I rcorson txccutveortce sc01 orcenvaley Drive Bloomington, th $5437 @PsychCorp ‘See SS tbe op a ani eee cecncaedoeca nage ees ene, arse ba ne Sher mar eerie eee Pearson, the PST logo, and PsychCorp are trademarks in the U.S. and/or other countries of Pearson Education, Inc, or its afliate(). Printed in the United States of America 161718 1920ABCOE Product Number 0154029270A. Clinical Interview With Adolescent and Parents “— ttis important to begin the clinica interview by questioning the adolescent frst, Most of the questions listed below aoe enor ne adolescent directly, You may rephrase questions as needed to ask the parent(s) about the adolescent," | Circle participants in the interview: Adolescent Mother Father Both Other: ——_4 1. Getting Started What's your understanding of why your parents have brought you here to talk with me today? How do you fee} about those reasons? Do you feel you have any problems in school or at home that you would like to change? Why are they and when did you first start to have these problems? 2. School and Peer Relationships ‘a. Current Schoolwork: Where do you go to school? What grade (year) are you in? What subjects (courses) do you have this term? What grades did you get on each subject on your last report card? How do those grades compare to what you usually get? Would you tell me about what you like or dislike about each of those courses/teachers? Do you get any extra help in school such as tutoring or special classes? b. Current (School) Relationships and Behavior: When you are in school, do you usually try to keep the rt ot do you get into trouble a lot? If you do get into trouble, what is it usually for? How often? Any detentions suspensions? At school, are you super popular, sort of popular, or not so popular? How often do you see or talk wit school friends after school, on weekends, or vacations? you have ©. Outside of School and at Home: What do you usually do after school most days? On weekends? Do a one or two friends you hang out with a lot, or do you hang out with a whole big bunch of friends, or do you oot 2 of things by yourself? What do you like to do for fun? Belong to any groups or teams? Take any lessons? AnY jobs? | : 4On most days, how much time do you usually spend on homework? How much of that time is actual work and how much is spent “circling the airport?” How do you think the time you spend on homework most nights compares with the time most other kids in your class spend on homework? When do you usually do your homework? Where? Does anyone help you with your homework or check your work? Are there frequent arguments at home about homework? Do teachers often complain about your homework being late or not done? © Self-Image: If were talking with kids who know you pretty well and asked them to describe you, what would they Probably say about you: Friendly and outgoing or quiet and shy? Good sense of humor or really serious? Gets angry Quickly and often, or doesn’t get angry very much? Mostly a leader or more a follower? Super smart, sort of smart, ©F not so smart? What things would they say you are really good at? ‘To parents: Do you agree with most of what you just heard? What would you add or have a different opinion about? Scores on Standardized Tests: Services: Currently or previously any special education or tutoring services being provided at school or outside? For what problems? For how long? Helpful? On IEP/S04 Plan?Previous School Experience: How are things going in school this year compared to previous years) uo concepts and skills? Getting work done? Behavior? Any special problems in early school years: Learning , = Learning math? Writing? at) 3. Family Family Members—To the adolescent: Who is in your family? Who lives with you? What are names and age your brothers/sisters? Where does each one go to school? Grade? Please tell me three things about each one. Wha they like to do? How they act? Treat you? If you forget about differences between age or gender, what isthe bges difference between you and (name of sibling)? What kind of work does your Dad do? What kind of work does jou { Mom do? Please tell me three things about your Mom and three things about your Dad. To the parent(s): Would each of you please tell me what schooling each of you has had and a little more about ya job, how long you have been there, and how much time you usually have to spend with your family? Family Stress—To the adolescent: Would you say that you usually do what you are supposed to at home: following directions, chores, keeping rules and curfew, showing respect? Do you get in trouble at home more than most Kids & ‘Are you rude to your parents? If you do get in trouble, what is it usually for? What punishments? Ever been ares : init ‘To the parent(s): Do you agree with most of what you just heard? What would you add or have a aitferent about? Have there been any special stresses in your fa ©.8., moving to a different home, se ny Spe esses in your family, i : loving to a differen es Problems, marital problems, losses, etc? |¢. Family Psychiatric History: To the parent(s): and adolescent: Please think of all the people in your immediate and extended family who are related by blood to (client’s name). [If adolescent is adopted, ask if information is available] Is there a blood-related relative, living or dead, who has had a lot of problems with paying attention or learning, or had other school problems? Do you have any blood relative(s) who seems much smarter than his/her school records might show? Anyone with a lot of problems with mood or being very hyper or both? Anyone who worries a lot/too much or who has panic attacks? Anyone with a really hot temper or who has lots of trouble controlling his/her behavior? Anyone with seri- ous drug or alcohol problems? For any such problems, note which side of family, whether diagnosed or just suspected. Ask how those family mem- bers have turned out or how they are now. 4, Health Health and Early Development—To the adolescent: How is your health’ Do you get sick much?. Do you have bad allergies?, Do you have problems with your vision or hearing? Do you wear glasses or contact lenses?. For what Do you take any medicines regularly?__ What medicines, and for what medical problems? Previously, what medicines did you take on a regular basis?, Have you ever been in the hospital overnight? For what?. When’ For how long Have you ever had a head injury that knocked you unconscious? 2