The BIPOLAR CHILD PARENT QUESTIONNAIRE - Version 1.2

 

(80 Item Behavioral and Symptom Checklist)

Demitri Papolos, M.D.

 

Name of person filling out form (optional)____________________________.

Email address (optional)______________________________.

 

Gender_____Age (Yrs.)______(Mos.) ______Date of Birth___/___/_____

Checked off by:  Mother_____  Father_____  Other_______________.

My child was diagnosed  with bipolar disorder by __________________________ who is trained as a general psychiatrist_____ pediatrician_____

child psychiatrist_____ neurologist_____ other_______________________.

 

 

Instructions:

We need to establish that each child who participates in this survey meets criteria for bipolar disorder. To make this independent determination, we need to know what specific symptoms and behaviors your child has displayed.

 

My child has and/or had the following symptoms and/or behaviors (please check all that apply: Past, Current). For example, if your child did display excessive distress when separated from his/her parent in the PAST but not CURRENTLY, an X would only be placed under PAST.  If he/she continues to experience separation anxiety in the present, then both PAST and CURRENT would be selected with an “X”.

 

 

 

 


PAST

CURRENT

SYMPTOM/BEHAVIOR

 

 

1) excessive distress when separated from family

 

 

2) frequently exhibits excessive anxiety or worry

 

 

3) has difficulty arising in the AM

 

 

4) is hyperactive and easily excited in the PM

 

 

5) has difficulty settling at night

 

 

6) has difficulty getting to sleep

 

 

7) sleeps fitfully

 

 

8) often awakens in the middle of the night

 

 

9) has night terrors

 

 

10) grinds teeth

 

 

11) wets bed

 

 

12) often craves sweet tasting foods

 

 

13) is easily distracted by extraneous stimuli

 

 

14) displays periods of extreme hyperactivity

PAST

CURRENT

SYMPTOM/BEHAVIOR

 

 

15) demonstrates inability to concentrate at school

 

 

16) easily distracted during repetitive chores & lessons

 

 

17) frequently attempts to avoid homework assignments

 

 

18) has been diagnosed with a non-verbal learning disability

 

 

19) has poor handwriting

 

 

20) has periods of inflated self-esteem

 

 

21) often has difficulty organizing tasks

 

 

22) has difficulty making transitions

 

 

23) is extremely sensitive to textures of clothes, labels

 

 

24) is extremely sensitive to certain odors

 

 

25) focuses intently on subjects of interest

 

 

26) often complains of being bored

 

 

27) at times is easily excitable

 

 

28) has many ideas at once

 

 

29) often interrupts or intrudes on others

 

 

30) has periods of excessive and rapid speech

 

 

31) has exaggerated ideas about self or abilities

 

 

32) tells tall tales

 

 

33) experiences periods of self doubt and poor self-esteem

 

 

34) feels easily rejected

 

 

35) feels easily humiliated or shamed

 

 

36) refuses to be subordinated by others

 

 

37) exhibits extreme sensitivity to sound and noise

 

 

38) displays abrupt, rapid mood swings during the day

 

 

39) has frequent irritable mood states

 

 

40) has frequent silly, goofy, giddy mood states

 

 

41) displays precocious sexual curiosity

 

 

42) exhibits inappropriate sexual behaviors

 

 

43) often takes excessive risks

 

 

44) often has periods of low energy

 

 

45) often fidgets with hands or feet

 

 

46) has periods of high, frenetic energy

 

 

47) at times has decreased initiative

 

 

48) relentlessly pursues own needs

PAST

CURRENT

SYMPTOM/BEHAVIOR

 

 

49) often loses temper

 

 

50) is often demanding

 

 

51) often argues with adults

 

 

52) often defies or refuses to comply with rules

 

 

53) often blames others for his/her mistakes

 

 

54) frequently lies

 

 

55) is frequently angered in response to limit setting

 

 

56) often has protracted, explosive temper tantrums

 

 

57) is often bossy towards others

 

 

58) has difficulty maintaining friendships

 

 

59) displays aggressive behavior toward others

 

 

60) has destroyed property intentionally

 

 

61) often curses viciously, uses foul language in anger

 

 

62) makes moderate threats to others or self

 

 

63) makes clear threats of violence to others or self

 

 

64) has made clear threats of suicide

 

 

65) has cut self with sharp objects or engaged in body piercing

 

 

66) is both fearful of and fascinated with gore and blood

 

 

67) is fearful of and fascinated by violent, horrific images

 

 

68) experiences auditory and/or visual hallucinations

 

 

69) is fearful of clowns

 

 

70) has difficulty estimating time

 

 

71) has concern with dirt or germs

 

 

72) has rituals to seek reassurance from other persons

 

 

73) often hoards or avidly seeks to collect objects or food

 

 

74) is intolerant of delays

 

 

75) complains of feeling hot despite neutral outside temp.

 

 

76) has complained about body temperature extremes

 

 

77) is very intuitive

 

 

78) is very creative

 

 

79) is viewed by others as a leader

 

 

80) has auditory processing or short-term memory deficit