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 |
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1) excessive distress
when separated from family |
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2) frequently exhibits
excessive anxiety or worry |
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3) has difficulty arising
in the AM |
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4) is hyperactive and
easily excited in the PM |
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5) has difficulty
settling at night |
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6) has difficulty getting
to sleep |
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7) sleeps fitfully |
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8) often awakens in the
middle of the night |
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9) has night terrors |
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10) grinds teeth |
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11) wets bed |
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12) often craves sweet
tasting foods |
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13) is easily distracted
by extraneous stimuli |
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14) displays periods of
extreme hyperactivity |
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PAST |
CURRENT |
SYMPTOM/BEHAVIOR |
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15) demonstrates
inability to concentrate at school |
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16) easily distracted
during repetitive chores & lessons |
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17) frequently attempts
to avoid homework assignments |
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18) has been diagnosed
with a non-verbal learning disability |
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19) has poor handwriting |
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20) has periods of
inflated self-esteem |
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21) often has difficulty
organizing tasks |
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22) has difficulty making
transitions |
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23) is extremely
sensitive to textures of clothes, labels |
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24) is extremely
sensitive to certain odors |
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25) focuses intently on
subjects of interest |
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26) often complains of
being bored |
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27) at times is easily
excitable |
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28) has many ideas at
once |
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29) often interrupts or
intrudes on others |
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30) has periods of
excessive and rapid speech |
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31) has exaggerated ideas
about self or abilities |
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32) tells tall tales |
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33) experiences periods
of self doubt and poor self-esteem |
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34) feels easily rejected |
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35) feels easily
humiliated or shamed |
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36) refuses to be
subordinated by others |
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37) exhibits extreme
sensitivity to sound and noise |
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38) displays abrupt,
rapid mood swings during the day |
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39) has frequent
irritable mood states |
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40) has frequent silly,
goofy, giddy mood states |
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41) displays precocious
sexual curiosity |
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42) exhibits
inappropriate sexual behaviors |
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43) often takes excessive
risks |
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44) often has periods of
low energy |
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45) often fidgets with
hands or feet |
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46) has periods of high,
frenetic energy |
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47) at times has
decreased initiative |
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48) relentlessly pursues
own needs |
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PAST |
CURRENT |
SYMPTOM/BEHAVIOR |
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49) often loses temper |
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50) is often demanding |
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51) often argues with
adults |
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52) often defies or
refuses to comply with rules |
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53) often blames others
for his/her mistakes |
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54) frequently lies |
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55) is frequently angered
in response to limit setting |
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56) often has protracted,
explosive temper tantrums |
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57) is often bossy
towards others |
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58) has difficulty
maintaining friendships |
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59) displays aggressive
behavior toward others |
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60) has destroyed
property intentionally |
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61) often curses
viciously, uses foul language in anger |
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62) makes moderate
threats to others or self |
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63) makes clear threats
of violence to others or self |
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64) has made clear
threats of suicide |
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65) has cut self with
sharp objects or engaged in body piercing |
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66) is both fearful of
and fascinated with gore and blood |
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67) is fearful of and
fascinated by violent, horrific images |
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68) experiences auditory
and/or visual hallucinations |
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69) is fearful of clowns |
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70) has difficulty
estimating time |
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71) has concern with dirt
or germs |
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72) has rituals to seek
reassurance from other persons |
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73) often hoards or
avidly seeks to collect objects or food |
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74) is intolerant of
delays |
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75) complains of feeling
hot despite neutral outside temp. |
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76) has complained about
body temperature extremes |
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77) is very intuitive |
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78) is very creative |
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79) is viewed by others
as a leader |
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80) has auditory
processing or short-term memory deficit |
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