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