3 years ago

Child & Youth Mental Health Algorithm - GPSC

Child & Youth Mental Health Algorithm - GPSC


Psychiatric HistoryAssessed in childhood/adolescence/adulthood? No Yes By whom:Previous diagnoses:Previous suicidal attempts or violent gesturestoward others: No YesDetails:Psychological treatments: No YesPrevious psychiatricevaluation/hospitalization: No YesDevelopmental HistoryPregnancy Problems: No YesDelivery on time Early (# of weeks: ______ )Late (# of weeks: ______ ) forceps usedCaesarean sectionbreechDetails:Difficulties gross motor: crawl, walk, two-wheeler,gym, sports: No YesDifficulties Fine motor: tracing, shoe laces,printing, writing: No YesLanguage difficulties: first language, first words,full sentences, stuttering No YesOdd behaviours noted:(e.g. rocking, flapping, no eye contact, odd play,head banging etc) No YesTemperament: (eg. difficult, willful, hyper, easy, quiet, happy, affectionate, calm, self soothes, intense)Parent description of child's temperament:Learning Disorder identified: No Yes dyslexia dysorthographia dyscalculia dsyphasia other: _____________Family History in First Degree RelativesChildhood temperament of the biological parents, if known: (e.g. internalizing versus externalizing)Father:Mother:Positive family history of:ADHD (probable) ADHD (confirmed) Learning Disorders Mental RetardationAutism Spectrum Disorders Congenital Disorders Anxiety DepressionBipolar Psychosis Personality Disorders SuicideSleep Disorders Tourette's/Tics Epilepsy Alcohol/Drug ProblemsLegal ConvictionsHistory of early cardiac death Known arrhythmias HypertensionDetails:________________________________________________________________________________________________________________________________________________________________________________________________CADDRA ADHD ASSESSMENT FORM 5/1291

Functioning and Lifestyle EvaluationGeneral Habits (depending on the subject’s age, some may not apply). Give frequency and/or details:ExerciseNutritionSelf care, personal hygieneAdequate leisure activitySleep Routine and Bedtime: Time to fall asleep: Wake up time:Quality of Sleep # Sleep hours: Melatonin: No Yes Dose:Sleep Problems? (BEARS) Bedtime resistance: No Yes Regularity: No YesExcessive daytime sleepiness: No Yes Snoring: No YesAwakening: No YesImportant Risk Factors to IdentifyIdentified Risk Factor No Yes Details and Attitude towards ChangeExcessive time on computer, TV,video gamesRepetitive accidents or injuriesExtreme sports (e.g. motorcycle,snowboarding, skateboarding, racing)Energy drinks, caffeineNicotine (e.g. including cigarettes,cigars, chewing tobacco)Alcohol (e.g. binge drinking, blackouts,seizures, DUI, complaints)Drug use/abuse (e.g. cannabis, acid,mushrooms, cocaine, stimulants, heroin,abuse of prescription drugs)Financial impulse (e.g. gambling,shopping, stock trading, real estate failure)Financial risk (e.g. bankruptcy, poormoney management, significant debt)Driving problems (e.g. speeding,lost license, accidents, violations)Relationship risks (e.g. lack ofcommitment, infidelity, unprotected sex)Parenting problems (e.g. Children’s Aid,inconsistent parenting, overwhelmed)Disciplinary or legal action(s)92 Version: January 2011. Refer to for latest updates.CADDRA ADHD ASSESSMENT FORM 6/12

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