Name_______ _____________________ Date__________________________

Symptom Check List for Mood DisorderTo be Completed by Parent for Children

SYMPTOM CHECK LISTAGES

SYMPTOMS AND BEHAVIORS 0 to 2 3 to 5 6 to 8 9 to 11 12 to 13 14 to 16 17 to 191. Bedwetting2. Night terrors3. Temper tantrums4. Excessive worry about harm befalling parents 5. Excessive distress when separated from family6. Extreme clinging behaviors7. Repeated complaints of physical symptoms8. Has marked changes in appetite9. Often has cravings for carbohydrates or sweets10. Periods of extreme sadness11. Elevated or irritable mood greater than 1hr/day12. Elevated or irritable mood greater than 6hrs/day13. Elevated or irritable mood greater than 2 days14. Depressed mood greater than 1hr/day15. Depressed mood greater than 6hrs/day16. Depressed mood 1-2 days in duration17. Depressed mood greater than 2 days in duration18. Has suicidal thoughts often19. Has cut self with sharp instrument20. Has made suicide attempt21. Has difficulty getting to sleep at night

AGESSYMPTOMS AND BEHAVIORS 0 to 2 3 to 5 6 to 8 9 to 11 12 to 13 14 to 16 17 to 1922. Often awakens in the middle of the night23. Frequently oversleeps24. Has decreased need to sleep25. At times has very fast speech26. Thoughts race/has many ideas at once27. Has wide swings in mood28. Often does not seem to listen when spoken to29. Often takes excessive risks30. Is easily distracted by extraneous stimuli31. Has periods of inflated self-esteem or grandiosity32. Has engaged in unrestrained buying sprees33. Often blurts out answers to questions34. Has difficulty engaging in playful activities35. As newborn, extremely irritable and difficult to settle36. Is extremely sensitive to sensory stimuli37. Often has difficulty organizing tasks38. Often loses things necessary for tasks39. Often is reluctant to engage in tasks40. Often fidgets with hands or feet41. Often leaves seat in classroom42. Often has difficulty waiting43. Often interrupts or intrudes on others44. Demonstrates an inability to concentrate at school

AGESSYMPTOMS AND BEHAVIORS 0 to 2 3 to 5 6 to 8 9 to 11 12 to 13 14 to 16 17 to 1945. Frequently attempts to avoid school46. Illicit drug use47. Alcohol use48. Migraine headaches49. Speech difficultiesspecify:_____________________50. Panic symptoms- marked anxiety attacks51. Excessive anxiety or worry (apprehensive expectation)52. Anxiety causes impairment in social functioning53. Marked and specific fear of closed spaces54. Marked and persistent fear of animals55. Marked and specific fear of heights56. Marked or specific fear of crowded places57. Hears voices58. Paranoid thinking59. Bizarre behavior specify:___________________60. Recurrent anxiety-producing thoughts or impulses61. Repetitive mental acts (counting, repeating words silently)62. Frequent and repetitive checking behavior63. Frequent and repetitive handwashing64. Tics: recurrent stereotyped movement or vocalization65. Frequently lies66. Has deliberately engaged in fire setting67. Is frequently mishievous68. Often bullies, threaten, or intimidates others69. Often initiates physical fights70. Has deliberately destroyed others property71. Has broken into someone's house

AGESSYMPTOMS AND BEHAVIORS 0 to 2 3 to 5 6 to 8 9 to 11 12 to 13 14 to 16 17 to 1972. Often lies to obtain good or favors73. Often stays out at night against curfew74. Has run away from home overnight at least twice75. Is often truant from school76. Often loses temper77. Often argues with adults78. Often defies or refuses to comply with rules79. Often blames others for his or her mistakes80. Is often touchy or easily annoyed by others81. Is often angry and resentful82. Has marked, persistent fear of social or performance situation83. Increased sexual interest84. Increased sexual behavior

85. Other:____________________

86. Other:____________________

87. Other:____________________

88. Other:____________________