Instructions: Please print and complete this questionnaire. Completed questionnaires should be sent to:

Demitri F. Papolos, M.D. 7 Whitney Extension Westport, CT 06880	Check here if you would agree to be contacted by e-mail for a follow-up study.
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From The Bipolar Child Web site (http://www.bipolarchild.com) by Demitri F. Papolos, M.D. and Janice Papolos. All rights reserved.

Age of child __________ Child's Sex __________ Date of birth __________ Current grade level _____

Are you the child's mother, father, other (please circle) Child's current psychiatric diagnosis _______________________ Was there a previous diagnosis ___________________________ State of residence ______________________________________ Country of Residence ___________________________________ Ethnic Group: __Caucasian ___Black ___Hispanic ___Indo-European ___Native American ___Asian

Age and sex of siblings ___________________________________________________________

1.	How old was your child when you first noticed any behavioral symptoms (for example temper tantrums, night terrors, excessive clinginess, separation anxiety, hyperactivity, rapid speech, periods of sadness, periods of irritability or elation, obsessive thoughts? Age _____ Please describe what you observed.
2.	Is there a history of alcohol or substance abuse in the family? Yes No If yes, who has or had the problem? ______________________________________________ Is it on the  maternal  or  paternal  side, or both? (Please circle one)
3.	Do you or your spouse suffer with any of the following psychiatric disorders? Mother: depression    manic-depression    phobia    OCD    panic disorder Father: depression    manic-depression    phobia    OCD    panic disorder
4.	Does anyone else on either side of the family have recurrent depression or manic depression? Yes No If yes, who has the illness (e.g. a maternal or paternal grandmother or a maternal or paternal uncle, etc.)?
5.	Have there been any suicides in the family? Yes   No On what side? ___Maternal ___Paternal More than one suicide? _____ Degree of relation to the child? (eg. uncle, cousin, grandparent)_______________
6.	Does your child have learning disabilities? Yes   No If yes, specify: Check all that apply and give specifc examples of deficit(s) that you or a qualified professional have observed. ___Language ___Mathematical abstraction ___Speech ___Reading and Decoding (Dyslexia, reading comprehension) ___Visuo-spatial
7.	Was your child ever put on Ritalin or another stimulant? Yes No Who first told you that it might be of help for your child? ___Teacher ___Guidance counselor ___Pediatrician ___Child psychologist ___Child Psychiatrist ___Other________________________ Who prescribed the medication? (circle all that apply) Pediatrician  or  Child Psychiatrist  or  Internist  or  Neurologist or   Other (please specify) ____________________________________ How did he or she respond to the medication? Please circle all that apply. Attention: Improved    No change    Became more distractible Mood swings: Improved    No change    Mood swings increased Hyperactivity or restlessness: Decreased    No change    Increased Mental state of alertness and arousal: Increased    No Change    Decreased    Became Psychotic Aggressive Tendencies (check all that apply): Stayed the same Increased Diminished Oppositionality       Defiance       Bullying       Physical Fighting       If the behavior of the child worsened after treatment with Ritalin or another stimulant, please describe what you observed. Was your child ever placed on a major tranquilizer such as Risperidone or Zyprexa? Yes No Did any of the following behaviors emerge or become more exaggerate? (Choose all that apply) Obsessions___ Compulsions___ Tics___ Has the child had periods of depression? Yes    No What was the original episode (i.e., the first episode of illness that the child manifested)? Mania/hypomania ____ irritability ______elation_____depression_____ (check all that apply) At what age did your child manifest any of the above mood states for longer than 1 hour? __________ What was the duration of the first episode? __________ What age was your child when you first noticed that wide swings in mood were frequent features of his/her personality? Who long did these moods last when they first appeared? minutes______hrs,______days______Weeks______ Was there a prominent pattern to the mood and energy cycle that your child displayed during the day? Choose one, all or none of the below. My child typically would have difficulty arising in the AM, want to stay in bed, have low energy, and lower levels of activity than during the rest of the day. My child typically would have high levels of activity, beginning either in the late afternoon, or evening, and would often be wired, filled with energy, doing projects and had racing thougnts. My child was on the go all day and was difficult to settle at night. Other ___________________________________________________ ___________________________________________________ ___________________________________________________.
8.	If your child was initially diagnosed as depressed, was anti-depressant medication prescribed? Yes No Which one? Prozac___ Paxil___ Zoloft___ Luvox___ Effexor___ Celexa___ Wellbutrin___ Imipramine___ If Yes, how did he or she respond to the antidepressant? Mood improved   No change in mood   Mood swings increased Became more aggressive   had trouble sleeping   other (please specify)_____________ If the behavior of the child worsened after treatment with an antidepressant, please describe what changes in behavior you observed. What was the frequency of the episodes prior to any treament?

9.

This question is to assess the cycle frequency pattern of the illness. Cycle frequency, or episode frequency refers to the pattern of manic/hypomanic (high energy) and depressive (low energy) cycles that occur within a specified period of time. There are a number of cycle patterns, and they are not mutually exclusive. For example, a child or adolescence may have several swings of mood and energy within a day, and also have longer and more dramatic mood swings at a specific times of year in a regular pattern.This question displays six possible cycle patterns. Please check the box below the diagram for any or all that you think apply to your child.

Hypomania or Mania  Depression Monday Wednesday Full episode or more within a 24-28 hour period

Hypomania or Mania  Depression Monday Sunday Full episode within a week.

Hypomania or Mania  Depression April May One episode per month

Hypomania or Mania  Depression January December One episode per year (A single episode of mania/hypomania or depression of any duration lasting more than 1 week, and occuring at any time during a twelve month period.)

Hypomania or Mania  Depression January December Four or more full episodes per year (4 discrete periods of elevated mood and energy followed by depressed mood and low energy states or depression and irritability occuring at any time during a 12 month period).

Comments about episode frequency: Does your child have regular seasonal epsiodes Yes____ No____ Don't know_____ If Yes, do these occur in the Spring____Summer_____Fall_____Winter_____? (check all that apply) Depressions and low energy states occur most frequently in Spring____Summer_____Fall_____Winter_____? Hypomanias/mania and high energy states occur most often in the Spring____Summer_____Fall_____Winter_____?

	Quality of Response
Type of Medication	Age Started	Max. Dose in 24 hrs.	Length of Trial	Excellent Response	Moderate Response	Minimal Response	None or Worse	Side-Effects
Lithium Carbonate	___	___	___	___	___	___	___	___
Sodium Valproate (Depakote)	___	___	___	___	___	___	___	___
Carbamazepine (Tegretol)	___	___	___	___	___	___	___	___
Topamax (Topiramate)	___	___	___	___	___	___	___	___
Major Tranquilizers (Zyprexa)	___	___	___	___	___	___	___	___
Major Tranquilizers (Risperidone)	___	___	___	___	___	___	___	___
Minor Tranquilizers (e.g., Ativan)	___	___	___	___	___	___	___	___
Tricyclic Antidepressants (e.g., Imipramine)	___	___	___	___	___	___	___	___
SSRIs (e.g., Prozac, Paxil, Zoloft)	___	___	___	___	___	___	___	___
MAO Inhibitors (e.g., Parnate, Nardil)	___	___	___	___	___	___	___	___
Bupropion (Wellbutrin)	___	___	___	___	___	___	___	___
Other (please specify) ___________________	___	___	___	___	___	___	___	___

In order to obtain more specific data about early symptoms of bipolar disorder we ask you to look at the following chart and please check off any signs or symptoms of a behavioral or emotional nature that your child displayed. Indicate the age the symptom occurred by placing an X in the box that corresponds to the intersection of the age and the symptom. For example, Jason was first noted to have significant fidgetiness in nursery school at age 4. The fidgetiness persisted until he was treated at age 8.

EXAMPLE

You would mark with an X as in the following example

SYMPTOMS AND BEHAVIORS	Ages 0-2	Ages 3-5	Ages 6-8	Ages 9-11	Ages 12-14	Ages 15-17	Ages 18-20
1. Fidgetiness	_____	__X_	X T	_____	_____	_____	_____

Please place a T next to the X to indicate when and if treatment began for this symptom, as in the above example.

SYMPTOMS AND BEHAVIORS	Ages 0-2	Ages 3-5	Ages 6-8	Ages 9-11	Ages 12-14	Ages 15-17	Ages 18-20
1. Bed Wetting	__	__	_____	_____	_____	_____	_____
2. Night Terrors	_____	_____	_____	_____	_____	_____	_____
3. Temper Tantrums	_____	_____	_____	_____	_____	_____	_____
4. Excessive worry about harm befalling parents	_____	_____	_____	_____	_____	_____	_____
5. Excessive distress when separated from family	_____	_____	_____	_____	_____	_____	_____
6. Extreme clinging behavior	_____	_____	_____	_____	_____	_____	_____
7. Repeated complaints of physical symptoms	_____	_____	_____	_____	_____	_____	_____
8. Has marked changes in appetite	_____	_____	_____	_____	_____	_____	_____
9. Often has cravings for carbohydrates or sweets	_____	_____	_____	_____	_____	_____	_____
10. Periods of Extreme Sadness	_____	_____	_____	_____	_____	_____	_____
11. Elevated or Irritable Mood Greater than 1 hour	_____	_____	_____	_____	_____	_____	_____
12. Elevated or Irritable Mood Greater than 6 hours	_____	_____	_____	_____	_____	_____	_____
13. Elevated or Irritable Mood Greater than 2 days	_____	_____	_____	_____	_____	_____	_____
14. Depressed Mood Greater than 1 hour/day	_____	_____	_____	_____	_____	_____	_____
15. Depressed Mood Greater than 6 hours/day	_____	_____	_____	_____	_____	_____	_____
16. Depressed Mood 1 to 2 Days in duration	_____	_____	_____	_____	_____	_____	_____
17. Depressed Mood Greater than 2 Days in duration	_____	_____	_____	_____	_____	_____	_____
18. Has suicidal thoughts often	_____	_____	_____	_____	_____	_____	_____
19. Has cut self with sharp instrument	_____	_____	_____	_____	_____	_____	_____
20. Has made suicide attempt	_____	_____	_____	_____	_____	_____	_____
21. Has difficulty getting to sleep at night	_____	_____	_____	_____	_____	_____	_____
22. Often awakens in the middle of the night	_____	_____	_____	_____	_____	_____	_____
23. Frequently oversleeps	_____	_____	_____	_____	_____	_____	_____
24. Has decreased need for sleep	_____	_____	_____	_____	_____	_____	_____
25. At times has very fast speech	____	____	____	____	____	____	____
26. Thoughts race/has many ideas at once	____	____	____	____	____	____	____
29. Often takes excessive risks	____	____	____	____	____	____	____
30. Is easily distracted by extraneous stimuli	____	____	____	____	____	____	____
31. Has periods of inflated self-esteem or grandiosity	____	____	____	____	____	____	____
32. Has engaged in unrestrained buying sprees	____	____	____	____	____	____	____
33. Often blurts out answers to questions	____	____	____	____	____	____	____
34. Has difficulty engaging in playful activities	____	____	____	____	____	____	____
35. As a newborn, extremely irritable and difficult to settle	____	____	____	____	____	____	____
36. Is extremely sensitive to sensory stimuli	____	____	____	____	____	____	____
37. Often has difficulty organizing tasks	____	____	____	____	____	____	____
38. Often loses things necessary for tasks	____	____	____	____	____	____	____
39. Often is reluctant to engage in tasks	____	____	____	____	____	____	____
40. Often fidgets with hands or feet	____	____	____	____	____	____	____
41. Often leaves seat in classroom	____	____	____	____	____	____	____
42. Often has difficulty waiting turn	____	____	____	____	____	____	____
43. Often interrupts or intrudes on others	____	____	____	____	____	____	____
44. Demonstrates an inability to concentrate at school	____	____	____	____	____	____	____
45. Frequently attempts to avoid school	____	____	____	____	____	____	____
46. Illicit drug use	____	____	____	____	____	____	____
47. Alcohol use	____	____	____	____	____	____	____
48. Migraine headaches	____	____	____	____	____	____	____
49. Speech difficulties, (specify) _______________________	____	____	____	____	____	____	____
50. Panic Symptoms/Marked anxiety attacks	____	____	____	____	____	____	____
51. Excessive anxiety or worry (apprehensive expectation)	____	____	____	____	____	____	____
52. Anxiety causes impairment in social functioning	____	____	____	____	____	____	____
53. Marked and specific fear of closed spaces	____	____	____	____	____	____	____
54. Marked and persistent fear of animals	____	____	____	____	____	____	____
55. Marked and specific fear of heights	____	____	____	____	____	____	____
56. Marked or specific fear of crowded places	____	____	____	____	____	____	____
57. Hears voices	____	____	____	____	____	____	____
58. Paranoid thinking	____	____	____	____	____	____	____
59. Bizarre behavior, (specify) _________________________	____	____	____	____	____	____	____
60. Recurrent anxiety-producing thoughts or impulses	____	____	____	____	____	____	____
61. Repetitive mental acts (counting, repeating words silently)	____	____	____	____	____	____	____
62. Frequent and repetitive checking behavior	____	____	____	____	____	____	____
63. Frequent and repetitive hand-washing	____	____	____	____	____	____	____
64. Tics: recurrent stereotyped movements or vocalizations	____	____	____	____	____	____	____
65. Frequently lies	____	____	____	____	____	____	____
66. Has deliberately engaged in fire setting	____	____	____	____	____	____	____
67. Is frequently mischievous	____	____	____	____	____	____	____
68. Often bullies, threatens or intimidates others	____	____	____	____	____	____	____
69. Often initiates physical fights	____	____	____	____	____	____	____
70. Has deliberately destroyed others property	____	____	____	____	____	____	____
71. Has broken into someone's house	____	____	____	____	____	____	____
72. Often lies to obtain goods or favors	____	____	____	____	____	____	____
73. Often stays out at night against curfew	____	____	____	____	____	____	____
74. Has run away from home overnight at least twice	____	____	____	____	____	____	____
75. Is often truant from school	____	____	____	____	____	____	____
76. Often loses temper	____	____	____	____	____	____	____
77. Often argues with adults	____	____	____	____	____	____	____
78. Often defies or refuses to comply with rules	____	____	____	____	____	____	____
79. Often blames others for his or her mistakes	____	____	____	____	____	____	____
80. Is often touchy or easily annoyed by others	____	____	____	____	____	____	____
81. Is often angry and resentful	____	____	____	____	____	____	____
82. Has marked, persistent fear of social or performance situation	____	____	____	____	____	____	____
83. Increased or heightened sexual concerns	____	____	____	____	____	____	____
84. Has periods of excessive sexual activity	____	____	____	____	____	____	____
85. Engages innappropriate sexual public displays	____	____	____	____	____	____	____