The Clinical Global Impression of Severity and Improvement

DETERMINING SEVERITY OF ILLNESS AND FUNCTIONAL IMPAIRMENT FOR CHILDREN AND ADOLESCENTS WITH ADHD AND DISRUPTIVE BEHAVIOUR DISORDERS

Instructions: The following categories for rating the SEVERITY OF ILLNESS are meant to provide general guidelines to clinicians who have a variety of sources of information regarding a patient, such as teacher and parent observations, history, developmental and academic information, or testing data.

Ratings of IMPROVEMENT use the same categories. For a patient to improve, he or she must move from one category to a lower category. Such changes are with reference to baseline severity as a benchmark comparison point. Similarly, ratings of worsening require an increase in score compared with baseline.

Although the categories are general, and some patients will fit more than one category, the clinician should try to make a best estimate on level of functioning based on the closest overall match to the categories.

1. The Normal child

• No significant problems socially, at home, or in school. Self-esteem is high
• Child makes and keeps friends easily and has good social skills
• Child socializes well, is considered empathic, and is concerned about the welfare of other classmates
• Home behaviour is generally in accord with family rules and expectations
• Child is considered easy to manage at home, with rare or no behaviour problems
• Child meets expectations for academic functioning in all or most areas of schooling
• Child is able to complete tasks satisfactorily and on time
• Child is considered well behaved at school with regards to classroom deportment
• Child has stable pattern of moods, copes well with stress, and has appropriate emotional reactions to challenges
• Child has a good repertoire of interests, activities and involvement in extra-curricular settings

2. Borderline Impairment.

• Problems are not present in more than one setting (home, school, peer relations, self-esteem/mood)
• Child has some problems in making or keeping friends, but is mostly well-accepted
• Some confrontations with peers or difficulties getting along or being accepted, but is not usually isolative or rejected
• There are some minor behaviour problems, oppositional, foot-dragging or stubbornness at home, but generally is considered responsive and manageable
• Child has some academic troubles or requires extra effort in homework or some difficulties in completing assignments, but usually manages eventually
• Is a minor problem in the class; occasionally disruptive or interfering, but most of the time is within acceptable limits for behaviour
• Some variability in mood; can be anxious or sad at times, but usually cheerful and in control of stress
• Interests and activities may be mildly restricted; child may feel "bored" by many activities but usually participates

3. Mildly Impaired

• Some impairment in a single area (social, family, school, self-esteem/mood)
• The level of impairment is such that it causes a definite problem needing some intervention, but does not pose a serious threat to family, school, social, self-esteem/mood)
• Child could get along without formal treatment beyond brief counselling or consultation
• Child or family may experience mild distress due to the problem, but overall feel that formal treatment may not be necessary

4. Moderately Impaired

• Some impairment in at least two areas of functioning (home, school, social, self-esteem and mood
• Some treatment is definitely indicated
• Distress in self or family is high on a frequent basis
• There are significant difficulties in managing behaviour or following expectations at home
• There are significant difficulties in school productivity, deportment, or social interactions. Grades are suffering or there is expectation of failure or rejection

5. Severely impaired

• There is impairment in three or more domains: home, school, social, or self/mood
• Treatment is necessary and desirable
• The level of impairment is such that it produces intolerable levels of stressful responses in the family, social and school environment
• There is marked resistance to authority and rules at home and school, or markedly disruptive behaviour in both of those settings
• There is a severe level of academic difficulty or academic productivity to a level requiring special educational or behavioural interventions
• The child has few friends or no friends at all; is frequently rejected or left off of teams; seldom if ever is invited to friends' houses

6. Extreme Impairment

• There is significant impairment in four domains: home, school, social, self/mood
• More than one modality of treatment is indicated
• Distress in self, home, school is very high and pervasive
• The child has virtually no friends; has difficulty making or keeping friends

7. Among the Most Extremely Impaired

• Unable to function at all in some areas of life; e.g., is not in school or will have to repeat grade; family looking to send the child away in desperation; no friends or social involvement
• Experiences enormous personal distress at inability to control behaviour; or is unaware of own behaviour until severe consequences result.
• Treatment seems mandatory to avoid inpatient restraints

CLINICAL GLOBAL IMPROVEMENT (CGI)

Rate total improvement whether or not, in your judgement, it is due entirely to Drug or other treatment intervention. Compared to his/her condition at assessment how much as he/she changed?

0 = Not assessed

1 = Very much improved The child has no symptoms at all, or only minor symptoms, that are brief and do not affect the child's daily activities or family routines.

2 = Much improved The child still has noticeable symptoms, and they sometimes affect the child's daily functioning and the family routine, but to a much lesser degree and/or less often than before study treatment.

3 = Minimally improved The child has shown noticeable improvement in some symptoms, but symptoms continue to affect the child's daily functioning and the family almost as much as before study treatment.

4 = No change The child has shown no noticeable change in symptoms since treatment started .

5 = Worse The child has shown noticeable worsening of some symptoms, but their effects on the child's daily functioning and on the family have not worsened

6 = Much worse The child has shown noticeable worsening of symptoms, and they have adversely affected the child and family on a daily basis.

7 = Very much worse The child has shown marked worsening of symptoms, and their effects on the child and family are severe.