Transcription of NICHQ Vanderbilt Assessment Scale—PARENT Informant
1 NICHQ Vanderbilt Assessment scale PARENT InformantToday s Date: _____ Child s Name: _____ Date of Birth: _____ Parent s Name: _____ Parent s Phone Number: _____Directions:Each rating should be considered in the context of what is appropriate for the age of your completing this form, please think about your child s behaviors in the past 6 this evaluation based on a time when the child was on medication was not on medication not sure?SymptomsNeverOccasionallyOftenVery Often1. Does not pay attention to details or makes careless mistakes 0123with, for example, homework2. Has difficulty keeping attention to what needs to be done01233. Does not seem to listen when spoken to directly01234. Does not follow through when given directions and fails to finish activities0123(not due to refusal or failure to understand)5.
2 Has difficulty organizing tasks and activities01236. Avoids, dislikes, or does not want to start tasks that require ongoing 0123mental effort7. Loses things necessary for tasks or activities (toys, assignments, pencils,0123or books)8. Is easily distracted by noises or other stimuli01239. Is forgetful in daily activities 012310. Fidgets with hands or feet or squirms in seat012311. Leaves seat when remaining seated is expected012312. Runs about or climbs too much when remaining seated is expected012313. Has difficulty playing or beginning quiet play activities 012314. Is on the go or often acts as if driven by a motor 012315. Talks too much012316. Blurts out answers before questions have been completed012317. Has difficulty waiting his or her turn012318.
3 Interrupts or intrudes in on others conversations and/or activities012319. Argues with adults012320. Loses temper012321. Actively defies or refuses to go along with adults requests or rules012322. Deliberately annoys people012323. Blames others for his or her mistakes or misbehaviors012324. Is touchy or easily annoyed by others012325. Is angry or resentful012326. Is spiteful and wants to get even012327. Bullies, threatens, or intimidates others012328. Starts physical fights012329. Lies to get out of trouble or to avoid obligations (ie, cons others)012330. Is truant from school (skips school) without permission012331. Is physically cruel to people012332. Has stolen things that have value0123 The information contained in this publication should not be used as a substitute for themedical care and advice of your pediatrician.
4 There may be variations in treatment thatyour pediatrician may recommend based on individual facts and 2002 American Academy of Pediatrics and National Initiative for Children sHealthcare QualityAdapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, - 1102D3HE0350 Symptoms (continued)NeverOccasionallyOftenVery Often33. Deliberately destroys others property012334. Has used a weapon that can cause serious harm (bat, knife, brick, gun)012335. Is physically cruel to animals012336. Has deliberately set fires to cause damage012337. Has broken into someone else s home, business, or car012338. Has stayed out at night without permission012339. Has run away from home overnight012340. Has forced someone into sexual activity012341.
5 Is fearful, anxious, or worried012342. Is afraid to try new things for fear of making mistakes012343. Feels worthless or inferior012344. Blames self for problems, feels guilty012345. Feels lonely, unwanted, or unloved; complains that no one loves him or her 012346. Is sad, unhappy, or depressed012347. Is self-conscious or easily embarrassed0123 SomewhatAboveof aPerformanceExcellentAverageAverageProbl emProblematic48. Overall school performance1 2 3 4 549. Reading1 2 3 4 550. Writing1 2 3 4 551. Mathematics1 2 3 4 552. Relationship with parents1 2 3 4 553. Relationship with siblings1 2 3 4 554.
6 Relationship with peers1 2 3 4 555. Participation in organized activities (eg, teams) 1 2 3 4 5 Comments:For Office Use OnlyTotal number of questions scored 2 or 3 in questions 1 9:_____Total number of questions scored 2 or 3 in questions 10 18:_____Total Symptom Score for questions 1 18:_____Total number of questions scored 2 or 3 in questions 19 26:_____Total number of questions scored 2 or 3 in questions 27 40:_____Total number of questions scored 2 or 3 in questions 41 47:_____Total number of questions scored 4 or 5 in questions 48 55:_____Average Performance Score:_____D3 NICHQ Vanderbilt Assessment scale PARENT Informant , continuedToday s Date: _____ Child s Name: _____ Date of Birth: _____ Parent s Name.
7 _____ Parent s Phone Number: _____11-19/rev1102
