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NICHQ Vanderbilt Assessment Scale—TEACHER …

NICHQ Vanderbilt Assessment scale teacher InformantTeacher s Name: _____ Class Time: _____ Class Name/Period: _____ Today s Date: _____ Child s Name: _____ Grade Level: _____Directions:Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: this evaluation based on a time when the child was on medication was not on medication not sure?SymptomsNeverOccasionallyOftenVery to give attention to details or makes careless mistakes in schoolwork0123 difficulty sustaining attention to tasks or not seem to listen when spoken to not follow through on instructions and fails to finish schoolwork0123(not due to oppositional behavior or failure to understand) difficulty organizing tasks and , dislikes, or is reluctant to engage in tasks that require sustained0123mental things necessary for tasks or activities (school assignments,0123pencils, or books) easily distracted by extraneous forgetful in daily activities012310.

Symptoms (continued) Never Occasionally Often Very Often 32. Feels worthless or inferior 0 1 2 3 33. Blames self for problems; feels guilty 0 1 2 3

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Transcription of NICHQ Vanderbilt Assessment Scale—TEACHER …

1 NICHQ Vanderbilt Assessment scale teacher InformantTeacher s Name: _____ Class Time: _____ Class Name/Period: _____ Today s Date: _____ Child s Name: _____ Grade Level: _____Directions:Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: this evaluation based on a time when the child was on medication was not on medication not sure?SymptomsNeverOccasionallyOftenVery to give attention to details or makes careless mistakes in schoolwork0123 difficulty sustaining attention to tasks or not seem to listen when spoken to not follow through on instructions and fails to finish schoolwork0123(not due to oppositional behavior or failure to understand) difficulty organizing tasks and , dislikes, or is reluctant to engage in tasks that require sustained0123mental things necessary for tasks or activities (school assignments,0123pencils, or books) easily distracted by extraneous forgetful in daily activities012310.

2 Fidgets with hands or feet or squirms in seat012311. Leaves seat in classroom or in other situations in which remaining 0123seated is expected12. Runs about or climbs excessively in situations in which remaining 0123seated is expected13. Has difficulty playing or engaging in leisure activities quietly012314. Is on the go or often acts as if driven by a motor 012315. Talks excessively012316. Blurts out answers before questions have been completed012317. Has difficulty waiting in line012318. Interrupts or intrudes on others (eg, butts into conversations/games) 0123 19. Loses temper012320. Actively defies or refuses to comply with adult s requests or rules0123 21. Is angry or resentful012322. Is spiteful and vindictive012323. Bullies, threatens, or intimidates others012324. Initiates physical fights012325. Lies to obtain goods for favors or to avoid obligations (eg, cons others)012326.

3 Is physically cruel to people012327. Has stolen items of nontrivial value012328. Deliberately destroys others property012329. Is fearful, anxious, or worried012330. Is self-conscious or easily embarrassed012331. Is afraid to try new things for fear of making mistakes0123 The recommendations in this publication do not indicate an exclusive course of treatmentor serve as a standard of medical care. Variations, taking into account individual circum-stances, may be 2002 American Academy of Pediatrics and National Initiative for Children sHealthcare QualityAdapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, - 1102 Symptoms (continued)NeverOccasionallyOftenVery Often32. Feels worthless or inferior012333. Blames self for problems; feels guilty012334. Feels lonely, unwanted, or unloved; complains that no one loves him or her 012335.

4 Is sad, unhappy, or depressed0123 SomewhatPerformanceAboveof aAcademic PerformanceExcellentAverageAverageProble mProblematic36. Reading1234537. Mathematics1234538. Written expression12345 SomewhatAboveof aClassroom Behavioral PerformanceExcellentAverageAverageProble mProblematic39. Relationship with peers1234540. Following directions1234541. Disrupting class1234542. Assignment completion1234543. Organizational skills12345 Comments: NICHQ Vanderbilt Assessment scale teacher InformantTeacher s Name: _____ Class Time: _____ Class Name/Period: _____ Today s Date: _____ Child s Name: _____ Grade Level: _____Please return this form to: _____Mailing address: _____Fax number:_____For Office Use OnlyTotal number ofquestions scored 2 or 3 in questions 1 9:_____Total number ofquestions scored 2 or 3 in questions 10 18:_____Total Symptom Score for questions 1 18:_____Total number ofquestions scored 2 or 3 in questions 19 28:_____Total number ofquestions scored 2 or 3 in questions 29 35:_____Total number ofquestions scored 4 or 5 in questions 36 43:_____Average Performance Score: _____


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