These forms should not be used alone for the …

1 These forms should not be used alone for the diagnosis of any condition. 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 not pay attention to details or makes careless mistakes 0123with, for example, difficulty keeping attention to what needs to be not seem to listen when spoken to not follow through when given directions and fails to finish activities0123(not due to refusal or failure to understand) difficulty organizing tasks and , dislikes, or does not want to start tasks that require ongoing 0123mental things necessary for tasks or activities (toys, assignments, pencils,0123or books) easily distracted by noises or other forgetful in daily activities 012310.

2 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. 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.

3 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. 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, - 1102 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.

4 Has forced someone into sexual activity012341. 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. Relationship with peers1 2 3 4 555. Participation in organized activities (eg, teams) 1 2 3 4 5 Comments: nichq Vanderbilt Assessment Scale PARENT InformantToday s Date: _____ Child s Name: _____ Date of Birth: _____ Parent s Name:_____ Parent s Phone 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 26:_____Total number ofquestions scored 2 or 3 in questions 27 40:_____Total number ofquestions scored 2 or 3 in questions 41 47:_____To t a l n u m b e r o f q u e stions scored 4 or 5 in questions 48 55: _____Average Performance Score: _____HE0351 nichq Vanderbilt Assessment Scale TEACHER InformantTeacher s Name: _____ Class Time: _____ Class Name/Period: _____ Today s Date: _____ Child s Name: _____ Grade Level: _____Directions.

5 Each rating should be considered in the context of what is appropriate for the age of the child you are ratingand 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 Often 1. Fails to give attention to details or makes careless mistakes in schoolwork0123 2. Has difficulty sustaining attention to tasks or activities01233. Does not seem to listen when spoken to directly01234. Does not follow through on instructions and fails to finish schoolwork0123(not due to oppositional behavior or failure to understand)5. Has difficulty organizing tasks and activities01236. Avoids, dislikes, or is reluctant to engage in tasks that require sustained0123mental effort7. Loses things necessary for tasks or activities (school assignments,0123pencils, or books)8.

6 Is easily distracted by extraneous stimuli01239. Is forgetful in daily activities012310. 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.

7 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, - 0303D4D4 nichq Vanderbilt Assessment Scale TEACHER Informant, continuedTeacher s Name: _____ Class Time: _____ Class Name/Period: _____Today s Date: _____ Child s Name: _____ Grade Level: _____Symptoms (continued)NeverOccasionallyOftenVery Often32. Feels worthless or inferior012333. Blames self for problems; feels guilty012334.

8 Feels lonely, unwanted, or unloved; complains that no one loves him or her 012335. 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:Please return this form to: _____Mailing address: _____Fax number:_____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 28:_____Total number of questions scored 2 or 3 in questions 29 35:_____Total number of questions scored 4 or 5 in questions 36 43:_____Average Performance Score:_____11-20/rev0303 nichq Vanderbilt Assessment Follow-up 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 child.

9 Please think about your child s behaviors since the last assessment scale was filled out when rating his/her this evaluation based on a time when the child was on medication was not on medication not sure?SymptomsNeverOccasionallyOftenVery Often 1. Does not pay attention to details or makes careless mistakes with,0123for 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 to0123finish activities (not due to refusal or failure to understand)5. Has difficulty organizing tasks and activities01236. Avoids, dislikes, or does not want to start tasks that require0123ongoing mental 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 activities012310. Fidgets with hands or feet or squirms in seat012311.

10 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. Interrupts or intrudes in on others conversations and/or activities0123 SomewhatAboveof aPerformanceExcellentAverageAverageProbl emProblematic19. Overall school performance1234520. Reading1234521. Writing1234522. Mathematics1234523. Relationship with parents1234524. Relationship with siblings1234525. Relationship with peers1234526. Participation in organized activities (eg, teams)12345 The information contained in this publication should not be used as a substitute for themedical care and advice of your pediatrician. 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.