NICHQ Vanderbilt Assessment Scale

Today'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 the child. When completing this form, please think about your child's behaviors in the past 6 months.

Please indicate the number of weeks or months you have been able to evaluate the behaviors:

Is this evaluation based on a time when the child

was on medication

was not on medication

not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework:

Never

Occasionally

Often

Very Often

2. Has difficulty keeping attention to what needs to be done:

Never

Occasionally

Often

Very Often

3. Does not seem to listen when spoken to directly:

Never

Occasionally

Often

Very Often

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand):

Never Occasionally

Often

Very Often

5. Has difficulty organizing tasks and activities:

Never

Occasionally

Often

Very Often

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort:

Never

Occasionally

Often

Very Often

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books):

Never

Occasionally

Often

Very Often

8. Is easily distracted by extraneous stimuli:

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities:

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat:

Never

Occasionally

Often

Very Often

11. Leaves seat in classroom or in other situations in which remaining seated is expected:

Never

Occasionally

Often

Very Often

12. Runs about or climbs excessively in situations in which remaining seated is expected:

Never

Occasionally

Often

Very Often

13. Has difficulty playing or engaging in leisure activities quietly:

Never

Occasionally

Often

Very Often

14. Is "on the go" or often acts as if "driven by a motor":

Never

Occasionally

Often

Very Often

15. Talks excessively:

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed:

Never

Occasionally

Often

Very Often

17. Has difficulty waiting his or her turn:

Never

Occasionally

Often

Very Often

18. Interrupts or intrudes on others (eg, butts into conversations/games):

Never

Occasionally

Often

Very Often

19. Argues with adults:

Never

Occasionally

Often

Very Often

20. Loses temper:

Never

Occasionally

Often

Very Often

21. Actively defies or refuses to go along with adults' requests or rules:

Never

Occasionally

Often

Very Often

22. Deliberately annoys people:

Never

Occasionally

Often

Very Often

23. Blames others for his or her mistakes or misbehaviors:

Never

Occasionally

Often

Very Often

24. Is touchy or easily annoyed by others:

Never

Occasionally

Often

Very Often

25. Is angry or resentful:

Never

Occasionally

Often

Very Often

26. Is spiteful and wants to get even:

Never

Occasionally

Often

Very Often

27. Bullies, threatens, or intimidates others:

Never

Occasionally

Often

Very Often

28. Starts physical fights:

Never

Occasionally

Often

Very Often

29. Lies to get out of trouble or to avoid obligation (ie, "cons" others):

Never Occasionally Often Very Often

30. Is truant from school (skips school) without permission:

Never

Occasionally

Often

Very Often

31. Is physically cruel to people:

Never

Occasionally

Often

Very Often

32. Has stolen things that have value:

Never

Occasionally

Often

Very Often

33. Deliberately destroys others' property:

Never

Occasionally

Often

Very Often

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun):

Never

Occasionally

Often

Very Often

35. Is physically cruel to animals:

Never

Occasionally

Often

Very Often

36. Has deliberately set fires to cause damage:

Never

Occasionally

Often

Very Often

37. Has broken into someone else's home, business, or car:

Never

Occasionally

Often

Very Often

38. Has stayed out at night without permission:

Never

Occasionally

Often

Very Often

39. Has run away from home overnight:

Never

Occasionally

Often

Very Often

40. Has forced someone into sexual activity:

Never

Occasionally

Often

Very Often

41. Is fearful, anxious, or worried:

Never

Occasionally

Often

Very Often

42. Is afraid to try new things for fear of making mistakes:

Never

Occasionally

Often

Very Often

43. Feels worthless or inferior:

Never

Occasionally

Often

Very Often

44. Blames self for problems, feels guilty:

Never

Occasionally

Often

Very Often

45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her":

Never

Occasionally

Often

Very Often

46. Is sad, unhappy, or depressed:

Never

Occasionally

Often

Very Often

47. Is self-conscious or easily embarrassed:

Never

Occasionally

Often

Very Often

Performance

48. Overall school performance:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

49. Reading:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

50. Writing:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

51. Mathematics:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

52. Relationship with parents:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

53. Relationship with siblings:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

54. Relationship with peers:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

55. Participation in organized activities (eg, teams):

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Comments:

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NICHQ Vanderbilt Assessment Scale - PARENT Informant

Symptoms

Performance