NICHQ Vanderbilt Assessment Scale (PARENT Informant)

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

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

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

3. Does not seem to listen when spoken to directly

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

5. Has difficulty organizing tasks and activities

6. Avoids dislikes or is reluctant to engage in tasks that require sustained mental effort.

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

8. Is easily distracted by extraneous stimuli

9. Is forgetful in daily activities

10. Fidgets with hands or feet or squirms in seat

11. Leaves seat when remaining seated is expected.

12. Runs about or climbs too much in situations in which remaining seated is expected

13. Has difficulty playing or beginning quiet play activities

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

15. Talk too much

16. Blurts out answers before questions have been completed

17. Has difficulty waiting his or her turn

18. Interrupts or intrudes in on other's conversations and/or activities

19. Argues with adults

20. Loses temper

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

22. Deliberately annoys people

23. Blames others for his or her mistakes or misbehaviors

24. Is touchy or easily annoyed by others

25. Is angry or resentful

26. Is spiteful and wants to get even

27. Bullies threatens or intimidate others

28. Starts physical fights

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

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

31. Is physically cruel to people

32. Has stolen things that have value

33. Deliberately destroys other's property

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

35. Is physically cruel to animals

36. Has deliberately set fires to cause damage

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

38. Has stayed out at night without permission

39. Has run away from home overnight

40. has forced someone into sexual activity

41. Is fearful, anxious, or worried

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

43. Feels worthless or inferior

44. Blames self for problems, feels guilty

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

46. Is sad, unhappy, or depressed

47. Is self- conscious or easily embarrassed

Performance

48. Overall school performance

49. Reading

50. Written expression

51. Mathematics

52. Relationship with parents

53. Relationship with siblings

54. Relationship with peers

55. Participation in organized activities (eg, teams)

Comments:

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

For Office Use Only

Total 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:

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