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

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

3. Does not seem to listen when spoken to directly

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

5. Has difficulty organizing tasks and activities

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

8. Is easily distracted by extraneous stimuli

Never (0) Occasionally (1) Often (2) Very Often (3)

9. Is forgetful in daily activities

Never (0) Occasionally (1) Often (2) Very Often (3)

10. Fidgets with hands or feet or squirms in seat

Never (0) Occasionally (1) Often (2) Very Often (3)

11. Leaves seat when remaining seated is expected.

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

13. Has difficulty playing or beginning quiet play activities

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

15. Talk too much

Never (0) Occasionally (1) Often (2) Very Often (3)

16. Blurts out answers before questions have been completed

Never (0) Occasionally (1) Often (2) Very Often (3)

17. Has difficulty waiting his or her turn

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

19. Argues with adults

Never (0) Occasionally (1) Often (2) Very Often (3)

20. Loses temper

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

22. Deliberately annoys people

Never (0) Occasionally (1) Often (2) Very Often (3)

23. Blames others for his or her mistakes or misbehaviors

Never (0) Occasionally (1) Often (2) Very Often (3)

24. Is touchy or easily annoyed by others

Never (0) Occasionally (1) Often (2) Very Often (3)

25. Is angry or resentful

Never (0) Occasionally (1) Often (2) Very Often (3)

26. Is spiteful and wants to get even

Never (0) Occasionally (1) Often (2) Very Often (3)

27. Bullies threatens or intimidate others

Never (0) Occasionally (1) Often (2) Very Often (3)

28. Starts physical fights

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

31. Is physically cruel to people

Never (0) Occasionally (1) Often (2) Very Often (3)

32. Has stolen things that have value

Never (0) Occasionally (1) Often (2) Very Often (3)

33. Deliberately destroys other's property

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

35. Is physically cruel to animals

Never (0) Occasionally (1) Often (2) Very Often (3)

36. Has deliberately set fires to cause damage

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

38. Has stayed out at night without permission

Never (0) Occasionally (1) Often (2) Very Often (3)

39. Has run away from home overnight

Never (0) Occasionally (1) Often (2) Very Often (3)

40. has forced someone into sexual activity

Never (0) Occasionally (1) Often (2) Very Often (3)

41. Is fearful, anxious, or worried

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

43. Feels worthless or inferior

Never (0) Occasionally (1) Often (2) Very Often (3)

44. Blames self for problems, feels guilty

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

46. Is sad, unhappy, or depressed

Never (0) Occasionally (1) Often (2) Very Often (3)

47. Is self- conscious or easily embarrassed

Never (0) Occasionally (1) Often (2) Very Often (3)

Performance

48. Overall school performance

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

49. Reading

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

50. Written expression

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

51. Mathematics

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

52. Relationship with parents

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

53. Relationship with siblings

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

54. Relationship with peers

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

55. Participation in organized activities (eg, teams)

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

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.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children's Healthcare Quality.
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, M.D. Revised - 1102

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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