NICHQ Vanderbilt Assessment Scale Follow-up - Teacher Informant

Today’s Date

Child’s Name

Child’s Date of Birth

Teacher’s Name

Class Time

Class Name/Period

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:

Symptoms

1. Fails to give attention to details or makes careless mistakes in schoolwork

Never Occasionally Often Very Often

2. Has difficulty sustaining attention to tasks or activities

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 on instructions and fails to finish schoolwork (not due to oppositional behavior 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 is reluctant to engage in tasks that require sustained mental effort

Never Occasionally Often Very Often

7. Loses things necessary for tasks or activities (school assignments, pencils, 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 in line

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

19. Loses temper

Never Occasionally Often Very Often

20. Activity defies or refuses to comply with adults’ requests or rules

Never Occasionally Often Very Often

21. Is angry or resentful

Never Occasionally Often Very Often

22. Is spiteful and vindictive

Never Occasionally Often Very Often

23. Bullies, threatens, or intimidates others

Never Occasionally Often Very Often

24. Initiates physical fights

Never Occasionally Often Very Often

25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)

Never Occasionally Often Very Often

26. Is physically cruel to people

Never Occasionally Often Very Often

27. Has stolen items of nontrivial value

Never Occasionally Often Very Often

28. Deliberately destroys others’ property

Never Occasionally Often Very Often

Academic Performance

29. Reading

Excellent Above Average Average Somewhat of a Problem Problematic

30. Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

31. Written expression

Excellent Above Average Average Somewhat of a Problem Problematic

Classroom Behavioral Performance

32. Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

33. Following directions

Excellent Above Average Average Somewhat of a Problem Problematic

34. Disrupting class

Excellent Above Average Average Somewhat of a Problem Problematic

35. Assignment completion

Excellent Above Average Average Somewhat of a Problem Problematic

36. Organizational skills

Excellent Above Average Average Somewhat of a Problem Problematic

Side Effects: Has the child experienced any of the following side effect or problems in the past week?

Are these side effects currently a problem?

Headache

None Mild Moderate Severe

Stomachache

None Mild Moderate Severe

Change of appetite - explain below

None Mild Moderate Severe

Trouble sleeping

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening - explain below

None Mild Moderate Severe

Socially withdrawn - decreased interaction with others

None Mild Moderate Severe

Extreme sadness or unusual crying

None Mild Moderate Severe

Dull, tired, listless behavior

None Mild Moderate Severe

Tremors/feeling shaky

None Mild Moderate Severe

Repetitive movements, tics, jerking, twitching, eye blinking - explain below

None Mild Moderate Severe

Picking at skin or fingers, nail biting, lip or check chewing - explain below

None Mild Moderate Severe

Sees or hears things that aren’t there

None Mild Moderate Severe

Explain/Comments

Adapted from the Pittsburgh side effects scale, developed by William E. Pelham, Jr, PhD. Available for downloading at no cost in expanded format at http://ccf.FIU.edu.

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