NICHQ Vanderbilt Assessment Scale Follow-up - Parent Informant

Today’s Date

Child’s Name

Child’s 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 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, books)

Never Occasionally Often Very Often

8. Is easily distracted by noises or other 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 when remaining seated is expected

Never Occasionally Often Very Often

12. Runs about or climbs too much when remaining seated is expected

Never Occasionally Often Very Often

13. Has difficulty playing or beginning quiet play activities

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 too much

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 in on others’ conversations and/or activities

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

Performance

27. Reading

Excellent Above Average Average Somewhat of a Problem Problematic

28. Writing

Excellent Above Average Average Somewhat of a Problem Problematic

29. Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

30. Relationship with parents

Excellent Above Average Average Somewhat of a Problem Problematic

31. Relationship with siblings

Excellent Above Average Average Somewhat of a Problem Problematic

32. Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

33. Participation in organized activities (eg, teams)

Excellent Above Average Average Somewhat of a Problem Problematic

Side Effects: Has your 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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