NICHQ Vanderbilt Assessment Scale - 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

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 obligations (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. Reading

Excellent Above Average Average Somewhat of a Problem Problematic

49. Writing

Excellent Above Average Average Somewhat of a Problem Problematic

50. Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

51. Relationship with parents

Excellent Above Average Average Somewhat of a Problem Problematic

52. Relationship with siblings

Excellent Above Average Average Somewhat of a Problem Problematic

53. Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

54. Participation in organized activities (eg, teams)

Excellent Above Average Average Somewhat of a Problem Problematic

Other Conditions

Tic Behaviors: To the best of your knowledge, please indicate if this child displays the following behaviors:

1. Motor Tics: Rapid, repetitive movements such as eye blinking, grimacing, nose twitching, head jerks, shoulder shrugs, arm jerks, body jerks, or rapid kicks.

No tics present.

Yes, they occur nearly every day but go unnoticed by most people.

Yes, noticeable tics occur nearly every day.

2. Phonic (Vocal) Tics: Repetitive noises including but not limited to throat clearing, coughing, whistling, sniffing, snorting, screeching, barking, grunting, or repetition of words or short phrases.

No tics present.

Yes, they occur nearly every day but go unnoticed by most people.

Yes, noticeable tics occur nearly every day.

3. If YES to 1 or 2, do these tics interfere with the child’s activities (like reading, writing, walking, talking, or eating)?

No

Yes

Previous Diagnosis and Treatment: To the best of your knowledge, please answer the following questions:

1. Has your child been diagnosed with a tic disorder or Tourette syndrome?

Yes No

2. Is your child on medication for a tic disorder or Tourette syndrome?

Yes No

3. Has your child been diagnosed with depression?

Yes No

4. Is your child on medication for depression?

Yes No

5. Has your child been diagnosed with an anxiety disorder?

Yes No

6. Is your child on medication for an anxiety disorder?

Yes No

7. Has your child been diagnosed with a learning or language disorder?

Yes No

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