Vanderbilt Assessment Scale, Follow-up

ADHD Toolkit Parent-Informant Form

Child's name

Parent's name

Date

DOB

Age

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 since you last rated them.

This evaluation is based on a time when your child:

Was on medication Was not on medication Not sure

1. Does not pay attention to details or makes mistakes that seem careless with, for example, homework

Never Occasionally Often Very Often

2. Has difficulty keeping attention on 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 on instructions and does not finish activities (not because of refusal or lack of comprehension)

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 (eg, 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 games

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 into others’ conversations or activities or both

Never Occasionally Often Very Often

19. Loses temper

Never Occasionally Often Very Often

20. Is touchy or easily annoyed

Never Occasionally Often Very Often

21. Is angry or resentful

Never Occasionally Often Very Often

22. Argues with authority figures or adults

Never Occasionally Often Very Often

23. Actively defies or refuses to adhere to requests or rules

Never Occasionally Often Very Often

24. Deliberately annoys people

Never Occasionally Often Very Often

25. Blames others for his or her mistakes or behaviors

Never Occasionally Often Very Often

26. Is spiteful and wants to get even

Never Occasionally Often Very Often

27. Overall school performance

Excellent Above Average Average Somewhat of a Problem Problematic

28. Reading

Excellent Above Average Average Somewhat of a Problem Problematic

29. Writing

Excellent Above Average Average Somewhat of a Problem Problematic

30. Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

31. Relationship with parents

Excellent Above Average Average Somewhat of a Problem Problematic

32. Relationship with siblings

Excellent Above Average Average Somewhat of a Problem Problematic

33. Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

34. 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 effects or problems in the past week?

Headache

Never Mild Moderate Severe

Stomachache

Never Mild Moderate Severe

Change of appetite - explain below

Never Mild Moderate Severe

Trouble sleeping

Never Mild Moderate Severe

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

Never Mild Moderate Severe

Socially withdrawn—that is, decreased interaction with others

Never Mild Moderate Severe

Extreme sadness or unusual crying

Never Mild Moderate Severe

Dull, tired, listless behavior

Never Mild Moderate Severe

Tremors or feeling shaky or both

Never Mild Moderate Severe

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

Never Mild Moderate Severe

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

Never Mild Moderate Severe

Sees or hears things that aren’t there

Never Mild Moderate Severe

Explanations and other comments:

Disclaimer:

The recommendations in this resource 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. Original resource included as part of Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Edition.

Inclusion in this resource does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of the resources mentioned in this resource. Website addresses are as current as possible but may change at any time.

The American Academy of Pediatrics (AAP) does not review or endorse any modifications made to this resource and in no event shall the AAP be liable for any such changes.

© 2020 American Academy of Pediatrics. All rights reserved.

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