Vanderbilt Assessment Scale

ADHD Toolkit Teacher-Informant Form

Child's name

Teacher's name

Date

School

Grade

Teacher's fax number

Time of day you work with child

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 behaviors of the school year.

Please indicate the number of weeks or months you have been able to evaluate the behaviors:

This evaluation is based on a time when your child:

Was on medication Was not on medication Not sure

1. Does not give attention to details or makes mistakes that seem careless in schoolwork

Never Occasionally Often Very Often

2. Has difficulty sustaining attention on 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 does not finish schoolwork (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 sustained mental effort

Never Occasionally Often Very Often

7. Loses things necessary for tasks or activities (eg, 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 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 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 excessively

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 on others’ conversations or activities

Never Occasionally Often Very Often

19. Loses temper

Never Occasionally Often Very Often

20. Actively defies or refuses to adhere to adult’s 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 get out of trouble or to avoid obligations (ie, cons others)

Never Occasionally Often Very Often

26. Is physically cruel to people

Never Occasionally Often Very Often

27. Has stolen things of nontrivial value

Never Occasionally Often Very Often

28. Deliberately destroys others’ property

Never Occasionally Often Very Often

29. Is fearful, anxious, or worried

Never Occasionally Often Very Often

30. Is self-conscious or easily embarrassed

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

32. Feels worthless or inferior

Never Occasionally Often Very Often

33. Blames self for problems or feels guilty

Never Occasionally Often Very Often

34. Feels lonely, unwanted, or unloved; often says that no one loves him or her

Never Occasionally Often Very Often

35. Is sad, unhappy, or depressed

Never Occasionally Often Very Often

36. Reading

Excellent Above Average Average Somewhat of a Problem Problematic

37. Writing

Excellent Above Average Average Somewhat of a Problem Problematic

38. Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

39. Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

40. Following directions

Excellent Above Average Average Somewhat of a Problem Problematic

41. Disrupting class

Excellent Above Average Average Somewhat of a Problem Problematic

42. Assignment completion

Excellent Above Average Average Somewhat of a Problem Problematic

43. Organizational skills

Excellent Above Average Average Somewhat of a Problem Problematic

Comments:

Tic behaviors: To the best of your knowledge, please indicate if your 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, and 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, and 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 your child’s activities (eg, reading, writing, walking, talking, eating)?

No Yes

Previous diagnosis and treatment: Please answer the following questions to the best of your knowledge:

1.Has your child been diagnosed as having ADHD or ADD?

No Yes

2.Is he or she on medication for ADHD or ADD?

No Yes

3.Has your child been diagnosed as having a tic disorder or Tourette syndrome?

No Yes

4.Is he or she on medication for a tic disorder or Tourette disorder?

No Yes

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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