ADHD Follow Up Visits

ADHD CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION

NICHQ Vanderbilt Assessment 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. Please think about your child’s behaviors since the last assessment scale was filled out when rating his or her behaviors.

Is this evaluation based on a time when the child

was on medication was not on medication not sure?

If on medication, please list medication name and dose:

Symptoms

Never = 0 | Occasionally = 1 | Often = 2 | Very Often = 3

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

0 1 3 4

2. Has difficulty keeping attention to what needs to be done:

0 1 2 3

3. Does not seem to listen when spoken to directly:

0 1 2 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand):

0 1 2 3

5. Has difficulty organizing tasks and activities:

0 1 2 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort:

0 1 2 3

7. Loses things necessary for tasks or activities (toys, assignments. pencils. books):

0 1 2 3

8. Is easily distracted by noises or other stimuli:

0 1 2 3

9. Is forgetful in daily activities:

0 1 2 3

For Office use Only::

10. Fidgets with hands or feet or squirms in seat:

0 1 2 3

11. Leaves seat when remaining seated is expected:

0 1 2 3

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

0 1 2 3

13. Has difficulty playing or beginning quiet play activities:

0 1 2 3

14. Is "on the go" or often acts as if "driven by a motor":

0 1 2 3

15. Talks too much:

0 1 2 3

16. Blurts out answers before questions have been completed:

0 1 2 3

17. Has difficulty waiting his or her turn:

0 1 2 3

18. Interrupts or intrudes in on others' conversations and/or activities:

0 1 2 3

For Office use Only:

19. Argues with adults:

0 1 2 3

20. Loses temper:

0 1 2 3

21. Actively defies or refuses to go along with adults' requests or rules:

0 1 2 3

22. Deliberately annoys people

0 1 2 3

23. Blames others for his or her mistakes or misbehaviors:

0 1 2 3

24. Is touchy or easily annoyed by others:

0 1 2 3

25. Is angry or resentful:

0 1 2 3

26. Is spiteful and wants to get even

0 1 2 3

For Office use Only:

Performance

27. Reading

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

28. Writing

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

For Office use Only:

29. Mathematics

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

For Office use Only:

30. Relationship with parents

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

31. Relationship with siblings

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

32. Relationship with peers

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

For Office use Only:

33. Participation in organized activities (eg, teams)

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a Problem 5 = Problematic

For Office use Only:

Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.

Other Conditions

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

Headache Are these side effects currently a problem?

None Mild Moderate Severe

Stomachache Are these side effects currently a problem?

None Mild Moderate Severe

Change of appetite - explain below Are these side effects currently a problem?

None Mild Moderate Severe

Trouble sleeping Are these side effects currently a problem?

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening explain below Are these side effects currently a problem?

None Mild Moderate Severe

Socially withdrawn - decreased interaction with others Are these side effects currently a problem?

None Mild Moderate Severe

Extreme sadness or unusual crying Are these side effects currently a problem?

None Mild Moderate Severe

Dull, tired, listless behavior Are these side effects currently a problem?

None Mild Moderate Severe

Tremors/feeling shaky Are these side effects currently a problem?

None Mild Moderate Severe

Repetitive movements, tics, jerking, twitching, eye blinking - explain below Are these side effects currently a problem?

None Mild Moderate Severe

Picking at skin or fingers, nail biting, lip or check chewing - explain below Are these side effects currently a problem?

None Mild Moderate Severe

Sees or hears things that aren’t there Are these side effects currently a problem?

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.

For Office Use Only

Total number of questions scored 2 or 3s in questions 1-9:

Total number of questions scored 2 or 3s in questions 10-18:

Total number of questions scored 2 or 3s in questions 19-26:

Total number of questions scored 4 in questions 27-29:

Total number of questions scored 5 in questions 27-29:

Total number of questions scored 4 in questions 30-33:

Total number of questions scored 5 in questions 30-33:

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