The SNAP-IV Teacher and Parent Rating Scale

Patient Name

Gender

Age

Grade

Ethnicity

Completed by:

Type of Class:

Class Size:

For each item, check the column which best describes this child:

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks

Not at all Just a little Quite a bit Very much

Often has difficulty sustaining attention in tasks or play activities

Not at all Just a little Quite a bit Very much

Often does not seem to listen when spoken to directly

Not at all Just a little Quite a bit Very much

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

Not at all Just a little Quite a bit Very much

Often has difficulty organizing tasks and activities

Not at all Just a little Quite a bit Very much

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

Not at all Just a little Quite a bit Very much

Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)

Not at all Just a little Quite a bit Very much

Often is distracted by extraneous stimuli

Not at all Just a little Quite a bit Very much

Often is forgetful in daily activities

Not at all Just a little Quite a bit Very much

Often has difficulty maintaining alertness, orienting to requests, or executing directions

Not at all Just a little Quite a bit Very much

Often fidgets with hands or feet or squirms in seat

Not at all Just a little Quite a bit Very much

Often leaves seat in classroom or in other situations in which remaining seated is expected

Not at all Just a little Quite a bit Very much

Often runs about or climbs excessively in situations in which it is inappropriate

Not at all Just a little Quite a bit Very much

Often has difficulty playing or engaging in leisure activities quietly

Not at all Just a little Quite a bit Very much

Often is “on the go” or often acts as if “driven by a motor”

Not at all Just a little Quite a bit Very much

Often talks excessively

Not at all Just a little Quite a bit Very much

ten blurts out answers before questions have been completed

Not at all Just a little Quite a bit Very much

Often has difficulty awaiting turn

Not at all Just a little Quite a bit Very much

Often interrupts or intrudes on others (e.g., butts into conversations/games)

Not at all Just a little Quite a bit Very much

Often has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home

Not at all Just a little Quite a bit Very much

Often loses temper

Not at all Just a little Quite a bit Very much

Often argues with adults

Not at all Just a little Quite a bit Very much

Often actively defies or refuses adult requests or rules

Not at all Just a little Quite a bit Very much

Often deliberately does things that annoy other people

Not at all Just a little Quite a bit Very much

Often blames others for his or her mistakes or misbehavior

Not at all Just a little Quite a bit Very much

Often touchy or easily annoyed by others

Not at all Just a little Quite a bit Very much

Often is angry and resentful

Not at all Just a little Quite a bit Very much

Often is spiteful or vindictive

Not at all Just a little Quite a bit Very much

Often is quarrelsome

Not at all Just a little Quite a bit Very much

Often is negative, defiant, disobedient, or hostile toward authority figure

Not at all Just a little Quite a bit Very much

Often makes noises (e.g., humming or odd sounds)

Not at all Just a little Quite a bit Very much

Often is excitable, impulsive

Not at all Just a little Quite a bit Very much

Often cries easily

Not at all Just a little Quite a bit Very much

Often is uncooperative

Not at all Just a little Quite a bit Very much

Often acts “smart”

Not at all Just a little Quite a bit Very much

Often is restless or overactive

Not at all Just a little Quite a bit Very much

Often disturbs other children

Not at all Just a little Quite a bit Very much

Often changes mood quickly and drastically

Not at all Just a little Quite a bit Very much

Often easily frustrated if demand are not met immediately

Not at all Just a little Quite a bit Very much

Often teases other children and interferes with their activities

Not at all Just a little Quite a bit Very much

Often is aggressive to other children (e.g., picks fights or bullies)

Not at all Just a little Quite a bit Very much

Often is destructive with property of others (e.g., vandalism)

Not at all Just a little Quite a bit Very much

Often is deceitful (e.g., steals, lies, forges, copies the work of others, or “cons” others)

Not at all Just a little Quite a bit Very much

Often and seriously violates rules (e.g., is truant, runs away, or completely ignores class rules)

Not at all Just a little Quite a bit Very much

Has persistent pattern of violating the basic rights of others or major societal norms

Not at all Just a little Quite a bit Very much

Has episodes of failure to resist aggressive impulses (to assault others or to destroy property)

Not at all Just a little Quite a bit Very much

Has motor or verbal tics (sudden, rapid, recurrent, nonrhythmic motor or verbal activity)

Not at all Just a little Quite a bit Very much

Has repetitive motor behavior (e.g., hand waving, body rocking, or picking at skin)

Not at all Just a little Quite a bit Very much

Has obsessions (persistent and intrusive inappropriate ideas, thoughts, or impulses)

Not at all Just a little Quite a bit Very much

Has compulsions (repetitive behaviors or mental acts to reduce anxiety or distress)

Not at all Just a little Quite a bit Very much

Often is restless or seems keyed up or on edge

Not at all Just a little Quite a bit Very much

Often is easily fatigued

Not at all Just a little Quite a bit Very much

Often has difficulty concentrating (mind goes blank)

Not at all Just a little Quite a bit Very much

Often is irritable

Not at all Just a little Quite a bit Very much

Often has muscle tension

Not at all Just a little Quite a bit Very much

Often has excessive anxiety and worry (e.g., apprehensive expectation)

Not at all Just a little Quite a bit Very much

Often has daytime sleepiness (unintended sleeping in inappropriate situations)

Not at all Just a little Quite a bit Very much

Often has excessive emotionality and attention-seeking behavior

Not at all Just a little Quite a bit Very much

Often has need for undue admiration, grandiose behavior, or lack of empathy

Not at all Just a little Quite a bit Very much

Often has instability in relationships with others, reactive mood, and impulsivity

Not at all Just a little Quite a bit Very much

Sometimes for at least a week has inflated self esteem or grandiosity

Not at all Just a little Quite a bit Very much

Sometimes for at least a week is more talkative than usual or seems pressured to keep talking

Not at all Just a little Quite a bit Very much

Sometimes for at least a week has flight of ideas or says that thoughts are racing

Not at all Just a little Quite a bit Very much

Sometimes for at least a week has elevated, expansive or euphoric mood

Not at all Just a little Quite a bit Very much

Sometimes for at least a week is excessively involved in pleasurable but risky activities

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has depressed mood (sad, hopeless, discouraged)

Not at all Just a little Quite a bit Very much

ometimes for at least 2 weeks has irritable or cranky mood (not just when frustrated)

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has markedly diminished interest or pleasure in most activities

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has psychomotor agitation (even more active than usual)

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has psychomotor retardation (slowed down in most activities)

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks is fatigued or has loss of energy

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has feelings of worthlessness or excessive, inappropriate guilt

Not at all Just a little Quite a bit Very much

Sometimes for at least 2 weeks has diminished ability to think or concentrate

Not at all Just a little Quite a bit Very much

Chronic low self-esteem most of the time for at least a year

Not at all Just a little Quite a bit Very much

Chronic poor concentration or difficulty making decisions most of the time for at least a year

Not at all Just a little Quite a bit Very much

Chronic feelings of hopelessness most of the time for at least a year

Not at all Just a little Quite a bit Very much

Currently is hypervigilant (overly watchful or alert) or has exaggerated startle response

Not at all Just a little Quite a bit Very much

Currently is irritable, has anger outbursts, or has difficulty concentrating

Not at all Just a little Quite a bit Very much

Currently has an emotional (e.g., nervous, worried, hopeless, tearful) response to stress

Not at all Just a little Quite a bit Very much

Currently has a behavioral (e.g., fighting, vandalism, truancy) response to stress

Not at all Just a little Quite a bit Very much

Has difficulty getting started on classroom assignments

Not at all Just a little Quite a bit Very much

Has difficulty staying on task for an entire classroom period

Not at all Just a little Quite a bit Very much

Has problems in completion of work on classroom assignments

Not at all Just a little Quite a bit Very much

Has problems in accuracy or neatness of written work in the classroo

Not at all Just a little Quite a bit Very much

Has difficulty attending to a group classroom activity or discussio

Not at all Just a little Quite a bit Very much

Has difficulty making transitions to the next topic or classroom period

Not at all Just a little Quite a bit Very much

Has problems in interactions with peers in the classroom

Not at all Just a little Quite a bit Very much

Has problems in interactions with staff (teacher or aide)

Not at all Just a little Quite a bit Very much

Has difficulty remaining quiet according to classroom rules

Not at all Just a little Quite a bit Very much

Has difficulty staying seated according to classroom rules

Not at all Just a little Quite a bit Very much

SCHOOL INFORMATION FOR PUPIL PRIOR TO PLACING ON THE ADHD PATHWAY

Child's Full Name

DOB

Address

Gender

First Language

Telephone No.

Parent (1) Information:

Parents/Carers' Full Name (1)

Address

Telephone No.

Relationship

Parent (2) Information:

Parents/Carers' Full Names (2)

Address

Telephone No.

Relationship

Child's Current Setting (if applicable)

Name of setting:

Class Teacher:

SENCO:

Telephone No:

Is the child supported through any of the following?

ENHANCED QUALITY FIRST PROVISION

INDIVIDUAL SEND SUPPORT PLAN

POSITIVE HANDLING PLAN

HIGH NEEDS TOP UP FUNDING

EHC PLAN

What do you hope to gain from service involvement?

Child's positive qualities, strengths and interests:

AREAS OF DIFFICULTY AND FURTHER LEARNING AND DEVELOPMENT

PLEASE INDICATE NAMES OF ANY PROFESSIONALS/ORGANISATIONS INVOLVED e.g. Health Visitor, Paediatrician, Early Help, Social Worker, Therapists etc (with contact details)

What are the barriers to learning for this child as you see them?

ADDITIONAL INFORMATION (e.g. medical condition or diagnosis, relevant information for professionals conducting home visits etc)

Parents/Carers Views

DOES THIS CHILD RECEIVE ANY OTHER INTERVENTIONS OR SPECIAL HELP? PLEASE SPECIFY, E.G. SMALL GROUP WORK, PASTORAL PROGRAMME, SPEECH AND LANGUAGE THERAPY ETC.

ARE THERE MEMBERS OF SCHOOL STAFF THAT THIS CHILD HAS A GOOD RELATIONSHIP WITH? (E.G. CLASS TEACHER, SUPPORT ASSISTANT, TEACHING MENTOR, DINNER SUPERVISOR)

Child's Current Attendance: (%)

HOW DOES THIS CHILD PRESENT WITH THE FOLLOWING? (RATING SCALE: 1 EXCELLENT, 2 GOOD, 3 FAIR, 4 POOR)

RELATIONSHIPS WITH OTHER CHILDREN

RELATIONSHIPS WITH ADULTS

RESPONSE TO RULES AND DISCIPLINE

HOME SCHOOL RELATIONSHIP

If known please state any risk factors for ADHD

CLASSROOM BEHAVIOUR

PLEASE DESCRIBE ANY CONCERNS YOU HAVE ABOUT HOW THIS CHILD BEHAVES IN CLASS E.G. CONCENTRATION, ABILITY TO SIT STILL, OPPOSITIONALITY, ORGANISATION, WAITING TURNS ETC?

HOW DOES THE CHILD RESPOND WHEN INSTRUCTED TO START A TASK IN CLASS?

HOW DOES THE CHILD CONTINUE WITH THE TASK?

SOCIAL BEHAVIOUR

HOW DOES THE CHILD BEHAVE DURING UNSTRUCTURED TIME - E.G. BREAK/DINNER TIMES?

PLEASE DESCRIBE THE QUALITY OF THE CHILD'S RELATIONSHIPS WITH PEERS: DO THEY SHOW INTEREST IN OTHERS, RESPOND TO OTHERS, HAVE FRIENDS, UNDERSTAND OTHERS FEELINGS, TAKE TURNS, PLAY CONSTRUCTIVELY?

PLEASE DESCRIBE THE QUALITY OF THE CHILD'S RELATIONSHIPS WITH ADULTS IN THE SCHOOL.

Page 5 of 6 PLEASE DESCRIBE ANY CONCERNS ABOUT HOW THIS CHILD USES AND/OR UNDERSTANDS SPOKEN LANGUAGE.

EMOTIONAL WELLBEING

PLEASE DESCRIBE THIS CHILD'S SELF-ESTEEM AND SELF-CONFIDENCE

DO YOU HAVE ANY CONCERNS REGARDING THIS CHILD'S EMOTIONAL WELL-BEING? IF YES, PLEASE DESCRIBE THESE AND THE IMPACT THEY HAVE.

FORM COMPLETED BY:

Name

Address

Signature

Today's Date

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