Vanderbilt Assessment Scale-Parent Informant NICHQ Vanderbilt Assessment Scale-PARENT InformantToday's Date* MM slash DD slash YYYY Child's Name* First Last Date of birth* MM slash DD slash YYYY Parent's Name* First Last 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 No sure? Symptoms1. 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, or 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 Performance48. Overall school performance* Excellent Above Average Average Somewhat of a Problem Problematic 49. Reading* Excellent Above Average Average Somewhat of a Problem Problematic 50. Writing* Excellent Above Average Average Somewhat of a Problem Problematic 51. Mathematics* Excellent Above Average Average Somewhat of a Problem Problematic 52. Relationship with parents* Excellent Above Average Average Somewhat of a Problem Problematic 53. Relationship with siblings* Excellent Above Average Average Somewhat of a Problem Problematic 54. Relationship with peers* Excellent Above Average Average Somewhat of a Problem Problematic 55. Participation in organized activities (eg, teams)* Excellent Above Average Average Somewhat of a Problem Problematic Comments:For Office Use OnlyTotal number of questions scored 2 or 3 in questions 1–9:Total number of questions scored 2 or 3 in questions 10–18:Total Symptom Score for questions 1–18:Total number of questions scored 2 or 3 in questions 19–26:Total number of questions scored 2 or 3 in questions 27–40:Total number of questions scored 2 or 3 in questions 41–47:Total number of questions scored 4 or 5 in questions 48–55:Average Performance Score:The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 110211-19/rev1102
