Island Coast Pediatrics
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1 Island Coast Pediatrics ADHD Assessment Form is composed of 2 parts. The first part is the parent s questionnaire and the second part is the teacher s questionnaire. Both parts would need to be completed.
2 VANDERBILT ADHD PARENT RATING SCALE Child s Name: Today s Date: Date of Birth: Age: Grade: Each rating should be considered in the context of what is appropriate for the age of your child. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1. Does not pay attention to details or makes careless mistakes, for example homework Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand.) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils, or books.) Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs about or climbs excessively in situations when remaining seated is expected Has difficulty playing or engaging in leisure/play activities quietly Is on the go: or often acts as if driven by a motor Talks too much Blurts out answers before questions have been completed
3 17. Has difficulty waiting his/her turn Interrupts or intrudes on others (e.g., butts into conversations or games.) Argues with adults Losses temper Actively defies or refuses to comply with adults requests or rules Deliberately annoys people Blames others for his or her mistakes or misbehaviors Is touchy or easily annoyed by others Is angry or resentful Is spiteful and vindictive Bullies, threatens, or intimidates others Initiates physical fights Lies to obtain goods for favors or to avoid obligations (i.e.., cons others.) Is truant from school (skips school) without permission Is physically cruel to people Has stolen items of nontrivial value Deliberately destroys others property Has used a weapon that can cause serious harm (bat, knife, brick, gun.) Is physically cruel to animals Has deliberately set fires to cause damage Has broken into someone else s home, business, or car Has stayed out at night without permission Has run away from home overnight Has forced someone into sexual activity Is fearful, anxious, or worried
4 42. Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved: complains that no one loves him/her Is sad, unhappy, or depressed Is self-conscious or easily embarrassed PERFORMANCE 1. Overall Academic Performance a. Reading b. Mathematics c. Written Expression PERFORMANCE 2. Overall Classroom Behavior a. Relationship with Peers b. Following Directions/Rules c. Disrupting Class d. Assignment Completion e. Organizational Skills
5 VANDERBILT TEACHER BEHAVIOR EVALUATION SCALE (VTBES) Name: Grade: Date of Birth: Teacher: School: Each rating should be considered in the context of what is appropriate for the age of the children you are rating and reflect his/her behavior. Please indicate the number of weeks or months you have been able to observe the behaviors. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1. Fails to give attention to details or makes careless mistakes in school Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand.) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils, or books.) Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs about or climbs excessively in situations when remaining seated is expected Has difficulty playing or engaging in leisure/play activities quietly Is on the go: or often acts as if driven by a motor Talks excessively Blurts out answers before questions have been completed
6 17. Has difficulty waiting in line Interrupts or intrudes on others (e.g., butts into conversations or games.) Loses temper Actively defies or refuses to comply with adults requests or rules Is angry or resentful Is spiteful and vindictive Bullies, threatens, or intimidates others Initiates physical fights Lies to obtain goods for favors or to avoid obligations (i.e.., cons others.) Is physically cruel to people Has stolen items of nontrivial value Deliberately destroys others property Is fearful, anxious, or worried Is self-conscious or easily embarrassed Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved: complains that no one loves him/her Is sad, unhappy, or depresses
7 ACADEMIC PERFORMANCE Reading Mathematics Written Expression Homework Completion CLASSROOM BEHAVIOR Relationship with Peers Following Directions/Rules Disrupting Class Assignment Completion Organizational Skills Please include any observations you feel are pertinent:
Island Coast Pediatrics
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