NICHQ Vanderbilt Assessment Scale PARENT Informant

Transcription

1 D3 NICHQ Vanderbilt Assessment Scale PARENT Informant Today s Date: Child s Name: 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. 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 not sure? Symptoms Never Occasionally Often Very Often 1. Does not pay attention to details or makes careless mistakes with, for example, homework 2. Has difficulty keeping attention to what needs to be done Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) 8. Is easily distracted by noises or other 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 too much when remaining seated is expected Has difficulty playing or beginning quiet play activities Is on the go or often acts as if driven by a motor Talks too much Blurts out answers before questions have been completed Has difficulty waiting his or her turn Interrupts or intrudes in on others conversations and/or activities Argues with adults Loses temper Actively defies or refuses to go along 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 wants to get even Bullies, threatens, or intimidates others Starts physical fights Lies to get out of trouble or to avoid obligations (ie, cons others) Is truant from school (skips school) without permission Is physically cruel to people Has stolen things that have value 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 HE0350

2 D3 NICHQ Vanderbilt Assessment Scale PARENT Informant, continued Today s Date: Child s Name: Date of Birth: Parent s Name: Parent s Phone Number: Symptoms (continued) Never Occasionally Often Very Often 33. 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 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 or her Is sad, unhappy, or depressed Is self-conscious or easily embarrassed Somewhat Above of a Performance Excellent Average Average Problem Problematic 48. Overall school performance Reading Writing Mathematics Relationship with parents Relationship with siblings Relationship with peers Participation in organized activities (eg, teams) Comments: For Office Use Only Total 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: 11-19/rev1102

3 Parent's Conners Questionnaire Child's Name Filled Out By Date Completed Please answer all questions. Beside each item, Indicate the degree of the problem by a check mark. 1. Picks at things (nails, fingers, hair. clothing). 2. Sassy To grown-ups 3. Problems with making or keeping friends. 4. Excitable, impulsive.. 5. Wants to run things. 6. Sucks or chews (thumb, clothing, blankets). 7. Cries easily or often. 8. Carries a chip on his shoulder. 9. Daydreams. 10. Difficulty in learning Restless in the "squirmy" sense Fearful (of new situations, new people or places; going to school). 13. Restless, always- up and on the go Destructive. 15. Tells lies or stories that aren t true. 16. Shy. 17. Gets into more trouble than others same age. 18. Speaks differently from others same age (baby talk; stuttering; hard to understand). 19. Denies mistakes or blames other Quarrelsome. 21. Pouts and sulks. 22. Steals. 23. Disobedient or obeys but resentfully. 24. Worries more than others (about being alone; illness or death). 25. Fails to finish things Feelings easily hurt. 27. Bullies others. 28. Unable to stop a repetitive activity. 29. Cruel. 30. Childish or immature (wants help when he shouldn't need; clings; needs constant reassurance) Distractibility or attention span a problem Headaches. 33. Mood changes quickly and drastically Doesn t like or doesn't follow rules or restriction. 35. Fights constantly. 36. Doesn't get along well with brothers or sisters. 37. Easily frustrated in efforts Disturbs other children. 39. Basically an unhappy child. 40. Problems with eating (poor appetite; up between bites). 41. Stomach aches. 42. Problems with sleep (can't foil asleep; up too early; up in the night). 43. Other aches and pains. 44. Vomiting or nausea. 45. Feels cheated in family circle. 46. Boasts and brags. 47. Lets self be pushed around. 48. Bowel problems (frequently loose; irregular habits; constipation). Not at all Child's Age Child s Sex M F Just a little Pretty much Very much Please mail or return these forms to Pediatrics West 120 Boston Road Groton, MA 01450

4 D4 NICHQ Vanderbilt Assessment Scale TEACHER Informant Teacher s Name: Class Time: Class Name/Period: Today s Date: Child s Name: Grade Level: 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 behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors:. Is this evaluation based on a time when the child was on medication was not on medication not sure? Symptoms Never Occasionally Often Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork 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) 5. Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 7. Loses things necessary for tasks or activities (school assignments, pencils, or books) 8. Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected 12. Runs about or climbs excessively in situations in which remaining seated is expected 13. Has difficulty playing or engaging in leisure 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 Has difficulty waiting in line Interrupts or intrudes on others (eg, butts into conversations/games) Loses temper Actively defies or refuses to comply with adult s 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 (eg, 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 The recommendations in this publication 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. 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 HE0351

5 D4 NICHQ Vanderbilt Assessment Scale TEACHER Informant, continued Teacher s Name: Class Time: Class Name/Period: Today s Date: Child s Name: Grade Level: Symptoms (continued) Never Occasionally Often Very Often 32. Feels worthless or inferior Blames self for problems; feels guilty Feels lonely, unwanted, or unloved; complains that no one loves him or her Is sad, unhappy, or depressed Somewhat Performance Above of a Academic Performance Excellent Average Average Problem Problematic 36. Reading Mathematics Written expression Somewhat Above of a Classroom Behavioral Performance Excellent Average Average Problem Problematic 39. Relationship with peers Following directions Disrupting class Assignment completion Organizational skills Comments: Please return this form to: Mailing address: Fax number: _ For Office Use Only Total 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 28: Total number of questions scored 2 or 3 in questions 29 35: Total number of questions scored 4 or 5 in questions 36 43: Average Performance Score: 11-20/rev0303

6 Teacher's Conners Questionnaire Child's Name Filled Out By Date Completed Child's Age Child s Sex M F Please answer all questions. Beside each item, Not at indicate the degree of the problem by a check mark. all 1. Restless in the "squirmy" sense.. 2. Makes inappropriate noises when he/she shouldn't. 3. Demands must be met immediately. 4. Acts "smart" (impudent or sassy). 5. Temper outbursts and unpredictable behavior.. 6. Overly sensitive to criticism. 7. Distractibility or attention span a problem.. Just a little Pretty much Very Much 8. Disturbs other children.. 9. Daydreams. 10. Pouts and sulks Mood changes quickly and drastically Quarrelsome. 13. Submissive attitude toward authority. 14. Restless. Always "up and on the go.". 15. Excitable, impulsive Excessive demands for teacher's attention. 17. Appears to be unaccepted by group. 18. Appears to be easily led by other children, 19. No sense of fair play. 20. Appears to lack leadership. 21. Fails to finish things that he/she starts Childish and Immature. 23. Denies mistakes or blames other. 24. Does not get along well with other children. 25. Uncooperative with classmates. 26. Easily frustrated in efforts Uncooperative with teacher. 28. Difficulty in learning. Please mail or return these forms to Pediatrics West 120 Boston Road Groton, MA 01450

7 Teacher CAP Rating Scale Child's Name Filled Out By Date Completed Child's Age Child s Sex M F Directions Below is a list of items that describe pupils. For each item that describes the pupil now or within the past week, check whether the item is Not True, Somewhat or Sometimes True, or Very or Often True. Please check all items as well as you can, even if some do not seem to apply to this pupil. Somewhat or Very or Not True Sometimes True Often True 1. Fails to finish things he/she starts ( ) ( ) ( ) 2. Can't concentrate, can't pay attention for long ( ) ( ) ( ) 3. Can't sit still, restless, or hyperactive ( ) ( ) ( ) 4. Fidgets ( ) ( ) ( ) 5. Daydreams or gets lost in his/her thoughts ( ) ( ) ( ) 6. Impulsive or acts without thinking ( ) ( ) ( ) 7. Difficulty following directions ( ) ( ) ( ) 8. Talks out of turn ( ) ( ) ( ) 9. Messy work ( ) ( ) ( ) 10. Inattentive, easily distracted ( ) ( ) ( ) 11. Talks too much ( ) ( ) ( ) 12. Fails to carry out assigned tasks ( ) ( ) ( ) Please feel free to write any comments about the pupil's work or behavior in the last week. Please mail or return these forms to Pediatrics West 120 Boston Road Groton, MA 01450

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