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NICHQ Vanderbilt Assessment Scales

NICHQ Vanderbilt Assessment Scale—PARENT Informant
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Name

First NameLast Name
Parent's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
This evaluation was based on a time when the child
Symptoms

Rows	Never (0)	Occasionally (1)	Often (2)	Very Often (3)
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
3. Does not seem to listen when spoken to directly
4. 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
6. 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
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others’ conversations and/or activities
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to go along with adults’ requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or resentful
26. Is spiteful and wants to get even
27. Bullies, threatens, or intimidates others
28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (ie, “cons” others)
30. Is truant from school (skips school) without permission
31. Is physically cruel to people
32. Has stolen things that have value
33. Deliberately destroys others’ property
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35. Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone else’s home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed

Performance

Rows	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)
48. Overall school performance
49. Reading
50. Writing
51. Mathematics
52. Relationship with parents
53. Relationship with siblings
54. Relationship with peers
55. Participation in organized activities (eg, teams)

Comments
For Office Use Only
Total number of questions scored 2 or 3 in question 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:

These scales should NOT be used alone to make any diagnosis. You must take into consideration information from multiple sources. Scores of 2 or 3 on a single Symptom question reflect often-occurring behaviors. Scores of 4 or 5 on Performance questions reflect problems in performance.

The initial assessment scales, parent and teacher, have 2 components: symptom assessment and impairment in performance. On both the parent and teacher initial scales, the symptom assess- ment screens for symptoms that meet criteria for both inattentive (items 1–9) and hyperactive ADHD (items 10–18).

To meet DSM-IV criteria for the diagnosis, one must have at least 6 positive responses to either the inattentive 9 or hyperactive 9 core symptoms, or both. A positive response is a 2 or 3 (often, very often) (you could draw a line straight down the page and count the positive answers in each subsegment). There is a place to
record the number of positives in each subsegment, and a place for total score for the first 18 symptoms (just add them up).

The initial scales also have symptom screens for 3 other comorbidities—oppositional-defiant, conduct, and anxiety/ depression. These are screened by the number of positive respon- ses in each of the segments separated by the “squares.” The specific item sets and numbers of positives required for each co-morbid symptom screen set are detailed below.

The second section of the scale has a set of performance measures, scored 1 to 5, with 4 and 5 being somewhat of a problem/problem- atic. To meet criteria for ADHD there must be at least one item of the Performance set in which the child scores a 4 or 5; ie, there must be impairment, not just symptoms to meet diagnostic criteria. The sheet has a place to record the number of positives (4s, 5s) and an Average Performance Score—add them up and divide by number of Performance criteria answered.
Parent Assessment Scale
Predominantly Inattentive subtype
- Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND
- Score a 4 or 5 on any of the Performance questions 48–55
Predominantly Hyperactive/Impulsive subtype
- Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND
- Score a 4 or 5 on any of the Performance questions 48–55
ADHD Combined Inattention/Hyperactivity
- Requires the above criteria on both inattention and hyperactivity/impulsivity
Oppositional-Defiant Disorder Screen
- Must score a 2 or 3 on 4 out of 8 behaviors on questions 19–26 AND
- Score a 4 or 5 on any of the Performance questions 48–55
Conduct Disorder Screen
- Must score a 2 or 3 on 3 out of 14 behaviors on questions 27–40 AND
- Score a 4 or 5 on any of the Performance questions 48–55
Anxiety/Depression Screen
- Must score a 2 or 3 on 3 out of 7 behaviors on questions 41–47 AND
- Score a 4 or 5 on any of the Performance questions 48–55
Teacher Assessment Scale
Predominantly Inattentive subtype
- Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND
- Score a 4 or 5 on any of the Performance questions 36–43
Predominantly Hyperactive/Impulsive subtype
- Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND
- Score a 4 or 5 on any of the Performance questions 36–43
ADHD Combined Inattention/Hyperactivity
- Requires the above criteria on both inattention and hyperactivity/impulsivity
Oppositional-Defiant/Conduct Disorder Screen
- Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND
- Score a 4 or 5 on any of the Performance questions 36–43
Anxiety/Depression Screen
- Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND
- Score a 4 or 5 on any of the Performance questions 36–43
The parent and teacher follow-up scales have the first 18 core ADHD symptoms, not the co-morbid symptoms. The section seg- ment has the same Performance items and impairment assessment as the initial scales, and then has a side-effect reporting scale that can be used to both assess and monitor the presence of adverse reactions to medications prescribed, if any.

Scoring the follow-up scales involves only calculating a total symptom score for items 1–18 that can be tracked over time, and the average of the Performance items answered as measures of improvement over time with treatment.

Parent Assessment Follow-up
- Calculate Total Symptom Score for questions 1–18.
- Calculate Average Performance Score for questions 19–26.
Teacher Assessment Follow-up
- Calculate Total Symptom Score for questions 1–18.
- Calculate Average Performance Score for questions 19–26.
Should be Empty:

Rows	Never(0)	Occasionally (1)	Often (2)	Very Often (3)
1. Fails to give attention to details or makes careless mistakes in schoolwork
2. Has difficulty sustaining attention to tasks or activities
3. Does not seem to listen when spoken to directly
4. 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
6. 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
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. 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
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks excessively
16. Blurts out answers before questions have been completed
17. Has difficulty waiting in line
18. Interrupts or intrudes on others (eg, butts into conversations/games)
19. Loses temper
20. Actively defies or refuses to comply with adult’s requests or rules
21. Is angry or resentful
22. Is spiteful and vindictive
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)
26. Is physically cruel to people
27. Has stolen items of nontrivial value
28. Deliberately destroys others’ property
29. Is fearful, anxious, or worried
30. Is self-conscious or easily embarrassed
31. Is afraid to try new things for fear of making mistakes
32. Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
35. Is sad, unhappy, or depressed

Rows	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)
19. Overall school performance 20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings
25. Relationship with peers
26. Participation in organized activities (eg, teams)

Rows	None	Mild	Moderate	Severe
Headache
Stomachache
Change of appetite—explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening—explain below
Socially withdrawn—decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Sees or hears things that aren’t there

Rows	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)
19. Reading
20. Mathematics
21. Written expression
22. Relationship with peers
23. Following direction
24. Disrupting class
25. Assignment completion
26. Organizational skills

Rows	None	Mild	Moderate	Severe
Headache
Stomachache
Change of appetite—explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening—explain below
Socially withdrawn—decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Sees or hears things that aren’t there

NICHQ Vanderbilt Assessment Scales

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.

Symptoms

Performance

For Office Use Only

NICHQ Vanderbilt Assessment Scales

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.

Symptoms

Performance

Performance

For Office Use Only

NICHQ Vanderbilt Assessment Scales

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.

Symptoms

Performance

Side Effects:

For Office Use Only

NICHQ Vanderbilt Assessment Scales

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.

Symptoms

Performance

Side Effects:

For Office Use Only

Parent Assessment Scale

Teacher Assessment Scale

Rows	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills