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Vanderbilt – Parent
Vanderbilt Assessment Scale-Parent Informant
NICHQ Vanderbilt Assessment Scale-PARENT Informant
Today'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?
Symptoms
1. 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
Performance
48. 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 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:
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 – 1102
11-19/rev1102
