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2014
March
V
Vanderbilt Assessment Scale - MOTHER Informant
Vanderbilt Assessment Scale - MOTHER Informant
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*
are required
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Hello Ms. Charlene Watson,
Please complete this online version of the NICHQ Vanderbilt Assessment Scale - PARENT Informant for Megan A. Coughlin, 4th Grader.
Your responses will be sent to Megan's pediatrician as part of her evaluation for Attention Deficit Disorder.
Thank you very much for your time and support. Please confirm that you are in fact the person completing this assessment. You can then begin the assessment by clicking on the
Continue
button below.
When you are finished be sure to click on the Submit Responses button to save your answers.
I Confirm that his evaluation is being completed by Ms. Charlene Watson, mother of Megan Coughlin.
*
Child's Date of Birth (MM/DD/YYYY):
*
Parent's Telephone Number (including area code):
*
Is this evaluation based on a time when the child:
was on medication
was not on medication
not sure
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
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
*
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
Symptoms
Never
Occasionally
Often
Very Often
*
16. Blurts out answers before questions have been completed
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17. Has difficulty waiting his or her turn
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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
Symptoms
Never
Occasionally
Often
Very Often
*
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
Never
Occasionally
Often
Very Often
*
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
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
*
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)
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