Health Topics : ADHD Vanderbilt Survey

http://www.vanderbiltchildrens.com/uploads/documents/ccdr_adhd_scale.pdf

 Child’s Name_________________________________________________      Date Completed___________________

 Date of Birth___________________________________      Age________________     Grade____________________  

 Parent Rating Scale:Each rating should be considered in the context of what is appropriate for the age of your child.

Frequency Code Never Occasionally Often Very Often
0 1 2 3
1. Does not pay attention to details or makes careless mistakes, for example homework        
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 when remaining seated is expected        
12. Runs about or climbs excessively in situations when remaining seated is expected        
13. Has difficulty playing or engaging in leisure/play activities quietly        
14. Is “on the go” or often acts as if “drive by a motor”        
15. Talks too much        
16. Blurts out answers before questions have been completed        
17. Has difficulty waiting his/her turn        
18. Interrupts or intrudes on others (e.g., butts into conversations or games)        
19. Argues with adults        
20. Loses temper        
21. Actively defies or refuses to comply 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 or vindictive        
27. Bullies, threatens, or intimidates others        
28. Initiates physical fights        
29. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)        
30. Is truant from school (skips school) without permission        
31. Is physically cruel to people        
Frequency Code Never Occasionally Often Very Often
  0 1 2 3
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: complains that “no one loves him/her”        
46. Is sad, unhappy, or depressed        
47. Is self-conscious or easily embarrassed        

 Academic Performance:

  Problematic Average Above Average
Overall Academic Performance 1 2 3 4 5
Reading 1 2 3 4 5
Mathematics 1 2 3 4 5
Written Expression 1 2 3 4 5

 Social Performance:

  Problematic Average Above Average
Overall Classroom Behavior 1 2 3 4 5
Relationship with peers 1 2 3 4 5
Following Directions/Rules 1 2 3 4 5
Disrupting Class 1 2 3 4 5
Assignment Completion 1 2 3 4 5
Organizational Skill 1 2 3 4 5

 Scoring Instructions:

  • Predominately inattentive subtype: requires 6 or 9 behaviors, (scores of 2 or 3 are positive) on items 1 through 9, and a performance problem (scores of 1 or 2) in any of the items on the performance section.
  • Predominately hyperactive/impulsive subtype: requires 6 or 9 behaviors, (scores of 2 or 3 are positive) on items 10 through 18, and a performance problem (scores of 1 or 2) in any of the items on the performance section.
  • Combined subtype: requires the above criteria on both inattention and hyperactivity/impulsivity.
  • Oppositional-defiant disorder: is screened by 4 of 8 behaviors, (scores of 2 or 3 are positive) on items 19 through 26.
  • Conduct disorder: is screened by 3 of 15 behaviors, (scores of 2 or 3 are positive) on items 27 through 40.
  • Anxiety or depression: are screened by 3 of 7 behaviors, (scores of 2 or 3 are positive) on items 41 through 47.