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CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION MONITORING AND FOLLOW-UP Page 1 of 3 Symptoms Never Occasionally Often Very Often 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 0 1 2 3 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, 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 in on others (eg, butts into conversations/games) 19. Loses temper 20. Activity defies or refuses to comply with adults’ requests or rules 21. Is angry or resentful NICHQ Vanderbilt Assessment Follow-up: Teacher Informant Child’s Name: Child’s Date of Birth: Teacher’s Name: Today’s Date: Class Time: Class Name/Period: 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 last assessment was filled out. Please indicate the number of weeks or months you have been able to evaluate the behaviors: . For Office Use Only __________/9 For Office Use Only __________/9

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Page 1: NICHQ Vanderbilt Assessment Follow-up: Teacher Informant · NICHQ Vanderbilt Assessment Follow-up: Teacher Informant MONITORING AND FOLLOW-UP Page 3 of 3 The recommendations in this

CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION

MONITORING AND FOLLOW-UP Page 1 of 3

Symptoms Never Occasionally Often VeryOften

1. Failstogiveattentiontodetailsormakescarelessmistakesinschoolwork

2. Hasdifficultysustainingattentiontotasksoractivities

3. Doesnotseemtolistenwhenspokentodirectly

4. Doesnotfollowthroughoninstructionsandfailstofinishschoolwork (notduetooppositionalbehaviororfailuretounderstand)

5. Hasdifficultyorganizingtasksandactivities 0 1 2 3

6. Avoids,dislikes,orisreluctanttoengageintasksthatrequiresustained mentaleffort

7. Losesthingsnecessaryfortasksoractivities(schoolassignments, pencils,books)

8. Iseasilydistractedbyextraneousstimuli

9. Isforgetfulindailyactivities

10. Fidgetswithhandsorfeetorsquirmsinseat

11. Leavesseatinclassroomorinothersituationsinwhichremaining seatedisexpected

12. Runsaboutorclimbsexcessivelyinsituationsinwhichremaining seatedisexpected

13. Hasdifficultyplayingorengaginginleisureactivitiesquietly

14. Is“onthego”oroftenactsasif“drivenbyamotor”

15. Talksexcessively

16. Blurtsoutanswersbeforequestionshavebeencompleted

17. Hasdifficultywaitinginline

18. Interruptsorintrudesinonothers(eg,buttsintoconversations/games)

19. Losestemper

20. Activitydefiesorrefusestocomplywithadults’requestsorrules

21. Isangryorresentful

NICHQ Vanderbilt Assessment Follow-up: Teacher InformantChild’sName:

Child’sDateofBirth:

Teacher’sName:

Today’sDate:

ClassTime:

ClassName/Period:

GradeLevel:

Directions:Eachratingshouldbeconsideredinthecontextofwhatisappropriatefortheageofthechildyouareratingandshouldreflectthatchild’sbehaviorsincethelastassessmentwasfilledout.Pleaseindicatethenumberofweeksormonthsyouhavebeenabletoevaluatethebehaviors:.

ForOfficeUseOnly

__________/9

ForOfficeUseOnly

__________/9

Page 2: NICHQ Vanderbilt Assessment Follow-up: Teacher Informant · NICHQ Vanderbilt Assessment Follow-up: Teacher Informant MONITORING AND FOLLOW-UP Page 3 of 3 The recommendations in this

NICHQ Vanderbilt Assessment Follow-up: Teacher Informant

MONITORING AND FOLLOW-UP Page 2 of 3

Symptoms(continued) Never Occasionally Often VeryOften

22. Isspitefulandvindictive

23. Bullies,threatens,orintimidatesothers

24. Initiatesphysicalfights

25. Liestoobtaingoodsforfavorsortoavoidobligations(eg,“cons”others)

26. Isphysicallycrueltopeople

27. Hasstolenitemsofnontrivialvalue

28. Deliberatelydestroysothers’property

Somewhat Above ofa AcademicPerformance Excellent Average Average Problem Problematic

29. Reading

30. Mathematics

31. Writtenexpression

ClassroomBehavioralPerformance

32. Relationshipwithpeers

33. Followingdirections

34. Disruptingclass

35. Assignmentcompletion

36. Organizationalskills

AdaptedfromtheVanderbiltRatingScalesdevelopedbyMarkL.Wolraich,MD.

AdaptedfromthePittsburghsideeffectsscale,developedbyWilliamE.Pelham,Jr,PhD.Availablefordownloadingatnocostinexpandedformatathttp://ccf.FIU.edu.

SideEffects:Hasthechildexperiencedanyofthefollowingsideeffect Arethesesideeffectscurrentlyaproblem?orproblemsinthepastweek? None Mild Moderate Severe

Headache

Stomachache

Changeofappetite——explainbelow

Troublesleeping

Irritabilityinthelatemorning,lateafternoon,orevening——explainbelow

Sociallywithdrawn——decreasedinteractionwithothers

Extremesadnessorunusualcrying

Dull,tired,listlessbehavior

Tremors/feelingshaky

Repetitivemovements,tics,jerking,twitching,eyeblinking——explainbelow

Pickingatskinorfingers,nailbiting,liporcheckchewing——explainbelow

Seesorhearsthingsthataren’tthere

Explain/Comments:

Pleasereturnthisformto:

Mailingaddress: Faxnumber:

ForOfficeUseOnly

__________/10

ForOfficeUseOnly

5s:_________/5

ForOfficeUseOnly

5s:_________/3

ForOfficeUseOnly

4s:_________/5

ForOfficeUseOnly

4s:_________/3

Page 3: NICHQ Vanderbilt Assessment Follow-up: Teacher Informant · NICHQ Vanderbilt Assessment Follow-up: Teacher Informant MONITORING AND FOLLOW-UP Page 3 of 3 The recommendations in this

NICHQ Vanderbilt Assessment Follow-up: Teacher Informant

MONITORING AND FOLLOW-UP Page 3 of 3

Therecommendationsinthispublicationdonotindicateanexclusivecourseoftreatmentorserveasastandardofmedicalcare.Variations,takingintoaccountindividualcircumstances,maybeappropriate.OriginaldocumentincludedaspartofCaring for Children With ADHD: A Resource Toolkit for Clinicians, 2ndEdition.Copyright©2012AmericanAcademyofPediatrics.AllRightsReserved.TheAmericanAcademyofPediatricsdoesnotrevieworendorseanymodificationsmadetothisdocumentandinnoeventshalltheAAPbeliableforanysuchchanges.

ForOfficeUseOnly

Totalnumberofquestionsscored2or3inquestions1––9:_____________

Totalnumberofquestionsscored2or3inquestions10–—18:_____________

Totalnumberofquestionsscored2or3inquestions19–—28:_____________

Totalnumberofquestionsscored4inquestions29–—31:_____________

Totalnumberofquestionsscored5inquestions29–—31:_____________

Totalnumberofquestionsscored4inquestions32–—36:_____________

Totalnumberofquestionsscored5inquestions32–—36:_____________


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