Parent Vanderbilt Questionnaire

NICHQ Vanderbilt Assessment Scale - PARENT Informant

Today's Date

Child's Full Name

Child's Date of Birth

Parent's Name

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 behaviours in the past 6 months.

Is this evaluation based on a time when the child *

was on medicationwas not on medicationnot sure?

Symptoms *

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not pay attention to details or makes careless mistakes with, for example, homework

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty keeping attention to what needs to be done

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not seem to listen when spoken to directly

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty organising tasks and activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

Never (0)Occasionally (1)Often (2)Very Often (3)

Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

Never (0)Occasionally (1)Often (2)Very Often (3)

Is easily distracted by noises or other stimuli

Never (0)Occasionally (1)Often (2)Very Often (3)

Is forgetful in daily activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Fidgets with hands or feet or squirms in seat

Never (0)Occasionally (1)Often (2)Very Often (3)

Leaves seat when remaining seated is expected

Never (0)Occasionally (1)Often (2)Very Often (3)

Runs about or climbs too much when remaining seated is expected

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty playing or beginning quiet play activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Is "on the go" or often acts as if "driven by a motor"

Never (0)Occasionally (1)Often (2)Very Often (3)

Talks too much

Never (0)Occasionally (1)Often (2)Very Often (3)

Blurts out answers before questions have been completed

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty waiting his or her turn

Never (0)Occasionally (1)Often (2)Very Often (3)

Interrupts of intrudes in on others' conversations and/or activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Argues with adults

Never (0)Occasionally (1)Often (2)Very Often (3)

Loses temper

Never (0)Occasionally (1)Often (2)Very Often (3)

Actively defies or refuses to go along with adults' requests or rules

Never (0)Occasionally (1)Often (2)Very Often (3)

Deliberately annoys people

Never (0)Occasionally (1)Often (2)Very Often (3)

Blames others for his or her mistakes or misbehaviours

Never (0)Occasionally (1)Often (2)Very Often (3)

Is touchy or easily annoyed by others

Never (0)Occasionally (1)Often (2)Very Often (3)

Is angry or resentful

Never (0)Occasionally (1)Often (2)Very Often (3)

Is spiteful and wants to get even

Never (0)Occasionally (1)Often (2)Very Often (3)

Bullies, threatens, or intimidates others

Never (0)Occasionally (1)Often (2)Very Often (3)

Starts physical fights

Never (0)Occasionally (1)Often (2)Very Often (3)

Lies to get out of trouble or to avoid obligations (e.g., "cons" others)

Never (0)Occasionally (1)Often (2)Very Often (3)

Is truant from school (skips school) without permission

Never (0)Occasionally (1)Often (2)Very Often (3)

Is physically cruel to people

Never (0)Occasionally (1)Often (2)Very Often (3)

Has stolen things that have value

Never (0)Occasionally (1)Often (2)Very Often (3)

Deliberately destroys others' property

Never (0)Occasionally (1)Often (2)Very Often (3)

Has used a weapon that can cause serious harm (bat, knife, brick, gun)

Never (0)Occasionally (1)Often (2)Very Often (3)

Is physically cruel to animals

Never (0)Occasionally (1)Often (2)Very Often (3)

Has deliberately set fires to cause damage

Never (0)Occasionally (1)Often (2)Very Often (3)

Has broken into someone else's home, business or car

Never (0)Occasionally (1)Often (2)Very Often (3)

Has stayed out at night without permission

Never (0)Occasionally (1)Often (2)Very Often (3)

Has run away from home overnight

Never (0)Occasionally (1)Often (2)Very Often (3)

Has forced someone into sexual activity

Never (0)Occasionally (1)Often (2)Very Often (3)

Is fearful, anxious, or worried

Never (0)Occasionally (1)Often (2)Very Often (3)

Is afraid to try new things for fear of making mistakes

Never (0)Occasionally (1)Often (2)Very Often (3)

Feels worthless or inferior

Never (0)Occasionally (1)Often (2)Very Often (3)

Blames self for problems, feels guilty

Never (0)Occasionally (1)Often (2)Very Often (3)

Feels lonely, unwanted, or unloved; complains that "no one loves them"

Never (0)Occasionally (1)Often (2)Very Often (3)

Is sad, unhappy, or depressed

Never (0)Occasionally (1)Often (2)Very Often (3)

Is self-conscious or easily embarrassed

Never (0)Occasionally (1)Often (2)Very Often (3)

Performance *

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Overall school performance

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Reading

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Writing

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Mathematics

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with parents

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with siblings

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with peers

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Participation in organised activities (e.g., teams)

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

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