NICHQ Vanderbilt Assessment Follow-up
TEACHER Informant

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 scale was filled out. Please indicate the number of weeks or months you have been able to evaluate the behaviors:

Is this evaluation based on a time when the child  
Was on medication    Was not on medication    Not sure   

Please SelectNeverOccasionallyOftenVery Often      1. Does not pay attention to details or makes careless mistakes with, for example, homework 

Please SelectNeverOccasionallyOftenVery Often      2. Has difficulty keeping attention to what needs to be done  

Please SelectNeverOccasionallyOftenVery Often      3. Does not seem to listen when spoken to directly  

Please SelectNeverOccasionallyOftenVery Often      4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) 

Please SelectNeverOccasionallyOftenVery Often      5. Has difficulty organizing tasks and activities  

Please SelectNeverOccasionallyOftenVery Often      6. Avoids, dislikes or does not want to start tasks that require ongoing mental effort 

Please SelectNeverOccasionallyOftenVery Often      7. Loses things necessary for tasks or activities (toys, school assignments, pencils or books)  

Please SelectNeverOccasionallyOftenVery Often      8. Is easily distracted by noises or other stimuli  

Please SelectNeverOccasionallyOftenVery Often      9. Is forgetful in daily activities  

Please SelectNeverOccasionallyOftenVery Often    10. Fidgets with hands or feet or squirms in seat  

Please SelectNeverOccasionallyOftenVery Often    11. Leaves seat when remaining seated is expected  

Please SelectNeverOccasionallyOftenVery Often    12. Runs about or climbs too much when remaining seated is expected  

Please SelectNeverOccasionallyOftenVery Often    13. Has difficulty playing or beginning quiet play activities  

Please SelectNeverOccasionallyOftenVery Often    14. Is “on the go” or often acts as if “driven by a motor”  

Please SelectNeverOccasionallyOftenVery Often    15. Talks too much  

Please SelectNeverOccasionallyOftenVery Often    16. Blurts out answers before questions have been completed  

Please SelectNeverOccasionallyOftenVery Often    17. Has difficulty awaiting his or her turn  

Please SelectNeverOccasionallyOftenVery Often    18. Interrupts or intrudes in on others’ conversations and/or activities  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    19. Reading  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    20. Mathematics  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    21. Written expression  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    22. Relationship with peers  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    23. Following directions  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    24. Disrupting class  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    25. Assignment completion  

Please SelectExcellentAbove AverageAverageSomewhat of a ProblemProblematic    26. Organizational skills  

Has the child experienced any of the following side effects or problems in the past week?
Currently a problem?

Please Select              NoneMildModerateSevere    Headache  

Please Select              NoneMildModerateSevere    Stomachache  

Please Select              NoneMildModerateSevere    Change of appetite  

Please Select              NoneMildModerateSevere    Trouble sleeping  

Please Select              NoneMildModerateSevere    Irritability in the late morning, late afternoon or evening  

Please Select              NoneMildModerateSevere    Socially withdrawn - decreased interaction with others  

Please Select              NoneMildModerateSevere    Extreme sadness or unusual crying  

Please Select              NoneMildModerateSevere    Dull, tired, listless behavior  

Please Select              NoneMildModerateSevere    Tremors/feeling shaky  

Please Select              NoneMildModerateSevere    Repetitive movements, tics, jerking, twitching, eye blinking  

Please Select              NoneMildModerateSevere    Picking at skin or fingers, nail biting, lip or cheek chewing  

Please Select              NoneMildModerateSevere    Sees or hears things that aren’t there  

Explain/Comments  

Adapted from the Pittsburgh side effects scale, developed by William E. Pelham, Jr, PhD.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

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 - 0303