PARENT informant

ADHD Vanderbilt Assessment Scale

Child’s name Birth date Today’s date

Parent’s name Grade School

Directions: Please rate your child’s performance, at home and during play, on the following symptom list. The form should take about 10 or 15 minutes to complete. I would also be grateful for any WRITTEN comments you would like to make. Please mail or fax this to me at the above address. Thank you very much!

-- Dr. Epstein

	Symptom	Never	Occasionally	Often	Very Often
1	Does not pay attention to details or makes careless mistakes with, for example, homework	0	1	2	3
2	Has difficulty keeping attention to what needs to be done.	0	1	2	3
3	Does not seem to listen when spoken to directly.	0	1	2	3
4	Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)	0	1	2	3
5	Has difficulty organizing tasks and activities	0	1	2	3
6	Avoids, dislikes, or does not want to start tasks that require ongoing mental effort	0	1	2	3
7	Loses things necessary for tasks or activities ( toys, assignments, pencils, or books)	0	1	2	3
8	Is easily distracted by noises or other stimuli	0	1	2	3
9	Is forgetful in daily activities	0	1	2	3
10	Fidgets with hands or feet or squirms in seat	0	1	2	3
11	Leaves seat when remaining seated is expected	0	1	2	3
12	Runs about and climbs too much when remaining seated is expected	0	1	2	3
13	Has difficulty playing or beginning quiet play activities	0	1	2	3
14	Is "on the go" or often acts if "driven by motor"	0	1	2	3
15	Talks too much	0	1	2	3
16	Blurts out answers before questions have been completed	0	1	2	3
17	Has difficulty waiting his or her turn	0	1	2	3
18	Interrupts or intrudes in others' conversations and/ or activities	0	1	2	3
19	Argues with adults	0	1	2	3
20	Loses temper	0	1	2	3
21	Actively defies or refuses to go along with adults' request or rules	0	1	2	3
22	Deliberately annoys people	0	1	2	3
23	Blames others for his or her mistakes or misbehaviors	0	1	2	3
24	Is touchy or easily annoyed by others	0	1	2	3
25	Is angry or resentful	0	1	2	3
26	Is spiteful and wants to get even	0	1	2	3
27	Bullies, threatens, or intimidates other	0	1	2	3
28	Starts physical fights	0	1	2	3
29	Lies to get out of trouble or the avoid obligations (ie, "cons" others)	0	1	2	3
30	Is truant from school ( skips school) without permission	0	1	2	3
31	Is physical cruel to people	0	1	2	3
32	Has stolen things that have value	0	1	2	3
33	Deliberately destroys others' property	0	1	2	3
34	Has used a weapon that can cause serious harm ( bat, knife, brick, gun)	0	1	2	3
35	Is physically cruel to animals	0	1	2	3
36	Has deliberately set fires to cause damage	0	1	2	3
37	Has broken into someone else's home, business, or car	0	1	2	3
38	Has stayed out at night without permission	0	1	2	3
39	Has run away from home overnight	0	1	2	3
40	Has forced someone into sexual activity	0	1