Vanderbilt Form – Fill Out and Use This PDF

The NICHQ Vanderbilt Assessment Scale – Parent Informant is a tool designed to help parents and healthcare professionals assess behavioral issues in children, focusing on symptoms of attention deficit hyperactivity disorder (ADHD) and other behavioral problems over the previous six months. It provides a structured way for parents to report on their child's behavior by rating various symptoms and their severity. If you believe this assessment could be beneficial for understanding your child's behavior, consider completing the form by clicking the button below.

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The NICHQ Vanderbilt Assessment Scale serves as a vital tool for parents and healthcare professionals aiming to assess and understand various behavioral and emotional conditions in children, particularly those that may indicate Attention Deficit Hyperactivity Disorder (ADHD) and other related issues. This comprehensive form, designed with the purpose of being filled out by parents, delves into a child's behavior over the last six months, offering a nuanced view of their actions in different contexts. It seeks detailed input on symptoms ranging from attention difficulties, impulsivity, and hyperactivity to conduct problems and symptoms of anxiety and depression. Each item on the scale is to be rated based on its frequency, allowing for a nuanced capture of the child's behavior. The Vanderbilt form also explores the child's performance in academic settings, their relationships with parents, siblings, and peers, and their participation in organized activities, providing a rounded perspective on the child's social functioning and academic performance. This multi-faceted approach not only aids in the accurate identification of ADHD and other developmental or emotional challenges but also helps in guiding subsequent steps for intervention and support tailored to the child's specific needs.

Question	Answer
Form Name	Vanderbilt Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	vanderbilt form parent, vanderbilt form fillable, vanderbilt parent forms, printable vanderbilt forms

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NICHQ VANDERBILT ASSESSMENT SCALE – PARENT INFORMANT*

Today’s Date: _________________ Child’s Name: ______________________________ 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 behaviors in the past 6 months.

Is this evaluation based on a time when the child was on medication was not on medication not sure?

	Symptoms	Never	Occasionally	Often	Very Often

1.	Does not pay attention to details or makes careless mistakes with, for example,	0	1	2	3
	homework

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	0	1	2	3
	to refusal or failure to understand)

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 or 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 as if “driven by a 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 on 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’ requests 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 others	0	1	2	3

28.	Starts physical fights	0	1	2	3

29.	Lies to get out of trouble or to avoid obligations (i.e. “cons” others)	0	1	2	3

30.	Is truant from school (skips school) without permission	0	1	2	3

31.	Is physically 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

NICHQVanderbiltParent.20050602

NICHQ VANDERBILT ASSESSMENT SCALE – PARENT INFORMANT*

Today’s Date: _________________ Child’s Name: ______________________________ Date of Birth:______________________

Parent’s Name: __________________________________________ Parent’s Phone Number:_____________________________

	Symptoms		Never	Occasionally	Often	Very Often

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	2	3

41.	Is fearful, anxious, or worried		0	1	2	3

42.	Is afraid to try new things for fear of making mistakes		0	1	2	3

43.	Feels worthless or inferior		0	1	2	3

44.	Blames self for problems, feels guilty		0	1	2	3

45.	Feels lonely, unwanted, or unloved; complains that “no one loves him or her”		0	1	2	3

46.	Is sad, unhappy, or depressed		0	1	2	3

47.	Is self-conscious or easily embarrassed		0	1	2	3

					Somewhat
			Above		of a
	Performance	Excellent	Average	Average	Problem	Problematic

48.	Overall school performance	1	2	3	4	5

49.	Reading	1	2	3	4	5

50.	Writing	1	2	3	4	5

51.	Mathematics	1	2	3	4	5

52.	Relationship with parents	1	2	3	4	5

53.	Relationship with siblings	1	2	3	4	5

54.	Relationship with peers	1	2	3	4	5

55	Participation in organized activities (e.g. teams)	1	2	3	4	5

Comments:

For Office Use Only

Total number of questions scored 2 or 3 in questions 1-9: ____________

Total number of questions scored 2 or 3 in questions 10-18: __________

Total Symptom Score for questions 1-18: _________________________

Total number of questions scored 2 or 3 in questions 19-26: __________

Total number of questions scored 2 or 3 in questions 27-40: __________

Total number of questions scored 2 or 3 in questions 41-47: __________

Total number of questions scored 4 or 5 in questions 48-55: __________

Average Performance Score: __________________________________

NICHQVanderbiltParent.20050602

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