"Adhd Diagnostic Parent Rating Scale Form - Vanderbilt"

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V
ADHD D
P
R
S
ANDERBILT
IAGNOSTIC
ARENT
ATING
CALE
Patient Name: _______________________________________________
Today’s Date: _______________________________
Date of Birth: ________________________________________________
Age: _______________________________________
Grade: _______________________________________________________________________________________________________
Each rating should be considered in the context of what is appropriate for the age of your child.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
1.
Does not pay attention to details or makes careless mistakes, such as in homework
0
1
2
3
2.
Has difficulty sustaining attention to tasks or activities
0
1
2
3
3.
Does not seem to listen when spoken to directly
0
1
2
3
4.
Does not follow through on instruction and fails to finish
0
1
2
3
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
0
1
2
3
7.
Loses things necessary for tasks or activities (school assignments, pencils, or books)
0
1
2
3
8.
Is easily distracted by extraneous 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 excessively in situations when remaining seated is expected
0
1
2
3
13. Has difficulty playing or engaging in leisure activities quietly
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 on others (butts into conversations or games)
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 comply with adults’ requests or rules
0
1
2
3
1
V
ADHD D
P
R
S
ANDERBILT
IAGNOSTIC
ARENT
ATING
CALE
Patient Name: _______________________________________________
Today’s Date: _______________________________
Date of Birth: ________________________________________________
Age: _______________________________________
Grade: _______________________________________________________________________________________________________
Each rating should be considered in the context of what is appropriate for the age of your child.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
1.
Does not pay attention to details or makes careless mistakes, such as in homework
0
1
2
3
2.
Has difficulty sustaining attention to tasks or activities
0
1
2
3
3.
Does not seem to listen when spoken to directly
0
1
2
3
4.
Does not follow through on instruction and fails to finish
0
1
2
3
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
0
1
2
3
7.
Loses things necessary for tasks or activities (school assignments, pencils, or books)
0
1
2
3
8.
Is easily distracted by extraneous 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 excessively in situations when remaining seated is expected
0
1
2
3
13. Has difficulty playing or engaging in leisure activities quietly
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 on others (butts into conversations or games)
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 comply with adults’ requests or rules
0
1
2
3
1
V
ADHD D
P
R
S
ANDERBILT
IAGNOSTIC
ARENT
ATING
CALE
Each rating should be considered in the context of what is appropriate for the age of your child.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
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 vindictive
0
1
2
3
27. Bullies, threatens, or intimidates others
0
1
2
3
28. Initiates physical fights
0
1
2
3
29. Lies to obtain goods for favors or to avoid obligations (“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 items of nontrivial 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
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
2
V
ADHD D
P
R
S
ANDERBILT
IAGNOSTIC
ARENT
ATING
CALE
Each rating should be considered in the context of what is appropriate for the age of your child.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
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
P
ERFORMANCE
Problematic
Average
Above Average
Academic Performance
1.
Reading
1
2
3
4
5
2.
Mathematics
1
2
3
4
5
3.
Written expression
1
2
3
4
5
Classroom Behavior
1.
Relationships with peers
1
2
3
4
5
2.
Following directions/rules
1
2
3
4
5
3.
Disrupting class
1
2
3
4
5
4.
Assignment completion
1
2
3
4
5
5.
Organizational skills
1
2
3
4
5
3
V
ADHD D
T
R
S
ANDERBILT
IAGNOSTIC
EACHER
ATING
CALE
Patient Name: _______________________________________________
Today’s Date: _______________________________
Date of Birth: ________________________________________________
Age: _______________________________________
Grade: _______________________________________________________________________________________________________
Each rating should be considered in the context of what is appropriate for the age of the children you are rating.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
1.
Fails to give attention to details or makes careless mistakes in schoolwork
0
1
2
3
2.
Has difficulty sustaining attention to tasks or activities
0
1
2
3
3.
Does not seem to listen when spoken to directly
0
1
2
3
4.
Does not follow through on instruction and fails to finish
0
1
2
3
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 sustaining mental effort
0
1
2
3
7.
Loses things necessary for tasks or activities (school assignments, pencils, or books)
0
1
2
3
8.
Is easily distracted by extraneous 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 in classroom or in other situations in which remaining seated is expected
0
1
2
3
12. Runs about or climbs excessively in situations in which remaining seated is expected
0
1
2
3
13. Has difficulty playing or engaging in leisure activities quietly
0
1
2
3
14. Is “on the go” or often acts as if “driven by a motor”
0
1
2
3
15. Talks excessively
0
1
2
3
16. Blurts out answers before questions have been completed
0
1
2
3
17. Has difficulty waiting in line
0
1
2
3
18. Interrupts or intrudes on others (eg, butts into conversations or games)
0
1
2
3
19. Loses temper
0
1
2
3
20. Actively defies or refuses to comply with adults’ requests or rules
0
1
2
3
21. Is angry or resentful
0
1
2
3
1
V
ADHD D
T
R
S
ANDERBILT
IAGNOSTIC
EACHER
ATING
CALE
Each rating should be considered in the context of what is appropriate for the age of the children you are rating.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
22. Is spiteful and vindictive
0
1
2
3
23. Bullies, threatens, or intimidates others
0
1
2
3
24. Initiates physical fights
0
1
2
3
25. Lies to obtain goods for favors or to avoid obligations (ie, “cons” others)
0
1
2
3
26. Is physically cruel to people
0
1
2
3
27. Has stolen items of nontrivial value
0
1
2
3
28. Deliberately destroys others’ property
0
1
2
3
29. Is fearful, anxious, or worried
0
1
2
3
30. Is self-conscious or easily embarrassed
0
1
2
3
31. Is afraid to try new things for fear of making mistakes
0
1
2
3
32. Feels worthless or inferior
0
1
2
3
33. Blames self for problems, feels guilty
0
1
2
3
34. Feels lonely, unwanted, or unloved; complains that “no one loves” him or her
0
1
2
3
35. Is sad, unhappy, or depressed
0
1
2
3
P
ERFORMANCE
Problematic
Average
Above Average
Academic Performance
1.
Reading
1
2
3
4
5
2.
Mathematics
1
2
3
4
5
3.
Written expression
1
2
3
4
5
Classroom Behavioral Performance
1.
Relationships with peers
1
2
3
4
5
2.
Following directions/rules
1
2
3
4
5
3.
Disrupting class
1
2
3
4
5
4.
Assignment completion
1
2
3
4
5
5.
Organizational skills
1
2
3
4
5
2
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