Name: Pediatric People
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NICHQ VANDERBILT ASSESSMENT SCALE
TEACHER INFORMANT

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STUDENT INFORMATION

Student*

First Last

Teacher*

First Last

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Date of Birth

Month

Day

Year

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Date

MM slash DD slash YYYY

Class Name / Period*

Class Time*

Grade Level*

Time you have been able to evaluate the behaviors*

This evaluation based on a time when the child*

SYMPTOM ASSESSMENT

Each rating should be considered in the context of what is appropriate for the age of the children you are rating.

1. Fails to give attention to details or makes careless mistakes in schoolwork.*

Never

Occasionally

Often

Very Often

2. Has difficulty sustaining attention to tasks or activities.*

Never

Occasionally

Often

Very Often

3. Does not seem to listen when spoken to directly.*

Never

Occasionally

Often

Very Often

4. Does not follow through on instruction and fails to finish schoolwork, not due to oppositional behavior or failure to understand.*

Never

Occasionally

Often

Very Often

5. Has difficulty organizing tasks and activities.*

Never

Occasionally

Often

Very Often

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustaining mental effort.*

Never

Occasionally

Often

Very Often

7. Loses things necessary for tasks or activities like school assignments, pencils, or books.*

Never

Occasionally

Often

Very Often

8. Is easily distracted by extraneous stimuli.*

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities.*

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat.*

Never

Occasionally

Often

Very Often

11. Leaves seat in classroom or in other situations in which remaining seated is expected.*

Never

Occasionally

Often

Very Often

12. Runs about or climbs excessively in situations in which remaining seated is expected.*

Never

Occasionally

Often

Very Often

13. Has difficulty playing or engaging in leisure activities quietly.*

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

15. Talks excessively.*

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed.*

Never

Occasionally

Often

Very Often

17. Has difficulty waiting in line.*

Never

Occasionally

Often

Very Often

18. Interrupts or intrudes on others, e.g., butts into conversations or games.*

Never

Occasionally

Often

Very Often

19. Loses temper.*

Never

Occasionally

Often

Very Often

20. Actively defies or refuses to comply with adults’ requests or rules.*

Never

Occasionally

Often

Very Often

21. Is angry or resentful.*

Never

Occasionally

Often

Very Often

22. Is spiteful and vindictive.*

Never

Occasionally

Often

Very Often

23. Bullies, threatens, or intimidates others.*

Never

Occasionally

Often

Very Often

24. Initiates physical fights.*

Never

Occasionally

Often

Very Often

25. Lies to obtain goods for favors or to avoid obligations, i.e., “cons” others.*

Never

Occasionally

Often

Very Often

26. Is physically cruel to people.*

Never

Occasionally

Often

Very Often

27. Has stolen items of nontrivial value.*

Never

Occasionally

Often

Very Often

28. Deliberately destroys others’ property.*

Never

Occasionally

Often

Very Often

29. Is fearful, anxious, or worried.*

Never

Occasionally

Often

Very Often

30. Is self-conscious or easily embarrassed.*

Never

Occasionally

Often

Very Often

31. Is afraid to try new things for fear of making mistakes.*

Never

Occasionally

Often

Very Often

32. Feels worthless or inferior.*

Never

Occasionally

Often

Very Often

33. Blames self for problems, feels guilty.*

Never

Occasionally

Often

Very Often

34. Feels lonely, unwanted, or unloved; complains that “no one loves him / her”.*

Never

Occasionally

Often

Very Often

35. Is sad, unhappy, or depressed.*

Never

Occasionally

Often

Very Often

ACADEMIC PERFORMANCE

36. Reading*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

37. Mathematics*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

38. Written Expression*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

CLASSROOM BEHAVIORAL PERFORMANCE

39. Relationship With Peers*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

40. Following Directions / Rules*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

41. Disrupting Class*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

42. Assignment Completion*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

43. Organizational Skills*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Comments

SCORES

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PREDOMINANTLY INATTENTIVE SUBTYPE

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

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PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE

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

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Total Symptom Score for questions 1–18:

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OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN

Total number of questions scored 2 or 3 in questions 19–28:

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ANXIETY / DEPRESSION SCREEN

Total number of questions scored 2 or 3 in questions 29–35:

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Average Performance Score:

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F76 Tie

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F77 Tie

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F78 Tie

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F80 Tie

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F81 Tie

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F82 Tie

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F83 Tie

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F84 Tie

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ACADEMIC PERFORMANCE

Total number of questions scored 4 or 5 in questions 36–43:

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PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE

Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.

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PREDOMINANTLY INATTENTIVE SUBTYPE SCORE

Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.

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ADHD COMBINED INATTENTION / HYPERACTIVITY

Requires the above criteria on both inattention and hyperactivity / impulsivity.

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OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN

Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.

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ANXIETY / DEPRESSION SCREEN

Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.

PREDOMINANTLY INATTENTIVE SUBTYPE:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.

PREDOMINANTLY INATTENTIVE SUBTYPE:
⚠ CRITERIA MET
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.

PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.

PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
⚠ CRITERIA MET
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.

ADHD COMBINED INATTENTION / HYPERACTIVITY:
✓ CRITERIA NOT MET
Requires the above criteria on both inattention and hyperactivity / impulsivity.

ADHD COMBINED INATTENTION / HYPERACTIVITY:
⚠ CRITERIA MET
Requires the above criteria on both inattention and hyperactivity / impulsivity.

OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.

OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN:
⚠ CRITERIA MET
Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.

ANXIETY / DEPRESSION SCREEN:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.

ANXIETY / DEPRESSION SCREEN:
⚠ CRITERIA MET
Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.

NICHQ VANDERBILT ASSESSMENT SCALE TEACHER INFORMANT

STUDENT INFORMATION

SYMPTOM ASSESSMENT

ACADEMIC PERFORMANCE

CLASSROOM BEHAVIORAL PERFORMANCE

SCORES

NICHQ VANDERBILT ASSESSMENT SCALE
TEACHER INFORMANT