Download - NICHQ Vanderbilt Assessment Follow-up: Teacher Informant · 2019-11-06 · NICHQ Vanderbilt Assessment Follow-up: Teacher Informant MONITORING AND FOLLOW-UP Page 2 of 3 Symptoms (continued)

CARING FOR CHILDREN WITH ADHD: A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION

MONITORING AND FOLLOW-UP of 3

Symptoms Never Occasionally Often VeryOften

1. Failstogiveattentiontodetailsormakescarelessmistakesinschoolwork

2. Hasdifficultysustainingattentiontotasksoractivities

3. Doesnotseemtolistenwhenspokentodirectly

4. Doesnotfollowthroughoninstructionsandfailstofinishschoolwork (notduetooppositionalbehaviororfailuretounderstand)

5. Hasdifficultyorganizingtasksandactivities 0 1 2 3

6. Avoids,dislikes,orisreluctanttoengageintasksthatrequiresustained mentaleffort

7. Losesthingsnecessaryfortasksoractivities(schoolassignments, pencils,books)

8. Iseasilydistractedbyextraneousstimuli

9. Isforgetfulindailyactivities

10. Fidgetswithhandsorfeetorsquirmsinseat

11. Leavesseatinclassroomorinothersituationsinwhichremaining seatedisexpected

12. Runsaboutorclimbsexcessivelyinsituationsinwhichremaining seatedisexpected

13. Hasdifficultyplayingorengaginginleisureactivitiesquietly

14. Is“onthego”oroftenactsasif“drivenbyamotor”

15. Talksexcessively

16. Blurtsoutanswersbeforequestionshavebeencompleted

17. Hasdifficultywaitinginline

18. Interruptsorintrudesinonothers(eg,buttsintoconversations/games)

19. Losestemper

20. Activitydefiesorrefusestocomplywithadults’requestsorrules

21. Isangryorresentful

NICHQ Vanderbilt Assessment Follow-up: Teacher InformantChild’sName:

Child’sDateofBirth:

Teacher’sName:

Today’sDate:

ClassTime:

ClassName/Period:

GradeLevel:

Directions:Eachratingshouldbeconsideredinthecontextofwhatisappropriatefortheageofthechildyouareratingandshouldreflectthatchild’sbehaviorsincethelastassessmentwasfilledout.Pleaseindicatethenumberofweeksormonthsyouhavebeenabletoevaluatethebehaviors:.

ForOfficeUseOnly

__________/9

ForOfficeUseOnly

__________/9

NICHQ Vanderbilt Assessment Follow-up: Teacher Informant


Symptoms(continued) Never Occasionally Often VeryOften

22. Isspitefulandvindictive

23. Bullies,threatens,orintimidatesothers

24. Initiatesphysicalfights

25. Liestoobtaingoodsforfavorsortoavoidobligations(eg,“cons”others)

26. Isphysicallycrueltopeople

27. Hasstolenitemsofnontrivialvalue

28. Deliberatelydestroysothers’property

Somewhat Above ofa AcademicPerformance Excellent Average Average Problem Problematic

29. Reading

30. Mathematics

31. Writtenexpression

ClassroomBehavioralPerformance

32. Relationshipwithpeers

33. Followingdirections

34. Disruptingclass

35. Assignmentcompletion

36. Organizationalskills

AdaptedfromtheVanderbiltRatingScalesdevelopedbyMarkL.Wolraich,MD.

AdaptedfromthePittsburghsideeffectsscale,developedbyWilliamE.Pelham,Jr,PhD.Availablefordownloadingatnocostinexpandedformatathttp://ccf.FIU.edu.

SideEffects:Hasthechildexperiencedanyofthefollowingsideeffect Arethesesideeffectscurrentlyaproblem?orproblemsinthepastweek? None Mild Moderate Severe

Headache

Stomachache

Changeofappetite——explainbelow

Troublesleeping

Irritabilityinthelatemorning,lateafternoon,orevening——explainbelow

Sociallywithdrawn——decreasedinteractionwithothers

Extremesadnessorunusualcrying

Dull,tired,listlessbehavior

Tremors/feelingshaky

Repetitivemovements,tics,jerking,twitching,eyeblinking——explainbelow

Pickingatskinorfingers,nailbiting,liporcheckchewing——explainbelow

Seesorhearsthingsthataren’tthere

Explain/Comments:

Pleasereturnthisformto:

Mailingaddress: Faxnumber:

ForOfficeUseOnly

__________/10

ForOfficeUseOnly

5s:_________/5

ForOfficeUseOnly

5s:_________/3

ForOfficeUseOnly

4s:_________/5

ForOfficeUseOnly

4s:_________/3

NICHQ Vanderbilt Assessment Follow-up: Teacher Informant


Therecommendationsinthispublicationdonotindicateanexclusivecourseoftreatmentorserveasastandardofmedicalcare.Variations,takingintoaccountindividualcircumstances,maybeappropriate.OriginaldocumentincludedaspartofCaring for Children With ADHD: A Resource Toolkit for Clinicians, 2ndEdition.Copyright©2012AmericanAcademyofPediatrics.AllRightsReserved.TheAmericanAcademyofPediatricsdoesnotrevieworendorseanymodificationsmadetothisdocumentandinnoeventshalltheAAPbeliableforanysuchchanges.

ForOfficeUseOnly

Totalnumberofquestionsscored2or3inquestions1––9:_____________

Totalnumberofquestionsscored2or3inquestions10–—18:_____________

Totalnumberofquestionsscored2or3inquestions19–—28:_____________

Totalnumberofquestionsscored4inquestions29–—31:_____________


