Chiropractic Neurology Center Vanderbilt Assessment ScaleTeacher Informant Name of student:___________________ Gender:______ Age:___ Grade:_____Date: ____________ Completed by:

_________________________ Teacher's Phone Number: ______________________ Directions: Each rating should be considered in the conte t of !hat is appropriate for the age of the child and should reflect that child's beha"ior since the beginning of the school year# Please indicate the number of !ee$s or months you ha"e been able to e"aluate the beha"iors: _____________ %s this e"aluation based on a time the child __ !as on medication __ !as not on medication __ not sure&
Symptoms 1 ! " # $ % & ' ( 'ails to gi"e attention to details or ma$es careless mista$es in school!or$ ,as difficulty sustaining attention to tas$s or acti"ities Does not seem to listen !hen spo$en to directly Does not follo! through on instructions and fails to finish school!or$ -not due to refusal or failure to understand. ,as difficulty organi/ing tas$s and acti"ities A"oids0 disli$es0 or is reluctant to engage in tas$s that re1uire sustained mental effort 2oses things necessary for tas$s or acti"ities -e#g#0 toys0 school assignments0 pencils0 or boo$s. %s easily distracted by noises or other stimuli %s forgetful in daily acti"ities
Never Occasionally Often Very Often

( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

* * * * * * * * * * * * * * * * * * *

+ + + + + + + + + + + + + + + + + + +

1) 'idgets !ith hands or feet or s1uirms in seat 11 2ea"es seat in classroom or in other situations in !hich remaining seated is e pected 1! 3uns about or climbs e cessi"ely in situations in !hich remaining seated is e pected 1" ,as difficulty playing or engaging in leisure acti"ities 1uietly 1# %s 4on the go4 or often acts as if 4dri"en by a motor4 1$ Tal$s e cessi"ely 1% 5lurts out ans!ers before 1uestions ha"e been completed 1& ,as difficulty !aiting in line 1' %nterrupts or intrudes on others -eg0 butts into con"ersations6games. 1( 2oses temper

!) !1 !! !" !# !$ !% !& !' !( ") "1 "! "" "# "$

Acti"ely defies or refuses to comply !ith adults' re1uests or rules %s angry or resentful %s spiteful and "indicti"e 5ullies0 threatens0 or intimidates others %nitiates physical fights 2ies to obtain goods for fa"ors or to a"oid obligations -eg0 4cons4 others. %s physically cruel to people ,as stolen items of nontri"ial "alue Deliberately destroys others' property %s fearful0 an ious0 or !orried %s self7conscious or easily embarrassed %s afraid to try ne! things for fear of ma$ing mista$es 'eels !orthless or inferior 5lames self for problems8 feels guilty 'eels lonely0 un!anted0 or unlo"ed8 compains that 4no one lo"es him or her4 %s sad0 unhappy0 or depressed *erformance Academic Performance +,cellent ) ) ) +,cellent ) ) ) ) ) Above Average * * * Above Average * * * * *

( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( Average + + + Average + + + + +

) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

* * * * * * * * * * * * * * * *

+ + + + + + + + + + + + + + + +

..

Some-hat of a *roblematic *roblem 9 9 9 : : :

"% 3eading "& ;athematics "' <ritten e pression Classroom Behavioral Performance "( 3elationship !ith peers #) 'ollo!ing directions #1 Disrupting class #! Assignment completion #" =rgani/ational s$ills

Some-hat of a *roblematic *roblem 9 9 9 9 9 : : : : :

Comments:
.or Office /se Only

Total number of items scored * or + in items )7>: _______ -AD,D0 predominantly inattenti"e type?@ or more symptoms. Total number of items scored * or + in items )(7)A:_______ -AD,D0 predominantly hyperacti"e7impulsi"e type?@ or more symptoms. Total number of items scored * or + for items )7)A:_______ -AD,D0 combined type?@ or more symptoms of both types. Total number of items scored * or + in items )>7*A:_______ -oppositional and conduct disorder screen?+ or more symptoms. Total number of items scored * or + in items *>7+::_______ -an iety6depression screen?+ or more symptoms. Total number of items scored * or + in items +@79+:_______ -academic and classroom beha"ior symptoms. Scoring Instructions for the Vanderbilt Assessment ScaleTeacher Informant The Banderbilt Assessment Ccale has t!o components: symptom assessment and impairment of performance# 'or the A010 screen0 the symptoms assessment component screens for symptoms that meet the criteria for both inattenti"e -items )7>. and hyperacti"e7impulsi"e AD,D -items )(7)A.# To mee t DSM-IV criteria for the diagnosis of AD,D0 one must ha"e at least @ responses of 4=ften4 or 4Bery =ften4 -scored * or +. to either the > inattenti"e or > hyperacti"e7impulsi"e items0 or both and a score of 9 or : on any of the Performance items -+@79+.# There is a place to record the number of symptoms that meet this criteria in each subgroup# The Banderbilt Assessment Ccale also contains items that screen for + other co7morbidities: oppositional defiant disorder -items )>7**.0 conduct disorder -items *+7*A.0 and an iety6depression -items*>7+:.# To screen for oppositional defiant disorder2conduct disorder one must ha"e at least + responses of 4=ften4 or 4Bery =ften4 on items )>7*A and a score of 9 or : on any of the Performance items -+@79+.# To screen for an,iety2depression one must ha"e at least + responses of 4=ften4 or 4Bery =ften4 on items *>7+: and a score of 9 or : on any of the Performance items +@79+# The Banderbilt Assessment Ccale should N=T be used alone to ma$e a diagnosis# The practitioner must consider information from other sources and may as$ for the child's report cards0 samples of the child's school!or$0 as !ell as any psychometric testing done#
Adapted from the Banderbilt 3ating Ccales de"eloped by ;ar$ 2# <olraich0 ;D# 3e"ised7))(*# 'or additional information about this scale see: <olraich0 ;# 2#0 et al# -)>>A. =btaining systematic teacher reports of disrupti"e beha"ior disorders utili/ing DC;7%B# -Diagnostic and Ctatistical ;anual of ;ental Disorders0 9th ed#. Dournal of Abnormal Child Psychology# =r "isit the follo!ing !ebsite: http:66!!!#findarticles#com6cf_dls6m(>(*6n*_"*@6*(A*9+@96p>6article#Ehtml&termF This form may be copied by acti"e myAD,D#com subscribers# Copyright G *((+ ,ealth 2in$ Cystems0 %nc# ;yAD,D#com