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NICHQ: Parent Informant

NICHQ Vanderbilt Assessment Scale—Parent Informant

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 medicationwas not on medicationnot sure?

Symptoms

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

NeverOccasionallyOftenVery Often

2. Has difficulty keeping attention to what needs to be done

NeverOccasionallyOftenVery Often

3. Does not seem to listen when spoken to directly

NeverOccasionallyOftenVery Often

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

NeverOccasionallyOftenVery Often

5. Has difficulty organizing tasks and activities

NeverOccasionallyOftenVery Often

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

NeverOccasionallyOftenVery Often

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

NeverOccasionallyOftenVery Often

8. Is easily distracted by noises or other stimuli

NeverOccasionallyOftenVery Often

9. Is forgetful in daily activities

NeverOccasionallyOftenVery Often

10. Fidgets with hands or feet or squirms in seat

NeverOccasionallyOftenVery Often

11. Leaves seat when remaining seated is expected

NeverOccasionallyOftenVery Often

12. Runs about or climbs too much when remaining seated is expected

NeverOccasionallyOftenVery Often

13. Has difficulty playing or beginning quiet play activities

NeverOccasionallyOftenVery Often

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

NeverOccasionallyOftenVery Often

15. Talks too much

NeverOccasionallyOftenVery Often

16. Blurts out answers before questions have been completed

NeverOccasionallyOftenVery Often

17. Has difficulty waiting his or her turn

NeverOccasionallyOftenVery Often

18. Interrupts or intrudes in on others’ conversations and/or activities

NeverOccasionallyOftenVery Often

19. Argues with adults

NeverOccasionallyOftenVery Often

20. Loses temper

NeverOccasionallyOftenVery Often

21. Actively defies or refuses to go along with adults’ requests or rules

NeverOccasionallyOftenVery Often

22. Deliberately annoys people

NeverOccasionallyOftenVery Often

23. Blames others for his or her mistakes or misbehaviors

NeverOccasionallyOftenVery Often

24. Is touchy or easily annoyed by others

NeverOccasionallyOftenVery Often

25. Is angry or resentful

NeverOccasionallyOftenVery Often

26. Is spiteful and wants to get even

NeverOccasionallyOftenVery Often

27. Bullies, threatens, or intimidates others

NeverOccasionallyOftenVery Often

28. Starts physical fights

NeverOccasionallyOftenVery Often

29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)

NeverOccasionallyOftenVery Often

30. Is truant from school (skips school) without permission

NeverOccasionallyOftenVery Often

31. Is physically cruel to people

NeverOccasionallyOftenVery Often

32. Has stolen things that have value

NeverOccasionallyOftenVery Often

33. Deliberately destroys others’ property

NeverOccasionallyOftenVery Often

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

NeverOccasionallyOftenVery Often

35. Is physically cruel to animals

NeverOccasionallyOftenVery Often

36. Has deliberately set fires to cause damage

NeverOccasionallyOftenVery Often

37. Has broken into someone else’s home, business, or car

NeverOccasionallyOftenVery Often

38. Has stayed out at night without permission

NeverOccasionallyOftenVery Often

39. Has run away from home overnight

NeverOccasionallyOftenVery Often

40. Has forced someone into sexual activity

NeverOccasionallyOftenVery Often

41. Is fearful, anxious, or worried

NeverOccasionallyOftenVery Often

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

NeverOccasionallyOftenVery Often

43. Feels worthless or inferior

NeverOccasionallyOftenVery Often

44. Blames self for problems, feels guilty

NeverOccasionallyOftenVery Often

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

NeverOccasionallyOftenVery Often

46. Is sad, unhappy, or depressed

NeverOccasionallyOftenVery Often

47. Is self-conscious or easily embarrassed

NeverOccasionallyOftenVery Often

Performance

48. Overall school performance

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

49. Reading

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

50. Writing

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

51. Mathematics

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

52. Relationship with parents

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

53. Relationship with siblings

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

54. Relationship with peers

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

55. Participation in organized activities (eg, teams)

ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

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April 14, 2022 7:41 am PDT

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April 25, 2022 10:16 am PDT

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