Vanderbilt Assessment Scale-Teacher Informant #6176

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Vanderbilt Assessment Scale—Teacher Informant #6176
Adapted from the Vanderbilt Rating Scale by Mark L. Wolraich, MD
Student:____________________________ Gender: ________ Age: ________ Grade: ___________
Completed by: ___________________________ Date: ____________________________________
Directions Each rating should be considered in the context of what is appropriate for the age of
the student. When completing this form, please think about the student's behaviors in the past
6 months. Is this evaluation based on a time when the student:
was on medication was not on medication not sure?
Symptoms Never Occa- Often Very

(0) sionally (2) Often
(1) (3)
1. Fails to pay attention to details or makes
careless mistakes in schoolwork
2. Has difficulty sustaining attention to tasks or
activities
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails
to finish schoolwork (not due to refusal or failure
to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort
7. Loses things necessary for tasks or activities
(e.g., toys, school assignments, pencils, books,
or tools)
8. Is distracted by extraneous stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat in classroom or in other situations in
which remaining seated is expected
12. Runs about or climbs excessively in situations in
which remaining seated is expected
13. Has difficulty playing or engaging in leisure
activities quietly
14. Is “on the go” or often acts as if “driven by a
motor”
15. Talks excessively
16. Blurts out answers before questions have been
completed
17. Has difficulty awaiting turn
18. Interrupts or intrudes on others (e.g., butts into
conversations/games)
19. Loses temper
20. Actively defies or refuses to go along with adult
requests or rules
21. Is angry or resentful
22. Is spiteful and wants to get even
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to get out of trouble or to avoid obligations
(ie, "cons" others)
26. Is physically cruel to people
27. Has stolen things that have value
28. Deliberately destroys others’ property
29. Is fearful, anxious, or worried
30. Is self-conscious or easily embarrassed
31. Is afraid to try new things for fear of making
mistakes
32. Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains
that “no one loves him or her”
35. Is sad, unhappy, or depressed
Performance
Excellent Above Average Somewhat of Problematic
Academic Average a Problem
Performance
36. Reading
37. Mathematics
38. Written Expression
Performance
Excellent Above Average Somewhat of Problematic
Classroom Average a Problem
Behavior
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills
Comments:
For Office Use Only
Total number of items scored 2 or 3 in items 1-9: _______ (ADHD, predominantly inattentive type—6 or
more symptoms)
Total number of items scored 2 or 3 in items 10-18:_______ (ADHD, predominantly hyperactive-

impulsive type—6 or more symptoms)
Total Symptoms Score for items 1-18:_______ (ADHD,predominantly combined type—6 or more
symptoms of both types)
Total number of items scored 2 or 3 in items 19-28:_______ (oppositional and conduct disorder
screen—3 or more symptoms)
Total number of items scored 2 or 3 in items 29-35:_______ (anxiety/depression screen—3 or more

symptoms)
Total number of items scored 2 or 3 in items 36-43:_______ (academic and classroom behavior
symptoms)
Average Performance Score:_______ (average score on items 36-43)

Scoring Instructions for the Vanderbilt Assessment Scale—Teacher Informant
The Vanderbilt Assessment Scale has two components: symptom assessment and impairment of
performance.
For the ADHD screen, the symptoms assessment component screens for symptoms that meet the
criteria for both inattentive (items 1-9) and hyperactive-impulsive ADHD (items 10-18). To meet DSM-IV
criteria for the diagnosis of ADHD, one must have at least 6 responses of "Often" or "Very Often"
(scored 2 or 3) to either the 9 inattentive or 9 hyperactive-impulsive items, or both and a score of 4 or 5
on any of the Performance items (36-43). There is a place to record the number of symptoms that meet
this criteria in each subgroup.
The Vanderbilt Assessment Scale also contains items that screen for 3 other co-morbidities:
oppositional defiant disorder (items 19-22), conduct disorder (items 23-28), and anxiety/depression
(items29-35).
To screen for oppositional defiant disorder/conduct disorder one must have at least 3 responses of
"Often" or "Very Often" on items 19-28 and a score of 4 or 5 on any of the Performance items (36-
43).
To screen for anxiety/depression one must have at least 3 responses of "Often" or "Very Often" on
items 29-35 and a score of 4 or 5 on any of the Performance items 36-43.
The Vanderbilt Assessment Scale should NOT be used alone to make a diagnosis. The practitioner
must consider information from other sources and may ask for the child's report cards, samples of the
child's schoolwork, as well as any psychometric testing done.
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised-1102.. This
form may be copied for personal use. Copyright © 2003 Health Link Systems, Inc. MyADHD.com

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myADHD.

Student:__________________ Gender: Age: Grade: _

Completed by: _ Date: __________

Symptoms Never Occa- Often Very

Total number of items scored 2 or 3 in items 10-18:_______ (ADHD, predominantly hyperactive-

Total number of items scored 2 or 3 in items 29-35:_______ (anxiety/depression screen—3 or more

Average Performance Score:_______ (average score on items 36-43)

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