Vanderbilt Assessment Parent/Guardian

Child's Name/Nombre del niño *

Date of Birth/Fecha de nacimiento * +

Parent/Guardian's Name(s)/Nombre del padre o de la madre *

Date/Fecha de hoy * +

English

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating. When completing this form, please think about the child’s behaviors in the PAST 6 MONTHS.

Is the evaluation based on a time when the child was:

on medication

not on medication

unknown

Symptoms

	Never 0	Occasionally 1	Often 2	Very Often 3
1. Does not pay attention to details or makes careless mistakes with, for example, homework	Never 0	Occasionally 1	Often 2	Very Often 3
2. Has difficulty keeping attention to what needs to be done	Never 0	Occasionally 1	Often 2	Very Often 3
3. Does not seem to listen when spoken to directly	Never 0	Occasionally 1	Often 2	Very Often 3
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)	Never 0	Occasionally 1	Often 2	Very Often 3
5. Has difficulty organizing tasks and activities	Never 0	Occasionally 1	Often 2	Very Often 3
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort	Never 0	Occasionally 1	Often 2	Very Often 3
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)	Never 0	Occasionally 1	Often 2	Very Often 3
8. Is easily distracted by noises or other activities	Never 0	Occasionally 1	Often 2	Very Often 3
9. Is forgetful in daily living activities	Never 0	Occasionally 1	Often 2	Very Often 3
10. Fidgets with hands or squirms in seat	Never 0	Occasionally 1	Often 2	Very Often 3
11. Leaves seat when remaining seated is expected	Never 0	Occasionally 1	Often 2	Very Often 3
12. Runs about or climbs too much when remaining seated is expected	Never 0	Occasionally 1	Often 2	Very Often 3
13. Has difficulty playing or beginning quiet play activities	Never 0	Occasionally 1	Often 2	Very Often 3
14. Is “on the go” or often acts as if “driven by a motor”	Never 0	Occasionally 1	Often 2	Very Often 3
15. Talks too much	Never 0	Occasionally 1	Often 2	Very Often 3
16. Blurts out answers before you have finished asking the question	Never 0	Occasionally 1	Often 2	Very Often 3
17. Has difficulty waiting for his or her turn	Never 0	Occasionally 1	Often 2	Very Often 3
18. Interrupts or intrudes in on others’ conversations and/or activities	Never 0	Occasionally 1	Often 2	Very Often 3
19. Argues with adults	Never 0	Occasionally 1	Often 2	Very Often 3
20. Loses temper	Never 0	Occasionally 1	Often 2	Very Often 3
21. Actively defies or refuses to go along with adults’ requests or rules	Never 0	Occasionally 1	Often 2	Very Often 3
22. Deliberately annoys people	Never 0	Occasionally 1	Often 2	Very Often 3
23. Blames others for his or her mistakes or misbehaviors	Never 0	Occasionally 1	Often 2	Very Often 3
24. Is touchy or easily annoyed by others	Never 0	Occasionally 1	Often 2	Very Often 3
25. Is angry or resentful	Never 0	Occasionally 1	Often 2	Very Often 3
26. Is spiteful and wants to get even	Never 0	Occasionally 1	Often 2	Very Often 3
27. Bullies, threatens, or intimidates others	Never 0	Occasionally 1	Often 2	Very Often 3
28. Starts physical fights	Never 0	Occasionally 1	Often 2	Very Often 3
29. Lies to obtain goods for favors or to avoid obligations (e.g. “cons” others)	Never 0	Occasionally 1	Often 2	Very Often 3
30. Is truant from school (skips school) without permission	Never 0	Occasionally 1	Often 2	Very Often 3
31. Is physically cruel to people	Never 0	Occasionally 1	Often 2	Very Often 3
32. Has stolen things that have value	Never 0	Occasionally 1	Often 2	Very Often 3
33.Deliberately destroys others’ property	Never 0	Occasionally 1	Often 2	Very Often 3
34. Has used a weapon that can cause serious harm or injury (e.g. bat, knife, brick, gun)	Never 0	Occasionally 1	Often 2	Very Often 3
35. Is physically cruel to animals	Never 0	Occasionally 1	Often 2	Very Often 3
36. Has deliberately set fires to cause damage	Never 0	Occasionally 1	Often 2	Very Often 3
37. Has broken into someone else’s home, business, or car	Never 0	Occasionally 1	Often 2	Very Often 3
38. Has stayed out at night without permission	Never 0	Occasionally 1	Often 2	Very Often 3
39. Has run away from home overnight	Never 0	Occasionally 1	Often 2	Very Often 3
40. Has forced someone into sexual activity	Never 0	Occasionally 1	Often 2	Very Often 3
41. Is fearful, anxious, or worried	Never 0	Occasionally 1	Often 2	Very Often 3
42. Is afraid to try new things for fear of making mistakes	Never 0	Occasionally 1	Often 2	Very Often 3
43. Feels worthless or inferior	Never 0	Occasionally 1	Often 2	Very Often 3
44. Blames self for problems; feels guilty	Never 0	Occasionally 1	Often 2	Very Often 3
45. Feels lonely, unwanted, or unloved; complains that “no one lives him or her”	Never 0	Occasionally 1	Often 2	Very Often 3
46. Is sad, unhappy, or depressed	Never 0	Occasionally 1	Often 2	Very Often 3
47. Is self-conscious or easily embarrassed	Never 0	Occasionally 1	Often 2	Very Often 3

Academic/Behavioral Performance

	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
48. Overall school performance	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
49. Reading	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
50. Writing	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
51. Math	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
52. Relationship with parents/guardians	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
53. Relationship with siblings (if applicable)	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
54. Relationship with friends or others his/her age	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5
55. Participation in organized activities (e.g. sports, teams)	Excellent 1	Above Average 2	Average 3	Somewhat of a Problem 4	Problematic 5

1. Does the child have problems with wetting his or her pants or bed? If so, how often does this happen?

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2. Does the child have bowel movements in her or her pants either accidentally or on purpose? If so, how often does this happen?

3. Does the child have any medical conditions that may cause these problems?

Espanol

Instrucciones: Conteste basándose en lo que considera apropiado para un niño de esa edad. Al completar este
cuestionario, piense por favor en la conducta de su niño(a) desde la última vez que llenó el primer
cuestionario.

Durante el período de evaluación su hijo:

tomaba medicamentos

no tomaba medicamentos

no lo recuerda

Síntomas

	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
1. No pone atención a los detalles o comete errores por descuido como por ejemplo, cuando hace la tarea	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
2. Se le dificulta mantenerse atento al llevar a cabo sus actividades	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
3. Parece no estar escuchando cuando se le habla directamente	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
4. No sigue las instrucciones hasta el final y no concluye sus actividades (no porque se rehúse a seguirlas o porque no las comprenda)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
5. Tiene dificultad al organizar sus tareas y actividades	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
6. Evita, le disgusta o no quiere comenzar actividades que requieren un continuo esfuerzo mental	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
7. Pierde cosas que son indispensables para cumplir con sus tareas o actividades (juguetes, tareas de la escuela, lápices o libros)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
8. Se distrae fácilmente con ruidos u otros estímulos externos	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
9. Es olvidadizo(a) en sus actividades cotidianas	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
10. Mueve constantemente las manos o los pies, o no se está quieto(a) en su asiento	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
11. Se pone de pie cuando debiera permanecer sentado(a)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
12. Corre o camina por todos lados cuando debiera permanecer sentado	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
13. Se le dificulta jugar o empezar actividades recreativas más tranquilas	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
14. Está en constante movimiento o actúa como si “tuviera un motor por dentro”	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
15. Habla demasiado	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
16. Responde precipitadamente, incluso antes de escuchar la pregunta complete	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
17. Tiene dificultad al esperar su turno	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
18. Interrumpe o se entromete en conversaciones o actividades ajenas	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
19.Discute con adultos	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
20. Se enfurece con facilidad	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
21. Desafia abiertamente o se niega a cumplir las 6rdenes o las reglas de Los adultos	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
22. Molesta adrede a los demas	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
23. Culpa a otros de sus propios errores o su ma! comportamiento	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
24. Se ofende o se molesta facilmente con otros	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
25. Esta enojado(a) o resentido(a)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
26. Es rencoroso y vengativo	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
27. Reta, amenaza o intimida a otros	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
28. Comienza peleas de contacto fisico	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
29. Miente con el fin de salir de apuros o para eludir sus obligaciones	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
30. Falta a la escuela sin permiso	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
31. Es fisicamente cruel con los demas	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
32. Ha robado cosas de valor	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
33. Destruye deliberadamente la propiedad ajena	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
34. Ha usado un objeto que puede herir a alguien (bate, cuchillo, ladrillo, pistola)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
35. Tortura animales	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
36. Ha provocado fuegos para causar dafios	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
37. Ha entrado a una casa, un negocio o un carro ajeno	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
38. Ha permanecido fuera de la casa sin permiso durante la noche	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
39. Se ha escapado de la casa durante la noche	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
40. Ha obligado a alguien a sostener algun tipo de actividad sexual	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
41. Siente miedo, ansiedad o esta preocupado	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
42. Teme hacer nuevas cosas por temor a cometer errores	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
43. Se desprecia a si mismo se siente inferior	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
44. Siente que los problemas son responsabilidad suya y se siente culpable	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
45. Se siente solo(a), rechazado(a) o sin amor; se queja de que nadie lo quiere	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
46. Se siente triste, infeliz o deprimido(a)	Nunca 0	A veces 1	Seguido 2	Muy seguido 3
47. Esta al pendiente de sus actos o se avergiienza facilrnente	Nunca 0	A veces 1	Seguido 2	Muy seguido 3

Comportamiento Performance

	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
48. Comportamiento general en la escuela	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
49. Lectura	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
50. Escritura	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
51. Matemáticas	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
52. Relación con sus padres	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
53. Rlación con sus hermanos	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
54. Relación con sus compañeros	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5
55. Participación en actividades organizadas (ejemplo: equipos deportivos)	Excellent 1	Sobre lo normal	Normal	Cieta dificultad	Con dificultad 5

1. ¿Sufre su niño de incontinencia urinaria, que se haga pipí en la cama o en su ropa? Si está en lo cierto, ¿Con qué frecuencia le pasa?

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2. ¿Tiene problemas con su niño de que defeque en sus pantalones, ya sea por accidente o a propósito? Si está en lo cierto, ¿Con qué frecuencia le pasa?

3. ¿Sabe si su niño tiene alguna condición médica que sea la causante de estos problemas?

Center Associates

9 N. 4th Ave.

Marshalltown, IA 50158