Vanderbilt Teacher Assessment Scale

Page 1

Todays Date: _________ Childs Name: ________________________________________ DOB: ________

Teachers Name: ______________________________________ School: _______________________________________ Grade: ________
Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that childs
behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the
behaviors: ________________
Is this evaluation based on a time when the child
was on medication
was not on medication
not sure

Never

Occasionally

Often

Very
Often

0
0

1
1

2
2

3
3

0
0

1
1

2
2

3
3

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 too much when 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 too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his/her turn
18. Interrupts or intrudes in others conversations and/or activities

0
0
0
0
0
0
0

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

19. Loses temper

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

0
0
0

1
1
1

2
2
2

3
3
3

SYMPTOMS
1. Fails to give attention to details or makes careless mistakes in
2.

3.
4.

5.
6.
7.

8.
9.

schoolwork
Has difficulty sustaining attention to task or activities
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish schoolwork
(not due to oppositional behavior or failure to understand)
Has difficulty organizing task and activities
Avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental efforts
Loses things necessary for tasks or activities (school assignments,
pencils, or books)
Is easily distracted by extraneous stimuli
Is forgetful in daily activities

20. Actively defies or refuses to comply with adults request or rules

21. Is angry or resentful

22. Is spiteful and vindictive
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (i.e., cons
others)
26. Is physically cruel to people
27. Has stolen items of nontrivial value
28. Deliberately destroys others property
FAX OR MAIL COMPLETED FORM TO:

Oxford Pediatrics
5141 Morning Sun Rd.
Oxford, OH 45056
Phone: 513-523-2156
Fax: 513-523-2503

-Please Turn Over-

Count #
2s & 3s

Count #
2s & 3s
TSS
1-18

Count #
2s & 3s

Vanderbilt Teacher Assessment Scale, continued

Page 2

Todays Date: _________ Childs Name: ________________________________________ DOB: ________

Teachers Name: ______________________________________ School: _______________________________________ Grade: ________
SYMPTOMS, continued

29.
30.
31.
32.

Is fearful, anxious, or worried

Is self-conscious or easily embarrassed
Is afraid to try new things for fear of making mistakes
Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains that no one loves
him/her
35. Is sad, unhappy, or depressed
IMPAIRMENT

Never

Occasionally

Often

Very
Often

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

Excellent

Above
Average

Average

Somewhat of
a Problem

Problematic

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5

A. Reading
B. Mathematics
C. Written Expression
D. Relationship with peers
E. Following directions
F. Disrupting class
G. Assignment completion
H. Organizational skills

Count #
2s & 3s

Count #
4s & 5s
APS
36-43

Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD

PRE-EXISTING PROBLEMS

Use the following to assess severity:

None:
The symptom is not present.
Mild:
The symptom is present but is not significant enough to cause concern to the child, to his/her friends, or adults.
Moderate: The symptom causes some impairment of functioning or social embarrassment.
Severe:
The symptom causes impairment of functioning or social embarrassment to such a degree that it requires specific
treatment.
None

Mild Moderate Severe

Motor Ticsrepetitive movements: jerking or twitching (e.g., eye blinkingeye opening,

facial or mouth twitching, shoulder or arm movements)describe:
Buccallingual movements: Tongue thrusts, jaw clenching, chewing movement besides
lip/cheek biting describe:
Picking at skin or fingers, nail biting, lip or cheek chewing describe:
Worried/Anxious
Dull, tired, listless
Headaches
Stomachache
Crabby, Irritable
Tearful, Sad, Depressed
Socially withdrawn decreased interaction with others
Hallucinations (see or hear things that arent there)
Loss of appetite
Trouble sleeping (time went to sleep)
Adapted from the Pittsburgh Side-Effects Rating Scale