Your Name: __________________________________________________

Name of the person being rated:___________________________________

Today's date:__________________________________________________

Psychological Functioning Scale For Children and Adolescents

Please rate the person’s functioning in the following areas over the last month (or other specified interval), where 0 is worst and 10 is best functioning.

Please use any number in the interval 0 to 10, including, if you wish, odd numbers or decimals such as 3.8.

Negative or harmful behaviors should pull the rating down. For example, despite lots of positive behavior, a few very harmful violent behaviors, or even one action if harmful enough, would result in a very low rating on the “free of harm to others” item.

0=Very undesirable, very great need for improvement.

2=Definitely undesirable, great need for improvement.

4= In the undesirable range, need for improvement.

6=OK, adequate, acceptable, but not great. Improvement is desirable.

8=Good functioning in this area. Would be just fine if pattern continued as is.

10=Excellent functioning in this area. Would be great, wonderful if pattern continued as is.

Reminder: 10 is best and 0 is worst

_____ F1. Acting kindly and cooperatively with family members; acting in ways that help improve the "family emotional climate"

_____ F2. Being respectful and compliant with teachers at school.

_____ F3. Getting along with peers at school.

_____ F4. Making and keeping friends

_____ F5. Performing up to potential in schoolwork.

_____ F6. Being happy, enjoying life, having fun.

_____ F7. Being free of psychological symptoms that distress the person himself or herself. (For example fears or depression or worries). (0 is worst; 10 is best.)

_____ F8. Being free of symptoms that bother other people.(For example misbehavior or aggression.) (0 is worst; 10 is best..

_____ F9. Doing “activities of daily living”: getting out of bed, getting dressed, bathing, brushing teeth, going to bed, cooperating with transportation, etc.

_____ F10. Doing useful work other than schoolwork, for example helping with family chores.

_____ F11. Being free, as far as you know, of considering or carrying out any act of self-harm. (10 is no problem with self-harm, 0 is very severe problems with self-harm)

_____ F12. Being free of threatening or carrying out any act of harm to others. (10 is no problem with harm of others, 0 is very severe problems with harm of others)

_____ F13. Being able to concentrate, stay on task, not be distracted, keep working long enough, have a high work capacity

_____ F14. Being organized.

_____ F15. Thinking before acting, not being impulsive.

_____ F16. Being able to sit still long enough and to be free from restlessness.

_____ F17. Making other people happy, having a net positive effect on others.

_____ F18. Now please rate overall functioning. Good functioning is the thoughts, feelings, and behaviors that tend to: produce happiness and well-being in both oneself and others; produce good social relations and positive achievement; and accomplish worthwhile goals. Please rate how strongly you would wish for this month's overall behavior pattern to continue.

VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE

Please note a new scale: 0 is best and 3 is worst.

0 = Never

1 = Occasionally

2 = Often

3 = Very Often

Please rate the person’s behavior in the last month.

_____V1. Does not pay attention to details or makes careless mistakes, with, for example, homework. (0 is best – never has this problem; 3 is worst – has this problem very often.)

_____V2. Has difficulty keeping attention to what needs to be done

_____V3. Does not seem to listen when spoken to directly

_____V4. Does not follow through when given directions and fails to finish activities

(not due to refusal or failure to understand

_____V5. Has difficulty organizing tasks and activities

_____V6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

_____V7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

_____V8. Is easily distracted by noises or other stimuli

_____V9. Is forgetful in daily activities

_____V10. Fidgets with hands or feet or squirms in seat

_____V11. Leaves seat when remaining seated is expected

_____V12. Runs about or climbs too much when remaining seated is expected

_____V13. Has difficulty playing or beginning quiet play activities

_____V14. Is “on the go” or often acts as if “driven by a motor”

_____V15. Talks too much

_____V16. Blurts out answers before questions have been completed

_____V17. Has difficulty waiting his or her turn

_____V18. Interrupts or intrudes in on others’ conversations and/or activities

_____V19. Argues with adults

_____V20. Loses temper

_____V21. Actively defies or refuses to follow adults' requests or rules

_____V22. Deliberately annoys people

_____V23. Blames others for his or her mistakes or misbehaviors

_____V24. Is touchy or easily annoyed by others

_____V25. Is angry or resentful

_____V26. Is spiteful and wants to get even

_____V27. Bullies, threatens, or intimidates others

_____V28. Starts physical fights

_____V29. Lies to get out of trouble or to avoid obligations (ie, “cons” others)

_____V30. Is truant from school (skips school) without permission

_____V31. Is physically cruel to people

_____V32. Has stolen things that have value

_____V33. Deliberately destroys others' property

_____V34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

_____V35. Is physically cruel to animals

_____V36. Has deliberately set fires to cause damage

_____V37. Has broken into someone else’s home, business, or car

_____V38. Has stayed out at night without permission

_____V39. Has run away from home overnight

_____V40. Has forced someone into sexual activity

_____V41. Is fearful, anxious, or worried

_____V42. Is afraid to try new things for fear of making mistakes

_____V43. Feels worthless or inferior

_____V44. Blames self for problems, feels guilty

_____V45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”

_____V46. Is sad, unhappy, or depressed

_____V47. Is self-conscious or easily embarrassed

Performance

Please note a new scale: 5 is best and 1 is worst.

5=Excellent

4=Above average

3=Average

2=Somewhat of a problem

1=Problematic

_____VF1. Overall school performance

_____VF2. Reading

_____VF3. Writing

_____VF4. Mathematics

_____VF5. Relationship with parents

_____VF6. Relationship with siblings

_____VF7. Relationship with peers

_____VF8. Participation in organized activities (eg, teams)