Complete Teacher Packet

Douglas R. Coombs, MD 520 East Medical Drive #301 Bountiful, Utah 84010 Phone (801)292-1464 Fax (801)292-1465

Date__________________

Dear Teacher, The parent(s) of ______________________ have asked us to evaluate him/her regarding behavioral or learning problems. Information you can provide will be invaluable in this endeavor. Attached, please find: Teacher Questionnaire Vanderbilt Teacher Assessment Scale School Symptom Screening Scale School Impairment Scale Please complete these forms as soon as you can find time to do so thoroughly. If there is additional information that you consider pertinent, please provide this on an additional sheet or call us at the office. As soon as you have completed the forms, please either mail them, fax them, or return them via the parents. If your school has the new ADHD manual, then completing and returning the pre-assessment packet would be greatly appreciated. We appreciate your help in what we hope will be a team effort in assisting this child. Please do not hesitate to contact us if we can be of any assistance. Thank you very much.

Sincerely,

Douglas R. Coombs, MD, FAAP Lisa Sharp, RN, FNP, BS Gina M. Capps, RN, CPNP Stacey A. Bushell, MSN, CPNP Kim Webb, RN, CPNP Brian J. Holdstock, MSN, CFNP

Questionnaire for Teachers Child's Name ________________________________ Date Completed _________________________ School Name ________________________________ Child's Grade ___________________________ Teacher's Name ______________________________ Subject Taught __________________________ Hours with child (daily average)_________________ Number of students in class________________

I. How long have you known this child? _______________ In your own words, describe briefly this child's main problem: _________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ II. How is this child doing in: English: ________________________________________________________________________________ Math: __________________________________________________________________________________ Reading:________________________________________________________________________________ Spelling:________________________________________________________________________________ Social Studies: ___________________________________________________________________________ Other: __________________________________________________________________________________ III. Please list or describe any special help of services this child is receiving: In your class: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Outside your class:________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ IV. Please rate this child's behavior compared to other children of the same age: Much worse _____ Worse _____ About the same _____ Better _____

Much better _____

NICHQ Vanderbilt Assessment Scale—TEACHER Informant ICHQ Vanderssment Scale—TEACHER Informant

Teacher’s Name: ____________________________ Class Time: ________ Class Name/Period: ________________ Today’s Date: __________ Child’s Name: _______________________________ Grade Level: _________________ Directions: 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 child’s 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? Symptoms

Never

Occasionally

Often

Very Often

1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3 2. Has difficulty sustaining attention to tasks or activities 0 1 2 3_____ 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through on instructions and fails to finish schoolwork 0 1 2 3 (not due to oppositional behavior or failure to understand)_____________________________________________________ 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained 0 1 2 3 mental effort _____ 7. Loses things necessary for tasks or activities (school assignments, 0 1 2 3 pencils, or books) 8. Is easily distracted by extraneous stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat in classroom or in other situations in which remaining 0 1 2 3 seated is expected____________________________________________________________________________________ 12. Runs about or climbs excessively in situations in which remaining 0 1 2 3 seated is expected____________________________________________________________________________________ 13. Has difficulty playing or engaging in leisure activities quietly 0 1 2 3 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks excessively 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting in line 0 1 2 3 18. Interrupts or intrudes on others (eg, butts into conversations/games) 0 1 2 3 19. Loses temper 0 1 2 3 20. Actively defies or refuses to comply with adult’s requests or rules 0 1 2 3 21. Is angry or resentful 0 1 2 3 22. Is spiteful and vindictive 0 1 2 3 23. Bullies, threatens, or intimidates others 0 1 2 3 24. Initiates physical fights 0 1 2 3 25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others) 0 1 2 3 26. Is physically cruel to people 0 1 2 3 27. Has stolen items of nontrivial value 0 1 2 3 28. Deliberately destroys others’ property 0 1 2 3 29. Is fearful, anxious, or worried 0 1 2 3 30. Is self-conscious or easily embarrassed 0 1 2 3 31. Is afraid to try new things for fear of making mistakes 0 1 2 3 The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD. Revised – 0303

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D4NICHQ Vanderbilt Assessment 4ICHQ Vanderssment Scale—TEACHER Informant

Scale—TEACHER Informant

Teacher’s Name: ____________________________ Class Time: ________ Class Name/Period: ________________ Today’s Date: __________ Child’s Name: _______________________________ Grade Level: _________________ NICHQ Vanderbilt Assessment Scale—TEACHER Informant, continued Symptoms (continued)

32. 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

Never

Occasionally

Often

Very Often

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

Average

Somewhat of a Problem

3 3 3

4 4 4

Performance Academic Performance

Excellent

Above Average

36. Reading 37. Mathematics 38. Written expression

1 1 1

2 2 2

Excellent

Above Average

Average

Somewhat of a Problem

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

Classroom Behavioral Performance

39. Relationship with peers 40. Following directions 41. Disrupting class 42. Assignment completion 43. Organizational skills Comments:

Problematic

5 5 5

Problematic

5 5 5 5 5

Please return this form to:________________________________________________________________________________ Mailing address: _______________________________________________________________________________________ _____________________________________________________________________________________________________ Fax number:___________________________________________________________________________________________ For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: __________________________ Total number of questions scored 2 or 3 in questions 10–18: ________________________ Total Symptom Score for questions 1–18:_______________________________________ Total number of questions scored 2 or 3 in questions 19–28: ________________________ Total number of questions scored 2 or 3 in questions 29–35: ________________________ Total number of questions scored 4 or 5 in questions 36–43: ________________________ Average Performance Score: _________________________________________________ The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD. 11-20/rev0303

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School Symptom Screening Scale ________________________________________________________________________________________________________________

Name

Grade

Age

Date

______________________________________________________________________________________________________________________________

Form Completed By

Position School Symptom Screening Scale

The SCHOOL SYMPTOM SCREENING SCALE should be completed by a teacher who is well acquainted wi th the student. This scale will provide a preliminary assessment of the student's ADHD symptomatology. Please rate each behavior according to the degree of problem the student is currently experiencing in school. When complete, add the ratings for each domain. Then add the three domain scores to obtain a to tal scale score. After t reatment is initiated, the scale should be administered again to determine t reatment effects on level of symptoms.

BEHAVIOR DOMAINS

No Problems =0

Mild Problem =1

Mod. Problem =2

Severe Problem =3

Is easily distracted Distractibility

Has difficulty following directions Has difficulty sustaining attention Shifts from one activity to another Does not seem to listen Loses materials DOMAIN SCORE___________

Impulsivity

Has difficulty waiting for turns Engages in dangerous activities Interrupts or intrudes Blurts out answers to questions DOMAIN SCORE___________

Hyperactivity

Fidgets or squirms in a chair Has difficulty playing quietly Talks excessively DOMAIN SCORE___________ TOTAL SCALE SCORE____________ (Add 3 Domain Scores) .

School Impairment Scale The SCHOOL IMPAIRMENT SCALE should be completed by a teacher who is well acquainted wi th the student and can rate his / her current level of functioning. It will provide a preliminary measure of the student's level of impairment. When complete, add the ratings for each domain. Then add the four domain scores to obtain a total scale score. The domain and to tal scale scores provide a baseline estimate of the child's degree of impairment at school. After t reatment is ini tiated, the scale should be administered again to determine t reatment effects on level of impairment.

BEHAVIOR DOMAINS

No Problems =0

Mild Problem =1

Mod. Problem =2

Severe Problem =3

Grades / test scores Academic Responsibilities

Completion of classwork Completion of homework Organization of materials Self-reliance Ability to follow directions Neatness / legibility of work Accuracy of work Ability to meet time demands DOMAIN SCORE___________

BEHAVIOR DOMAINS

No Problems =0

Mild Problem =1

Mod. Problem =2

Severe Problem =3

Compliance to school rules Anger control Respect for authority figures Respect for school property Inappropriate language Classroom Behavior

Dishonesty / antisocial behavior (stealing, lying, cheating) Suspended / expelled from school Tardies / sluffs Substance abuse Hyperactivity / Impulsivity Inattentiveness Peer relationships Oppositional behavior Aggressive behavior Mood disorder (depression / anxiety) DOMAIN SCORE___________

Relates well to classmates Relates well with adults Social Relationships

Cooperates in groups / games Teases others Is teased by others Withdrawn from classmates Aggressive toward peers Respect for others' property Respect for others' feelings DOMAIN SCORE___________

Emotional Domain

Resists attending school Complains of aches and pains Says “nobody likes me” Cries for no apparent reason Socially withdrawn Is excessively fearful/anxious DOMAIN SCORE___________ TOTAL SCALE SCORE____________ (Add 4 Domain Scores) .

DOMAINS OF SCHOOL IMPAIRMENT

OTHER ACADEMIC PERFORMANCE MEASURES 100-80%

|

60-80%

|

40-60%

|

20-40%

|

0-20%

Academic Performance

Overall percent of work completed in class Overall accuracy of work completed in class Percent of language arts work completed in class Accuracy of language arts work Percent of math work completed in class Accuracy rate of math work Mean on-task behavior GPA (circle one)

3.0-4.0

2.5-3.0

2.0-2.5

1.5-2.0

1.0-1.5

0-1.0

Note: Some students display symptoms of ADHD without experiencing impairment. To receive a diagnosis of ADHD, there must be impairment in two or more settings (school, home, and/or work). This scale assesses impairment in one domain only.