Parent Questionnaire 2-R7

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, 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.
n=Not applicable, not answerable, or not known

_____ F1. Getting along with mother or female caretaker.
_____ F2. Getting along with father or male caretaker.
_____ F3. Getting along with brothers or sisters.
_____ F4. Being respectful and compliant with teachers at school.
_____ F5. Getting along with peers at school.
_____ F6. Making and keeping friends
_____ F7. Performing up to potential in schoolwork.
_____ F8. Being happy, enjoying life, having fun.
_____ F9. 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.)
_____ F10. Being free of symptoms that bother other people.(For example misbehavior or aggression.) (0 is worst; 10 is best..
_____ F11. Doing “activities of daily living”: getting out of bed, getting dressed, bathing, brushing teeth, going to bed, cooperating with transportation, etc.
_____ F12. Doing useful work for the family, helping with chores.
_____ F13. Doing useful work for people outside the family (volunteer or paid). (Enter “n” if no opportunity or too young.)
_____ F14. 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)
_____ F15. 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)
_____ F16. Being able to concentrate, stay on task, not be distracted, keep working long enough, have a high work capacity
_____ F17. Being organized.
_____ F18. Thinking before acting, not being impulsive.
_____ F19. Being able to sit still long enough and to be free from restlessness.
_____ F20. Making other people happy, having a net positive effect on others.
_____ F21. 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.

Psychological Skills Rating Scale

Please rate the person’s functioning in the following areas over the last month, 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 “nonviolence” 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.
n=Not applicable, not answerable, or not known

_____ P1. Productivity: concentrating, staying on task, getting things finished, working well, having high work capacity
_____ P2. Joyousness: feeling good about accomplishments; cheerfulness, pleasant mood, being happy, not being depressed
_____ P3. Kindness: trying to make others happy; sharing, consideration, courtesy, helpfulness
_____ P4. Honesty: Telling the truth, keeping promises, not cheating or stealing
_____ P5. Fortitude: handling not getting your way, putting up with hardship, not getting too upset when things don’t go as desired
_____ P6. Good individual decisions: Thinking before acting, using good judgment
_____ P7. Good joint decisions or conflict-resolution: acting in ways that make it more likely that problems or conflicts with other people are solved peacefully and sensibly
_____ P8. Nonviolence: No physical hitting, kicking, etc., no threats to hurt
_____ P9. Respectful talk: Not being rude, not doing unkind talk, being tactful, expressing approval
_____ P10. Friendship-building: Having good chats, letting people get to know you, being a good listener, developing positive relationships
_____ P11. Self discipline: Being able to do what’s best to accomplish goals rather than just doing what you feel like doing
_____ P12. Loyalty: Honoring commitments, preserving relationships, sticking up for friends
_____ P13. Conservation: Not being wasteful of money, time, or resources
_____ P14. Self-care: Taking care of your own health and safety, being careful
_____ P15. Compliance: Obeying parents, teachers, and the law, when they are reasonable authorities
_____ P16. Positive fantasy rehearsal: Not enjoying violent or cruel fantasies or entertainments; using imagination to rehearse ways of accomplishing good goals
_____ P17. Courage: Not being hindered by anxiety, unrealistic fear, worrying, or unnecessarily avoiding certain situations.

VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE

0 = Never
1 = Occasionally
2 = Often
3 = Very Often
n=not applicable, not answerable, or not known

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

_____V1. Does not pay attention to details or makes careless mistakes, for example homework. (0 is best – never has this problem; 3 is worst – has this problem very often.)
_____V2. Has difficulty attending 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 things
_____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 needed for tasks or activities (assignments, pencils, books)
_____V8. Is easily distracted by noises or other things
_____V9. Is forgetful in daily activities
_____V10. Fidgets with hands or feet or squirms in seat
_____V11. Leaves seat when he is suppose to stay in his seat
_____V12. Runs about or climbs too much when he/she is supposed to stay seated
_____V13. Has difficulty playing or starting quiet games
_____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/her turn
_____V18. Interrupts or bothers others when they are talking or playing games
_____V19. Argues with adults
_____V20. Loses temper
_____V21. Actively disobeys or refuses to follow an adult’s requests or rules
_____V22. Bothers people on purpose
_____V23. Blames others for his or her mistakes or misbehaviors
_____V24. Is touchy or easily annoyed by others
_____V25. Is angry or bitter
_____V26. Is hateful and wants to get even
_____V27. Bullies, threatens, or scares others
_____V28. Starts physical fights
_____V29. Lies to get out of trouble or to avoid jobs (i.e., “cons” others)
_____V30. Skips school without permission
_____V31. Is physically unkind to people
_____V32. Has stolen things that have value
_____V33. Destroys others’ property on purpose
_____V34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
_____V35. Is physically mean to animals
_____V36. Has set fires on purpose 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, nervous, or worried
_____V42. Is afraid to try new things for fear of making mistakes
_____V43. Feels useless or inferior
_____V44. Blames self for problems, feels at fault
_____V45. Feels lonely, unwanted, or unloved; complains that “no one loves him/her”
_____V46. Is sad or unhappy
_____V47. Feels different and easily embarrassed

How is your child doing?

1=Large Problem
2=Problem
3=Average
4=Above Average
5=Well Above Average

_____VF1. Rate how your child is doing in school overall
_____VF2. How is your child doing in reading?
_____VF3. How is your child doing in writing?
_____VF4. How is your child doing in math?
_____VF5. How does your child get along with you?
_____VF6. How does your child get along with brothers and sisters?
_____VF7. How does your child get along with others his/her own age?
_____VF8. How does your child do in activities such as games or team play?

Columbia Impairment Scale

Name of person being rated:__________________________

Rater’s Name:_____________________________________

Today’s date:______________________________________

0=No problem
1=Very small problem
2=Some problem
3=Moderate problem
4=Very bad problem

Please rate the behavior over the last month. Use any number between 0 and 4; you can use numbers like 1.6 or 3.8 if you wish. How much of a problem do you think he/she has had, during this time, with

_____ C1. Getting into trouble?
_____ C2. Getting along with you? (or his/her mother or his/her female caregiver)
_____ C3. Getting along with you? (or his/her father or his/her male caregiver)
_____ C4. Feeling unhappy or sad?
_____ C5. His/her behavior at school?
_____ C6. Having fun?
_____ C7. Getting along with adults other than you? (and/or his/her mom/dad, etc.)
_____ C8. Feeling nervous or afraid?
_____ C9. Getting along with his/her brother(s)/sister(s)?
_____ C10. Getting along with other kids his/her age?
_____ C11. Getting involved in activities like sports or hobbies?
_____ C12. His/her school work?
_____ C13. His/her behavior at home?