DSM V—ADHD Symptom Checklist—Child and Adolescent Version # 7177
Completed By: _______________________________ Relationship to Child:_____________ Date:__________
Check the box that best describes this child's behavior over the past six months.
|Not at all||Just a little||Often||Very Often|
|1.|| fails to give close attention to details or makes careless mistakes in schoolwork,
work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
|2.||has difficulty sustaining attention in tasks or play activities(e.g., has difficulty remaining focused during lectures; conversations, or lengthy reading).|
|3.||does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).|
|4.|| does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
|5.||has difficulty organizing tasks and activities(e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized with work; has poor time management; fails to meet deadlines).|
|6.||avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).|
|7.||loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).|
|8.||is easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).|
|9.||is forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).|
|10.||fidgets with or taps hands or feet or squirms in seat.|
|11.||leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).|
|12.||runs about or climb in situations in which it is inappropriate (NOTE: in adolescents or adults, may be limited to feelings restless).|
|13.||unable to play or engage in leisure activities quietly.|
|14.||is "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).|
|16.||blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation).|
|17.||has difficulty waiting his or her turn (e.g., while waiting in line).|
|18.||interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).|
|Approximately when did you first notice the behaviors that occur often or very often?|
|Do these symptoms impair this person's functioning in two or more settings? (Yes, No, DK)|
|Where is their impairment? Family? School? Work? Social? (list all)|
Scoring Instructions for the ADHD Symptom ChecklistTo meet DSM-V criteria for ADHD in childhood, a child must have at least 6 responses of "Often" or "Very Often" (scored 2 or 3) to either the 9 inattentive items (1-9) or the 9 hyperactive-impulsive items (10-18), or both. For older adolescents and adults (age 17 and older), at least five symptoms are required. The clinician may consider ADHD as a possible diagnosis if 5 or more symptoms are scored 2 or 3 in either one or both domains. In addition, symptoms must have occurred by age 12, they must impair the individual's functioning in two or more settings, and they must not be primarily due to any other factors or conditions. Depending on the domains affected, ADHD, predominantly inattentive type; ADHD, predominantly hyperactive-impulsive type; or ADHD, combined type may be considered. Using a rating scale such as this, however, is not sufficient in and of itself to diagnose ADHD. Other sources of information should be considered and an appropriate health professional should be consulted.
| From: myADHD. Copyright 2013. Health Link Systems, Inc.
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