Con ners' Porent Ratir,lQ

, by c.

Seo le-Revised (S)

K~itbCnn~rs,Ph.D.
Child'sID:

Gendr: M, F'
,(Cirele One)

I
Month

I
Day

Year

Age: ---

S~l1~olGrade:

lnti'uctions; Below are a number of commo'problems that children haye. Please rate'each item according to yOUT'
child;s behaviorin'the last month. FOf eachitem, askyourself, "How much of a p~8l:lenhas tlJ,isbeen in the las!
rnonth?", and cirele the best answer for each one. If none, not at all, seldom, or very infrequently, you would cirele O.
If very much true, or it occurs very often or frequently, youwould circleS. You would circle 1 orZsfor ratings.in
between. PIe ase .respond to each.item,
" ,',
NOTTRUE
; JUST A " l>lTfY '~RYMuCH
Al" ALL
(Never,
Seldom) '"

LITrLE
MUClITRUE
TRUE
11WE
(afien. Quite a (Vcryafien.
Bil)
Ve!)' Frequent)
(Occasionally)
,

',1. Inattentive, easily distract~d

2,

!iH

:,.,

Angry and resentful

"
MHS
Difficulty doing or completing

SE3.

4.
5.
6.
7.
8.
9.
10.

,
;

'

~.....

O
O
O
O

1
1
1
1

Ccpyright 1997. Multi~He.lth Systems Ine. AIJ rights reserved, In me United Statcs, P.O. Bo.~
950. North 'lbnawanda, NY 14120-0950. 1-8(10-456-3003.
In Can.da, 3770 Victoria Park Ave., Toronto, ON M1H 31\0161.800268~6011. 1-416-492-2627. Fax l-41(r492~3343.

homework
:..:
Is always "onthe go" or acts as if driven by a motor

Short attention span

:
Argues with adu1ts
, ,.
:
Fidgets with hands or feet or squirms in seat
Fails to complete assignments
Hard to control in malls or while grocery sbopping
Messyor disorganized at horne OI school
,
,
11. Loses temper
12. Needs close supervision to get through assignments55
13. Only attends if it is something he/she is Yery interested in

J4.

..
':: .

~t,

'

;.'..: .
.
..
:
..
..
:
.
.
.

Runs about or climbs excessively in situations w here it is inappropriate ..

15. Distractibility or attention span a probleni
,
.
16. Irritable
~
.
17. Avoids, expresses reluctance about, or has difficulties engaging in tasks
that require sustained mental effort (such as schoolwork or homework)'.
18. Restless in the "squirmy" sense
.'
.
19. Gets distracted when given instructions to do sometbing
.
20. Actively defies OI refuses to comply with adults' requests
.
21. Has trouble concentrating irl class
:
..
22. Has difficulty waiting in lines or awaiting tum in games or group situations
23. Leaves seat in classroorn or in other situations in which remaining seated is
expected
.
24. Deliberately does tbings that annoy other people
.
25. Does not follow through on instructions and fails to finish scboolwork,
chores or duties in the workplace (not due to oppositional behavior or
failure to understand instructions)
..
26: Has difficulty playing or engaging in leisure activities quietly
..
27. Easily frustrated in efforts
;
.

O
O
O
O
O

1
1

1
1
1

O
O

1
1
1
1

O
O
O
O

1
1

O
O
O

1
1

O
O

1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

2
2
2
2
2
2

3
3
3
3
3
3

2
2

3
3

3
3
3

2
2