‘ON THE FOLLOWING DAYS: je |i i | 2 ee NGS THAT REQUIRE A LOT OF MENTAL EFFORT. 26. TAKES ANGER OUT ON OTHERS; TRIES TO GET EVEN. “Unauthorized reproductions of © 1997 CHECKMATE PLUS, LTD., P.0. BOX 696, STONY BROOK, NY 11790-0696. instrument areé : 3 : & : feADHD SYMPTOM CHECKLIST-4: SCORE SUMMARY RECORD (Page 2) SYMPTOM SEVERITY SCORES DIRECTIONS FOR SYMPTOM SEVERITY SCORES: ITEMS FOR ALL CATEGORIES ARE SCORED AS FOLLOWS: NEVER =0; SOMETIMES = 1; OFTEN=2; VERY OFTEN =3. Enter the Symptom Severity scores from the parent-completed Checklist (PARENT SCORE) and the teacher-completed Checklist (TEACHER SCORE) in the appropriate box. Then find the matching Symptom Severity scores for this child's sex and age group on the ADHD-SC4 SCORE SHEETS (or Quick Guide Tables) to determine the level of severity. Then check (/) the appropriate box below. The degree of symptom severity (low, moderate, high) is based on the standard deviation approach where scores between one and two standard deviations above the mean (i.e., T scores from 60 to 69) and scores two or more standard deviations above the mean (7 scores of 70 or more) indicate symptoms of moderate and high severity, respectively. For children whose caregivers are concerned about social or academic functioning, scores in the moderate and high severity range indicate that a more thorough evaluation may be warranted. PARENT-COMPLETED CHECKLIST ‘SYMPTOM. LEVEL OF SEVERITY (seo PARENT SEVERITY SCORE SCORE SHEET or QUICK GUIDE) CAT. DISORDER TeMs PARENT SCORE tow | MODERATE | HIGH SEVERITY | SEVERITY | SEVERITY A AD/HD, INATTENTIVE TYPE 19 A AD/HD, HYPERACTIVE-IMPULSIVE TYPE | 10-18, A AD/HD, COMBINED TYPE 1-18 B OPPOSITIONAL DEFIANT DISORDER 19-26 iS PEER CONFLICT SCALE 27-36 TEACHER-COMPLETED CHECKLIST ‘SYMPTOM LEVEL OF SEVERITY (see TEACHER SEVERITY SCORE SCORE SHEET or QUICK GUIDE) CAT. DISORDER iTems TEACHER SCORE Low | MODERATE | _ HIGH severity | Severity |_ severity A ADJHD, INATTENTIVE TYPE 19 A AD/HD, HYPERACTIVE-IMPULSIVE TYPE | 10-18 A__| AD/HD, COMBINED TYPE 118 8 OPPOSITIONAL DEFIANT DISORDER 19-26 c PEER CONFLICT SCALE 27-36 © 1997 CHECKMATE PLUS, LTD., P.O. BOX 696, STONY BROOK, NY 11790-0696. Unauthorized reproductions of this form are not permitted.ADHD SYMPTOM CHECKLIST-4: SCORE SUMMARY RECORD (Page 1) SYMPTOM COUNT SCORES CHILD'S NAME, 0.0.8, AGE, DATE COMPLETED, DIRECTIONS FOR SYMPTOM COUNT SCORES: ITEMS FOR ALL CATEGORIES ARE SCORED AS FOLLOWS: NEVER=0; SOMETIMES = OFTEN=1. DSM-IV describes the symptoms of each disor the minimum number of symptoms necessary for making a SC4, the minimum number of symptoms is the Criterion Sc sm number of symptoms necessary for a child receives a Screening Cutoff Score of YES, which indi jation may be warranted. CATEGORY DISORDER iTems CRITERION | PARENT | TEACHER | SCREENING CUTOFF SCORE ‘SCORE SCORE ‘SCORE (YES/NO) A AD/HD INATTENTIVE TYPE 19 26 A AD/HD HYPERACTIVE-IMPULSIVE TYPE 10-18 26 A AD/HD COMBINED TYPE 19 z6 10-18 26 B OPPOSITIONAL DEFIANT DISORDER 19:26 24 1. Discr scores may indicate the ferent in the two settings or one of these care providers is a more ac: behaviors. Because this is a screening instrument, a Screening Cutoff Score of YES from either parent or teacher should be investigated further if the child's problems are serious enough to warrant an in-depth clinical evaluation. 2. If the Screening Cutoff Score is YES, the should consider whether any other disorder can account for the child's problems. For example, a child whose Screening Cutoff Score is YES for ADHD, Inattentive Type may not have AD/HD. Instead, the child may be inattentive due to an anxiety or depressive disorder. 3. Ifthe Se Cutoff Score is YES, a qualified ets all DSM-N ia for the disorder. For example, a diagnosis luration of symptoms, extent of impairment in functioning, and exclusionary conditions and disorders. ‘and limitations of psychological/psychiatric screening and diagnostic procedures. Unauthorized reproductions of this © 1997 CHECKMATE PLUS, LTD., P.O. BOX 696, STONY BROOK, NY 11790-0696. form are not permitted.High -> Mod. Low 1 High = Mod. Low TEACHER ADHD-SC4 SYMPTOM SEVERITY PROFILE CHILD'S NAME, AGE GENDER, DIRECTIONS FOR SYMPTOM SEVERITY SCORES: Items are scored as follows: Never =0; Sometimes =1; Often=2; Very often=3. Select appropriate age group and circle the Symptom Severity score for each TEACHER category. MALES 3 TO 18 YEARS ‘ADIMO ADMD AD/HD ‘OPPOSITIONAL PEER ATTEN | HYPERACTIVEnMPULsive | COMBINED DEFIANT, ‘CONFLICT 7] 318 | a5 | 612 3s | cre | 35 | 61s | a5 | o12| 7 yeors | yoors | yoors yours | yoors | yoors_| years | years | years t | | i t 78 27+ 22+ | 19+] S44 | 43+ 21+ | 15+ | 234 | 10+] 78 78 | 28 27+} 21 | 18 | 5263 | 4142 | 20 | 14 | 22 76 | 25 26} 20 | 17 | 4951 | 940 | 19 | 13 | 21 | 9 | 74 72 | 23-24 | 24-25 | 18.19 | 15-16] 4648 | 3738 | 18 | 12 | 20 2 yo | “22 237 | a | aes | 3436 | i617 | 11 | 1819 |__| 70 es} a1 | azz] ie | 13 | aoa2 | aaa] ts | 10 | 17 | 7 | 68 66 | 1920 | 20 | 18 | 12 | 739 | 2031 | 14 | 15-16 | 66 64] i718 | 19) 14 | 11 | 3536 | 2728 | 13 | 9 | 14 | 6 | 66 e2| 16 17 {1213} 10 | s2a¢ | 2526 | 12 | 8 13 | os | 62 so| 15 | iste} 11 | 9 | 2031 | 2226 | 11 7_ [bavi 60 se] 1314 “4 10 | 8 | 2628 | 2021 | 10 6 10 4 | 58 se] 12 | its! 9 | 7 | 2425 | te19 | 9 5 9 56 sa] oa | 11 | 78 | 6 | 223 | tsa | oa | 8 3 | 54 s2| 9 10; 6 } 8 | 1820 | 1316] 67 | 4 | o7 | 2 | 82 50) 7-8 as | 8 4 [wei | 2] 6 3 5 50 ‘ Ll | 4 FEMALES 3 TO 18 YEARS ‘AD/HD ADD ADIKD OPPOSITIONAL PEER warren | Hvpenmutsive | COMBINED DEFIANT CONFLICT rt] a18 | a5 | es | 35 | ce | 35 | ore] a5 | or2| 7 yoors | yoors | years | years years | yoors | yoars_|_yoars ' I | tit we| zie | 22+} 12+ | aie | 304 | 19+] 4 | a7s | 78 76| 20 21 11 | 3940 2829 | 18 16 | 76 |= ya| 19 20 3738 | 2627 | 17 8 1B | s+ | 74 |S 72 | ang 9 | 10 | 3436 | 25 16 4 n yo | 1617 | 17-18} 9 3233 | 2324 | 15 | 7 nol] ama) 70 | ea] 15 16 8 gost | 222 | 14 2 | 68 66) 14 15 2729 | 20 13 f 6 feet 86 | = ea] 13 4 7 25.26 | 1819 | 11-12 hol; 39a] es |= 62) 12 13 2324 | 1617 | 10 | 5 8 62 |S go] 1011 [uti 6 20.22 | 1415 | 9 sie 60 | _ sa| 8 10 5 wero | 13 a ipa 2 ie iB s6| 8 9 we7 | maz] 7 | 3 6 sé | se] 7 8 4 1415 | 910 | 6 5 54 | sz| 6 67 3 1243 | 8 5 2 4 1 | 52 so] 5 5 2 on | 67 4 1 3 50 | 4 t ‘ © 1999 CHECKMATE PLUS rot permitted. Unauthorized reproductions of this form “POW uBIH = MoyCHILD'S NAME, DIRECTIONS FOR SYMPTOM SEVERITY SCORES: Items are scored as follows: Neve AGE, GENDER. Sometimes ‘often=3. Select appropriate age group and circle the Symptom Severity score for each PARENT category. MALES 3 TO 18 YEARS PARENT ADHD-SC4 SYMPTOM SEVERITY PROFILE ADIHO ADIHD ADIHO ovo | Peer INATTEN | HYPERACTIVE/MPULSIVE COMBINED CON 7 | 318 612 | 1348 | 342 | 1348 | a18 | 35 | 7 yours y yours years_| yoors | yoars lt | | + |t 73 | 21+ | 23+ | | 17+ | 12+] 78 | 76 | 20 22 | 4+] 374 | 324 | te | 11 | 76 |Z 2] | 19 a | 13 | 38 | 30 am |e 2 18 20 | 3435 | 2829 | 18 | 10 | 72 Lz 7 is | 12_| 3293 | 2627 | 14 s_| 7 | 8 | 16 3 | 1 | 3031 | 25 13 88 BI 6s 15 | to | 2829 | 2326 | 12 8 | 66 S| 64 14 16 9 7 | 6 |= 62 13 | 1448 | 8 ” 62 [8 _ [60 12 18:3 wo | 6 | 60 58 ct 12} 10} 7 . 5 58 3] 58 10 " 8 6 8 ses |. 8] 54 9 10 | 8 5 7 a | sa 18 +) 52 8 8 7 4 6 3 | 52/2 50 7 3 | 38 5 50 4t4 ag | + FEMALES 3 TO 18 YEARS ADIHD ‘ADHD AD/HD ovo | Peer INATTEN | _HYPERACTIVE/IMPULSIVE COMBINED CON 7 | 318 | 35 | 612 | 1318 612 3s |r yoors | yoors yours oars led | | t 78 a+ | 19+) 16+) 1s to+ | 78 s| 76 16 18 | 9 | 76 S| 7 16 1% | 10 274 4 =z. 14 7 4 26 8 72 70 ie a Pe 24-25 70 68 13 15 12 3 23 7 68 3] 68 12 na 21-22 66 SB] se | on 13, | 10 7 20 6 | 6s 62 120 18-19 62 60 10 ie 9 6 W s__| 60 58 9 eis 15:16 4 | 88 =| 56 8 10 a 14 56 5] sa 7 9 es 1213 3 | 56 3] 82 6 bee 5 (| 1 52 50 5 7mifea |. 3 9.10 2 | 50 es i i 4 Often=2; Very 1 4H > “pow = 07 © 1999 CHECKMATE PLUS Unauthorized reproductions of this form are not permitted.