Attention & Behavior Rating Form-Home Version: Adolescent (English)

PART 1
Please select the answer that best describes your child's behavior over the past 6 months.

How often does your teenager display the following behavior?*

	Never/Rarely	Sometimes	Often	Very Often
Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities.
Has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during conversations or lengthy reading).
Does not seem to listen when spoken to directly.
Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.
Has difficulty organizing tasks and activities.
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; preparing reports).
Loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Easily distracted.
Forgetful in daily activities (e.g., doing chores, running errands, returning calls, keeping appointments).

How much do the nine behaviors in the previous question cause problems for your teenager:*

	No Problem	Minor Problem	Moderate Problem	Severe Problem
Getting along with family members
Getting along with other teenagers
Completing or returning homework
Performing academically in school
Controlling behavior in school
Feeling good about himself/herself

How often does your teenager display the following behavior?*

	Never or Rarely	Sometimes	Often	Very Often
Fidgets with or taps hands or feet or squirms in seat.
Leaves seat in situations when remaining seated is expected.
Runs about or climbs in situations where it is inappropriate or feels restless.
Unable to play or engage in leisure activities quietly (e.g., is unable to be or is uncomfortable being still for an extended period of time).
"On the go," acts as if "driven by a motor".
Talks excessively.
Blurts out an answer before a question has been completed.
Has difficulty waiting his or her turn (e.g., while waiting in line).
Interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may intrude into or take over what others are doing).

How much do the nine behaviors in the previous question cause problems for your teenager:*

	No Problem	Minor Problem	Moderate Problem	Severe Problem
Getting along with family members
Getting along with other teenagers
Completing or returning homework
Performing academically in school
Controlling behavior in school
Feeling good about himself/herself

Part 1 & 2 of this form is adapted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright© 2013. American Psychiatric Association. All rights reserved. From the ADHD Rating Scale-5 for Children and Adolescents: Checklists, Norms, and Clinical Interpretation by George J. DuPaul, Thomas J. Power, Arthur D. Anastopoulos, and Robert Reid. Copyright© 2016 the authors.

Permission to copy this form is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details).
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Attention and Behavior Rating Form