Childhood Adhd Symptoms Scale Chart - Self-Report
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CHILDHOOD ADHD SYMPTOMS SCALE
SELF-REPORT
-
Name___________________________________________ Date___________
Instructions
WHEN YOU
Please circle the number next to each item that best describes your behavior
WERE A CHILD AGE 5 TO 12 YEARS.
Very
Never or
Some-
Often
Items:
Often
Rarely
times
1. Failed to give close attention to details or make
0
1
2
3
careless mistakes in my work
2. Fidgeted with hands or feet or squirm in seat
0
1
2
3
3. Difficulty sustaining my attention in tasks or fun
0
1
2
3
activities
4. Left my seat in classroom or in other situations in
0
1
2
3
which seating was expected
5. Didn’t listen when spoken to directly
0
1
2
3
6. Felt restless
0
1
2
3
7. Didn’t follow through on instructions and failed to
0
1
2
3
finish work
8. Had difficulty engaging in leisure activities or doing
0
1
2
3
fun things quietly
9. Had difficulty organizing tasks and activities
0
1
2
3
10. Felt “on the go” or “driven by a motor”
0
1
2
3
11. Avoided, disliked, or was reluctant to engage in
0
1
2
3
work that requires sustained mental effort
12. Talked excessively
0
1
2
3
13. Lost things necessary for tasks or activities
0
1
2
3
14. Blurted out answers before questions had been
0
1
2
3
completed
15. Easily distracted
0
1
2
3
16. Had difficulty awaiting turn
0
1
2
3
17. Forgetful in daily activities
0
1
2
3
18. Interrupted or intruded on others
0
1
2
3
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