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| Symptom
Checklist for Child Attachment Disorder |
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| Please place a mark in the appropriate column for each symptom as it pertains to your child. Please give a brief description of your child's behavior regarding each of the symptoms checked as moderate or severe. This form is for personal reference only. | ||||
NONE
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MILD
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MODERATE
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SEVERE
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|---|---|---|---|---|
| 1. Lack of impulse control | ___
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| 2. Self destructive behaviors | ___
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| 3. Intense displays of anger (rage) | ___
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| 4. Destruction of property | ___
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| 5. Preoccupation with fire, gore, or evil | ___
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| 6. Aggression toward others | ___
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| 7. Inappropriate sexual conduct and attitudes | ___
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| 8. Cruelty to animals | ___
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| 9. Frequently defies rules (oppositional) | ___
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| 10. Cannot tolerate limits and external control | ___
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| 11. Victimizes others (perpetrator, bully) | ___
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| 12. Exploitive (manipulative, controlling) | ___
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| 13. Bossy | ___
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| 14. Consistently irresponsible | ___
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| 15. Inappropriately demanding and clingy | ___
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| 16. Marked mood changes | ___
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| 17. Stealing | ___
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| 18. Deceitful (lying, conning) | ___
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| 19. Hoarding | ___
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| 20. Sleep disturbance | ___
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| 21. Enuresis (wets self) | ___
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| 22. Encopresis (soils self) | ___
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| 23. Hyperactivity | ___
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| 24. Abnormal eating habits | ___
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| 25. Persistent nonsense questions and incessant chatter | ___
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| 26. Lack of cause and effect thinking | ___
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| 27. Lack of remorse and conscience | ___
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| 28. Learning disorders | ___
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| 29. Language disorders | ___
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| 30. Perceives self as victim (helpless) | ___
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| 31. Grandiose sense of self-importance | ___
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| 32. Perceives others as unsafe, dangerous | ___
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| 33. Not affectionate on parents' terms | ___
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| 34. Frequently depressed, sad | ___
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| 35. Feelings of hopelessness | ___
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| 36. Inappropriate emotional response | ___
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| 37. Superficially engaging and charming | ___
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| 38. Lack of eye contact on parents terms | ___
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| 39. Indiscriminately affection with strangers | ___
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| 40. Lack of long-term friends | ___
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| 41. Unstable peer relationships | ___
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| 42. Blames others for own mistakes or problems | ___
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| 43. Victimized by others | ___
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| 44. Lacks trust of caretaking or control by others | ___
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| 45. Accident prone | ___
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| 46. Child is adopted (check one) Yes___ No___ |
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| 47. Child experienced separations from birth mother during
first 2 years Yes___ No___ |
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| 48. Child experienced unrelieved pain during first 2 years Yes___ No___ |
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