Symptoms Checklist

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Child's Name:   Completed By:
Child's Date of Birth: (mm/dd/yyyy) E-MAIL ADDRESS:
      Phone Number:

There are six categories of traits and symptoms of attachment disorder: behavioral, cognitive, emotional, social, physical, and moral-spiritual.   Children vary in regard to the number of symptoms they have and in the severity of their symptoms.

Please place a mark in the appropriate column for each symptom as it pertains to your child.   For each of the symptoms checked as moderate or severe, please give a brief description of your child's behavior.   Specific examples (given by parents) are available by clicking on a question, as desired.
 
  None Mild Moderate Severe
1. Lack of impulse control
 
  None Mild Moderate Severe
2. Self-destructive, physical/psychological
 
  None Mild Moderate Severe
3. Destruction of property
 
  None Mild Moderate Severe
4. Aggression toward others, physical/verbal
 
  None Mild Moderate Severe
5. Consistently irresponsible
 
  None Mild Moderate Severe
6. Inappropriately demanding and clingy
 
  None Mild Moderate Severe
7. Stealing
 
  None Mild Moderate Severe
8. Deceitful (lying, conning)
 
  None Mild Moderate Severe
9. Hoarding
 
  None Mild Moderate Severe
10. Inappropriate sexual conduct and attitudes
 
  None Mild Moderate Severe
11. Cruelty to animals
 
  None Mild Moderate Severe
12. Sleep disturbance
 
  None Mild Moderate Severe
13. Enuresis and encopresis
 
  None Mild Moderate Severe
14. Frequently defies rules (oppositional)
 
  None Mild Moderate Severe
15. Hyperactivity
 
  None Mild Moderate Severe
16. Abnormal eating habits
 
  None Mild Moderate Severe
17. Preoccupation with fire, gore, or evil
 
  None Mild Moderate Severe
18. Persistent nonsense questions and incessant chatter
 
  None Mild Moderate Severe
19. Hyper vigilant
 
  None Mild Moderate Severe
20. Difficulty with novelty and change
 
  None Mild Moderate Severe
21. Lack of cause and effect thinking
 
  None Mild Moderate Severe
22. Learning disorders
 
  None Mild Moderate Severe
23. Speech Disorders
 
  None Mild Moderate Severe
24. Perceives self as victim (helpless)
 
  None Mild Moderate Severe
25. Grandiose sense of self-importance/entitlement
 
  None Mild Moderate Severe
26. Not affectionate on parents' terms
 
  None Mild Moderate Severe
27. Intense displays of anger (rage)
 
  None Mild Moderate Severe
28. Frequently sad, depressed or hopeless
 
  None Mild Moderate Severe
29. Inappropriate emotional responses
 
  None Mild Moderate Severe
30. Marked mood changes
 
  None Mild Moderate Severe
31. Superficially engaging and charming
 
  None Mild Moderate Severe
32. Lack of eye contact for closeness
 
  None Mild Moderate Severe
33. Indiscriminately affectionate with strangers
 
  None Mild Moderate Severe
34. Lack of or stable peer relationships
 
  None Mild Moderate Severe
35. Cannot tolerate limits and external control
 
  None Mild Moderate Severe
36. Doesn't like criticism and blames others for own mistakes or problems
 
  None Mild Moderate Severe
37. Victimizes others (perpetrator, bully), revenge
 
  None Mild Moderate Severe
38. Victimized by others
 
  None Mild Moderate Severe
39. Lacks trust in others
 
  None Mild Moderate Severe
40. Exploitative, manipulative, controlling, bossy
 
  None Mild Moderate Severe
41. Poor hygiene
 
  None Mild Moderate Severe
42. Chronic body tension
 
  None Mild Moderate Severe
43. Accident prone
 
  None Mild Moderate Severe
44. High pain tolerance/overreaction to minor injury
 
  None Mild Moderate Severe
45. Tactilely defensive
 
  None Mild Moderate Severe
46. Genetic predispositions/hypochondriac
 
  None Mild Moderate Severe
47. Lack of meaning and purpose
 
  None Mild Moderate Severe
48. Lack of faith, compassion, and other spiritual values
 
  None Mild Moderate Severe
49. Identification with evil and the dark side of life
 
  None Mild Moderate Severe
50. Lack of remorse and conscience
 
 
                   

   


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