Childhood Attachment Disruption/Disorder: A Symptom …

[Pages:2]Childhood Attachment Disruption/Disorder: A Symptom Checklist

Check appropriate indicator for each symptom displayed by child. Give brief description of child's behavior when moderate or severe.

None

1. Intense displays of anger (rage)

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2. Self destructive behaviors

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3. Destruction of property

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4. Aggression toward others

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5. Cruelty to animals

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6. Inappropriate sexual conduct and attitudes

___

7. Victimizes others (perpetrator, bully)

___

8. Exploitive (manipulative, controlling)

___

9. Argumentative ? often over ridiculous things

___

10. Bossy

___

11. Severe need for control over everyone/everything ___

12. Lack of impulse control

___

13. Hyperactivity

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14. Preoccupation with fire, gore, or evil

___

15. Lack of remorse and conscience

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16. Cannot tolerate limits and external control

___

17. Frequently defies rules (oppositional)

___

18. Consistently irresponsible

___

19. Inappropriately demanding and clingy

___

20. Persistent nonsense questions / incessant chatter ___

21. Lack of cause and effect thinking

___

22. Perceives self as victim (helpless)

___

23. Grandiose sense of self-importance

___

24. Presumptive entitlement issues

___

25. Perceives others as unsafe, dangerous

___

26. Not affectionate on parents' terms

___

27. Lack of eye contact on parents' terms

___

28. Superficially engaging and charming

___

29. Indiscriminately affectionate with strangers

___

30. Unstable peer relationships

___

31. Lack of long-term friends

___

32. Blames others for own mistakes or problems ___

33. Triangulation of adults

___

34. Stealing

___

35. Deceitful (con artist)

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36. Lying about the obvious (crazing lying)

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37. False allegations of abuse

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38. Lacks trust of caretaking or control by others ___

39.Victimized by others

___

40. Marked mood changes

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41. Frequently depressed, sad

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42. Feelings of hopelessness

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43. Inappropriate emotional response

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44. Hoarding

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45. Abnormal eating patterns/habits

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46. Refuses to eat

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47. Gorges on food

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48. Hides food

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49. Eats strange things

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50. Sleep disturbance

___

51. Enuresis (wets self)

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52. Encopresis (soils self)

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53. Developmental delays

___

54. Learning disorders

___

55. Language disorders

___

56. Accident prone

___

57. Avoids physical contact

___

58. Isolates him/herself

___

Mild ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Moderate Severe

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Comments ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Signs and Symptoms of Reactive Attachment Disorder in Infancy

Check appropriate indicator for each symptom displayed by infant. Give brief description of infant's behavior when symptom range is moderate or severe.

1. Withdrawn, sad and listless appearance 2. Failure to smile 3. Doesn't follow others with eyes 4. Failure to reach out when picked up 5. No interest in baby or interactive games 6. No interest in playing with toys 7. Engages in self-soothing behaviors

rocking or self-stroking 8. Calm when left alone

None ___ ___ ___ ___ ___ ___

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Mild ___ ___ ___ ___ ___ ___

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Moderate Severe

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Comments ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

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Risk Factors in Childhood Attachment Disruption

A child may be placed at risk for attachment disruption/disorder if any of the following conditions occurred during the first 36 months of the child's life. Place a check in either "yes" or "no" to reflect circumstances of child's life. Add comments as necessary.

1. Unwanted pregnancy

Yes _____

2. Maternal ambivalence

Yes _____

3. Abused mother

Yes _____

4. Premature birth

Yes _____

5. Suffering a birth or prenatal trauma

Yes _____

6. Pre-birth exposure to trauma, drugs, alcohol

Yes _____

7. On-going maternal alcohol and/or drug use

Yes _____

8. Parent/s with psychiatric diagnoses

Yes _____

9. Parent/s with anger management problems

Yes _____

10. Young or inexperienced parents ? poor parenting skills Yes _____

11. Inconsistent, inappropriate or harsh care

Yes _____

12.Parent/s, caregiver/s under or over stimulated child Yes _____

13. Parent/s, caregivers are isolated

Yes _____

14. Significant family trauma, such as death or divorce Yes _____

15. Lack of attunement between mother and child

Yes _____

16. Childcare on a time-scheduled

Yes _____

17. Chronically depressed mother (postpartum depression) Yes _____

18. Neglect

Yes _____

19. Physical abuse

Yes _____

20. Emotional abuse

Yes _____

21. Sexual abuse

Yes _____

22. Abandonment

Yes _____

23. Multiple caregivers

Yes _____

24. Frequent changes in foster care providers

Yes _____

25. Change in daycare providers

Yes _____

26. Extreme poverty

Yes _____

27. Separation from mother (illness/death of mother)

Yes _____

28. Forced removal from neglectful or abusive home

Yes _____

29. Lived in an orphanage

Yes _____

30. Institutional care

Yes _____

31. Adoption

Yes _____

32. Ongoing, unrelieved pain (colic, hernia, ear infections) Yes _____

33. Prolonged hospitalization of child

Yes _____

34. Traumatic medical intervention

Yes _____

35. Failure to thrive

Yes _____

No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____ No _____

Comments __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________

Compiled by Victoria A. Fitton, PhD, LMSW, ACSW, RPT-S References: DMS-IV-TR, The Mayo Clinic, SAMHSA, National Institutes of Health, and National Institute of Mental Health.

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