Child Attachment Checklist - Reactive Attachment Disorder ...
[Pages:1]Child Attachment Checklist
Child's Name: ___________________________________________________________Date: ____________
Parent's Name: ___________________________________________________________________________
Symptoms
1 Is unable to give and receive love 2 Is oppositional, argumentative, defiant 3 Is emotionally phony, hollow or empty 4 Is manipulative or controlling 5 Has frequent or intense angry outbursts 6 Is an angry child inside 7 Unable to cry about something sad 8 Avoids or resists physical closeness and touch 9 Cannot be trusted 10 Has little or no conscience 11 Is superficially engaging and charming 12 Lack of eye contact on parental terms 13 Indiscriminate affection with strangers 14 Not affectionate on parents' terms 15 Destructive to self, others, and property 16 More disobedient toward mom than dad 17 Cruel to animals 18 Steals 19 Lies about the obvious (crazy lying) 20 Is impulsive or hyperactive 21 Lacks cause and effect thinking 22 Gorges or hoards food 23 Has poor peer relationships 24 Preoccupation with fire, blood, or violence 25 Persistent nonsense questions or incessant
chatter 26 Inappropriately demanding and clingy 27 Sexual acting out 28 Bossy with peers
None
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mild
1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
Moderate
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
0
123 4567
0
123 4567
0
123 4567
Severe
8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10
8 9 10 8 9 10 8 9 10
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