Reactive Attachment Disorder

Symptom Checklist

 

Name: _________________________________      Date: _________

 

Completed by: __________________________      DOB: _________

 

                                                                                                CA:    _________

 

                                                           

SYMPTOM

None

Mild

Moder-

ate

Severe

 

1. Lack of impulse control       

D

2. Self-destruction      

 

 

 

 

D

3. Destruction of property      

 

 

 

 

D

4. Aggression toward others     

 

 

 

 

D

5. Consistently irresponsible

 

 

 

 

I D

6. Inappropriate demanding &

    clinging

 

 

 

 

I D

7. Stealing

 

 

 

 

I

8. Deceitful (lying, conning)

 

 

 

 

I D

9. Hoarding (food, toys)

 

 

 

 

I

10. Inappropriate sexual conduct

 

 

 

 

I D

11. Cruelty to animals

 

 

 

 

D

12. Sleep disturbances

 

 

 

 

I

13. Enuresis or encopresis

 

 

 

 

I

14. Frequently defies rules

     (oppositional)

 

 

 

 

I D

15. Hyperactivity

 

 

 

 

D

16. Abnormal eating habits

 

 

 

 

I D

17. Preoccupation with fire, gore,

      blood

 

 

 

 

I D

18. Persistent nonsense questions

      & chatter

 

 

 

 

I D

19. Poor hygiene

 

 

 

 

I D

20. Difficulty with novelty & change

 

 

 

 

I

21. Lack of cause-effect thinking

 

 

 

 

I D

22. Learning disorders

 

 

 

 

I D

23. Language disorders

 

 

 

 

I D

24. Perceives self as victim

      (helpless)

 

 

 

 

I

25. Grandiose sense of self-

      importance

 

 

 

 

D

26. Not affectionate on parent’s

      terms

 

 

 

 

I D

27. Intense displays of anger/rage

 

 

 

 

 

D

 

 

 

 

 

 

 

 

 

 

SYMPTOM

None

Mild

Moder-

ate

Severe

 

28. Frequently sad, depressed, or

      hopeless

 

 

 

 

I

29. Inappropriate emotional

      responses

 

 

 

 

I D

30. Marked mood changes

 

 

 

 

D

31. Superficially engaging &

      charming

 

 

 

 

I D

32. Lack of eye contact for

      closeness

 

 

 

 

I D

33. Indiscriminately affectionate

      with strangers

 

 

 

 

I

34. Lack of, or unstable, peer

      relationships

 

 

 

 

D

35. Cannot tolerate limits and

      external control

 

 

 

 

I D

36. Blames others for own

      mistakes or problems

 

 

 

 

I

37. Victimizes others (perpetrator,

      bully)

 

 

 

 

D

38. Victimized by others

 

 

 

 

I

39. Lacks trust in others

 

 

 

 

I D

40. Exploitative

 

 

 

 

I  D

41. Manipulative

 

 

 

 

ID

42. Controlling

 

 

 

 

ID

43. Bossy

 

 

 

 

ID

44. Chronic body tension

 

 

 

 

I

45. Accident prone

 

 

 

 

D

46. High pain tolerance

 

 

 

 

D

47. Tactily defensive

 

 

 

 

I D

48. Genetic predispositions

 

 

 

 

I D

49. Lack of meaning & purpose

 

 

 

 

I

50. Lack of faith, compassion, &

      other spiritual values

 

 

 

 

I

51. Identification with evil and the

      dark side of life

 

 

 

 

I D

52. Lack of remorse or conscience

 

 

 

 

I D

53. Depersonalized

 

 

 

 

I

54. Complete denial

 

 

 

 

I

55. Lack of concentration

 

 

 

 

ID

56. No perseverance

 

 

 

 

I

57. Affect doesn’t match situation

 

 

 

 

ID

58. Memory problems

 

 

 

 

ID

 

 

TOTAL SCORE _____  None _____  Mild _____  Mod. _____  Severe_____

 

Inhibited                     Disinhibited               Disorganized