Suggested Diagnostic Check List (Form E-1)

APPENDIX (p.  219-236)

Suggested Diagnostic Check List
(Experimental Form 1)

The accompanying check list is an experimental approximation of an instrument designed to facilitate accurate differentiation of individual cases of infantile autism from childhood schizophrenia for clinical and research purposes. An age range of about 3 to 7 is assumed. The form is designed for completion by the child’s parents.

Tentative scoring keys are given below. Ultimately, keying should depend upon empirical identification of items found to discriminate between groups of accurately diagnosed cases.

It should be understood that the form is, at the present time, merely an “armchair” instrument, provided to facilitate research. The check list will need administration to groups of parents of accurately diagnosed cases of infantile autism and of childhood schizophrenia to permit the item analyses requisite to refinement of the scoring keys. Prior to the time when a sufficient number of cases for item analysis has been accumulated, it may be possible to provide tentative norms based on carefully diagnosed cases. For each child an “A” (Autism) and an “S” (Schizophrenia) score would be needed. Presumably, in an adequate instrument, the “A” score would considerably exceed the “S” score for true cases of autism, and vice-versa for true cases of schizophrenia. The ratio of “A” to “S” responses may be a good diagnostic index.

Consideration was given to devising a forced-choice form of the instrument which would pair autistic and schizophrenic traits of somewhat equal attractiveness. For example, the respondents might be asked to pick the most appropriate response from the paired descriptive statements: A. has outstanding memory; B. likes affection. This approach was not used for several reasons, one of which is that the present format permits the questionnaire to be used in rating normal children. Item and score comparisons between normals, autistic children, and schizophrenic children would be of considerable interest Other investigators may wish to construct a forced-choice version of the questionnaire, as a means of overcoming parental tendencies to rate their child favorably.

Certain unkeyed items have been included (e.g., sex of child) where it was believed that the information requested would be of possible interest in the etiology of the behavior disorder

The questionnaire was designed to facilitate recording of the responses on punched cards for later analysis. There are 76 items, each requiring one card column. Four columns (77 -80) have been reserved for punching a case or identification number into the card. Use of a constant format by a number of investigators would greatly facilitate combining of data in the event a large sample must be accumulated for a purpose such as factor analysis.

Investigators wishing to reproduce the check list for research purposes may do so without requesting specific permission from the author or publisher. Correspondence with the author is invited.

AUTISM KEY (Item number followed by response number): 2-1 or 2; 3-4; 4-1; 5-2 or 3; 6-2; 9-2 or 3; 10–1; 11-4; 12-3; 13-3; 14-2; 15-1 or 3; 16-1; 17-1 or 2; 18-1; 19-1; 20-1; 21-1; 22-3; 23-3; 24-1 or 2; 25-3 or 4; 26-1 or 2; 27-1; 28-2, 3,4 or 5; 29-2, 3, 4,5, 6, or 7; 30–2; 31-2 or 3; 32-1 or 3; 33-3; 34-1 or 2; 35-1 or 2; 36-1; 37-1 or 2; 40–1; 41-1; 42-1; 43-1; 44-2 or 3; 45-1 or 2; 46-3; 47-4; 48-1 or 2; 49-1; 50–2; 51-2 or 3; 52-2 or 3; 53-3 or 4; 54-3; 55-2 or 3; 56-4, 5, or 6; 57-3 or 4; 58-3 or 4; 59-3; 60-3 or 4; 61-1; 62-1; 63-1; 64-1; 65-1; 66-1; 67-2; 70-5, 6 or 7; 71-5, 6 or 7; 72-4 or 5; 73-4 or 5; 74-1 or 2; 75-1 or 2; 76-1.

SCHIZOPHRENIA KEY (Item ·number followed by response number): 1-1 or 3; 4-2 or 3; 6-1; 9-1; 10-2; 11-1, 2, or 3; 12-1 or 2; 13-1 or 2; 14-1; 16-2 or 3; 18-2 or3;19-3 or 4; 22-1; 23-1; 24-3 or 4; 25-1 or 2; 26-3, 4, 5 or 6; 27-2 or 3; 28-7 or 8; 29-8; 30–4, 5, 6 or 7; 31-6, 7 or 8; 38-1 or 2; 39-1 or 2; 41-3 or4; 42-3; 43-2; 46-1; 47-1, 2 or 3; 48-3; 50-3; 51-1; 52-1; 53-1; 54-1; 55-5 or 6;56-3; 57-2; 58-2; 63-2; 67-3; 68 and 69- score one for each person listed; 76-2, 3 or 4.

DIAGNOSTIC CHECK LIST FOR BEHAVIOR-DISTURBED CHILDREN
(Form E-1)

Name of Child ____________________________________________________

Name of Person Completing this form: ___________________________

                                    Street Address:   _____________________________

                                                     City:  ______________________________

Relationship to Child:

                          Mother ________________ Other ____________________

                          Father _________________

Father’s Occupation_____________________________________________

Mother’s Occupation (Present) __________________________________

            (Before Marriage) _________________________________________

Has this child been diagnosed before?

If so, what was diagnosis: _______________________________________

            Diagnosed by: ____________________________________________

                       Where? ____________________________________________

Instructions: You are being asked to fill out this questionnaire concerning your child in order to provide research information which will be helpful in learning more about the causes and types of behavior disturbances in children. Please pick the one answer you think is most accurate for each question. If you want to comment or add something about a question, add it right next to the question, if there is room. Or circle the number of the question, copy the number on the back of the questionnaire and write your comment there. Your additional comments are welcome, but even if you do add comments, please mark the printed question as well as you can. Remember, pick just one answer, and mark it with an “X,” for each question.

PLACE AN “X” TO DESIGNATE THE BEST ANSWER FROM THE CHOICES GIVEN
FOR EACH QUESTION. OMIT NO QUESTION.

1. What is the sex of the child and was breast-feeding attempted?

__ 1     Boy, breast-fed
__ 2     Boy, bottle only
__ 3     Girl, breast-fed
__ 4     Girl, bottle only

2. Present age of child:

__ 1     Under 2 years
__ 2     2-3years
__ 3     3-4years
__ 4     4-5 years
__ 5     5-6 years
__ 6     6-7 years
__ 7     7 or older

3. Is child part of a set of twins?

__ 1     No, single birth
__ 2     Yes, he has (or had) a fraternal twin of same sex
__ 3     Yes, he has (or had) a fraternal twin of opposite sex
__ 4     Yes, he has (or had) an identical twin
__ 5     No, he is one of triplets

4. Was the pregnancy and birth normal?

__ 1     Pregnancy and birth both normal
__ 2     Pregnancy and birth both complicated and difficult
__ 3     Pregnancy troubled, birth uncomplicated
__ 4     Pregnancy untroubled, birth was difficult
__ 5     Don’t know

5. Was the birth premature and was oxygen given to the child in the first week? (Premature: Birth wt. under 5 lbs.)

__ 1     Birth not premature, oxygen not used
__ 2     Birth was premature, oxygen was used
__ 3     Birth not premature, oxygen was needed anyway
__ 4     Birth was premature, but oxygen was not used
__ 5     Don’t know

6. Appearance of child during first few weeks after birth:

__ 1     Premature looking (pale, weak, delicate)
__ 2     Normal, not premature looking
__ 3     Don’t know

7. How many children (including this child) are there in the family?

__ 1     Child is an only child
__ 2     There is one other child
__ 3     There are two other children
__ 4     There are three other children
__ 5     There are four other children
__ 6     There are five or more other children

8. How many living children were born to mother before this child?

__ 1     Child is first born
__ 2     Child is second born
__ 3     Child is third born
__ 4     Child is fourth born
__ 5     Child is fifth born
__ 6     Child is sixth or later born

9. Were there colds or respiratory difficulties in the first 6 months?

__ 1     Yes, frequent or definite respiratory problems in first 6 months (more than one cold)
__ 2     About average respiratory conditions
__ 3     No respiratory problems
__ 4     Don’t know

10. Appetite in infancy:

__ 1     Ate a lot (unusual amount)
__ 2     Poor eater (ate too little)
__ 3     Normal
__ 4     Don’t know

11. Elimination in infancy:

__ 1     Diarrhea frequent
__ 2     Constipation frequent
__ 3     Both diarrhea and constipation frequent
__ 4     Normal
__ 5     Don’t know

12. Digestive problems in infancy:

__ 1     Trouble keeping food down
__ 2     Colic
__ 3     Normal
__ 4     Don’t know

13. Skin condition in infancy and early childhood:

__ 1     Sensitive and delicate to touch (bruised easily)
__ 2     Sensitive to rash and/ or infection
__ 3     Normal
__ 4     Don’t know

14. Temperature regulation in infancy:

__ 1     Poor (sweating, shivering too much, cold hands or feet)
__ 2     Normal (no signs of trouble)
__ 3     Don’t know

15. Was child interested in surroundings during first 3 to 4 months?

__ 1     Yes, unusually alert to sounds, colors, etc.
__ 2     Child was about average in interest
__ 3     No, very disinterested during first 3 to 4 months
__ 4     Don’t know

16. Was the child’s sleep pattern normal in infancy and early childhood?

__ 1     Yes, seemed to be normal
__ 2     No, slept for short naps only
__ 3     No, mixed up–sometimes slept days, etc.
__ 4     Don’t know

17. During the child’s first year, how intelligent did you believe he was (from appearance)?

__ 1     Suspected very high intelligence
__ 2     Suspected above average intelligence
__ 3     Suspected intelligence just normal
__ 4     Child looked a little dull

18. Has the child been given an electroencephalogram? (EEG)

__ 1     Yes, it was considered normal
__ 2     Yes, it was considered borderline
__ 3     Yes, it was considered abnormal
__ 4     No, or don’t know, or don’t know results

19. Is the child interested in music?

__ 1     Unusually strong interest
__ 2     Fairly strong interest
__ 3     About average interest
__ 4     Weak or absent interest in music

20. Does the child have unusual food fads, such as refusing to drink from a transparent container, extreme sensitivity to temperature, eat only one or two foods, etc.?

__ 1     Yes, definitely
__ 2     To some extent
__ 3     No
__ 4     Don’t know

21. Did he rock in his crib as a baby?

__ 1     Yes, quite a lot
__ 2     Yes, sometimes
__ 3     No, or very little
__ 4     Don’t know

22. During first two years, was he a cuddly baby?

__ 1     Yes, lots of clinging to adults
__ 2     About average (liked to be held)
__ 3     No, rather stiff and hard to hold
__ 4     Don’t know

23. During ages 2 to 6 years was (is) he cuddly?

__ 1     Yes, lots of clinging to adults
__ 2     About average (liked to be held)
__ 3     No, rather stiff and hard to hold
__ 4     Don’t know

24. When being held as an infant, did he bang his head against the head of the person holding him?

__ 1     Yes, on several occasions
__ 2     Yes, once or twice
__ 3     No, I don’t believe so
__ 4     No, he never did
__ 5     Don’t know

25. During his first 4-5 months, did the child reach out or prepare himself to be picked up when mother approached him?

__ 1     Yes, definitely
__ 2     Yes, I believe so
__ 3     No, I don’t think he did
__ 4     No, definitely not
__ 5     Don’t know

26. At what age did the child learn to walk?

__ 1     8-12 months
__ 2     13-15 months
__ 3     16-18 months
__ 4     19-24 months
__ 5     25-36 months
__ 6     37 months or later

27. Which phrase best describes the change from crawling to walking?

__ 1     Changed from crawling to walking very suddenly
__ 2     Usual amount of time
__ 3     Rather slow in changing from a crawl to a walk
__ 4     Don’t know

28. When (if ever) did you first suspect the child might not be normal?

__ 1     I think child is normal
__ 2     In first 3 months
__ 3     4-6 months
__ 4     7-12 months
__ 5     13-24 months
__ 6     2 years-3 years
__ 7     3 years-4 years
__ 8     After 4th year

29. When (if ever) did you become convinced the child was not normal?

__ 1     I think child is normal
__ 2     In first 3 months
__ 3     4-6 months
__ 4     7-12 months
__ 5     13-24 months
__ 6     2 years-3 years
__ 7     3 years-4 years
__ 8     After 4th year

30. Was there an early period of good or normal behavior, and how long did it last?

__ 1     Child is still normal
__ 2     Never was a period of normality
__ 3     Normal during all or part of first year
__ 4     Normal during first 2 years
__ 5     Normal during first 3 years
__ 6     Normal during first 4 years
__ 7     Normal during first 5-6 years

31. Today, in looking back over the past, at what age do you think the child’s abnormal behavior (if any) could first have been detected? (In other words, when did the abnormal behavior actually begin?) Note that the question refers to actions, not health or appearance.

__ 1     I think child is normal
__ 2     In first 3 months
__ 3     4-6 months
__ 4     7-12 months
__ 5     13-24 months
__ 6     2 years-3 years
__ 7     3 years-4 years
__ 8     After 4th year

32. Did the child show unusually strong fear of strangers, dogs, etc. during his first three years?

__ 1     Yes
__ 2     No (normal fears only)
__ 3     No, very indifferent child

33. How much interest did (does) the child have in mechanical things such as the stove or vacuum cleaner?

__ 1     No unusual interest
__ 2     Seems moderately interested
__ 3     Fascinated by certain mechanical things

34. Did (does) the child stare into space for long periods of time as though lost in thought?

__ 1     Yes, frequently
__ 2     Yes, sometimes
__ 3     No

35. Does the child treat people (including his parents) impersonally, like things or objects?

__ 1     Yes, frequently
__ 2     Yes, sometimes
__ 3     No

36. Did you ever suspect the child was very nearly deaf?

__ 1     Yes
__ 2     No

37. Did (do) you ever find it hard to get the child’s attention because he seemed preoccupied?

__ 1     Yes, frequently
__ 2     Yes, sometimes
__ 3     No

38. Did (does) the child walk on his tip-toes?

__ 1     Yes, frequently
__ 2     Yes, once or twice
__ 3     No, don’t believe so

39. Did (does) he tend to spin or whirl himself around like a top?

__ 1     Yes, sometimes, by himself
__ 2     Yes, if you start him out
__ 3     No, he shows no tendency to whirl

40. Has (does) the child refused to use his hands for an extended period of time?

__ 1 Yes, he has done this
__ 2 No

41. How well physically coordinated is the child (running, walking, balancing, climbing)?

__ 1     Unusually skillful
__ 2     About average
__ 3     Somewhat below average
__ 4     Poor

42. How skillful is the child in doing fine work with his fingers or playing with small objects?

__ 1     Exceptionally good
__ 2     Average for age
__ 3     A little awkward
__ 4     Don’t know

43. Which terms best describe the child?

__ 1     Aloof, disinterested, self sufficient
__ 2     Confused, frightened, perplexed, dependent

44. Did (does) it disturb the child if you change things such as furniture arrangement, the order in which you do things, or the route you take going somewhere?

__ 1     No, doesn’t bother him especially
__ 2     Some changes might bother him
__ 3     He gets very upset at changes, even some very minor ones

45. Does the child ever “look through” or “walk through” people, as though they weren’t there?

__ 1     Yes, often
__ 2     Yes, I think so
__ 3     No, doesn’t do this

46. Was (is) the child sensitive to criticism?

__ 1     Yes, very sensitive
__ 2     Not unusually sensitive
__ 3     Not aware of or concerned about criticism
__ 4     Don’t know

47. Did (does) the child act as though he sees or hears things that are not really there?

__ 1     Yes, he reacts to “voices” or “sounds”
__ 2     Yes, he reacts to things he appears to “see”
__ 3     Yes, both of above
__ 4     Not to my knowledge

48. Does the child spend unusually long periods of time playing with some object repetitively, with no apparent purpose?

__ 1     Yes, this is very typical
__ 2     Yes, this is typical
__ 3     Yes, this happens occasionally
__ 4     Not true of him

49. Will the child readily accept new sweaters, pajamas, etc.?

__ 1     No, he often resists
__ 2     Yes, doesn’t seem to mind

50. Was the child given an intelligence (IQ) test between ages 4 and 7?

__ 1     No; or Yes, but don’t know results
__ 2     Yes, IQ was less than 70
__ 3     Yes, IQ was between 70 and 100
__ 4     Yes, IQ was over 100
__ 5     Not 4 yet

51. Is (was) the child destructive?

__ 1     Yes, this is definitely a problem
__ 2     Yes, but not deliberately or severely destructive
__ 3     Not especially destructive

52. Is (was) the child very worried or concerned about himself?

__ 1     Yes, definitely
__ 2     Not unusually so
__ 3     Hardly self-concerned at all

53. Did (does) the child seem to want to be liked?

__ 1     Yes, unusually so
__ 2     Just normally so
__ 3     Unusually indifferent to being liked or not
__ 4     Seems happiest when left alone

54. Is the child unusually physically pliable (you can lead him easily; he melts into your arms)?

__ 1     Yes
__ 2     Seems normal in this way
__ 3     Definitely not pliable

55. At what age did he say his first words?

__ 1     Still hasn’t used words
__ 2     8-12 months
__ 3     13-15 months
__ 4     16-24 months
__ 5     2 years-3 years
__ 6     3 years-4 years
__ 7     After 4 years old
__ 8     Don’t know

56. How did he switch from words to sentences?

__ 1     Doesn’t use words
__ 2     Words only-no sentences yet
__ 3     Gradual change to sentences
__ 4     Sudden switch (at least one sentence) before 15 months old
__ 5     Sudden switch (at least one sentence) before 20 months old
__ 6     Sudden switch (at least one sentence) before 24 months old
__ 7     Don’t know

57. Did (does) he use the word “Yes,” before age 6?

__ 1     Doesn’t use words
__ 2     Uses word ”Yes” fairly well
__ 3     Almost never uses word ”Yes”
__ 4     Never uses word ”Yes”

58. Did (does) he use the word “I,” before age 6?

__ 1     Doesn’t use words
__ 2     Uses word ”I” fairly well
__ 3     Almost never uses word ”I”
__ 4     Never uses word ”I”

59.If you asked the child, between ages 3 and 6, “Do you want some candy?” how would he most likely respond?

__  l     He would say ”Yes” or “OK”
__ 2     He would say “want it” or “I want it”
__ 3     He would say “Do you want some candy?”
__ 4     Wouldn’t say anything-just take it
__ 5     Wouldn’t say anything-just refuse it

60. Between ages 3 and 6, how would the child say “No”

__ 1     He would just say “No”
__ 2     He would ignore you
__ 3     He would grunt and wave his arms
__ 4     He would use some certain rigid phrase (like “don’t want it!”)
__ 5     Don’t know-or none of above

61. How was (is) his memory for nursery rhymes, TV commercials, etc.?

__ 1     Extremely good, repeats long sections
__ 2     Pretty good
__ 3     Average
__ 4     Poor, or can’t tell

62. Did (does) the child consistently substitute one word or idea for another (Example: Uses “cookie” to mean cookies, cake or candy; or uses “cherry” for “red”).

__ 1     Yes, definitely, many examples
__ 2     Yes, but rarely
__ 3     No

63. Did (does) he say phrases over and over in a hollow, parrot-like or echo-like voice, to no purpose?

__ 1     Yes, definitely
__ 2     Yes, possibly
__ 3     No, not true of him

64. Did (does) he consistently use the word “You” when he should say “I”?

__ 1     Yes
__ 2     No

65. After the child started to talk did he ever stop and begin to whisper instead, for a time?

__ 1     Yes
__ 2     No
__ 3     Never started to talk

66. After the child started to talk did he become silent again for a time (a week or more)?

__ 1     Yes
__ 2     No
__ 3     Never started to talk

67. Before age 6, if the child talked (talks) do you feel he understood (understands) what he is saying?

__ 1     Doesn’t talk at all
__ 2     No, he is just repeating what he has heard
__ 3     He understands pretty much of what he is saying
__ 4     No doubt that he understands what he is saying

68. List the five closest blood relatives of the mother, if any, who have been in a mental hospital or were definitely known to have been seriously mentally ill. (If NONE, check here _________.)
(List mother of child, if applicable.)

            Relationship                                        Diagnosis (If Known)

__ 1     _______________________              _________________________

__ 2     _______________________              _________________________

__ 3     _______________________              _________________________

__ 4     _______________________              _________________________

__ 5     _______________________              _________________________

__ 6     _______________________              _________________________

69. List the five closest blood relatives of the father, if any, who have been in a mental hospital or were definitely known to have been seriously mentally ill. (If NONE, check here____________.)
(List father of child, if applicable.)

            Relationship                                        Diagnosis (If Known)

__ 1     _______________________              _________________________

__ 2     _______________________              _________________________

__ 3     _______________________              _________________________

__ 4     _______________________              _________________________

__ 5     _______________________              _________________________

__ 6     _______________________              _________________________

70. Check father’s highest educational level.

__ 1     Elementary school
__ 2     Some high school
__ 3     High school graduate
__ 4     Some college
__ 5     College graduate
__ 6     Some graduate work
__ 7     Graduate degree (___________)

71. Check mother’s highest educational level.

__ 1     Elementary school
__ 2     Some high school
__ 3     High school graduate
__ 4     Some college
__ 5     College graduate
__ 6     Some graduate work
__ 7     Graduate degree (___________)

72. Compared to most people, is the father considered sociable (does he like to be with people)?

__ 1     Very sociable
__ 2     Above average
__ 3     About average
__ 4     Less sociable than average
__ 5     Less sociable than most people, definitely

73. Compared to most people, is the mother considered sociable (does she like to be with people)?

__ 1     Very sociable
__ 2     Above average
__ 3     About average
__ 4     Less sociable than average
__ 5     Less sociable than most people, definitely

74. Compared to most people, does the father try to be especially careful (cautious) and orderly?

__ 1     Much more careful than most people
__ 2     More careful than most people
__ 3     Average in carefulness
__ 4     Not greatly concerned with carefulness
__ 5     Tends to be impulsive at times

75. Compared to most people, does the mother try to be especially careful (cautious) and orderly?

__ 1     Much more careful than most people
__ 2     More careful than most people
__ 3     Average in carefulness
__ 4     Not greatly concerned with carefulness
__ 5     Tends to be impulsive at times

76. Has either parent been divorced or separated?

__ 1     No
__ 2     Yes, father has
__ 3     Yes, mother has
__ 4     Yes, both parents

Supplementary information on mother’s pregnancies: (Fill in years).
In what year was the above child born? 19___.

In what year(s) were his sister(s) born?
19___, 19___, 19___, 19___ (No sisters___).

In what year(s) were his brother(s) born?
19___, 19___, 19___, 19___ (No brothers___).

In what year(s) did you have stillbirth(s) or miscarriages?
19___, 19___, 19___, 19___ (None___).

In the space below, write in information about the child’s sisters or brothers which you think may be significant. (For example: Twins, living or dead; Behavior problems; IQ scores, if known.) Attach another sheet of paper, if necessary.