Suggested Diagnostic Check List (Form E-1)

APPENDIX (p. 219-236)

Suggested Diagnostic Check List
(Experimental Form 1)

The accompanying checklist 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 checklist 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 checklist 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.

APPENDIX (p. 219-236)

Suggested Diagnostic Check List (Experimental Form 1)

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

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.

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

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? _________________________________________________

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?

Suggested Diagnostic Check List
(Experimental Form 1)

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

Mother Other __________

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1 Yes, frequently
2 Yes, sometimes
__ 3 No

1 Yes, frequently
2 Yes, sometimes
__ 3 No

1 Yes
2 No

1 Yes, frequently
2 Yes, sometimes
__ 3 No

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

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

1 Yes, he has done this
2 No

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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