RECORD SHEET DEVELOPMENTAL PSYCHOPATHOLOGY CHECK LIST FOR CHILDREN
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1 RECORD SHEET DEVELOPMENTAL PSYCHOPATHOLOGY CHECK LIST FOR CHILDREN Sl. No : Date: Name of the child: Age: Sex: Class: Mother tongue: Medium of Instruction: Languages spoken: Handedness: Details regarding the family: Age education Occupation: Child lives with: Father (Others )Mother Number of siblings and the order of birth: / ( ) ( ) ( ) ( ) (mark 0 for girls and ( ) for boys, darken the circle 0 for the index child) Consanguinity : If present, specify: Urban Rural A. Developmental History 1. Pre- peri post natal problems of Mother Post natal problems of child Epilepsy, head injury, infections Poor vision Poor hearing Gross motor Fine motor Speech/ language Emotional social Self help 0 1
2 B. Developmental Problems 11. Clumsiness Breath holding Tics, mannerisms Speech / articulation Sluttering / stammering Elective mutism Echolalia Language ( expressive) Language ( receptive) Language ( deviant) Inability to relate to people Inability to play with children Feeding problems Enuresis (Primary) Enuresis (Secondary) Encopresis Sleeping Sexual Problems 0 1 C. Psychopathology 29. Poor attention Distractible 0 1
3 31. Restless Impulsive 0 1 Attention deficit hyperactivity 33. Stubbornness Disobedient Disruptive Quarrelsome Aggressive Temper tantrums Truancy Lying & stealing 0 1 Conduct Problems 41. School refusal Poor school performance Reading difficulty Writing difficulty Arithmetic difficulty Forgetfulness, poor memory 0 1 Learning Difficulties 47. Day dreaming Withdrawn Talks little Worrying Anxious 0 1
4 52. Shyness Fearful Clinging Cries easily 0 1 Emotional difficulties 56. OCD 0 1 OCD 57. Dizziness Aches and pains Tiredness Stomach ache Fainting spells Fits Pulling sensation Chronic physical illness Physical handicaps 0 1 Somatic problems 66. Hallucinations Catatonic feature Delusions Talking / laughing to self Poor appetite Poor sleep Incontinence ` Loss of interest Psychomotor retardation 0 1
5 75. Depression Pressure of ideas Irritable Elated 0 1 Psychoses D. Psychosocial Factors Family History of 79. Mental illness Alcoholism Epilepsy Learning problems Bed wetting Speech problems Mental retardation Precipitating factor Problems with parents Sibling rivalry Marital disharmony Punitiveness Over expectation Over involvement Over indulgence Indifference Inconsistent disciplining 0 1
6 96. Multiple care taking Single parent Change in school/ medium/subjects Problem with teachers Problem with peers Poverty 0 1 E. Temperamental dimensions 102. Management Independence Dependability Sensitivity (others) Sensitivity (self) Trusting Trustworthy Moral Sleep pattern Appetite Activity Emotionality Persistence Sociability (family) Sociability (others) Aggressive (verbal) Aggressive (physical) 0 1 1
7 F. Helpful factors 119. Helpful person Friends Interests Talents Sports Creativity 0 1 Sl No Summary Total Score Cut Off Obtained Score 1 Dev. History Dev. Problems / Disorders HyperKinesis Conduct Disorder Learning Disorder Emotional Disorder Obsessive Compulsive Disorder Somatisation Psychoses Family History Stressors Temperament
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9 Sl. No : RECORD SHEET DEVELOPMENTAL PSYCHOPATHOLOGY CHECK LIST FOR CHILDREN Date: Name of the child: Age: Sex: Class: Mother tongue: Medium of Instruction: Languages spoken: Handedness: Details regarding the family: Age education Occupation: Child lives with: Father (Others )Mother Number of siblings and the order of birth: / ( ) ( ) ( ) ( ) (mark 0 for girls and ( ) for boys, darken the circle 0 for the index child) Consanguinity : If present, specify: Urban Rural A. Developmental History 1. Pre- peri post natal problems of Mother 1 2. Post natal problems of child Epilepsy, head injury, infections Poor vision Poor hearing Gross motor Fine motor Speech/ language Emotional social Self help 0 1 B. Developmental Problems 11. Clumsiness Breath holding Tics, mannerisms Speech / articulation Sluttering / stammering Elective mutism Echolalia Language ( expressive) Language ( receptive) Language ( deviant) Inability to relate to people Inability to play with children Feeding problems Enuresis (Primary) Enuresis (Secondary) Encopresis Sleeping Sexual Problems 0 1 1
10 C. Psychopathology 29. Poor attention Distractible Restless 0 1Attention-deficit 32. Impulsive 0 1 Hyperactivity 33. Stubbornness Disobedient Disruptive Quarrelsome Aggressive Temper tantrums Truancy Lying & stealing 0 1 Conduct 41. School refusal Poor school performance Reading difficulty Writing difficulty Arithmetic difficulty 0 1 Learning difficulties 46. Forgetfulness, poor memory Day dreaming Withdrawn Talks little Worrying Anxious ` Shyness Fearful Clinging Cries easily 0 1 Emotion 56. OCD 0 1 OCD 57. Dizziness Aches and pains Tiredness Stomach ache Fainting spells Fits Pulling sensation Chronic physical illness Physical handicaps 0 1 Somatic 66. Hallucinations Catatonic feature Delusions Talking / laughing to self Poor appetite Poor sleep Incontinence ` Loss of interest Psychomotor retardation Depression Pressure of ideas Irritable Elated 0 1 Psychoses D. Psychosocial Factores Family History 79. Mental illness 0 1 2
11 80. Alcoholism Epilepsy Learning problems Bed wetting Speech problems Mental retardation Precipitating factor Problems with parents Sibling rivalry Marital disharmony Punitiveness Over expectation Over involvement Over indulgence Indifference Inconsistent disciplining Multiple care taking Single parent Change in school/ medium/subjects Problem with teachers Problem with peers Poverty etc. 0 1 E. Temperamental dimension 102. Management Independence Dependability Sensitivity (others) Sensitivity (self) Trusting Trustworthy Moral Sleep pattern Appetite Activity Emotionality Persistence Sociability (family) Sociability (others) Aggressive (verbal) 118. Aggressive (physical) F. Helpful factors 119. Helpful person 120 Friends 121. Interests 122 Talents 123. Sports 124. Creativity 3
12 Sl No Summery Total Score Cut Off Obtained Score 1 Dev. History Dev. Problems / Disorders H K CD L D ED OCN Som Psy Family History Stressors Temperament
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