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:0 0 0 0 0 0 0 0 0 / ( ) ( ) ( ) ( ) (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 0 1 2. Post natal problems of child 0 1 3. Epilepsy, head injury, infections 0 1 4. Poor vision 0 1 5. Poor hearing 0 1 6. Gross motor 0 1 7. Fine motor 0 1 8. Speech/ language 0 1 9. Emotional social 0 1 10 Self help 0 1
B. Developmental Problems 11. Clumsiness 0 1 12. Breath holding 0 1 13. Tics, mannerisms 0 1 14. Speech / articulation 0 1 15. Sluttering / stammering 0 1 16. Elective mutism 0 1 17. Echolalia 0 1 18. Language ( expressive) 0 1 19. Language ( receptive) 0 1 20. Language ( deviant) 0 1 21. Inability to relate to people 0 1 22. Inability to play with children 0 1 23 Feeding problems 0 1 24. Enuresis (Primary) 0 1 25. Enuresis (Secondary) 0 1 26. Encopresis 0 1 27. Sleeping 0 1 28. Sexual Problems 0 1 C. Psychopathology 29. Poor attention 0 1 30. Distractible 0 1
31. Restless 0 1 32. Impulsive 0 1 Attention deficit hyperactivity 33. Stubbornness 0 1 34. Disobedient 0 1 35. Disruptive 0 1 36. Quarrelsome 0 1 37. Aggressive 0 1 38. Temper tantrums 0 1 39. Truancy 0 1 40. Lying & stealing 0 1 Conduct Problems 41. School refusal 0 1 42. Poor school performance 0 1 43. Reading difficulty 0 1 44. Writing difficulty 0 1 45. Arithmetic difficulty 0 1 46. Forgetfulness, poor memory 0 1 Learning Difficulties 47. Day dreaming 0 1 48. Withdrawn 0 1 49. Talks little 0 1 50. Worrying 0 1 51. Anxious 0 1
52. Shyness 0 1 53. Fearful 0 1 54. Clinging 0 1 55. Cries easily 0 1 Emotional difficulties 56. OCD 0 1 OCD 57. Dizziness 0 1 58. Aches and pains 0 1 59. Tiredness 0 1 60 Stomach ache 0 1 61. Fainting spells 0 1 62. Fits 0 1 63. Pulling sensation 0 1 64. Chronic physical illness 0 1 65. Physical handicaps 0 1 Somatic problems 66. Hallucinations 0 1 67. Catatonic feature 0 1 68. Delusions 0 1 69. Talking / laughing to self 0 1 70 Poor appetite 0 1 71. Poor sleep 0 1 72. Incontinence ` 0 1 73. Loss of interest 0 1 74. Psychomotor retardation 0 1
75. Depression 0 1 76. Pressure of ideas 0 1 77. Irritable 0 1 78. Elated 0 1 Psychoses D. Psychosocial Factors Family History of 79. Mental illness 0 1 80. Alcoholism 0 1 81. Epilepsy 0 1 82. Learning problems 0 1 83. Bed wetting 0 1 84. Speech problems 0 1 85. Mental retardation 0 1 86. Precipitating factor 0 1 87. Problems with parents 0 1 88. Sibling rivalry 0 1 89. Marital disharmony 0 1 90 Punitiveness 0 1 91. Over expectation 0 1 92. Over involvement 0 1 93. Over indulgence 0 1 94. Indifference 0 1 95. Inconsistent disciplining 0 1
96. Multiple care taking 0 1 97. Single parent 0 1 98. Change in school/ medium/subjects 0 1 99. Problem with teachers 0 1 100. Problem with peers 0 1 101. Poverty 0 1 E. Temperamental dimensions 102. Management 0 1 1 103. Independence 0 1 1 104. Dependability 0 1 1 105. Sensitivity (others) 0 1 1 106. Sensitivity (self) 0 1 1 107. Trusting 0 1 1 108. Trustworthy 0 1 1 109. Moral 0 1 1 110. Sleep pattern 0 1 1 111. Appetite 0 1 1 112. Activity 0 1 1 113. Emotionality 0 1 1 114. Persistence 0 1 1 115. Sociability (family) 0 1 1 116. Sociability (others) 0 1 1 117. Aggressive (verbal) 0 1 1 118. Aggressive (physical) 0 1 1
F. Helpful factors 119. Helpful person 0 1 120 Friends 0 1 121. Interests 0 1 122. Talents 0 1 123. Sports 0 1 124. Creativity 0 1 Sl No Summary Total Score Cut Off Obtained Score 1 Dev. History 10 3-2 Dev. Problems / Disorders 10 5-3 HyperKinesis 4 2-4 Conduct Disorder 8 4-5 Learning Disorder 6 3-6 Emotional Disorder 9 3-7 Obsessive Compulsive Disorder 1 1-8 Somatisation 9 3-9 Psychoses 12 3-10 Family History 7 - - 11 Stressors 16 - - 12 Temperament 17 - -
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:0 0 0 0 0 0 0 0 0 / ( ) ( ) ( ) ( ) (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 0 1 3. Epilepsy, head injury, infections 0 1 4. Poor vision 0 1 5. Poor hearing 0 1 6. Gross motor 0 1 7. Fine motor 0 1 8. Speech/ language 0 1 9. Emotional social 0 1 10 Self help 0 1 B. Developmental Problems 11. Clumsiness 0 1 12. Breath holding 0 1 13. Tics, mannerisms 0 1 14. Speech / articulation 0 1 15. Sluttering / stammering 0 1 16. Elective mutism 0 1 17. Echolalia 0 1 18. Language ( expressive) 0 1 19. Language ( receptive) 0 1 20. Language ( deviant) 0 1 21. Inability to relate to people 0 1 22. Inability to play with children 0 1 23 Feeding problems 0 1 24. Enuresis (Primary) 0 1 25. Enuresis (Secondary) 0 1 26. Encopresis 0 1 27. Sleeping 0 1 28. Sexual Problems 0 1 1
C. Psychopathology 29. Poor attention 0 1 30. Distractible 0 1 31. Restless 0 1Attention-deficit 32. Impulsive 0 1 Hyperactivity 33. Stubbornness 0 1 34. Disobedient 0 1 35. Disruptive 0 1 36. Quarrelsome 0 1 37. Aggressive 0 1 38. Temper tantrums 0 1 39. Truancy 0 1 40. Lying & stealing 0 1 Conduct 41. School refusal 0 1 42. Poor school performance 0 1 43. Reading difficulty 0 1 44. Writing difficulty 0 1 45. Arithmetic difficulty 0 1 Learning difficulties 46. Forgetfulness, poor memory 0 1 47. Day dreaming 0 1 48. Withdrawn 0 1 49. Talks little 0 1 50. Worrying 0 1 51. Anxious ` 0 1 52. Shyness 0 1 53. Fearful 0 1 54. Clinging 0 1 55. Cries easily 0 1 Emotion 56. OCD 0 1 OCD 57. Dizziness 0 1 58. Aches and pains 0 1 59. Tiredness 0 1 60 Stomach ache 0 1 61. Fainting spells 0 1 62. Fits 0 1 63. Pulling sensation 0 1 64. Chronic physical illness 0 1 65. Physical handicaps 0 1 Somatic 66. Hallucinations 0 1 67. Catatonic feature 0 1 68. Delusions 0 1 69. Talking / laughing to self 0 1 70. Poor appetite 0 1 71. Poor sleep 0 1 72. Incontinence ` 0 1 73. Loss of interest 0 1 74. Psychomotor retardation 0 1 75. Depression 0 1 76. Pressure of ideas 0 1 77. Irritable 0 1 78. Elated 0 1 Psychoses D. Psychosocial Factores Family History 79. Mental illness 0 1 2
80. Alcoholism 0 1 81. Epilepsy 0 1 82. Learning problems 0 1 83. Bed wetting 0 1 84. Speech problems 0 1 85. Mental retardation 0 1 86. Precipitating factor 0 1 87. Problems with parents 0 1 88. Sibling rivalry 0 1 89. Marital disharmony 0 1 90 Punitiveness 0 1 91. Over expectation 0 1 92. Over involvement 0 1 93. Over indulgence 0 1 94. Indifference 0 1 95. Inconsistent disciplining 0 1 96. Multiple care taking 0 1 97. Single parent 0 1 98. Change in school/ medium/subjects 0 1 99. Problem with teachers 0 1 100. Problem with peers 0 1 101. Poverty etc. 0 1 E. Temperamental dimension 102. Management 0 1 1 103. Independence 0 1 1 104. Dependability 0 1 1 105. Sensitivity (others) 0 1 1 106. Sensitivity (self) 0 1 1 107. Trusting 0 1 1 108. Trustworthy 0 1 1 109. Moral 0 1 1 110. Sleep pattern 0 1 1 111. Appetite 0 1 1 112. Activity 0 1 1 113. Emotionality 0 1 1 114. Persistence 0 1 1 115. Sociability (family) 0 1 1 116. Sociability (others) 1 117. Aggressive (verbal) 118. Aggressive (physical) F. Helpful factors 119. Helpful person 120 Friends 121. Interests 122 Talents 123. Sports 124. Creativity 3
Sl No Summery Total Score Cut Off Obtained Score 1 Dev. History 10 3-2 Dev. Problems / Disorders 10 5-3 H K 4 2-4 CD 8 4-5 L D 6 3-6 ED 9 3-7 OCN 1 1-8 Som 9 3-9 Psy 12 3-10 Family History 7 - - 11 Stressors 16 - - 12 Temperament 17 - - 4