Childhood Attachment Disruption/disorder Symptom Checklist Page 2
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1
2Signs and Symptoms of Reactive Attachment Disorder in Infancy
Check appropriate indicator for each symptom displayed by infant. Give brief description of infant’s behavior when symptom range is
moderate or severe.
None
Mild
Moderate Severe
Comments
1. Withdrawn, sad and listless appearance
___
___
___
___
______________________________
2. Failure to smile
___
___
___
___
______________________________
3. Doesn’t follow others with eyes
___
___
___
___
______________________________
4. Failure to reach out when picked up
___
___
___
___
______________________________
5. No interest in baby or interactive games
___
___
___
___
______________________________
6. No interest in playing with toys
___
___
___
___
______________________________
7. Engages in self-soothing behaviors
rocking or self-stroking
___
___
___
___
______________________________
8. Calm when left alone
___
___
___
___
______________________________
Risk Factors in Childhood Attachment Disruption
A child may be placed at risk for attachment disruption/disorder if any of the following conditions occurred during the first 36 months
of the child’s life. Place a check in either “yes” or “no” to reflect circumstances of child’s life. Add comments as necessary.
Comments
1. Unwanted pregnancy
Yes _____
No _____
__________________________________
2. Maternal ambivalence
Yes _____
No _____
__________________________________
3. Abused mother
Yes _____
No _____
__________________________________
4. Premature birth
Yes _____
No _____
__________________________________
5. Suffering a birth or prenatal trauma
Yes _____
No _____
__________________________________
6. Pre-birth exposure to trauma, drugs, alcohol
Yes _____
No _____
__________________________________
7. On-going maternal alcohol and/or drug use
Yes _____
No _____
__________________________________
8. Parent/s with psychiatric diagnoses
Yes _____
No _____
__________________________________
9. Parent/s with anger management problems
Yes _____
No _____
__________________________________
10. Young or inexperienced parents – poor parenting skills Yes _____
No _____
__________________________________
11. Inconsistent, inappropriate or harsh care
Yes _____
No _____
__________________________________
12.Parent/s, caregiver/s under or over stimulated child
Yes _____
No _____
__________________________________
13. Parent/s, caregivers are isolated
Yes _____
No _____
__________________________________
14. Significant family trauma, such as death or divorce
Yes _____
No _____
__________________________________
15. Lack of attunement between mother and child
Yes _____
No _____
__________________________________
16. Childcare on a time-scheduled
Yes _____
No _____
__________________________________
17. Chronically depressed mother (postpartum depression) Yes _____
No _____
__________________________________
18. Neglect
Yes _____
No _____
__________________________________
19. Physical abuse
Yes _____
No _____
__________________________________
20. Emotional abuse
Yes _____
No _____
__________________________________
21. Sexual abuse
Yes _____
No _____
__________________________________
22. Abandonment
Yes _____
No _____
__________________________________
23. Multiple caregivers
Yes _____
No _____
__________________________________
24. Frequent changes in foster care providers
Yes _____
No _____
__________________________________
25. Change in daycare providers
Yes _____
No _____
__________________________________
26. Extreme poverty
Yes _____
No _____
__________________________________
27. Separation from mother (illness/death of mother)
Yes _____
No _____
__________________________________
28. Forced removal from neglectful or abusive home
Yes _____
No _____
__________________________________
29. Lived in an orphanage
Yes _____
No _____
__________________________________
30. Institutional care
Yes _____
No _____
__________________________________
31. Adoption
Yes _____
No _____
__________________________________
32. Ongoing, unrelieved pain (colic, hernia, ear infections) Yes _____
No _____
__________________________________
33. Prolonged hospitalization of child
Yes _____
No _____
__________________________________
34. Traumatic medical intervention
Yes _____
No _____
__________________________________
35. Failure to thrive
Yes _____
No _____
__________________________________
Compiled by Victoria A. Fitton, PhD, LMSW, ACSW, RPT-S
References: DMS-IV-TR, The Mayo Clinic, SAMHSA, National Institutes of Health, and National Institute of Mental Health.
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