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Post-Separation Visitation Disputes: Differential Interventions

BACKGROUND PAPER

(2001-FCY-6)

APPENDIX 2: CHILD BEHAVIOUR CHECKLIST FOR AGES 4-18, TEACHER’S RATING FORM FOR AGES 5-18

CHILD BEHAVIOUR CHECKLIST FOR AGES 4-18

Below is a list of items that describe children and youth. For each item that describes your child now or within the past 2 months, please circle the 2 if the item is very true or often true of your child. Circle the 1 if the item is somewhat or sometimes true for your child. If the item is not true of the pupil, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to your child.

Please Print

0 = Not True (as far as you know)1 = Somewhat or Sometimes True2 = Very True or Often True

  1. 0 1 2 Acts too young for his/her age
  2. 0 1 2 Allergy (describe):
  3. 0 1 2 Argues a lot
  4. 0 1 2 Asthma
  5. 0 1 2 Behaves like opposite sex
  6. 0 1 2 Bowel movements outside toilet
  7. 0 1 2 Bragging, boasting
  8. 0 1 2 Can’t concentrate, can’t pay attention for long
  9. 0 1 2 Can’t get his/her mind off certain thoughts; obsessions (describe):
  10. 0 1 2 Can’t sit still, restless, or hyperactive
  11. 0 1 2 Clings to adults or too dependent
  12. 0 1 2 Complains of loneliness
  13. 0 1 2 Confused or seems to be in a fog
  14. 0 1 2 Cries a lot
  15. 0 1 2 Cruel to animals
  16. 0 1 2 Cruelty, bullying, or meanness to others
  17. 0 1 2 Day-dreams or gets lost in his/her thoughts
  18. 0 1 2 Deliberately harms self or attempts suicide
  19. 0 1 2 Demands a lot of attention
  20. 0 1 2 Destroys his/her own things
  21. 0 1 2 Destroys things belonging to his/her family or others
  22. 0 1 2 Disobedient at home
  23. 0 1 2 Disobedient at school
  24. 0 1 2 Doesn’t eat well
  25. 0 1 2 Doesn’t get along with other kids
  26. 0 1 2 Doesn’t seem to feel guilty after misbehaving
  27. 0 1 2 Easily jealous
  28. 0 1 2 Eats or drinks things that are not food – don’t include sweets (describe):
  29. 0 1 2 Fears certain animals, situations, or places other than school (describe):
  30. 0 1 2 Fears going to school
  31. 0 1 2 Fears he/she might think or do something bad
  32. 0 1 2 Feels he/she has to be perfect
  33. 0 1 2 Feels or complains that no one loves him/her
  34. 0 1 2 Feels others are out to get him/her
  35. 0 1 2 Feels worthless or inferior
  36. 0 1 2 Gets hurt a lot, accident-prone
  37. 0 1 2 Gets in many fights
  38. 0 1 2 Gets teased a lot
  39. 0 1 2 Hangs around with others who get in trouble
  40. 0 1 2 Hears sounds or voices that aren’t there (describe):
  41. 0 1 2 Impulsive or acts without thinking
  42. 0 1 2 Would rather be alone than with others
  43. 0 1 2 Lying or cheating
  44. 0 1 2 Bites fingernails
  45. 0 1 2 Nervous, high-strung, or tense
  46. 0 1 2 Nervous movements or twitching (describe):
  47. 0 1 2 Nightmares
  48. 0 1 2 Not liked by other kids
  49. 0 1 2 Constipated, doesn’t move bowels
  50. 0 1 2 Too fearful or anxious
  51. 0 1 2 Feels dizzy
  52. 0 1 2 Feels too guilty
  53. 0 1 2 Overeating
  54. 0 1 2 Overtired
  55. 0 1 2 Overweight
  56. 0 1 2 Physical problems without known medical cause:
    1. 0 1 2 Aches or pains (not stomach or headaches)
    2. 0 1 2 Headaches
    3. 0 1 2 Nausea, feels sick
    4. 0 1 2 Problems with eyes (not if corrected by glasses) Describe:
    5. 0 1 2 Rashes or other skin problems
    6. 0 1 2 Stomach aches or cramps
    7. 0 1 2 Vomiting, throwing up
    8. 0 1 2 Other (describe):
  57. 0 1 2 Physically attacks people
  58. 0 1 2 Picks nose, skin, or other parts of body (describe):
  59. 0 1 2 Plays with own sex parts in public
  60. 0 1 2 Plays with own sex parts too much
  61. 0 1 2 Poor school work
  62. 0 1 2 Poorly coordinated or clumsy
  63. 0 1 2 Prefers being with older kids
  64. 0 1 2 Prefers being with younger kids
  65. 0 1 2 Refuses to talk
  66. 0 1 2 Repeats certain acts over and over; compulsions (describe):
  67. 0 1 2 Runs away from home
  68. 0 1 2 Screams a lot
  69. 0 1 2 Secretive, keeps things to self
  70. 0 1 2 Sees things that aren’t there (describe):
  71. 0 1 2 Self-conscious or easily embarrassed
  72. 0 1 2 Sets fires
  73. 0 1 2 Sexual problems:
  74. 0 1 2 Showing off or clowning
  75. 0 1 2 Shy or timid
  76. 0 1 2 Sleeps less than most kids
  77. 0 1 2 Sleeps more than most kids during day and/or night (describe):
  78. 0 1 2 Smears or plays with bowel movements
  79. 0 1 2 Speech problem (describe):
  80. 0 1 2 Stares blankly
  81. 0 1 2 Steals at home
  82. 0 1 2 Steals outside the home
  83. 0 1 2 Stores up things he/she doesn’t need (describe):
  84. 0 1 2 Strange behaviour (describe):
  85. 0 1 2 Strange ideas (describe):
  86. 0 1 2 Stubborn, sullen or irritable
  87. 0 1 2 Sudden changes in mood or feelings
  88. 0 1 2 Sulks a lot
  89. 0 1 2 Suspicious
  90. 0 1 2 Swearing or obscene language
  91. 0 1 2 Talks about killing self
  92. 0 1 2 Talks or walks in sleep (describe):
  93. 0 1 2 Talks too much
  94. 0 1 2 Teases a lot
  95. 0 1 2 Temper tantrums or hot temper
  96. 0 1 2 Talks about sex too much
  97. 0 1 2 Threatens people
  98. 0 1 2 Thumb-sucking
  99. 0 1 2 Too concerned with neatness or cleanliness
  100. 0 1 2 Trouble sleeping (describe):
  101. 0 1 2 Truancy, skips school
  102. 0 1 2 Underactive, slow moving, or lacks energy
  103. 0 1 2 Unhappy, sad, or depressed
  104. 0 1 2 Unusually loud
  105. 0 1 2 Uses alcohol or drugs for nonmedical purposes (describe):
  106. 0 1 2 Vandalism
  107. 0 1 2 Wets self during the day
  108. 0 1 2 Wets the bed
  109. 0 1 2 Whining
  110. 0 1 2 Wishes to be of opposite sex
  111. 0 1 2 Withdrawn, doesn't get involved with others
  112. 0 1 2 Worries
  113. 113.Please write in any problems your child has that were not listed above:
    • 0 1 2
    • 0 1 2
    • 0 1 2

PLEASE BE SURE YOU HAVE ANSWERED ALL ITEMS UNDERLINE ANY YOU ARE CONCERNED ABOUT

TEACHER’S RATING FORM FOR AGES 5-18

Please Print

Below is a list of items that describe pupils. For each item that describes the pupil now or within the past 2 months, please circle the 2 if the item is very true or often true of the pupil. Circle the 1 if the item is somewhat or sometimes true for the pupil. If the item is not true of the pupil, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to this pupil.

0 = Not True (as far as you know)1 = Somewhat or Sometimes True2 = Very True or Often True

  1. 0 1 2 Acts too young for his/her age
  2. 0 1 2 Hums or makes other odd noises in class
  3. 0 1 2 Argues a lot
  4. 0 1 2 Fails to finish things he/she starts
  5. 0 1 2 Behaves like opposite sex
  6. 0 1 2 Defiant, talks back to staff
  7. 0 1 2 Bragging, boasting
  8. 0 1 2 Can’t concentrate, can’t pay attention for long
  9. 0 1 2 Can’t get his/her mind off certain thoughts; obsessions (describe):
  10. 0 1 2 Can’t sit still, restless, or hyperactive
  11. 0 1 2 Clings to adults or too dependent
  12. 0 1 2 Complains of loneliness
  13. 0 1 2 Confused or seems to be in a fog
  14. 0 1 2 Cries a lot
  15. 0 1 2 Fidgets
  16. 0 1 2 Cruelty, bullying, or meanness to others
  17. 0 1 2 Daydreams or gets lost in his/her thoughts
  18. 0 1 2 Deliberately harms self or attempts suicide
  19. 0 1 2 Demands a lot of attention
  20. 0 1 2 Destroys his/her own things
  21. 0 1 2 Destroys property belonging to others
  22. 0 1 2 Difficulty following directions
  23. 0 1 2 Disobedient at school
  24. 0 1 2 Disturbs other pupils
  25. 0 1 2 Doesn’t get along with other pupils
  26. 0 1 2 Doesn’t seem to feel guilty after misbehaving
  27. 0 1 2 Easily jealous
  28. 0 1 2 Eats or drinks things that are not food – don’t include sweets (describe):
  29. 0 1 2 Fears certain animals, situations, or places other than school (describe):
  30. 0 1 2 Fears going to school
  31. 0 1 2 Fears he/she might think or do something bad
  32. 0 1 2 Feels he/she has to be perfect
  33. 0 1 2 Feels or complains that no one loves him/her
  34. 0 1 2 Feels others are out to get him/her
  35. 0 1 2 Feels worthless or inferior
  36. 0 1 2 Gets hurt a lot, accident-prone
  37. 0 1 2 Gets in many fights
  38. 0 1 2 Gets teased a lot
  39. 0 1 2 Hangs around with others who get in trouble
  40. 0 1 2 Hears sounds or voices that aren’t there (describe):
  41. 0 1 2 Impulsive or acts without thinking
  42. 0 1 2 Would rather be alone than with others
  43. 0 1 2 Lying or cheating
  44. 0 1 2 Bites fingernails
  45. 0 1 2 Nervous, high-strung, or tense
  46. 0 1 2 Nervous movements or twitching (describe):
  47. 0 1 2 Overconforms to rules
  48. 0 1 2 Not liked by other pupils
  49. 0 1 2 Has difficulty learning
  50. 0 1 2 Too fearful or anxious
  51. 0 1 2 Feels dizzy
  52. 0 1 2 Feels too guilty
  53. 0 1 2 Talks out of turn
  54. 0 1 2 Overtired
  55. 0 1 2 Overweight
  56. 0 1 2 Physical problems without known medical cause:
    1. 0 1 2 Aches or pains (not stomach or headaches)
    2. 0 1 2 Headaches
    3. 0 1 2 Nausea, feels sick
    4. 0 1 2 Problems with eyes (not if corrected by glasses) Describe:
    5. 0 1 2 Rashes or other skin problems
    6. 0 1 2 Stomach aches or cramps
    7. 0 1 2 Vomiting, throwing up
    8. 0 1 2 Other (describe):
  57. 0 1 2 Physically attacks people
  58. 0 1 2 Picks nose, skin, or other parts of body (describe):
  59. 0 1 2 Sleeps in class
  60. 0 1 2 Apathetic or unmotivated
  61. 0 1 2 Poor school work
  62. 0 1 2 Poorly coordinated or clumsy
  63. 0 1 2 Prefers being with older children or youths
  64. 0 1 2 Prefers being with younger children
  65. 0 1 2 Refuses to talk
  66. 0 1 2 Repeats certain tasks over and over; compulsions (describe):
  67. 0 1 2 Disrupts class discipline
  68. 0 1 2 Screams a lot
  69. 0 1 2 Secretive, keeps things to self
  70. 0 1 2 Sees things that aren’t there (describe):
  71. 0 1 2 Self-conscious or easily embarrassed
  72. 0 1 2 Messy work
  73. 0 1 2 Behaves irresponsibly (describe):
  74. 0 1 2 Showing off or clowning
  75. 0 1 2 Shy or timid
  76. 0 1 2 Explosive and unpredictable behaviour
  77. 0 1 2 Demands must be met immediately, easily frustrated
  78. 0 1 2 Inattentive, easily distracted
  79. 0 1 2 Speech problem (describe):
  80. 0 1 2 Stares blankly
  81. 0 1 2 Feels hurt when criticized
  82. 0 1 2 Steals
  83. 0 1 2 Stores up things he/she doesn’t need (describe):
  84. 0 1 2 Strange behaviour (describe):
  85. 0 1 2 Strange ideas (describe):
  86. 0 1 2 Stubborn, sullen or irritable
  87. 0 1 2 Sudden changes in mood or feelings
  88. 0 1 2 Sulks a lot
  89. 0 1 2 Suspicious
  90. 0 1 2 Swearing or obscene language
  91. 0 1 2 Talks about killing self
  92. 0 1 2 Underachieving, not working up to potential
  93. 0 1 2 Talks too much
  94. 0 1 2 Teases a lot
  95. 0 1 2 Temper tantrums or hot temper
  96. 0 1 2 Seems preoccupied with sex
  97. 0 1 2 Threatens people
  98. 0 1 2 Tardy to school or class
  99. 0 1 2 Too concerned with neatness or cleanliness
  100. 0 1 2 Fails to carry out assigned tasks
  101. 0 1 2 Truancy or unexplained absence
  102. 0 1 2 Underactive, slow moving, or lacks energy
  103. 0 1 2 Unhappy, sad, or depressed
  104. 0 1 2 Unusually loud
  105. 0 1 2 Uses alcohol or drugs for nonmedical purposes (describe):
  106. 0 1 2 Overly anxious to please
  107. 0 1 2 Dislikes school
  108. 0 1 2 Is afraid of making mistakes
  109. 0 1 2 Whining
  110. 0 1 2 Unclean personal appearance
  111. 0 1 2 Withdrawn, doesn’t get involved with others
  112. 0 1 2 Worries
  113. Please write in any problems the pupil has that were not listed above:
    • 0 1 2
    • 0 1 2
    • 0 1 2

PLEASE BE SURE YOU HAVE ANSWERED ALL ITEMS

Date Modified: 2012-08-03
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