On the line to the right of the problem number, put a 3,
2, 1, or 0. A 3 means that the problem has been observed during the reporting
period and parents and others are VERY CONCERNED about it. A 2 means the
problem has been observed during the reporting period and parents and others
are SOMEWHAT CONCERNED about it. A 1 means the problem has been observed during
the reporting period but parents and others are NOT VERY CONCERNED about it. A
0 means that parents and others have not observed the problem during the
reporting period; and no one has told you about the child's having the problem.
(Generally, it is appropriate to use the preceding month as the reporting
completing the inventory, focus your analysis first on those items scored at
the “3" or “2" levels. Combining that with focus on the categories as
indicated will assist in isolating the child’s difficulties and in developing
an issue oriented intervention plan. A child who receives no “3" or
“2" ratings is unlikely to have serious adjustment difficulties but you
should be alert to possible patterns of mild behavior difficulty and to slowly name=QuickMark>developing problems.
style='mso-spacerun: yes'> 1. ____style='mso-tab-count:1'> Is restless and has trouble calming down.
style='mso-spacerun: yes'> 2. ____style='mso-tab-count:1'> Has trouble concentrating and paying
style='mso-spacerun: yes'> 3. ____style='mso-tab-count:1'> Has problems going to sleep. (Might wake up
during the night.)
style='mso-spacerun: yes'> 4. ____style='mso-tab-count:1'> Has bad dreams. (Also might have
style='mso-spacerun: yes'> 5. ____style='mso-tab-count:1'> Has headaches.
style='mso-spacerun: yes'> 6. ____style='mso-tab-count:1'> Has problems with an upset stomach.
style='mso-spacerun: yes'> 7. ____style='mso-tab-count:1'> Cries very easily. (Also might have crying
style='mso-spacerun: yes'> 8. ____style='mso-tab-count:1'> Loses his/her temper easily and quickly.
of low self-esteem)
style='mso-spacerun: yes'> 9. ____style='mso-tab-count:1'> Worries and frets about not doing things
well enough and about failing.
____ Does not start things
because he/she is afraid they will turn out badly anyway.
____ Gives up quickly and easily.
____ Does not feel good about
his/her physical and sexual development.
____ Does not like him/herself.
(Also might put him/herself down.)
____ Does not feel he/she fits in
or belongs anywhere.
____ Does not feel loved by
____ Does not feel like someone
anyone can love.
of suicidal thoughts and feelings)
17.style='mso-tab-count:1'> ____ Lost
an important relationship and can hardly live without it.
18.style='mso-tab-count:1'> ____ Became
very embarrassed over something and cannot face it.
____ Is not getting over a
serious loss or disappointment.
____ Can hardly handle having
lost a physical ability or skill.
____ Feels unable to do anything
about what happens to him/her.
____ Thinks about suicide.
____ Attempted suicide.
of emotional and mental illness)
____ Has extreme mood swings.
(His/her mood jumps from one extreme to the other and he/she cannot control
____ Goes on extreme eating
binges. (Might be unusually overweight.)
____ Vomits after eating or uses
laxatives to control his/her weight.
____ Starves him/herself.
____ Does not trust anyone and
thinks people are out to get him/her.
____ Has very strange thoughts
and feelings he/she cannot understand or control.
____ Has extreme fears that keep
him/her from doing things most people the same age do easily.
____ Refuses to keep clean and
take care of his/her personal needs.
____ Cannot stand having people
close or touching him/her.
____ Urinates or defecates in
____ Cuts or hurts him/herself on
____ Is interested in fire,
watching fires, setting fires, and doing things with fire.
____ Hears voices and sees things
others do not hear and cannot see.
of school and learning problems)
____ Has trouble making choices
____ Cannot express his/her
thoughts and ideas.
____ Cannot do things others
his/her age can do.
____ Does not understand
assignments and what people expect.
____ Does not understand what
____ Gets confused.
____ Trying harder does not lead
to his/her work and skills getting better.
____ Does some assignments very
well and others very badly.
____ Forgets what to do or what
____ Does not follow instructions
____ Does not pay attention to
time. (Also might not manage time very well.)
____ Gets bad grades.
____ Does not ask for help or let
____ Has trouble accepting or
dealing with criticism.
____ Has excuses for not doing
____ Thinks his/her not doing
well is someone else's fault.
____ Has to have an adult
standing over him/her to be sure his/her work gets done.
____ Feels teachers have it in
____ Disrupts the class or the
activities of others.
____ Does not make any effort to
cooperate and get along.
____ Misses school.
of relationship problems)
____ Pouts and is hard to live
____ Is hateful and in a bad
____ Gets very angry when things
do not go his/her way.
____ Screams and yells at people.
____ Breaks or damages things.
____ Hits or hurts people.
____ Starts or gets into fights.
____ Bullies and picks on others.
____ Is cruel to others.
____ Lost interest in people and
activities he/she had enjoyed.
____ Has trouble making and
____ Avoids people and stays away
from social activities.
70.style='mso-tab-count:1'> ____ Prefers
activities he/she can do alone.
____ Does not talk to anyone
about his/her feelings and thoughts.
____ Wants to keep his/her
friends all to him/herself.
____ Gets his/her feelings hurt.
____ Is the brunt of teasing and
____ Gets up‑tight and
nervous when someone is angry or upset.
____ Does not stick up for
____ Tries to please everyone and
keep everyone happy.
____ Feels most people do not
79.style='mso-tab-count:1'> ____ People
his/her age do not like him/her.
of value difficulty)
____ Does not follow the rules or
behave as most others do.
____ Does not accept the
authority of parents, teachers, or others in charge.
____ Behaves in socially
____ Uses illegal drugs.
____ Thinks rules and laws are
for someone else.
____ Has friends who get into
____ Is not someone others depend
on or trust.
____ Does not care if he/she
upsets or hurts people.
____ Gets into trouble with the
police or courts.
of whether you have observed the problem, respond to the next signs with
whether the child has EVER experienced them. On the blank next to the number,
use 3, 2, or 1 to show how much the problem affected the youngster. 3 = an
extreme effect, 2 = a moderate effect, and 1 = a mild to no effect. N = never
of abuse and abusive families)
____ Parents did not care what
he/she thought and felt.
____ Parents did not know what
he/she needed and what was important to him/her. (Knowing but not doing
anything is included here.)
____ He/she could not live up to
what others expected.
____ Parents did not know about
or help with his/her problems and difficulties. (Knowing but not doing anything
is included here.)
____ People in his/her family
fought and argued.
____ People in his/her family
were violent and hurt each other.
____ Members of his/her family
abused alcohol or other drugs.
____ Members of his/her family
did illegal or immoral things.
____ Parents (or someone else)
were abusing him/her sexually, physically, or in other ways.
98.style='mso-tab-count:1'> ____ Had
sex with much younger or older people.
____ Wanted to escape from or get
away from his/her home or from members of his/her family.
____ Cannot be permitted to live
with his/her family. (May be due to his/her problems or those of the family.)