Achenbach Child Behavior Observation Checklist for Ages 1½ - 5

• Child's name

• Gender

• Age

• Child's birthdate

  Date

• Attending Physician

• Date Conducted

  Date

General Information

• Form filled out by

• Relation to the child

  Mother

  Father

  Other

• Please specify relation to child

• Does the child have any illness or disability (either physical or mental)?

  No

  Yes

  N/A

• Please describe

• What concerns you most about the child?

• Please describe the best things about the child

Language Development

• Was the child born earlier than the usual 9 months after conception?

  No

  Yes

  N/A

• How many weeks early?

• How much did the child weigh at birth? (provide information in pounds, ounces or grams)

• How many ear infections did the child have before the age 24 months?

  0-2

  3-5

  6-8

  9 or more

• Is any language besides English spoken in the child's home?

  No

  Yes

  N/A

• specify the languages

• Has anyone in the child's family been slow in learning to talk?

  No

  Yes

  N/A

• please list their relationship to the child (i.e brother, father)

• Are you worried about the child's language development?

  No

  Yes

  N/A

• If yes, why?

• Does the child spontaneously say words in any language (not just imitates or understands words)?

  Yes

  No

  N/A

• Does the child combine 2 or more words into phrases? (i.e "more cookie," "car bye-bye")

  Yes

  No

  N/A

• Please print 5 of the child's longest and best phrases or sentences. (For each phrase that is not in english, print the name of the language.)

General Behavior

• Acts too young for his/ her age

  Not True

  Somewhat True

  Very True

• Afraid to try new things

  Not True

  Somewhat True

  Very True

• Avoids looking others in the eye

  Not True

  Somewhat True

  Very True

• Trouble concentrating or can't pay attention for a longer time

  Not True

  Somewhat True

  Very True

• Can't stand waiting; wants everything now

  Not True

  Somewhat True

  Very True

• Can't sit still, restless or hyperactive

  Not True

  Somewhat True

  Very True

• Clings to adults or too dependent

  Not True

  Somewhat True

  Very True

• Constantly seeks help

  Not True

  Somewhat True

  Very True

• Constipated, doesn't move bowels (not when sick)

  Not True

  Somewhat True

  Very True

• Cries a lot

  Not True

  Somewhat True

  Very True

• Cruel to animals

  Not True

  Somewhat True

  Very True

• Defiant

  Not True

  Somewhat True

  Very True

• Doesn't want to sleep alone

  Not True

  Somewhat True

  Very True

• Doesn't answer when people talk to him/ her

  Not True

  Somewhat True

  Very True

• Disturbed by any change in routine

  Not True

  Somewhat True

  Very True

• Destroys his/ her or others things on purpose

  Not True

  Somewhat True

  Very True

• Doesn't eat well

  Not True

  Somewhat True

  Very True

• Don't get along with other kids

  Not True

  Somewhat True

  Very True

• Doesn't feel any guilt after misbehaving

  Not True

  Somewhat True

  Very True

• Easily jealous

  Not True

  Somewhat True

  Very True

• Fears certain animals, situations or places other than school

  Not True

  Somewhat True

  Very True

• Feelings are easily hurt

  Not True

  Somewhat True

  Very True

• Gets hurt a lot, accident-prone

  Not True

  Somewhat True

  Very True

• Gets in many fights

  Not True

  Somewhat True

  Very True

• Hits others

  Not True

  Somewhat True

  Very True

• Angry moods

  Not True

  Somewhat True

  Very True

• Holds his/ her breath

  Not True

  Somewhat True

  Very True

• Looks unhappy without good reason

  Not True

  Somewhat True

  Very True

• Nervous movements or twitching

  Not True

  Somewhat True

  Very True

• Nightmares or Night terrors

  Not True

  Somewhat True

  Very True

• Overeating

  Not True

  Somewhat True

  Very True

• Overtired

  Not True

  Somewhat True

  Very True

• Shows panic for no good reason

  Not True

  Somewhat True

  Very True

• Painful bowel movements (without medical cause)

  Not True

  Somewhat True

  Very True

• Picks nose, skin, or other parts of body

  Not True

  Somewhat True

  Very True

• Poorly coordinated or clumsy

  Not True

  Somewhat True

  Very True

• Plays with own sex parts too much

  Not True

  Somewhat True

  Very True

• Screams a lot

  Not True

  Somewhat True

  Very True

• Selfish or won't share

  Not True

  Somewhat True

  Very True

• Shows little affection toward people

  Not True

  Somewhat True

  Very True

• Too shy or timid

  Not True

  Somewhat True

  Very True

• Sleeps less than most kids during day and/ or night

  Not True

  Somewhat True

  Very True

• Stubborn, sullen, or irritable

  Not True

  Somewhat True

  Very True

• Sudden changes in mood or feelings

  Not True

  Somewhat True

  Very True

• Too fearful or anxious

  Not True

  Somewhat True

  Very True

• Uncooperative

  Not True

  Somewhat True

  Very True

• Wakes up often at night

  Not True

  Somewhat True

  Very True

• Wanders away

  Not True

  Somewhat True

  Very True

• Others that were not mentioned

Behavior

• Define behavior

• Rate behavior

  Not True

  Somewhat True

  Very True

Completion

• Name & Signature of Parent/Caregiver

  Sign

• Name & Signature of Attending Physician

  Sign