Child Dissociative Checklist (CDC)

Version 3.0



Directions

Below is a list of behaviors that describe children.  For each item that describes your child now or within the past 12 months, please circle one of the corrisponding numbers. Circle 2 if the item is very true of your child, circle 1 if the item is somewhat or sometimes true of your child.  If the item is not true of your child, circle 0.


Name: _________     Date: ____     Age: ___     Sex:   M  /   F

 

0     1     2

1.         Child does not remember or denies traumatic or painful experiences that are known to have occurred.

 

0     1     2

2.         Child goes into a daze or trance-like state at times or often appears “spaced out.”  Teachers may report that he or she “daydreams” frequently in school.

 

0     1     2

3.         Child shows rapid changes in personality.  He or she may go from being shy to being outgoing, from feminine to masculine, from timid to aggressive

 

0     1     2

4.         Child is unusually forgetful or confused about things that he or she should know, e.g. may forget the names of friends, teachers or other important people, loses possessions or gets lost easily.

 

0     1     2

5.         Child has a very poor sense of time.  He or she loses track of time, may think that it is morning when it is actually afternoon, gets confused about what day it is, or becomes confused about when something happened.

 

0     1     2

6.         Child shows marked day-to-day or even hour-to-hour variations in his or her skills, knowledge, food preferences, athletic abilities, e.g. changes in handwriting, memory for previously learned information such as multiplication tables, spelling, use of tools or artistic ability.

 

0     1     2

7.         Child shows rapid regressions in age-level of behavior e.g., a twelve-year-old starts to use baby-talk, sucks thumb or draws like a four-year-old.

 

0     1     2

8.         Child has a difficult time learning from experience, e.g. explanations, normal discipline or punishment do not change his or her behavior.

 

0     1     2

9.         Child continues to lie or deny misbehavior even when the evidence is obvious.

 

0     1     2

10.       Child refers to him or herself in the third person (e.g. as she or her) when talking about self, or at times insists on being called by a different name.  He or she may also claim that things that he or she did actually happened to another person.

 

0     1     2

11.       Child has rapidly changing physical complaints such as headache or upset stomach.  For example, he or she may complain of a headache one minute and seem to forget all about it the next.

 

0     1     2

12.       Child is unusually sexually precocious and may attempt age-inappropriate sexual behavior with other children or adults.

 

0     1     2

13.       Child suffers from unexplained injuries or may even deliberately injure self at times.

 

0     1     2

14.       Child reports hearing voices that talk to him or her.  The voices may be friendly or angry and may come from “imaginary companions” or sound like the voices of parents, friends or teachers.

 

0     1     2

15.       Child has a vivid imaginary companion or companions.  Child may insist that the imaginary companion(s) is responsible for things that he or she has done.

 

0     1     2

16.       Child has intense outbursts of anger, often without apparent cause and may display unusual physical strength during these episodes.

 

0     1     2

17.       Child sleepwalks frequently.

 

0     1     2

18.       Child has unusual nighttime experiences, e.g. may report seeing “ghosts” or that things happen at night that he or she can’t account for (e.g. broken toys, unexplained injuries).

 

0     1     2

19.       Child frequently talks to him or herself, may use a different voice or argue with self at times.

 

0     1     2

20.       Child has two or more distinct and separate personalities that take control over the child’s behavior.