Child Developmental Therapy Questionnaire

Prior to our initial consultation you will be asked to complete a detailed questionnaire which will allow us to gain a better understanding of your child’s requirements.

Prior to our initial consultation you will be asked to complete a detailed questionnaire which will allow us to gain a better understanding of your child’s requirements.


  • Whilst pregnant were there any medical problems?
  • Was the birth artificially induced?
  • Was your child born either 14 days early or late?
  • Was the birth unusual or difficult in any way?
  • Was there anything unusual about the way your baby looked at birth (Jaundice, blue baby, etc?)
  • Did your child weigh less than 5lbs at birth?
  • Did your child have projectile vomiting, accompanied by screaming sessions, during the first three months of life?
  • During the first three months of life, was your child the ‘good baby’ hardly moving and very quiet, to the point that you had to check to see if he/she was still breathing?
  • Was your child very demanding, needing little sleep and a lot of stimulation and attention between six and twelve months of age?
  • When old enough to sit unaided, did your child start to rock backwards and forwards, sometimes violently enough to move the cot across the floor, or pram against the brake?
  • Did your child have head-banging episodes against the floor or on the walls, when very young?
  • Did your child rush into rooms, bouncing off the walls and furniture.
  • Did your child walk very early (14 months is average), not crawling on hands and knees for long?
  • Was he/she older than 18 months before starting to walk?
  • Was your child slow at learning to talk or did he/she have any speech impediments?
  • Did your child suffer with any serious illnesses before the age of 5?
  • Was he/she the sort of child who often caught the minor infections (colds, coughs, sore throats, earaches, etc.)?
  • Did your child still suck a finger or thumb at the age of 5 or over?

SECTION 2 – Schooling

Did you have difficulty learning how to:

  • Dress yourself – do up your buttons, laces, tie correctly?
  • Read. Was reading more difficult for you to master than the majority of the other members in your class?
  • Write. Was it harder for you to learn how to write than for others in your class?
  • Change from infant printing to joined-up cursive script?
  • Tell the time. Did you find it hard to learn how to read a clock?
  • Catch. Were you a butterfingers, always dropping the ball or avoiding games such as cricket or rounders?
  • Co-ordinate. Did you find it hard to do such exercises as cartwheels?
  • Sit quietly. Were you the classroom fidget or chatterbox?
  • Do you tend to print rather than use longhand?
  • Do you regularly feel dizzy or faint whilst standing in assembly?
  • If the teacher asks you a question in front of the class to which you know the answer, do you go over and over the question in your mind, to be sure the answer is correct?
  • Up to puberty did you start to suffer with regular travel sickness?

SECTION 3 – Current Functioning

  • If a passenger in a car or coach, do you find it difficult to read a book whilst travelling?
  • Do you now suffer with regular headaches which are made worse by physical tension or stress?
  • Do you find bright light disturbing?
  • Do you find that your tolerance to noise is lower than other members of your family or friends?
  • Whilst amongst a group of people do you find that if several are talking at once you become confused with rising levels of anxiety or stress?
  • Do you tend to rock during periods of tension or anxiety?
  • If you have to stand in a busy crowded place, do you start to feel rising levels of tension or anxiety, or feel light-headed, dizzy or faint?
  • If you walk out over the sea on a pier, does the movement of the sea as seen through the gaps in the boards make you feel uneasy?
  • Do you have trouble with “lefts” and “rights” when giving or receiving directions?
  • Whilst writing, is there a tendency for your spelling to get worse?
  • Do you tend to over-react to sudden loud noises?
  • After puberty did you start to suffer with regular headaches or migraines?


  • Often fidgets with hands or feet or squirms in seat.
  • Has difficulty remaining seated when required to do so.
  • Is easily distracted by external stimuli.
  • Has difficulty awaiting turn in games or group situations. Often blurts out answers to questions before they have been completed.
  • Has difficulty following through on instructions from others (not due to oppositional behaviour or failure of comprehension) e.g. fails to finish tasks.
  • Has difficulty sustaining attention in tasks or play activities. Often shifts from one uncompleted activity to another.
  • Has difficulty playing quietly.
  • Often talks excessively.
  • Often interrupts or intrudes on others (e.g. butts into other children’s games).
  • Often does not seem to listen to what is being said to him/her.
  • Often loses things necessary for tasks or activities at school or at home (e.g. toys, pencils, books, homework).
  • Often engages in physically dangerous activities without considering possible consequences – not for the purpose of thrill-seeking (e.g. runs into street without looking).

SECTION 5 – Social

  • Marked lack of awareness of the existence of feelings of others (e.g. treats a person as if he or she were a piece of furniture; does not notice another person’s distress; apparently has no concept of the need of others for privacy).
  • No or abnormal seeking of comfort at times of distress (e.g. does not come for comfort even when ill, hurt or tired; seeks comfort in a stereotyped way, says “cheese, cheese, cheese” whenever hurt).
  • No or impaired imitation (e.g. does not wave bye-bye; does not copy mother’s domestic activities; mechanical imitation of others’ actions out of context).
    No or abnormal social play (e.g. does not actively participate in simple games; prefers solitary play activities; involves other children in play only as ‘mechanical aids’)
  • Gross impairment in ability to make peer friendship (e.g. no interest in making peer friendships; despite interest in making friends, demonstrates lack of understanding of conventions of social interaction, for example, reads phone book to uninterested peer).

SECTION 6 – Communication

  • Markedly abnormal non-verbal communication, as in the use of eye-to-eye gaze, facial expression, body posture, or gestures to initiate or modulate social interaction (e.g. does not anticipate being held, stiffens when held, does not look at the person or smile when making a social approach, does not greet parents or visitors, has a fixed stare in social situations).
  • Absence of imaginative activity, such as playacting of adult roles, fantasy characters or animals; lack of interest in stories about imaginary events.
  • Marked abnormalities in the production of speech, including volume, pitch, stress, rate, rhythm and intonation (e.g. monotonous tone, question like melody or high pitch).
  • Marked abnormalities in the form or content of speech, including stereotyped and repetitive use of speech (e.g. immediate echolalia or mechanical repetition of TV commercial); use of “you” when “I” is meant (e.g. using “you want biscuit?” to mean “I want a biscuit”); idiosyncratic use of words or phrases (e.g. “Go on green riding” to mean “I want to go on the swing”); or frequent irrelevant remarks (e.g. starts talking about train schedules during a conversation about sports).
  • Marked impairment in the ability to initiate or sustain a conversation with others, despite adequate speech (e.g. indulging in lengthy monologues on one subject regardless of interjections from others).

SECTION 7 – Restricted repertoire of activities & interests

  • Stereotyped body movement (e.g. hand-flicking or twisting, spinning, head-banging, complex whole-body movements).
  • Persistent preoccupation with parts of objects (e.g. sniffing or smelling objects, repetitive feeling of texture of materials, spinning wheels of toy car) or attachment to unusual objects (e.g. insists on carrying around a piece of string).
  • Marked distress over changes in trivial aspects of environment (e.g. when a vase is moved from usual position).
  • Unreasonable insistence on following routines in precise detail (e.g. insisting that exactly the same route always be followed when shopping).
  • Markedly restricted range of interests and preoccupation with one narrow interest (e.g. interested only in lining up objects, in amassing facts about meteorology, or in pretending to be a fantasy character).


  • Has stolen without confrontation of a victim on more than one occasion (including forgery).
  • Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning).
  • Often lies.
  • Has deliberately engaged in fire-setting.
  • Is often truant from school.
  • Has broken into someone else’s house, building, or car.
  • Has deliberately destroyed others’ property (other than by fire-setting).
  • Has been physically cruel to animals.
  • Has forced someone into sexual activity with him or her.
  • Has used a weapon in more than one fight.
  • Often initiates physical fights.
  • Has stolen with confrontation of a victim (e.g. mugging, purse snatching, extortion, armed robbery).
  • Has been physically cruel to people.


  • Often loses temper.
  • Often argues with adults.
  • Often actively defies or refuses adult requests or rules (e.g. refuses to do chores at home).
  • Often deliberately does things that annoy other people (e.g. grabs other children’s hats).
  • Often blames others for his or her own mistakes.
  • Is often touchy or easily annoyed by others.
  • Is often angry and resentful.
  • Is often spiteful or vindictive.
  • Often swears or uses obscene language.


  • Unrealistic and persistent worry about possible harm befalling major attachment figures or fear that they will leave and not return.
  • Unrealistic and persistent worry that an untoward calamitous event will separate the child from a major attachment figure (e.g. the child will be lost, kidnapped, killed, or be the victim of an accident).
  • Persistent reluctance or refusal to go to school in order to stay with major attachment figures or at home.
  • Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to go to sleep away from home.
  • Persistent avoidance of being alone, including, ‘clinging’ to and ‘shadowing’ major attachment figures.
  • Repeated nightmares involving the theme of separation.
  • Complaints of physical symptoms (e.g. headaches, stomach-aches, nausea, or vomiting) on many school days or on other occasions when anticipating separation from major attachment figures.
  • Recurrent signs or complaints of excessive distress in anticipation or separation from home or major attachment figures (e.g. temper tantrums or crying, pleading with parents not to leave.)
  • Recurrent signs or complaints of excessive distress when separated from home or major attachment figures (e.g. wants to return home, needs to call parents when they are absent or when child is away from home).


  • Is your child currently on any medication?
  • Has your child been diagnosed with any particular condition?
  • Has your child ever had any serious illnesses or injuries?
  • Has your child been given any vaccinations? If yes, which ones?
  • How did you hear about Jo Rodhouse Neuro Developmental Therapy?