Compulsive Behavior Checklist
For Clients with Mental Retardation
Client:_____________________________________ Report Date:__________/_________/____________
MONTH
DAY
YEAR
Instructions: Checkmark Behaviors present and underline words that apply.
Mark “N” if the behavior has not been observed.
Sum the types of Compulsions present (of the 25 Listed)
1. ORDERING COMPLUSIONS
___Arranges objects (cutlery, dresser items, toys) in a certain pattern
___Arranges certain items (pencils, toys, specific clothes) in one spot
___Wants chairs in fixed arrangement (@ table, in living room)
___Wants/ Arranges peers to sit in certain chairs
___Uses same chair or location when in a particular room
___Insists on doing a certain activity/chore at same time each day
Other Compulsions (e.g. “Evening Up” actions):___________________________________________________
DESCRIBE:_______________________________________________________________________________________
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2. COMPLETENESS/INCOMPLETENESS COMPULSIONS
___Insists on closing open doors, open cupboards
___Takes all items out of clothes closet, linen closet, cupboard, drawer, purse, and spice rack
___Removes many items, then puts each back one by one, repeats process
___Tries to empty all toiletry bottles in bathroom; wants serving jug or dish to be empty at end of meals; or similar
activity
___Puts garments on then off, or hangs it up then puts it on, over and over
___Insists on doing a certain chore, resists letting anyone else do it
Other related Complusions:____________________________________________________________________
DESCRIBE________________________________________________________________________________________
_________________________________________________________________________________________________
3. CLEANING/TIDINESS COMPULSIONS
___Insists on doing hygiene steps (dressing/toileting/grooming) in a fixed sequence, may start at beginning of sequence if
interrupted
___Cleans body part excessively, (e.g. hands, part of face, teeth)
___Insists on picking up stray bits off the ground; does the motion of picking lint off clothes even when there is no lint
___Picks at loose threads, seams of clothing, edge of upholstery; picks at or rips garments/linens/grass/shrubs often if not
prevented
___Insists that a certain activity is done: taking out garbage bag when full; having dishwasher started once full; or similar
insistence
__Hides particular objects away or collects/ hoards objects
Other related Compulsion: ____________________________________________________________________
DESCRIBE:_______________________________________________________________________________________
_________________________________________________________________________________________________
4. CHECKING/TOUCHING COMPULSIONS
___Opening cupboard, may look in, closes door, repeats with other cupboard doors, opens and clothes drawer repeatedly
___Touches or taps item repeatedly (doors, walls, window panes floor)
___Touching or stepping pattern: predictably touches item B after touching item A so many times; takes 2-3 steps
forward then steps backward before going forward
___Does unusual sniffing
Other related Compulsions:____________________________________________________________________
DESCRIBE:_______________________________________________________________________________________
_________________________________________________________________________________________________
5. DEVIANT GROOMING COMPULSIONS
___Picks at face/hands/legs to point or gouging skin
___Checks teeth, hair, face, etc.; checks self in mirror excessively
___Inappropriately cuts hair, eyebrows or pubic hair; pulls at hair as if “to make it longer”; pulls out hair when sitting
calmly. (Do not count hair-pulling during a screaming outburst)
Other related compulsions:_____________________________________________________________________
DESCRIBE:_______________________________________________________________________________________
_________________________________________________________________________________________________
NUMBER OF TYPES OF COMPULSIONS (OF THE 25 LISTED)
NUMBER OF CATEGORIES REPRESENTED (OF THE 25 LISTED)
EXTENT OF INTERFERENCE WITH DAILY LIVING (Checkmark items that apply)
Compulsions take more than an hour a day (if not prevented)……………………………………___
Compulsions significantly interfere with the person’s normal routine……………………………___
Compulsions significantly interfere with usual social activities…………………………………..___
Compulsions significantly interfere with relationship with others………………………………..
RESPONSE TO STAFF INTERRUPTION OF COMPULSION ( Circle: 0= Never, 1=Rare, 2= Occasional, 3= Often )
Halts momentarily, then resumes compulsive activity
0
1
2
3
Waits until caregiver is not in immediate area then resumes
0
1
2
3
Becomes angry, may hit or kick staff who intervene
0
1
2
3
Becomes upset, may bite self, hit self, or headbang
0
1
2
3
Other Response:____________________________
0
1
2
3
COMMENTS:______________________________________________________________________________________
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Please fax back to Sherry Howe Administrative Assistant Department of Psychiatry
p 508-334-6693 f 508-334-2029