Education

Jackson Functional Behavior Assessment

Child with Problem Behavior(s): Jackson Date of Interview: 9/25

Age: 4 Yrs* Mos Sex: M* F

Interviewer: Lise Respondent(s): Carey

A. Describe the Behavior(s)

1. What are the behaviors of concern? For each, define how it is performed, how often it occurs per day, week, or month, how long it lasts when it occurs, and the intensity in which it occurs (low, medium, high).

Behavior

How is it performed?

How often?

How long?

Intensity?

Screams

4–10 x/day

Brief

Very disruptive

Throws toys, objects

4–10 x/day

Brief

Very disruptive

Yells shut-up

4–10 x/day

Brief

Very disruptive

Throws chair

2x in past 6 months

Dangerous

2. Which of the behaviors described above occur together (e.g., occur at the same time; occur in a predictable “chain”; occur in response to the same situation)?

May start with screaming or saying shut-up, and then will throw object.

B. Define Potential Ecological Events that May Affect the Behavior(s)

1. What medications does the child take, and how do you believe these may affect his/her behavior?

None

2. What medical complication (if any) does the child experience that may affect his/her behavior (e.g., asthma, allergies, rashes, sinus infections, seizures)?

None

3. Describe the sleep cycles of the child and the extent to which these cycles may affect his/her behavior.

No issues

4. Describe the eating routines and diet of the child and the extent to which these routines may affect his/her behavior.

Eats well, very healthy 4 year old

5. Briefly list the child’s typical daily schedule of activities and how well he/she does within each activity.

C. Daily Activities

Time

Activity

Child’s Reaction

6:00 am

Arrival

A little stiff; looks out window; difficulty joining group

7:00 am

Planning

Needs prompts

8:00 am

Centers

Does okay; rigidity of activities; favorite activities are computer/blocks with cars; may have problems with peers or when asked to do an activity

9:00 am

Hand washing/Snack

Does okay unless it’s not the snack he wants

10:00am

Wiggle time/Small group

Reluctant to participate; needs prompts; sometimes refuses to participate; moves to books; is explosive when redirected

11:00 am

Story Time

Resists; gets own book

12:00 pm

Outside

No problem; restricted repertoire of activities and partners

1:00 pm

Lunch

Does well

2:00 pm

Outdoor play

No problem; restricted repertoire of activities and partners

3:00 pm

Afternoon circle

Can be difficult; often does not want to participate; resists and, if I insist, can be explosive

4:00 pm

Dismissal

Animated to see parents; leaves without problems

1. Describe the extent to which you believe activities that occur during the day are predictable for your child. To what extent does the child know what he/she will be doing and what will occur during the day (e.g., when to get up, when to eat breakfast, when to play outside)? How does your child know this?

Knows schedule

2. What choices does the child get to make each day (e.g., food, toys, activities)?

Understands choices

D. Define Events and Situations that Predict Occurrences of the Behavior(s)

1. Time of Day: When are the behaviors most and least likely to happen?

Most likely: Early morning

Least likely: Outdoor play in morning and afternoon

2. Settings: Where are the behaviors most and least likely to happen?

Most likely: Classroom, small group

Least likely: Outside

3. Social Control: With whom are the behaviors most and least likely to happen?

Most likely: Teacher

Least likely: Peers who will not make demands on him

4. Activity: What activities are most and least likely to produce the behaviors?

Most likely: Structured activity, demands, social interactions, sharing objects

Least likely: Reading a book by himself

5. Are there particular situations, events, etc. that are not listed above that “set off” the behaviors that cause concern (particular demands, interruptions, transitions, delays, being ignored, etc.)?

If he falls or gets bumped

6. What one thing could you do that would most likely make the problem behavior occur?

Insist on participation in something he does not want to do

7. What one thing could you do to make sure the problem behavior did not occur?

Give him all the cars he wants; talk about cars

EDSP 429

Page 1 of 9

E. Describe the Child’s Play Abilities and Difficulties

1. Describe how your child plays (with what? how often?).

Solitary – fine

Parellell – o.k.

Limited social play

2. Does your child have problem behavior when playing? Describe.

If peers suggest he play a different way or take his vehicles

3. Does your child play alone? What does he/she do?

Cars, Car “World,” computer

4. Does your child play with adults? What toys or games?

Not well, issues with turn taking, object exchange

5. Does your child play with other children his/her age? What toys or games?

Not often, he prefers solitary play

6. How does your child react if you join in a play activity with him/her?

Sometimes tells adult to go away or says “shut-up” in response to a play to a play suggestion

7. How does your child react if you stop playing with him/her?

No problem

8. How does your child react if you ask him/her to stop playing with a toy and switch to a different toy?

Problem behavior

F. Identify the “Function” of the Undesirable Behavior(s)

1. Think of each of the behaviors listed in Section A, and define the function(s) you believe the behavior serves for the child (i.e., what does he/she get and/or avoid by doing the behavior?)

Behavior

What does he/she get? OR What exactly does he/she avoid?

Shut-up

People move away or give him what he wants or allow him to do the activities he desires

Throwing

People move away or give him what he wants or allow him to do the activities he desires

Screaming

People move away or give him what he wants or allow him to do the activities he desires

2. Describe the child’s most typical response to the following situations:

a. Are the above behavior(s) more likely, less likely, or unaffected if you present him/her with a difficult task?

More likely

b. Are the above behavior(s) more likely, less likely, or unaffected if you interrupt a desired event (eating ice cream, watching a video)?

More likely

c. Are the above behavior(s) more likely, less likely, or unaffected if you deliver a “stern” request/command/reprimand?

More likely

d. Are the above behavior(s) more likely, less likely, or unaffected if you are present but do not interact with (ignore) the child for 15 minutes.

Less likely

e. Are the above behavior(s) more likely, less likely, or unaffected by changes in routine?

More likely

f. Are the above behavior(s) more likely, less likely, or unaffected if something the child wants is present but he/she can’t get it (i.e., a desired toy that is visible but out of reach)?

More likely

g. Are the above behavior(s) more likely, less likely, or unaffected if he/she is alone (no one else is present)?

Less likely

G. Define the Efficiency of the Undesirable Behavior(s)

1. What amount of physical effort is involved in the behaviors (e.g., prolonged intense tantrums vs. simple verbal outbursts, etc.)?

Simple outbursts that are brief, but highly disruptive

2. Does engaging in the behaviors result in a “payoff” (getting attention, avoiding work) every time? Almost every time? Once in a while?

We try to keep him calm, we usually give in right away

3. How much of a delay is there between the time the child engages in the behavior and gets the “payoff”? Is it immediate, a few seconds, longer?

Immediate

H. Define the Primary Method(s) Used by the Child to Communicate

1. What are the general expressive communication strategies used by or available to the child? (e.g., vocal speech, signs/gestures, communication books/boards, electronic devices, etc.) How consistently are the strategies used?

Good verbal communication; advanced in his language on some topics

2. If your child is trying to tell you something or show you something and you don’t understand, what will your child do? (repeat the action or vocalization? modify the action or vocalization?)

Doesn’t repair well; is mumbly if you don’t get it the first time

3. Tell me how your child expresses the following:

Grab & Reach

Give

Point

Lead

Gaze Shift

Move to You

Move away from You

Head nod/Head Shake

Facial Expression

Vocalize

Immediate Echo

Delayed Echo

Creative Single Word

Creative Multi Word

Simple Signs

Complex Signs

Self-Injury

Aggression

Tantrum

Cry or Whine

Other

None

Functions

Requests an Object

X

Requests an Action

X

Protests or Escapes

X

Requests Help

X

Requests a Social Routine

X

Requests Comfort

X

Indicates Illness

X

Shows you Something

X

Notes:

4. With regard to receptive communication ability:

a. Does the child follow verbal requests or instructions? If so, approximately how many? (List, if only a few.)

Understands everything you may say

b. Is the child able to imitate someone demonstrating how to do a task or play with a toy?

Yes, but may refuse

c. Does the child respond to sign language or gestures? If so, approximately how many? (List, if only a few.)

Understands well

d. How does the child tell you “yes” or “no” (if asked whether he/she wants to do something, go somewhere, etc.)?

Speaks

H. What Events, Actions, and Objects are Supportive or Present Challenges to the Child?

1. Describe the things that your child really enjoys. For example, what makes him/her happy? What might someone do or provide that makes your child happy?

Computer, cars, blocks, round food, chairs with the word taped to it, the color yellow, and things that are yellow

2. What kinds of things have you or your child’s care providers done to try and change the problem behaviors?

Warnings – effective

Follow through – “I’ll help you”

Don’t rush him. Reprimand may set him off more.

I. Develop Summary Statements for Each Major Predictor and/or Consequence

Distant

Setting

Event

Triggers

Problem

Behavior

Maintaining

Consequence

Function

Adapted from: O’Neill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional Assessment and Program Development for Problem Behavior. Pacific Grove, CA: Brooks/Cole Publishing.

Page 9 of 9

EDSP 42

9

Page

1

of

2

J

ACKSON

F

UNCTIONAL

B

EHAVIOR

A

S

S

E

SSMENT

Child

with Problem Be

h

avior(s):

J

a

c

k

s

o

n

Date of Inter

v

iew:

9/25

Age:

4

Yrs

*

Mos

Sex:

M

*

F

Interviewer:

Lise

R

e

sp

o

nden

t

(s):

Ca

r

ey

A.

Descr

i

b

e the Be

ha

vior(s)

1.

What

a

re the

behavi

o

rs of

co

n

c

e

rn?

F

o

r each, define

how it is per

f

orm

e

d, how

o

ften it

occ

u

rs

per day, w

ee

k

, or month, how

l

ong it lasts

when it occurs,

and the int

e

n

s

ity in

which it occ

u

rs (l

o

w, medium, hi

g

h).

Behavior

How is it

performed?

How often?

How long?

Intensity?

Screams

4

10 x/day

Brief

Very disruptive

Throws toys,

objects

4

10 x/day

Brief

Very disruptive

Yells shut

up

4

10 x/day

Brief

Very disruptive

Throws chair

2x in past 6

months

Dangerous

2.

Wh

i

c

h

of

the

behaviors

d

escri

b

ed

a

bov

e

occur

to

g

ether

(e.g.,

occur

at

the

same

time;

occur

i

n

a

pr

ed

ictable

“c

h

ai

n

”; occur in res

p

o

n

se to the same

s

i

tuation)?

May

start wi

t

h screa

m

ing

or s

a

yi

n

g s

hu

t

up

,

and th

e

n

will throw

o

b

j

ect.

B.

Define Potential Ecological Events

that May Affect the Be

h

avio

r(

s)

1.

What

m

edic

a

tions

d

o

es t

h

e child t

a

ke, and h

o

w do

y

ou believe t

h

ese may aff

e

ct his/h

e

r

be

h

avior?

No

n

e

2.

What

m

edical

co

m

plication

(if any) do

e

s the chi

l

d exp

e

rie

n

ce that

m

ay affect

his/her b

e

havi

o

r (e.g., asthma, allerg

i

es,

r

a

s

hes,

s

i

n

u

s infectio

n

s

,

se

i

z

u

re

s

)?

No

n

e

3.

D

e

scribe the

sle

e

p cyc

l

es

of the child

a

nd the extent to which

these cycl

e

s may

affect

his/h

e

r

behavi

o

r.

No i

s

s

u

es

4.

D

e

scribe the

eating r

o

utin

e

s and d

i

et

of the chi

l

d and

t

he extent to wh

i

c

h th

e

s

e

routin

e

s may

affect his/h

e

r behavi

o

r.

EDSP 429

Page 1 of 2

JACKSON FUNCTIONAL BEHAVIOR ASSESSMENT

Child with Problem Behavior(s): Jackson Date of Interview: 9/25

Age: 4 Yrs* Mos Sex: M* F

Interviewer: Lise Respondent(s): Carey

A.

Describe the Behavior(s)

1. What are the behaviors of concern? For each, define how it is performed, how often it

occurs per day, week, or month, how long it lasts when it occurs, and the intensity in

which it occurs (low, medium, high).

Behavior

How is it

performed?

How often? How long? Intensity?

Screams 4–10 x/day Brief Very disruptive

Throws toys,

objects

4–10 x/day Brief Very disruptive

Yells shut-up 4–10 x/day Brief Very disruptive

Throws chair

2x in past 6

months

Dangerous

2. Which of the behaviors described above occur together (e.g., occur at the same time;

occur in a predictable “chain”; occur in response to the same situation)?

May start with screaming or saying shut-up, and then will throw object.

B.

Define Potential Ecological Events that May Affect the Behavior(s)

1. What medications does the child take, and how do you believe these may affect his/her

behavior?

None

2. What medical complication (if any) does the child experience that may affect

his/her behavior (e.g., asthma, allergies, rashes, sinus infections, seizures)?

None

3. Describe the sleep cycles of the child and the extent to which these cycles may affect

his/her behavior.

No issues

4. Describe the eating routines and diet of the child and the extent to which these

routines may affect his/her behavior.

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