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Functional Assessment Interview Form: A. Describe The Behavior (S)

Ben is a 9-year-old boy who engages in tantrums with physical aggression and hiding behaviors multiple times per day. The tantrums typically last 5-10 minutes and involve yelling, kicking, and hitting. The hiding behaviors involve screaming for others to get away and hiding underneath objects. These behaviors often occur together. Ben's behaviors are most likely during transitions, when asked to stop preferred activities, and around his mother or others asking him to do things. His behaviors serve to gain attention, extra time for preferred activities, and avoid demands or transitions. Ben enjoys activities like Legos, iPad, and physical games while challenges include transitions and requests to stop preferred activities.

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93 views3 pages

Functional Assessment Interview Form: A. Describe The Behavior (S)

Ben is a 9-year-old boy who engages in tantrums with physical aggression and hiding behaviors multiple times per day. The tantrums typically last 5-10 minutes and involve yelling, kicking, and hitting. The hiding behaviors involve screaming for others to get away and hiding underneath objects. These behaviors often occur together. Ben's behaviors are most likely during transitions, when asked to stop preferred activities, and around his mother or others asking him to do things. His behaviors serve to gain attention, extra time for preferred activities, and avoid demands or transitions. Ben enjoys activities like Legos, iPad, and physical games while challenges include transitions and requests to stop preferred activities.

Uploaded by

api-469538687
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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FUNCTIONAL ASSESSMENT INTERVIEW FORM

Child with Problem Behaviour(s): Ben Digby Date of Interview: 5th of June 2019

Sex: M Age: 9 years 3 months

Interviewer: Eunice Respondent(s): Mother & Father

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).

Behaviour How is it How often? How long? Intensity?


performed?

Tantrum with Yells at others, 3-4x’s per day 5-10 minutes each High (with much
physical tries to kick or hit physical effort)
aggression when people
approach

Hides or buries Screams “get away 2-3x’s per day 5-10 minutes each Medium (with
himself from me!”, will run some physical
underneath over to a spot in effort)
another object the house and hide

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)?

Tantrum and hiding often occur together. Tries to hit or kick when others approach his hiding spot.

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? He’s
currently trialing Ritalin for his ADHD. He appears more physical when he takes these meds.

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

3. Describe the sleep cycles of the child and the extent to which these cycles may affect his/her behavior. Needs
10 hours of sleep to be “happy”. Bedtime is 7:30-9:30. Falls asleep quickly and does not wake up during the night.

4. Describe the eating routines and diet of the child and the extent to which these routines may affect his/her
behavior. Picky eater. Eats with family but not some things. Likes French fries and chicken strips. Tends to
wander when eating.
5. 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? Most days are 90%
predictable (verbally tell him); I verbally tell him the day’s activities.

7. What choices does the child get to make each day (e.g., food, toys, activities?) Computer game, videos, toys,
colors of items (cups, towels), chooses own snack for school

C. 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: When we need to go somewhere and I ask him to put away the activity he is working on (ex.
lego, Ipad)

Least likely: When he gets out of bed in the morning, when he’s eating highly preferred foods. When you
give him what he wants, when he’s rested

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

Most likely: At home during transitions, at school

Least likely: At home during play time

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

Most likely: With mom or anyone who asks him to do things.

Least likely: With strangers

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

Most likely: When he is playing with a preferred activity (like playing Lego or watching youtubes on an
Ipad)

Least likely: When he’s in the car, when he’s ready for bed.

D. DESCRIBE THE CHILD’S PLAY ABILITIES AND DIFFICULTIES

1. Describe how your child plays (with what? how often?). Plays for 30-40 min. after school till dinner time.
Isolated play. Usually with lego or blocks, sometimes plays apps on the Ipad.

2. Does your child have problem behavior when playing? Describe. Only when he has play dates with others.
Has a hard time with turn taking.

3. How does your child react if you ask him/her to stop playing with a toy and switch to a different toy? If
preferred toy/activity, he won’t switch. If you try to make him, will tantrum and throw objects. Other
times he is fine with it.

E. IDENTIFY THE “FUNCTION” OF THE UNDESIRABLE BEHAVIOR(S)


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?)

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

Tantrum with physical aggression Attention, Extra time to with Avoids a demand
preferred activity

Hides or buries himself Space Escape or delay transition


underneath another object

F. 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? Lego, ball games, water play, bike, iPad, physical chasing
games, candies, going to the playground

2. What kinds of things have you or your child’s care providers done to try and change the problem behaviors?
Being silly to distract; Giving into his “requests”; Avoidance of behavior; avoid situation of cause; Give him
food to calm or distract;

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