FUNCTIONAL ASSESSMENT INTERVIEW FORM—YOUNG CHILD

Child with Problem Behavior(s): Date of Interview:

Age: Yrs Mos Sex: M F

Interviewer: Respondent(s):

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?

1.

2.

3.

4.

5.

6.

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)?

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?

2. What medical complication (if any) does the child experience that may affect his/her behavior
(e.g., asthma, allergies, rashes, sinus infections, seizures)?
3. Describe the sleep cycles of the child and the extent to which these cycles may affect his/her behavior.

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

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

DAILY ACTIVITIES
Activity Child's Reaction

6:00 am

7:00 am

8:00 am

9:00 am

10:00 am

11:00 am

12:00 pm

1:00 pm

2:00 pm

3:00 pm

4:00 pm

5:00 pm

6:00 pm

7:00 pm

8:00 pm

9:00 pm
6 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?

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

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:

Least likely:

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

Most likely:

Least likely:

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

Most likely:

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

Most likely:

Least likely:

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.)?

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

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

D. DESCRIBE THE CHILD'S PLAY ABILITIES AND DIFFICULTIES

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

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

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

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

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

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

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

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

E. 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?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
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?

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

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

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.

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

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)?

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

F. 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.)?

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

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?
G. 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?

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?)

3. Tell me how your child expresses the following:

MEANS

CREATIVE SINGLE WORD

HEAD NOD/HEAD SHAKE
MOVE AWAY FROM YOU

CREATIVE MULTI WORD

FACIAL EXPRESSION

IMMEDIATE ECHO

COMPLEX SIGNS
DELAYED ECHO
GRAB & REACH

CRY OR WHINE
SIMPLE SIGNS
MOVE TO YOU

AGGRESSION
SELF-INJURY
GAZE SHIFT

VOCALIZE

TANTRUM

OTHER
POINT

NONE
LEAD
GIVE

FUNCTIONS
Requests an Object

Requests an Action

Protests or Escapes

Requests Help

Requests a Social Routine

Requests Comfort

Indicates Illness

Shows You Something

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).

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

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

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

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?

2. What kinds of things have you or your child's care providers done to try and change the problem behaviors?
 I. DEVELOP SUMMARY STATEMENTS FOR EACH MAJOR PREDICTOR AND/OR CONSEQUENCE
Distant Immediate
Setting Antecedent Problem Maintaining
Event (Trigger) Behavior Consequences Function