EDUC 624 FUNCTIONAL BEHAVIOR ASSESSMENT INTERVIEW FORM

EDUC 624 FUNCTIONAL BEHAVIOR ASSESSMENT INTERVIEW FORM

1. For EACH of the behaviors of concern, define the topography (how it is performed), frequency (how often it occurs per day, week, or month), duration (how long it lasts when it occurs), and intensity (how damaging or destructive the behaviors are when they occur).
Behavior Topography Frequency Duration Intensity

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2. Which of the behaviors described above are likely to occur together in some way? Do they occur about the same time? In some kind of predictable sequence or “chain”? In response to the same type of situation? Discuss in detail.

A. DEFINE ECOLOGICAL EVENTS (SETTING EVENTS) THAT PREDICT OR SET UP THE PROBLEM BEHAVIORS
1. What medications is the person taking (if any), and how do you believe these may affect his or her behavior?
2. What medical or physical conditions (if any) does the person experience that may affect his or her behavior (e.g., asthma, allergies, rashes, sinus infections, seizures, problems related to menstruation)?
3. Describe the sleep patterns of the individual and the extent to which these patterns may affect his or her behavior.
4. Describe the eating routines and diet of the person and the extent to which these may affect his or her behavior.

5.
a. Briefly list below the person’s typical daily schedule of activities. (Check the boxes by those activities the person enjoys and those activities most associated with problems.)
Time Activity Description Enjoys Problems

b. To what extent are the activities on the daily schedule predictable for the person, with regard to what will be happening, when it will occur, with whom, and for how long?

c. To what extent does the person have the opportunity during the day to make choices about his or her activities and reinforcing events? (e.g., food, clothing, social companions, leisure activities)

6. How many other persons are typically around the individual at home, school, or work (including staff, classmates, and housemates)? Does the person typically seem bothered in situations that are more crowded and noisy?

7. What is the pattern of staffing support that the person receives in home, school, work, and other settings (e.g., 1:1, 2:1)? Do you believe that the number of staff, the training of staff, or their social interactions with the person affect the problem behaviors?
B. DEFINE SPECIFIC, IMMEDIATE ANTECEDENT EVENTS THAT PREDICT WHEN THE BEHAVIORS ARE LIKELY AND NOT LIKELY TO OCCUR.
1. Times 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. People: 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 or idiosyncratic situations or events not listed above that sometimes seem to “set off” the behaviors, such as particular demands, noises, lights, clothing?
6. What one thing could you do that would most likely make the undesirable behaviors occur?

7. Briefly describe how the person’s behavior would be affected if…
a. You asked him or her to perform a difficult task.
b. You interrupted a desired activity, such as eating ice cream or watching TV.
c. You unexpectedly changed his or her typical routine or schedule of activities.
d. She or he wanted something but wasn’t able to get it (e.g., a food item up on a shelf).
e. You didn’t pay attention to the person or left her or him alone for a while (e.g., 15 minutes).
C. IDENTIFY THE CONSEQUENCES OF OUTCOMES OF THE PROBLEM BEHAVIORS THAT MAY BE MAINTAINING THEM (I.E., THE FUNCTIONS THEY SERVE FOR THE PERSON IN PARTICULAR SITUATIONS)
1. Think of EACH of the behaviors listed in Section A, and try to identify the specific consequences or outcomes the person gets when the behaviors occur in different situations.
Behavior Particular situations What exactly
does he or she get? What exactly
does she or he avoid?

D. CONSIDER THE OVERALL EFFICIENCY OF THE PROBLEM BEHAVIORS. EFFICIENCY IS THE COMBINED RESULT OF (1) HOW MUCH PHYSICAL EFFORT IS REQUIRED, (2) HOW OFTEN THE BEHAVIOR IS PERFORMED BEFORE IT IS REWARDED, AND (3) HOW LONG THE PERSON MUST WAIT TO GET THE REWARD
Problem Behavior Low Efficiency High Efficiency

E. WHAT FUNCTIONAL ALTERNATIVE BEHAVIORS DOES THE PERSONAL ALREADY KNOW HOW TO DO?
1. What socially appropriate behaviors or skills can the person already perform that may generate the same outcomes or reinforcers produced by the problem behaviors?

F. WHAT ARE THE PRIMARY WAYS THE PERSON COMMUNICATES WITH OTHER PEOPLE?
1. What are the general expressive communication strategies used by or available to the person? These might include vocal speech, signs and gestures, communication boards and books, or electronic devices. How consistently are the strategies used?

2. On the following chart, indicate the behaviors the person uses to achieve the communicative outcomes listed:
Communicative
Functions Complex speech (sentences) Multiple-word phrases One-word utterances Echolalia Other vocalizing Complex signing Single signs Pointing Leading Shaking head Grabbing/reaching Giving objects Increased movement Moving close to you Moving away or leaving Fixed gaze Facial expression Aggression Self-injury Other
Request attention
Request help
Request preferred
food/objects/activities
Request break
Show you something
or some place
Indicate physical pain (e.g., headache, illness)
Indicate confusion
or unhappiness
Protest or reject a
situation or activity
3. With regard to the person’s receptive communication, or ability to understand other persons…
a. Does the person follow spoken requests or instructions? If so, approximately how many? (List if only a few.)
b. Does the person respond to signed or gestural requests or instructions? If so, approximately how many? (List if only a few.)
c. Is the person able to imitate if you provide physical models for various tasks or activities? (List if only a few.)

d. How does the person typically indicate yes or no when asked if she or he wants something, wants to go somewhere, etc.?
G. WHAT ARE THINGS YOU SHOULD DO AND THINGS YOU SHOULD AVOID IN WORKING WITH AND SUPPORTING THIS PERSON?
1. What things can you do to improve the likelihood that a teaching session or other activity will go well with this person?

2. What things should you avoid that might interfere with or disrupt a teaching session or activity with this person?

H. WHAT ARE THINGS THE PERSON LIKES AND ARE REINFORCING FOR HIM OR HER?
1. Food items:

2. Toys and objects:

3. Activities at home

4. Activities/outings in the community

5. Other

I. WHAT DO YOU KNOW ABOUT THE HISTORY OF THE UNDESIRABLE BEHAVIORS, THE PROGRAMS THAT HAVE BEEN ATTEMPTED TO DECREASE OR ELIMINATE THEM, AND THE EFFECTS OF THOSE PROGRAMS?
Behavior How long has this been a problem? Programs Effects

J. DEVELOP SUMMARY STATEMENTS FOR EACH MAJOR PREDICTOR AND/OR CONSEQUENCE
Distant Setting Event Immediate Antecedent
(Predictor) Problem Behavior Maintaining
Consequence
a.
Write summary statement A in a complete sentence:
b.
Write summary statement B in a complete sentence.
c.
Write summary statement C in a complete sentence.
d.
Write summary statement D in a complete sentence.
e.
Write summary statement E in a complete sentence.
f.
Write summary statement F in a complete sentence.
g.
Write summary statement G in a complete sentence.
h.
Write summary statement H in a complete sentence.
i.
Write summary statement I in a complete sentence.
j.
Write summary statement J in a complete sentence.

How confident are you that Summary Statement A is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement B is accurate?
Not very confident Very Confident
1 2 3 4 5 6
How confident are you that Summary Statement C is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement D is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement E is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement F is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement G is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement H is accurate?
Not very confident Very Confident
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How confident are you that Summary Statement I is accurate?
Not very confident Very Confident
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How confident are you that this Summary Statement J is accurate?
Not very confident Very Confident
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