JACKSON’S FUNCTIONAL BEHAVIOR ASSESSMENT

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QUESTION

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

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