Teacher Presenting Case:  __________________

Child’s First Name:________________________

Form completed by:  ______________________


Behavioral Description from Teacher





Influences on Behavior








Structured Teaching

Notes (describe how)

___ 1. Physical organization of classroom


___ 2. Visual schedule


___ 3.Positive routines


___ 4. Individual work systems


___ 5. Teaching strategies (e.g., prompts, materials, etc.)





Communication Training

_____  1.  Choose the functional concept the child needs to use (e.g. help, finished, no, more, etc.)


_____  2.  Choose the form of communication to teach the child (e.g. verbal, signs/gestures, pictures, objects)


_____  3.  Create opportunities for the child to use communication throughout the day


_____  4.  Design structured activities to elicit communication


_____  5.  Reward the child for communicating


Behavior Management

A.  Decreasing problematic behavior by addressing motivations

_____  1.  Providing other appropriate ways to satisfy the motivation (e.g. by allowing the child to meet the need appropriately if he/she has the skill, or by teaching him/her another way to meet the need appropriately):

_____  2.  Changing the consequences of the problematic behavior so that it does not satisfy the motivation:

_____  a.  If the motivation is escape, require the child to complete a task

_____  b.  If  the motivation is attention, provide a brief time-out

_____  c.  If the motivation is stimulatory, remove the stimulation

_____  d.  If the motivation is tangible, do not allow access to the object

B.  Increasing appropriate alternative behavior

_____  1.  Define an appropriate alternative behavior

_____  2.  Teach the child this new adaptive alternative behavior by:

_____  a.  Physically guiding the child through the new behavior

_____  b.  Providing lots of opportunities to practice the new behavior

_____  3.  Reward the child when he/she exhibits the new behavior in a way that is consistent with the motivation of the original inappropriate behavior:

_____  a.  If the child uses problematic behaviors to gain escape, reward good behavior with opportunities to escape

_____  b.  If the child uses problematic behaviors to gain attention, reward the good behavior with attention

_____  c.  If the child uses problematic behaviors to gain stimulation, reward the good behavior with something stimulating

_____  d.  If the child uses problematic behaviors to get a tangible object, reward the good behavior with access to the object

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