Child: _____________________ Observer: ________________
Date/Time: _________________ Setting: _________________
Target Behavior: _____________________________
Definition of Behavior: ________________________________________
____________________________________________________________
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Behavior can be influenced by three factors: the child’s characteristics, the features of the environment, and the characteristics of the child’s interactive partner.
Which of the following characteristics of autism/PDDNOS might influence this behavior? (check all that apply)
___ lack of social reciprocity
___ preference for being alone
___ unusual expression of affect
___ limited understanding of the feelings of others
___ little use of expressive communication (e.g., gestures, pictures, words)
___ inconsistent ability to understand communications of others
___ unusual visual interests
___ inconsistent responses to sounds
___ insensitivity to pain
___ hypersensitivity to touch or taste
___ variable attention span
___ hyperactivity/impulse control difficulties
___ lack of functional use of objects
___ insistence on sameness and repetition
___ difficulty organizing responses
___ difficulty focusing on relevant aspects of situation
Other: _____________________________________________________
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Which characteristics of the physical environment might influence this behavior? (check all that apply)
___ temperature (e.g., too hot, too cold)
___ proximity to other people (e.g., near, far)
___ noise level (e.g., too loud, too quiet)
___ number of people (e.g., too crowded)
___ unclear boundaries (e.g., wide open space, lack of visual borders)
___ limits on movement (e.g., required to sit at table)
___ restricted access to preferred materials/toys
___ absence of visual cues to clarify expectations
___ absence of visual schedule to clarify order of activities
___ lack of access to augmentative communication system
Other: _____________________________________________________
___________________________________________________________
___________________________________________________________
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Which characteristics of the child’s interactive partner might influence this behavior? (choose all that apply)
___ voice tone (e.g., too soft, too firm)
___ verbosity (i.e., using too many words)
___ physical contact (i.e., touching the child)
___ social demands (i.e., pressing the child to interact)
___ failing to respond to the child’s efforts to interact
___ unpredictable behavior (i.e., provides few warnings before actions)
___ showing a strong affective response in reaction to the child’s behavior
___ providing extra attention to the child after exhibition of behavior
___ allowing the child to escape a demanding situation after the behavior
___ letting the child have his/her way after exhibiting the behavior
Other: _____________________________________________________
___________________________________________________________
___________________________________________________________
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Of the three factors listed above (i.e., characteristics of autism, features of the environment and the characteristics of the child’s social interactive partner), which can be changed? Describe how you might change those characteristics to promote positive behavior:
Characteristics of Autism:
Characteristics of Environment:
Characteristics of Partner:
