Child:  _____________________             Observer: ________________

Date/Time:   _________________            Setting:  _________________

Target Behavior: _____________________________

Definition of Behavior:  ________________________________________



            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:  _____________________________________________________



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:  _____________________________________________________





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:  _____________________________________________________





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:











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