FUNCTIONAL BEHAVIOR ASSESSMENT STRUCTURED TEACHER INTERVIEW/SURVEY Student's Name: Ray Smith School: Teacher/House: DOB: Grade: 5th Date: Please briefly describe (in behavioral terms) the student's primary behavioral difficulties * Uses disrespectful language to adults and peers * Does not finish tasks * Does not follow teacher directions * After a verbal reminder - speaks disrespectfully In what settings are these behaviors generally exhibited? * Classrooms * Hallways Are there any settings where the behavior does not occur? If so, do you have any hypotheses as to why the child's behavior is better in these settings? * Outside * Playing a game Who is generally present when the behavior occurs? * Adult in charge, other peers What activities or interactions take place just prior to the behavior? * Verbal reminder to get back on task * Warning about losing a point What usually happens immediately after the behavior? * Loses behavioral check * Sent out of group * Sent out of classroom What do you believe is the primary function/purpose of this student's behavioral difficulties? Please also refer to the checklist on the top of the back page. * Impulsivity * Lack of focus and practice Portland School District 8.S.1
Possible functions of student misbehavior. Which apply in this student's case? X Escape from overly difficult work (not being able to do the work) (Thinking he can't do the work OR not liking it) X Get attention from adults or other students An inappropriate expression of anger (doesn't know how to control his anger or boredom) Wanting to intimidate others Relief from anxiety (about...?) Wanting power and control Performing behaviors modeled by other students Needing sensory stimulation Cognitive distortions (i.e., erroneous interpretations of events, inaccurate attributions of the causes of events, negative self-beliefs, persecutory beliefs) What interventions have been at least marginally effective in addressing this student's behavioral difficulties? * Holding onto reinforcers until work is completed * Making sure he repeats directions * When possible, giving him a choice What interventions have been unsuccessful in addressing this student's behavioral difficulties? * Parental contact * Giving some choices, usually wants to be part of a group, so will try to choose a more difficult book or project, which might be more difficult Portland School District 8.S.2
TARGET BEHAVIORS: BEHAVIOR PLAN 2/5/01 1. To increase amount of work completion: a. homework b. class work 2. To improve Ray's social skills: a. Taking responsibility for his actions b. Being respectful towards others --using appropriate language --following reuests made to him by others (students and teachers) BEHAVIOR PLAN: 1. Ray will be working with an incentive program. He will earn or lose minutes of time with Mr. Smith when he demonstrates success with group social skills and/or completing his work. Ray can cash in up to 15 minutes/week of his time earned with Mr. Smith. 2. Ray will go to homework helpers two times or more per week in order to help him complete his homework. 3. Ray will spend parts of his free time, recess time or snack time making up work for time not used wisely during class to complete his work. Portland School District 8.S.3
TARGET BEHAVIORS: 1. Ray will remain on task: --stay in his seat --do his work --listen to his teacher(s) BEHAVIOR PLAN REVISED 3/11/01 2. Ray will be respectful to adults and peers: --use respectful language --use respectful body language BEHAVIOR PLAN: 1. Ray will be working with a daily behavior chart incentive program. He will earn points each half hour of the school day. He will earn activity time with these points. The points needed for the student activity time will be determined at the beginning of each school day. At the end of each day he and his teacher will document ow he did that for that day relative to the two target behaviors. A copy of this behavior chart will go home with him each day in order to communicate with his family on a daily basis. 2. If Ray is having difficulties in any of the above target behavior areas, this can result in warnings. A. If he is given one warning within a half hour time block, he does not earn a point for that block. B. If he persists with off target behavior, he will no longer be a part of the class community. C. Conseuences can include: --time in room 2 --time in principle's office --loss of break time --loss of recess POSITIVE SUPPORTS: 1. For a good chart (with very few warnings and all checkmarks), Ray can earn extra points, break times or special activity time. 2. The school social worker is in communication with Ray and his family. 3. Ray receives three and a half hours per week direct instructional time for reading and writing. Portland School District 8.S.4
BEHAVIORAL/SOCIAL ISSUES REFERRAL FORM Student s Name Grade Date Date of Birth Teacher/House: A) Describe the student s behavior problems that most concern you. What do they look like in behavioral terms? 1. 2. 3. B) Please place a check next to each of the accommodations/interventions listed below that have been tried with this student. Then provide an indication of how effective these strategies have been using the following scale: 1 - ineffective; 2 somewhat effective; and, 3 = very effective Preferential seating 1 2 3 Ignoring inappropriate behaviors 1 2 3 Specific praise for appropriate behavior 1 2 3 Reduced or modified assignments 1 2 3 Redirection or repeated directions 1 2 3 Verbal or nonverbal cues/signals to student 1 2 3 Reprimands 1 2 3 Student/teacher meetings 1 2 3 Parent/teacher meetings 1 2 3 Office referrals 1 2 3 Warnings provided in a counting context (i.e., 123 Magic ) 1 2 3 Phone calls to parent 1 2 3 Classroom time-outs 1 2 3 Contracting with student about behavior 1 2 3 Taking away privileges (i.e.: recess privileges) 1 2 3 Daily home/school behavior sheets (also known as daily school behavior report cards ) 1 2 3 Positive reinforcement charts (i.e.: sticker charts) 1 2 3 After school detentions 1 2 3 Response-cost behavioral strategies 1 2 3 Having student practice ( overlearn ) appropriate behaviors 1 2 3 : 1 2 3 C) What are this student s behavioral/social strengths? D) Is this student easily frustrated? Yes No More than most students If you checked yes, what types of things tend to frustrate or threaten this student? 8.S.5
E) What seems to be the function of this student s misbehavior? For the first two target behaviors you listed on the front page, please complete the following functional behavioral charts (the first chart should be used for the first problem behavior and the second chart should be used for the second problem behavior). This information will be very helpful to the behavior intervention plan so please do not leave this section blank. Thank you! Behavior # Precipitating Conditions Specific Behavior Conseuences Events Setting, time, or other Exactly what the that typically follow situations. Typically student does or does the behavior occurring before the not do behavior Unstructured time in Teacher attention Function of the Behavior Hypothesized the purpose the behavior serves Escape/avoidance Academic instruction in Peer attention Gaining attention When given a directive to Verbal warning / reprimand Expression of anger When close to Loss of privilege (what kind?) Frustration When unable to Time out (where/ how long?) Vengeance When provoked by Detention (how long?) Seeking of power/ control Removal from class in-school suspension (how long?) Intimidation None observed Relief Of fear/ anxiety 8.S.6
Behavior # Precipitating Conditions Specific Behavior Conseuences Events Setting, time, or other Exactly what the that typically follow situations. Typically student does or does the behavior occurring before the not do behavior Unstructured time in Teacher attention Function of the Behavior Hypothesized the purpose the behavior serves Escape/avoidance Academic instruction in Peer attention Gaining attention When given a directive to Verbal warning / reprimand Expression of anger When close to Loss of privilege (what kind?) Frustration When unable to Time out (where/ how long?) Vengeance When provoked by Detention (how long?) Seeking of power/ control Removal from class in-school suspension (how long?) Intimidation None observed Relief Of fear/ anxiety 8.S.7
STUDENT FUNCTIONAL ASSESSMENT INTERVIEW Student School Date DOB Examiner SECTION I What are the things you like best about school? Why? What are the things you dislike the most about school? Why? In general is your schoolwork too hard for you? Yes Sometimes No In general, is your schoolwork too easy for you? Yes Sometimes No When you ask for help in school, do you get it? Yes Sometimes No Does your teacher spend too much time on any subject activity? Yes Sometimes No Does your teacher spend too little time on any subject or activity? Yes Sometimes No When you do seatwork, do you do better when someone works with you? Yes Sometimes No Do you think your teacher(s) notices when you do a good job? Yes Sometimes No Do you think your teacher(s) give you too much of a hard time about things? Yes Sometimes No Do you think you get the credit (grades/rewards) 8.S.8
you deserve for doing good work? Yes Sometimes No Are there things in the classroom that distract you? (make it hard for you to pay attention?) Yes Sometimes No (If yes) What are they? Are there things in school (or about school) that really frustrate you? (can make you mad or upset?) Yes Sometimes No (If yes) What are they? Your teacher says you re good at Do you think that s true? Your teacher says that you can have a hard time with (target behaviors reported by school staff). Do you think that s true? (If the child admits to these difficulties) Why do you think you (target behaviors)? When do you think you have the fewest problems with (target behaviors) in school? Why do you do better during this/these times? When do you think you have the most problems with (target behaviors) in school? Why do you have more problems during this/these times? What changes could be made at school so you d have fewer problems with (target behaviors)? Are there any kinds of rewards you would like for good behavior or good schoolwork? Please tell me how much you like these subjects 8.S.9
Hate it It s Okay Like it a lot Reading 1 2 3 4 5 Math 1 2 3 4 5 Spelling 1 2 3 4 5 Handwriting 1 2 3 4 5 Science 1 2 3 4 5 Social Studies (History) 1 2 3 4 5 English (Language Arts) 1 2 3 4 5 Music 1 2 3 4 5 Art 1 2 3 4 5 PE 1 2 3 4 5 Computers 1 2 3 4 5 ABC Analysis Child's Name: Date Time Antecedent (What Happened Before) Behavior (Briefly Describe) Conseuence (What You Did) Child's Response to Conseuences Antecedent: An antecedent is anything that happens immediately before the behavior. Including who, what, where and why reuests (to do something or stop doing something) that were made. Behavior: A clear description of what the behavior looked like and how long it lasted. Conseuence: What did you do immediately following the behavior? What did you say? Child s Response: How did the child react to the conseuences? What did he/she do? 8.S.10
FUNCTIONAL BEHAVIORAL ANALYSIS OBSERVATION FORM Student Today s Date: Observer: Directions: The purpose of this form is to collect systematic, direct observation data that can be used in a functional behavioral assessment. For each of the target behaviors listed below, please indicate whether the behavior has occurred within a given interval by placing a check in the top box. Each interval should be about 15 minutes in duration. Then rate the severity/intensity of the behavior by using the following three-point scale: 1 = mild; 2 = moderate; and, 3 = severe. Target Behavior 1: Mild (1) Moderate(2) Severe (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Target Behavior 2: Mild (1) Moderate(2) Severe (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Target Behavior 3: Mild (1) Moderate(2) Severe (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 8.S.11
Please take a moment to complete the next 2 pages at the end of the data collection process (i.e.: at the end of the school day or end of whatever number of days has been designated as the data collection period). If you re collecting data over more than one day, only complete Part 2 at the end of the data collection process. Part 2: Observed antecedents of Target Behavior 1: Target Behavior 2: Target Behavior 3: Given a directive to Given a directive to Given a directive to Academic instruction in Academic instruction in Academic instruction in Unstructured time in Unstructured time in Unstructured time in When close to When close to When close to When provoked by When provoked by When provoked by When unable to When unable to When unable to None observed None observed None observed Events that were observed to typically follow each of the target behaviors Target Behavior 1: Target Behavior 2: Target Behavior 3: Teacher attention Peer attention Verbal warning / reprimand Loss of privilege (what kind?) Time out (where/how long?) Detention (how long?) Removal from class In-school suspension Sent home Teacher attention Peer attention Verbal warning / reprimand Loss of privilege (what kind?) Time out (where/how long?) Detention (how long?) Removal from class In-school suspension Sent home Teacher attention Peer attention Verbal warning / reprimand Loss of privilege (what kind?) Time out (where/how long?) Detention (how long?) Removal from class In-school suspension Sent home 8.S.12
Hypothesized purpose of... Target Behavior 1 Target Behavior 2 Target Behavior 3 Escape/avoidance Gaining attention Expression of anger Frustration Vengeance Seeking power/control Intimidation Relief of fear/anxiety Escape/avoidance Gaining attention Expression of anger Frustration Vengeance Seeking power/control Intimidation Relief of fear/anxiety Escape/avoidance Gaining attention Expression of anger Frustration Vengeance Seeking power/control Intimidation Relief of fear/anxiety 8.S.13