EDUC 624
FUNCTIONAL BEHAVIOR ASSESSMENT INTERVIEW FORM TEMPLATE
Person of concern JILL SMITH
Age 12 YEARS
Gender Female
Date of interview March 20, 2022
Interviewer H. Screen
Respondents Mother, Teachers (Special Ed, General classroom teacher, & Part-time Para Pro)
A. DESCRIBE THE BEHAVIORS
1. For EACH of the behaviors of concern, define the topography (how it is performed), frequency (how
often it occurs per day, week, or month), duration (how long it lasts when it occurs), and intensity
(how damaging or destructive the behaviors are when they occur).
Behavior
a. Tantrum
Topography
Crying, Moaning,
Yelling/Outbursts
b. Stereotypy
(physical
stemming)
Rocking her body
back and forth
c. Physical
Aggression
d. Insomnia
e. Vocal
Stemming
f. Noncomplianc
e
Frequency
Daily
Daily
Duration
Desired need/want
is received
Intensity
Situational
High
Low
Hits herself on the
legs and slap
herself on the head
Situational (not
feeling happy, has a
nightmare, or loses
an item)
Sometimes
(situational as it
depends on
topography)
Until she receives
intervention to
tend to her needs
Varies (depends on
how long the
triggering issue is
resolved)
Jill hums to herself
Daily
Situational
Low
Daily
Varies (requires
multiple verbal
redirections)
Moderate
Ignores given
directions
Daily
Extremely High
Medium to High
Jill will stare until
Daily
Varies
Low
she’s redirected
2. Which of the behaviors described above are likely to occur together in some way? Do they occur
about the same time? In some kind of predictable sequence or “chain”? In response to the same type
of situation? Discuss in detail.
g. Daydreaming
Some of Jill's behaviors can/do occur together and begin to appear as her mood changes, when her
environment becomes too noisy, moving between places, or when her regular routine is interrupted.
For example, when she feels anxious or frustrated, she begins to physically stem (rock/sway back &
forth) and shifts to physical aggression and tantrum behavior (yelling).
B. DEFINE ECOLOGICAL EVENTS (SETTING EVENTS) THAT PREDICT OR SET UP THE PROBLEM BEHAVIORS
1. What medications is the person taking (if any), and how do you believe these may affect his or her
behavior? Guardian indicates that Jill is not currently taking any medications. Her lack of
medications may be a factor in her current behaviors.
2. What medical or physical conditions (if any) does the person experience that may affect his or her
behavior (e.g., asthma, allergies, rashes, sinus infections, seizures, problems related to menstruation)?
Jill was diagnosed with ASD after her 3rd birthday. No further medical or physical
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conditions have been diagnosed.
3. Describe the sleep patterns of the individual and the extent to which these patterns may affect his or
her behavior.
According to Jill’s parents, on the occasions she has nightmares, she is only able to get a few
hours of sleep; another sleep disruptor occurs if she is unable to locate an item from her
collection. The latter situation leads Jill to refusing sleep until the item is located. Her
parents also mentioned Jill being allowed to have the tv on to help lull her to sleep.
4. Describe the eating routines and diet of the person and the extent to which these may affect his or her
behavior.
Jill maintains an organic diet while at home and at school. While she will eat white rice, she
also eats cereal in the mornings. She also will eat her lunch at school, despite not liking the
lunchroom.
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5.
a. Briefly list below the person’s typical daily schedule of activities. (Check the boxes by those
activities the person enjoys and those activities most associated with problems.)
Time
Activity Description
Enjoys
Problems
6:00 AM
Wakes up & Breakfast
X
X
7:00
Heads to School
X
8:00
Classes Start
X
9:00
English
X
10:00
Music
X
11:00
Lunch
X
12:00 PM
Recess
X
1:00
Social Studies
X
2:00
Math & Science
X
3:00
Returns Home
X
4;00
Play Time
X
5:00
Dinner
X
6:00
Homework
X
7:00
Free time
X
8:00
Prepares for Bedtime
X
9:00
Bedtime
X
10:00
Sleep Time
X
b. To what extent are the activities on the daily schedule predictable for the person, with regard to
what will be happening, when it will occur, with whom, and for how long?
Jill appears to erupt into disruptive behaviors when her schedule is interrupted or
changed.
c.
To what extent does the person have the opportunity during the day to make choices about his or
her activities and reinforcing events? (e.g., food, clothing, social companions, leisure activities)
The only time Jill is prohibited from making her own choice is with her diet; all other
areas, she has a choice while also being allotted the freedom to walk around her class
at school.
6.
How many other persons are typically around the individual at home, school, or work (including staff,
classmates, and housemates)? Does the person typically seem bothered in situations that are more
crowded and noisy?
Jill currently resides with her mother and sisters (2) while her father is deployed (military).
At school, she is around her teachers, a paraprofessional, and other children (her classmates).
When in the school cafeteria or a church, Jill tends to display challenging behaviors; she
doesn’t like loud noises or crowds.
7.
What is the pattern of staffing support that the person receives in home, school, work, and other
settings (e.g., 1:1, 2:1)? Do you believe that the number of staff, the training of staff, or their social
interactions with the person affect the problem behaviors?
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Jill has a positive support system at home of her mother and sisters (3:1) while at school, she
receives support from her teacher and the paraprofessional (2:1).
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C. DEFINE SPECIFIC, IMMEDIATE ANTECEDENT EVENTS THAT PREDICT WHEN THE BEHAVIORS ARE
LIKELY AND NOT LIKELY TO OCCUR.
1. Times of Day: When are the behaviors most and least likely to happen?
Most likely: interruption of routine, before bed, & before going to lunch at school
Least likely: free time like recess, when watching tv, & any other time of free play
2. Settings: Where are the behaviors most and least likely to happen?
Most likely: Home, at school (lunchroom), in her classroom
Least likely: During unstructured play like leisure activities, recess, etc
3. People: With whom are the behaviors most and least likely to happen?
Most likely: Teachers, Paraprofessional, Family (Mom & sisters)
Least likely: Her dad
4. Activity: What activities are most and least likely to produce the behaviors?
Most likely: when her routine is interrupted, if she loses an item from her collection(s), too
much noise (i.e. the lunchroom at school, going to church, etc)
Least likely: Free play/unstructured leisure time like art, recess, getting to watch
television, having all of her items in their respective collection
5. Are there particular or idiosyncratic situations or events not listed above that sometimes seem
to “set off” the behaviors, such as particular demands, noises, lights, clothing?
Loud noises from people, places, or things as well as interruptions in her routine.
6.
What one thing could you do that would most likely make the undesirable behaviors occur?
Make a lot of noise from playing the television loud or music.
7.
Briefly describe how the person’s behavior would be affected if...
a.
You asked him or her to perform a difficult task.
Client would begin noncompliance by ignoring the mand(s) being put on her. This could
include tantrums, physical aggression, or her stereotypy.
b. You interrupted a desired activity, such as eating ice cream or watching TV.
Jill would act out (noncompliance and tantrum behavior) and begin to yell.
c. You unexpectedly changed his or her typical routine or schedule of activities.
Jill would act out (noncompliance and tantrum behavior) and begin to yell. This
would escalate into her attacking herself with hits to the head.
d.
She or he wanted something but wasn’t able to get it (e.g., a food item up on a shelf).
This would lead to acting out and a tantrum until she was appeased.
e.
You didn’t pay attention to the person or left her or him alone for a while (e.g., 15
minutes).
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Jill has shown a proclivity for being solo so the likelihood of her having a meltdown or
tantrum would be significantly decreased.
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D. IDENTIFY THE CONSEQUENCES OF OUTCOMES OF THE PROBLEM BEHAVIORS THAT MAY BE
MAINTAINING THEM (I.E., THE FUNCTIONS THEY SERVE FOR THE PERSON IN PARTICULAR SITUATIONS)
1. Think of EACH of the behaviors listed in Section A, and try to identify the specific consequences or
outcomes the person gets when the behaviors occur in different situations.
Behavior
a. Tantrum (Crying,
Moaning,
Yelling/Outbursts)
Particular situations
What exactly
does he or she get?
What exactly
does she or he avoid?
Interruptions to her
routine
The item she desires
b. Stereotypy (physical
stemming)
(Swaying/Rocking her
body backwards &
forward)
Feeling anxious,
agitated, etc
This is her way of
calming/comforting
herself
Avoidance of high
anxiety situations and
routine interruptions
c. Physical Aggression
(SIB-hits herself on
the legs and slaps
head)
Loud noise from the
lunchroom or when in
church
She is allowed to go to
the playground to
calm down
Avoidance of the
lunchroom’s loudness
d. Insomnia
Situational (not
feeling happy, has a
nightmare, or loses an
item)
e. Vocal Stemming
(Hums)
f. Noncompliance
(Ignores given
directions)
Opportunity to watch
television OR the
missing item is found
and returned to her
collection
She is allowed to go to
the playground to
calm down
At recess and when
it’s lunchtime
High stress situations
Possible nightmares or
an interruption to her
routine
She gets her solo time
Avoidance of high
anxiety situations and
routine interruptions
Attention
Someone will walk
Avoidance of the
with her the
lunchroom’s loudness
lunchroom
E. CONSIDER THE OVERALL EFFICIENCY OF THE PROBLEM BEHAVIORS. EFFICIENCY IS THE COMBINED
RESULT OF (1) HOW MUCH PHYSICAL EFFORT IS REQUIRED, (2) HOW OFTEN THE BEHAVIOR IS
PERFORMED BEFORE IT IS REWARDED, AND (3) HOW LONG THE PERSON MUST WAIT TO GET THE
g. Daydreaming
Lunch preparation
REWARD
Problem Behavior
a. Tantrum (Crying, Moaning,
Yelling/Outbursts)
b. Stereotypy (physical stemming)
(Swaying/Rocking her body backwards &
forward)
Low
Efficiency
1
2
3
4
High
Efficiency
5
1
2
3
4
5
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c. Physical Aggression (SIB-hits herself on
the legs and slaps head)
1
2
3
4
5
d. Insomnia
1
2
3
4
5
e. Vocal Stemming (Hums)
1
2
3
4
5
f. Noncompliance (Ignores given
directions)
1
2
3
4
5
g. Daydreaming
1
2
3
4
5
F. WHAT FUNCTIONAL ALTERNATIVE BEHAVIORS DOES THE PERSONAL ALREADY KNOW HOW TO DO?
1.
What socially appropriate behaviors or skills can the person already perform that may
generate the same outcomes or reinforcers produced by the problem behaviors?
Jill does say “good morning” to others and mostly participates in her class with her peers.
She also produces simple answers to direct questions.
G. WHAT ARE THE PRIMARY WAYS THE PERSON COMMUNICATES WITH OTHER PEOPLE?
1. What are the general expressive communication strategies used by or available to the person?
These might include vocal speech, signs and gestures, communication boards and books, or
electronic devices. How consistently are the strategies used?
Jill keeps her communication simple with sign & body language as well as using short
phrases
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2.
On the following chart, indicate the behaviors the person uses to achieve the communicative
outcomes listed:
Communicative
Functions
Request attention
Request help
Request preferred
food/objects/activ
ities
Request break
Show you
something
or some place
Indicate physical
pain (e.g.,
headache, illness)
Indicate
confusion
or unhappiness
Protest or reject a
situation or
activity
3. With regard
to the person’s
receptive
communicatio
n, or ability to
understand
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O
t
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e
r
EDUC 624
other
persons...
a.
Does the
person
follow
spoken
requests or
instruction
s? If so,
approxima
tely how
many?
(List if
only a
few.)
Jill does follow
spoken requests
but mainly
provides 1 word
responses.
b.
Does the
person
respond to
signed or
gestural
requests or
instruction
s? If so,
approxima
tely how
many?
(List if
only a
few.)
Not at the
moment.
c. Is the
person
able to
imitate if
you
provide
physical
models for
various
tasks or
activities?
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(List if
only a
few.)
Jill can imitate
her
paraprofessional
and classmates
with various
tasks.
d. How does
the person
typically
indicate
yes or no
when
asked if
she or he
wants
something
, wants to
go
somewher
e, etc.?
Jill provides 1
word answers
but knows other
phrases and
chooses not to
utilize them.
H. WHAT ARE THINGS YOU SHOULD DO AND THINGS YOU SHOULD AVOID IN WORKING WITH AND
SUPPORTING THIS PERSON?
1.
What things can you do to improve the likelihood that a teaching session or other activity will
go well with this person?
Maintain Jill’s routine while allowing space and time for her during group activities in
and out of the classroom. Try to put her desk in an area when she won’t suffer a sensory
overload from people or noise. When having to make a change to her routine,
communicate it to Jill first (to prepare her) then slowly integrate it (if possible). Maintain
allowing her to move around the classroom freely (when needed). Keep a box of her
reinforcers in the vicinity.
2.
What things should you avoid that might interfere with or disrupt a teaching session or activity
with this person?
Changing her routine, loud noises, strangers, and moving things out of place.
I. WHAT ARE THINGS THE PERSON LIKES AND ARE REINFORCING FOR HIM OR HER?
1.
Food items: Cereal and Rice
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2.
Toys and objects: Caps (from bottles), shiny objects, twist ties, colorful items
3. Activities at home: Leisure (watching television, unstructured play, art)
4. Activities/outings in the community: Swings on the playground
5. Other
J. WHAT DO YOU KNOW ABOUT THE HISTORY OF THE UNDESIRABLE BEHAVIORS, THE PROGRAMS THAT
HAVE BEEN ATTEMPTED TO DECREASE OR ELIMINATE THEM, AND THE EFFECTS OF THOSE
PROGRAMS?
Behavior
How long has this
been a problem?
Programs
Effects
a. Tantrum (Crying,
Moaning,
Yelling/Outbursts)
Since being a toddler
Removing her until
she calms down
Tantrum ends
b. Stereotypy
(physical
stemming)
(Swaying/Rocking
her body backwards
& forward)
Since being a toddler
Removing her until
she calms down
Stereotypy ends
c. Physical
Aggression
(SIB-hits herself on
the legs and slaps
head)
Recent Months
Removing her until
she calms down
SIB ends
d. Insomnia
Situational
throughout the years
Finding the missing
item or letting her
watch television
She becomes calm
e. Vocal Stemming
(Hums)
Since being a toddler
Removing her until
she calms down
Stemming ends
Situational
Use prompts and
removing her until
she calms down
Becomes compliant
Recent Months
Changing her
environemnt
Daydreaming ends
f. Noncompliance
(Ignores given
directions)
g. Daydreaming
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K. DEVELOP SUMMARY STATEMENTS FOR EACH MAJOR PREDICTOR AND/OR CONSEQUENCE
Distant Setting Event
a. Lunchroom
Write summary statement
A in a complete sentence:
b. Music classroom
Write summary statement
B in a complete sentence.
c. Home
Immediate
Antecedent
(Predictor)
Maintaining
Consequence
Problem Behavior
SIB & Physical
Interruption to
Leaving area to go to
Stemming (rocking &
routine
playground
swaying)
When it is time for lunch, Jill will begin to SIB and go into her physical
stereotypy (anxiety inducing situation) as the lunchroom is loud; these
behaviors will continue until either she gets into an area that is quieter
(with her lunch).
Parapro remains with
JIll or sometimes
Interruption to
Tantrum & SIB
appropriately
routine
restraining her is
needed.
Her undesired behaviors will manifest until she is removed to a more
comfortable setting to calm down.
Her collection isn’t
Finding the missing
complete
Crying
item & returning it to
her.
Write summary statement
C in a complete sentence.
d. School
Jill will begin to cry and have outbursts until her items are returned.
Something is missing
Finding the missing
from her area or an
Crying
item & returning it to
interruption to her
her.
routine
Write summary statement
Jill will begin to cry and have outbursts until her routine is back on
D in a complete sentence.
track or she is taken to an area to calm down like the playground.
How confident are you that Summary Statement A is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
How confident are you that Summary Statement B is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
How confident are you that Summary Statement C is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
How confident are you that Summary Statement D is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
How confident are you that Summary Statement E is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
How confident are you that Summary Statement F is accurate?
Not very confident
Very Confident
1
2
3
4
5
6
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