FUNCTIONAL ASSESSMENT INTERVIEW

(adapted from ONeill, R., Horner, R., Albin, R., Sprague, J. R., Storey, K., and Newton, J. S. 1997.
Functional Assessment Interview. In Functional Assessment and Program Development: A Practical
Handbook, 2nd Edition. Pacific Grove: Brooks/Cole Publishing Company)
Student Name
Child B
Date of Interview
2nd November 2014
Respondents
Teacher

Age
7
Interviewer Teacher

Sex

Male

I. Student Behavior
A. List the strengths and competencies of the student in each of the domains:
Social:

Able to respond to familiar social actions (eg. Hi-5, shake hands, accepting items)

Able to stay in a small group with his peers during group work sessions

Able to demonstrate level of awareness by taking toys from his peers when they take them
away from him

Academic / Cognitive:

Matching object to object, object to picture and picture to picture

Grouping functionally related objects (dressing, feeding)

Grouping and matching colours (red, blue, green, yellow)

Pre numeracy skills (eg. 1 to 1 correspondence)

Perceptual-Motor:

Able to complete simple fine motor tasks (eg. threading, simple shoe box tasks)

Able to complete gross motor activities (eg. walking, jumping, balancing, heavy weight
lifting)

Adaptive Behavior:

Currently working on indicating toileting needs but able to go through all the steps of
toileting when brought to the toilet to change his diapers

Able to go through all the steps of dressing and undressing himself

Able to tolerate teeth brushing with physical assistance

Communication:

Currently on Picture Exchange Communication System (PECS)

Able to complete Phase I of PECS simple 1 to 1 exchange with different reinforcers

Currently working on Phase II and III of PECS walking across the room to complete the
exchange and discriminating between two different PECS cards
a) Describe the behaviors of concern:

1.
Behaviour
1. Flooring

2. Biting Shirt

Description
Child will drop to the
ground (sometimes roll
on the floor) and begin
to purposely make him
feel heavy so that
others are not able to
carry him.
Child will bite his shirt
constantly and that
would cause many
holes on his shirts.

Frequency
Whenever he does not
want to do something
that the teacher directs
him to.

Duration
3mins 10 mins
(depending on what
the teacher requires
him to do)

Intensity
High Child will
struggle when teacher
tries to carry him to
stand up.

Whenever he gets Over 30 mins when

upset, angry or overly teacher
does
not
excited.
prompt him to stop
biting his shirt.
5
seconds
when
teacher prompts him
to stop biting his shirt.

Low Child does not

show frustration when
he is prompted to stop
biting his shirt. Also,
he does not trigger
other children in the
class
with
this
behaviour.
High Child will
shout and causes loud
noises that would
disrupt
the
other
children in the class.
Some children will be
triggered and have
meltdowns as well
due to the loud noises.
High throwing
things may hit other
children and also
cause a lot of teachers
to clean up after him.

3. Kicking and
Crying

Child will lie down on Whenever he is put in Over 15 mins for

the floor; use his hands a setting that he is not every meltdown.
to cover his ears and comfortable with.
cry, kicking whatever
teacher, peer or toys
around him.

4. Throwing things

Child will throw things

with a lot of force
(toys, food) onto the
floor.

Whenever he is sick
of the food or given
toys that he does not
want.

2
seconds
for
throwing, at most 1
min of throwing all
the things on the
table.

2. Which of the behaviors described above are likely to occur together in some way?
Throwing things and biting shirt
Flooring, kicking and crying
3. 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?
Behaviour
How long has this been a
Programs
Effects
problem?

1. Flooring

Child has always been

flooring but has started
becoming behaviour since 7
months ago.
Child has been biting his
shirt since he was 5 years
old.

2. Biting Shirt

3. Kicking and
Crying

4. Throwing things

Child will be given snacks

(eg. oreo) to pacify him and
motivate him to walk.

Child will be given fruits

such as oranges (for the
sour taste) and apples (for
the crunch) for his sensory
diet.
Child has always been Child will be put to a
kicking and crying but the corner to kick and cry until
frequency increased since 5 he calms down.
months ago.
Child has started throwing Child will be asked to pick
things since 5 months ago.
up whatever he has thrown.

Program has been effective to a

certain extend as child will get up
from the floor most of the time.
Program has been effective in the
beginning when he had just started
the sensory diet. However, recently
he still bites his shirt when frustrated
even after eating fruits.
Program has been effective but he
takes a long time to calm down and
this also disrupts the class.
Program has been effective as he
learns a consequence for throwing
things. However, this has not stopped
his throwing action.

B. Define events that are set up or predict the behavior. NA

1. Medications
Stimulants
Adderall
Concerta
Cylert
Dexadrine
Ritalin

Anti-Depressants
Celexa
Effexor
Paxil
Wellbutrin
Zyprexa

Anti-Psychotics
Geodon
Mellaril
Risperdal
Seroquel
Trilaton

Anti-Hypertensive
Clondine
Tenex

Anti-Anxiety
Xanax
Valium

Anti-Convulsant
Depakote/Depakene
Lamictal
Klonopin
Tegretol

Medication name
How you think it may affect the students behavior:

Note: For more information on medications go to www.whatmeds.com.

2. Medical / Physical conditions that may affect his/her behavior:
Allergies
Asthma
Problems related to Menstruation
Others (describe)

Describe symptoms of
any checked:

GI Problems
Rashes

Headaches
Seizures

Pain/Discomfort
Sinus Infections

3. Describe sleep patterns and possible relationship to behavior:

Child sleeps regular hours and does not have any possible relation to his behaviour
4. Describe eating routines and diet and possible relationship to behavior:
Child eats basic three meals a day but also snacks alot throughout the day. Food is used as a
strategy to pacify him when he misbehaves.
5. Students daily schedule (Indicate whether they are activities he/she enjoys or are associated with problems;
whether the activities are predictable for what will be happening, with whom, when and for how long; and
whether the student has choices about the activities and/or reinforcing events.)
Child only comes to school from 3pm to 6pm.
Enjoys

Problems

Whom

Predicable
How long

Choices

6:00

7:00

8:00

9:00
10:0
11:00

For the first hour

Child has choices

to choose toys that
he wants to play
with

For 1 hour

Activity is teacher
directed (eg. such
as walking). Child
floors most during
this period

Snack time - 30
mins, Group work
- 30 mins

Snack Time - child

eats food that
parents have
brought and differs
everyday. Does not
have a choice.
Group work teacher directed
and is not able to
choose activity

12:00
0
1:00
2:00

Gross Motor Activities

Child participates in
arrival routine and
is prompted to play
freely
Child participates in
gross motor
activities such as
walking, jumping
and obstacle
courses

Snack Time and Group

Work Activities

Child participates
during snack time
and group work.
Snack time - child
participates in
PECS. Group work teacher directed.
Circle time is
included under
group activity

6:00

Dismissal

Child participates in
dismissal routine
and is brought to the
school bus to go
back home

Peers, teachers,
bus drivers

Child does not

have a choice to
go home but enjoys
going home. Thus,
no behaviour is
usually seen

7:00

3:00

4:00
Enjoys
snack
time

What

Arrival and free play

period

Dislikes
group
activities

5:00

Peers, teachers

Peers, teachers

Peers, teachers

8:00

9:00

Further details:

Unable to fill up the schedule for child B before he attends class due to the parents discretion

6. How many other persons are typically around the student? Does the student typically seem bothered in
situations that are more crowded and noisy?
School

Home

Teacher

Helper

Teacher Aide

Parents

Teacher Aide

Siblings

Child seems to be more bothered in crowded and noisy situations like in school when there are more students
around him.
7. What is the pattern of staffing support the student receives? Do you believe that the number of staff, the
training of staff, or their social interactions with the student affect the desirable or target behavior?
School
Teacher
Teacher Aide - trained in handling children
with severe ASD, proactive in classroom
settings
Teacher Aide - trained in handling children
with severe ASD, proactive in class settings
and trained in toileting

Home
Helper - has been with child ever since he
was born
Parents

Siblings

Pattern or staff and training of staff are sufficient for the class child B is in. Students are all diagnosed with ASD,
similar to child B.
8. What agencies are involved with the student?

If there is any social agency involvement please see Agency Involvement Questionnaire - Attachment 1.
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

Desirable
When child is asked to move from one
setting to another

Target

When child does not get what he wants

When child is asked to participate in

anything that is teacher directed
Least Likely

When child is able to select his choice of

activity

2. Settings: Where are the behaviors most and least likely to happen?
Most Likely

Least Likely

Desirable
During circle time setting

Target

During group activity setting

3. People: With whom are the behaviors most and least likely to happen?
Desirable
Most Likely

Least Likely

Target

4. Activity: What activities are most and least likely to produce the behavior?
Desirable
Most Likely

Least Likely

Target

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?

6. What one thing could you do that would most likely make the behaviors occur?
Desirable
Target

7. Briefly describe how the target behavior would be affected if. . .

a)

You asked him or her to perform a difficult task:

Child B will floor and struggle when being physically brought to perform a task.

b) You interrupted an enjoyable activity, such as eating ice cream or watching TV:
Child will push teachers away and throw whatever that was presented to him (eg. crayons)
when he is interrupted
c) You unexpectedly changed the students typical routine or schedule of activities:

Child will floor and struggle, not wanting to move from one area to another if the routine is
disrupted. Unless it is to bring him to an activity that he prefers (eg. water play), child will
particiapte and will not show behaviour
d) The student wanted something but was unable to get it:
Child will push teachers out of the way in order to get something that he prefers
e)

You didnt pay attention to the student or left the student alone for awhile (e.g., 15 minutes).
If child is engaged in his preferred activity (eg. playing with his preferred toys), child will not
show any behaviour. However, after awhile, he will start to run around the classroom and
throw things on the floor.

D. Identify the consequences or outcomes of the problem behaviors that may be maintaining them
(i.e., the functions they serve for the student in particular situations). Think of the behaviors listed in Section B,
and identify the specific consequences or outcomes the person gets when the behaviors occur in different situations.
Behavior
Particular Situations
What exactly does the
What does the student avoid?
student get?
a)

b)

c)

d)

e)

E. Consider the overall efficiency of the problem behaviors. Efficiency if the combined result of (A) how
much physical effort is required, (B) how often the behavior is performed before it is rewarded, and (C)
how long the student must wait to get the reward.
Behavior

Low
Efficiency

High
Efficiency

F. What functional alternative behaviors does the student already know how to do? (What socially appropriate
behaviors or skills can the person already perform that may generate the same outcomes or reinforces produced by
the problem behaviors?) -See Section A for strengths and competencies.

G. What are the primary ways the student communicates with other people?
1. What are the general expressive communication strategies used by or available to the student? These might
include vocal speech, signs/gestures, communication boards/books, or electronic devices.

2. How consistently are the strategies used?

Other

Self-injury

Aggression

Facial expression

Fixed gaze

Moves away or leaves

Moves close to you

Increased movement

Gives objects

Grabs/reaches

Shakes head

Leading

Pointing

Single signs

Complex signing

Other vocalizing

Echolalia

One-word utterances

Multiple-word phrases

Communication
Functions

(sentences)

Complex speech

3. On the following chart, indicate the behaviors the person uses to achieve the communicative outcomes listed.

Request attention
Request help
Request preferred
food-objects activities
Request break
Show you something
or some place
Indicate physical pain
(headache, illness)
Indicate confusion
or unhappiness
Protest or reject a
situation or activity

4. With regard to the students receptive communication, or ability to understand other persons. (For each
item, list if only a few).
a) Does the student follow spoken request or instructions? If so, approximately how many?

b) Does the student respond to signed or gestural requests or instructions? If so, approximately how many?

c)

Is the student able to imitate if you provide physical models for various tasks or activities?

How does the student typically indicate yes or no when asked if he or she wants something, wants to go
d) somewhere, and so on?

I. What are the 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 student?

2. What things should you avoid that might interfere with or disrupt a teaching session or activity with
this student?

J. What are things the student likes and are reinforcing for him or her?
1. Activities in school:
2. Activities at home:
3. Activities in community:
4. Objects/items:
5. Food items:
6. Other:

Attachment 1
Questions to ask if a student is in foster care:
1. Who has custody of the child? Is this a parent/foster parent/ relative/ friend?
a.
b.

Comments/Notes

2. If the child is in public custody, who is the childs case worker?

a. The case worker acts as custodian.
b. There is a specific group of children who are being served by a Childrens
Home. These children are all eligible for adoption, and awaiting families. In
these cases, the staff person from Childrens Home acts as the custodian.

3. In what type of foster home is the child placed?

4. Who is the childs Guardian Ad Litem / Court Appointed Special Advocate?

a. The Guardian Ad Litem (GAL) is a person appointed by a magistrate in
juvenile court to represent the childs best interest. Most GALs are employed
by the Public Defenders Office.
b. Some cases will have an additional person appointed called a Court Appointed
Special Advocate (CASA). CASAs are volunteers who are trained to advocate
for the child, and carry a very small caseload of 1-2 families.

5. Does a surrogate parent need to be requested /appointed?

a. Any student in public custody who has, or is suspected of having an IDEA
disability must have a surrogate parent appointed.

6. If the child is in public custody, what is the reunification plan?

a. In most situations JFS is required to work toward family reuinification for a
minimum time period.
b. Children who are placed in a permanent planned living arrangement (PPLA)
are children who are in most situations not expected to return home.

7. What services is the child receiving?

a.
b.

8. Does the child have an active case with a mental health agency or provider?
a. A child involved with mental health services will have an Individualized
Service Plan, (ISP) that delineates the goals the child is working on in therapy.
ISPs and IEPs should be coordinated.
b. Some therapists can be available to attend school meetings.

10

Excitement

Gratification

Dons Know

Sensory
Other/

activity Access to: desired

Access a task -

Teacher Attention

Food

Perceived Functions
Get/Obtain
Other -

Person -

Activity\Task (Group)

Tchr. Demand/Request

Time

Escape/Avoid
group Does not want to be in a

Alone (no attention)

Interruption

Demand/Request

Difficult Task

Transitions

Predictors
Throwing things

Kicking and Crying

Biting Shirt

Flooring

Behaviors

Ending Date:

Peer Attention

Attachment 2
Functional Assessment Observation Form
Name:

Starting Date:

Actual
Conseq.
(if nothing
happened in
period, write
initials)

Comments:

5.30pm

6pm

3pm

1
7

3.30pm

4pm

1
7

2
5
8

1
7

2
5
8

2
5
8

1
7

5
8

1
7

2
5
8

2
5
8

2
5
8

4.30pm
5pm

Totals

6
9

3
6
9

3
6
9

3
6
9

3
6
9

3
6
9

6
9

3
6
9

3
6
9

3
6
9

Events: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Date:

Student Directed Functional Assessment Interview

Student Name:
Referring Teacher:
I.

Interviewer:
Date:

Opening. We are meeting today to find ways to change school so that you like it more. This interview will take about 30 minutes. I can help you best if you answer
honestly. You will not be asked anything that might get you in trouble.
Positive questions first -

Assist the student to identify specific behaviors that are resulting in problems in the school or classroom. Making suggestions or paraphrasing statements can help the
student clarify his or her ideas. You should have a list of behaviors nominated by the referring teacher.
II. List the strengths and competencies of the student. What are the things you think you do well? What are the things you think others believe you do well?
(Prompts: Good helper? On time? Good at drawing?)
Behavior
Comments
1.

2.

3.

4.

5.

III. Define the behaviors of concern.* What are the things you do that get you in trouble or are a problem?
(Prompts: Late to class? Talk out in class? Dont get work done? Fighting?)
Behavior
Comments
1.

2.

3.

4.

5.

IV. Complete student schedule. Use the Student Daily Schedule matrix to identify the times and classes in which the student perform problem behavior. Focus the
interview on those that re most likely to result in problem behavior.

Student Directed Functional Assessment Interview, p.2

*You will use the numbers to the left as codes for the identified behaviors as you complete the rest of the interview.
Summary Statement Form
Activity or Event

What Happens Before

Behavior(s)

What Happens After

Complete the diagram following the numbered sequence (Behavior(s) first, then Predictors, etc.). Consider the items below as possible elements for inclusion in the
diagram. Complete a different diagram for each new consequence.
What important events or activities
tend to set up the behavior?
Lack of sleep
Illness
Physical pain
Hunger
Trouble at home
Fight/conflict with peers
Noise/distractions
Activity/class
(seating arrangements)

What appears to set off problem behavior?

Class demands that are:
Too hard
Boring
Unclear
Long
Teacher reprimands
Peer teasing
Peer encouragement
Other
(teacher error correction)

What do the problem behaviors look like?

Late to class
Talk out in class
Disruptions
Inappropriate language
Disrespective behavior
Property destruction
Carrying weapons
Fidget
Not completing work
Steal
Threaten
Vandalism
Other
(looking around and walking)

Student Directed Functional Assessment Interview, p.3

Student Daily Schedule

What do you gain from the

problem behaviors?
Escape or Avoid
Teacher demands
Teacher reprimands/ correction
Peer social contact (teasing)
Tasks (hard, long)
Get Attention
From peers
From teacher/adult
Get Activity or Item
Access to game
Access to toy
Access to food
Access to money
Access to task
Sensory
Physical gratification
Excitement/arousal

Please place an X in each column to show the times and classes where you have difficulty with the behaviors we talked about. If you have a lot of difficulty during a
period, place an X on or near the 6. If you have a little difficulty during the class or hall time, place the X on or near the 1. We can practice on a couple together
before we start.

Subject,
Teacher
Most
Difficult

Before
School

1st
Period

Hall

2nd
Period

Hall

3rd
Period

Hall

4th
Period

Lunch

5th
Period

Hall

6th
Period

Hall

7th
Period

Hall

8th
Period

After
School

None

None

None

None

None

None

None

None

None

6
5

2
Least
Difficult

Table 1
Hypothesis Summary Statement Worksheet

Setting and/or History Event or Activity

Setting and/or History Event or Activity

Setting and/or History Event or Activity

Predictor or Trigger
(Antecedent)

Predictor or Trigger
(Antecedent)

Predictor or Trigger
(Antecedent)

Target Behavior

Maintaining Consequence
(Goal of the Behavior)

Target Behavior

Maintaining Consequence
(Goal of the Behavior)

Target Behavior

Maintaining Consequence
(Goal of the Behavior)

Table 2

Setting and/or History

Event or Activity

Setting and/or History

Event or Activity

Setting and/or History

Event or Activity

Summary Statement of Replacement Behavior Strategies Worksheet

Predictor or Trigger
Replacement Behavior
Desired Behavior Result
(Antecedent)
(takes the place of the
undesired behavior)

Predictor or Trigger
(Antecedent)

Predictor or Trigger
(Antecedent)

Replacement Behavior
(takes the place of the
undesired behavior)

Replacement Behavior
(takes the place of the
undesired behavior)

Desired Behavior Result

Desired Behavior Result

Maintaining consequence

Maintaining consequence

Maintaining consequence

List Strategies that Make the Problem Behavior Irrelevant, Ineffective, & Inefficient

Setting Event
Strategies

Predictor
Strategies

Teaching
Strategies

Consequence
Strategies

Building a Support Plan

Desired Behavior

Setting Events

Predictors

Consequences

Problem Behavior

Replacement Behavior

Prevention
What are ways to change the
context to make the problem
behavior unnecessary?

What are ways to prevent the problem

behavior?

Clarify rules and expected

behavior for whole class

Reminders about behavior

when problem behavior is likely

Written contract with the Students

Student self-manipulator sheet

Provide extra assistance

Modify assignments to match student skills

Maintaining Consequences

Prevention
What can be done to increase
expected behaviors or to teach a
replacement behavior?
Practice expected behavior in class
Self-management program
Other (give prompts for expected behavior)

Intervention

What should happen when

desired or replacement
behavior occurs?
Reward program?
Praise from teacher
Other

Change seating arrangements

Change schedule

Counseling

Other (e.g.; more sleep at home)

Other (e.g.; shorter assignments, more time)

What should happen when a problem behavior

occurs? (What strategies from the previous
page would you use when the behavior occurs?)

Behavior Support Plan

Student Name:

DOB:

Date of Plan:

Teacher(s):

Participant(s):

1.

Target Behavior(s) (state the problem behavior in observable and measurable terms):

2.

Medical History/Medication/Mental Health Diagnosis:

3.

Hypothesis(es) (refer to Table 1):

4.

Current Level of Functioning (state the frequency, intensity, and duration of the behavior based
on baseline data):

5.

Goals & Objectives (include statement of Replacement Behaviors and Desired Behavior Results):

6.

Data Collection Method:

7.

Prevention Activities (refer to Building a Support Plan):

8.

Intervention Activities (refer to Building a Support Plan):

9.

Crisis Management Procedures:

10. Responsibilities:
The following staff will be managing the overall implementation of the plan:

Who notifies other staff of their responsibilities?

List prevention and intervention steps and those individuals responsible for each:
Prevention Step
Responsible Person
Intervention Step
Responsible Person

11.

Required materials, training, and staff to implement plan:

a. Materials:
b. Training:
c. Staff:

12. Follow-up Plans:

Who will meet again and when:

Your signature indicates you are aware of and are in agreement with the implementation of this plan.

Parent/ Guardian/Surrogate

Teacher

Student

Teacher

School Psychologist

Principal

Agency Representative

Agency Representative

Other -Title

Other -Title