II-10. Relationship with Peers Child has good relations with Child has occasional Child has difficult relations Child has very difficult peers. Any concerns are difficulties relating with at with peers that notably relations with all peers. age appropriate or this least one peer. interferes with his / her Relations with peers information is unknown to education. currently prevents child from me. learning. If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-11. Atypical Behaviors (PAST 30 DAYS) (repetitive head banging, spinning, hand flapping, finger-flicking, rocking, toe walking, staring at lights, repetitive speech) Child has no evidence of History or reports of atypical Clear evidence of atypical Clear evidence of atypical atypical behaviors. Any behaviors from others that behaviors reported by behaviors that are concerns are age have not been observed by caregivers that are observed consistently present and appropriate or this the individual completing this on an ongoing basis. interfere with the infants / information is unknown to form. functioning on a child’s me. regular basis. If the needs / functioning fall within a shaded box, explain why: child’s II-12. Impulsivity / Hyperactivity (PAST 30 DAYS) No evidence of impulsivity / Some problems with Clear evidence of problems Clear evidence of a hyperactivity. Any concerns impulsive, distractible or with impulsive, distractible or dangerous level of impulsive are age appropriate or this hyperactive behavior. hyperactive behavior that is behavior that can place the information is unknown to interfering with the child at risk of physical child’s me. Child is under the age ability to function. harm. of 3. If the needs / functioning fall within a shaded box, explain why: child’s II-13. Oppositional Behaviors (PAST 30 DAYS) No evidence of oppositional History or recent onset (past Clear evidence of Clear evidence of a behaviors. Child displays 6 weeks) of defiance oppositional and / or defiant dangerous level of age appropriate resistance towards authority figures. behaviors which are oppositional behavior towards adults or this interfering with the involving the threat of child’s information is unknown to functioning and/or causing physical harm to others me. emotional harm to others. which interferes with child’s social and emotional development. If the needs / functioning fall within a shaded box, explain why: child’s
II-10. Relationship with Peers Child has good relations with peers. Any concerns are age appropriate or this information is unknown to me. Child has occasional difficulties relating with at least one peer. Child has difficult relations with peers that notably interferes with his / her education. Child has very difficult relations with all peers. Relations with peers currently prevents child from learning. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-11. Atypical Behaviors (PAST 30 DAYS) (repetitive head banging, spinning, hand flapping, finger-flicking, rocking, toe walking, staring at lights, repetitive speech) Child has no evidence of atypical behaviors. Any concerns are age appropriate or this information is unknown to me. History or reports of atypical behaviors from others that have not been observed by the individual completing this form. Clear evidence of atypical behaviors reported by caregivers that are observed on an ongoing basis. Clear evidence of atypical behaviors that are consistently present and interfere with the infants / child’s functioning on a regular basis. If the child’s needs / functioning fall within a shaded box, explain why: II-12. Impulsivity / Hyperactivity (PAST 30 DAYS) No evidence of impulsivity / hyperactivity. Any concerns are age appropriate or this information is unknown to me. Child is under the age of 3. Some problems with impulsive, distractible or hyperactive behavior. Clear evidence of problems with impulsive, distractible or hyperactive behavior that is interfering with the child’s ability to function. Clear evidence of a dangerous level of impulsive behavior that can place the child at risk of physical harm. If the child’s needs / functioning fall within a shaded box, explain why: II-13. Oppositional Behaviors (PAST 30 DAYS) No evidence of oppositional behaviors. Child displays age appropriate resistance towards adults or this information is unknown to me. History or recent onset (past 6 weeks) of defiance towards authority figures. Clear evidence of oppositional and / or defiant behaviors which are interfering with the child’s functioning and/or causing emotional harm to others. Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others which interferes with child’s social and emotional development. If the child’s needs / functioning fall within a shaded box, explain why:
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