Neuropsychological Assessment Behavioral Observations Step 1 of 2 50% Patient Name* First Last Examiner Name*Dr. Terry-Ann Adjmul-HislopOtherIf other, provide name below First Last Date of testing* MM slash DD slash YYYY Were there multiple days of testing?* Yes No Second day of testing (if multiple days) MM slash DD slash YYYY Number of hours tested*Please enter a number from 1 to 12.Number of hours scored*Please enter a number from 1 to 12.ArrivalDid the family arrive on time?* Yes No Who accompanied the patient?* Alone Mother Father Grandmother Grandfather Other family member Separation* Easily Normal Difficult AppearanceDress* Casual Formal Disheveled Inappropriate Grooming* Neat Appropriate Unkempt (e.g., hair not combed, spills) Assistive DevicesCheck all that apply* Glasses Contacts Hearing aid AAC (device) None HandednessSelect below:* Right Left Ambidextrous Hearing & VisionVisual acuity* Adequate Poor Did child hold materials close to face to see them?* Yes No Hearing: Was examiner required to use a loud voice?* Yes No Motor SkillsWere the child's motor skills/gait perceptually judged as typical?* Yes No If no, provide more details below.Was the child's ambulation perceptually judged as typical?* Yes No If no, provide more details below.Did the child present with any unusual mannerisms?* Yes No If yes, provide more details below.Level of ArousalSelect below* Alert Lethargic Non-responsive Interpersonal StyleSelect below* Easily engaged Guarded Select below* Active Passive Select below* Friendly Hostile Select below* Appropriate Disinhibited Provide examples of interpersonal style below*Attitude Towards TestingSelect below* Relaxed (confident) Tense (lacks confidence) Distrust (threatened) Irritable Fears failure Apathy Cooperation LevelSelect below* Full (cooperative - interested/involved) Less than full (Uncooperative - uninvolved or resistant) Fluctuating Provide examples of cooperation level below*Effort LevelPut forth good effort:* Consistent Inconsistent (variable) Minimal Improves as assessment progresses Provide examples of effort level below*Work HabitsResponse time* Slow Medium Fast Movements* Neat Clumsy Careless Persistence* Persistent Gives up easily Planning/thought process* Trial and error Planned and deliberate Impulsive?* Yes No Perseverative?* Yes No Easily distracted?* Yes No Lost set?* Yes No Provide examples of work habits below*Self-MonitoringDoes child self-monitor work?* Yes No Is child aware of failure?* Yes No Reaction to failure* Insightful Disinterest Frustration Negative self-talk Inappropriate Provide examples of self-monitoring below*EncouragementResponse to encouragement* No change Increased Decreased Needs frequent encouragement DirectionsAble to understand directions?* Yes Expl No Able to remember?* Yes No Able to follow directions?* Yes No Requires prompts/redirection?* Yes No If yes, explain frequency of prompts/redirection Provide examples of following directions below*Expressive LanguageSpontaneous* Yes No Fluency* Fluent Halting Non-fluent Volume* Loud Soft Pace* Fast Slow Articulation* Articulate Reduced articulation Other features: check all that apply* Dysnomic Paraphasic Aprosodic Perseverative Tangential Poor initiation None of the above Thought ProcessCheck all that apply* Clear Topic-focused Concrete Tangential Circumstantial Irrelevant Bizarre Confabulates Delusional Rambling AffectCheck all that apply* Appropriate/full Constricted Restricted Labile Blunt Flat MoodCheck all that apply* Euthymic Euphoric Depressed Dysphoric Anxious Irritable Angry Apathetic Tearful Supplemental FormsWas the evaluation assessing signs of autism?* Yes No Was the evaluation assessing signs of ADHD?* Yes No Autism SupplementSpeech abnormalities associated with autism?* Yes No If yes, check all areas that are atypical Intonation Volume Rhythm Rate Describe examples of each of these areas belowEcholalia?* Yes No If yes, give examples belowOffers information?* Yes No If yes, offers information: Spontaneously Occasionally Rarely Gestures?* Yes No If yes, check all gestures that apply Descriptive: pantomime actions used when trying to describe or represent an action, object, or event for communicative purposes (e.g., casting arm out to show a person fishing) Conventional: have a standard social meaning within a particular culture (e.g., shaking head to mean no, waving goodbye) Instrumental: intended to achieve a goal (e.g., beckoning another person to come nearer, holding out hands to beg) Informational: used to convey specific information (e.g., holding up two fingers to mean two) Emotional: used to express emotion (e.g., shaking fist to show anger, putting arms up and saying "Hooray!") Emphatic: hand movements (beats) that are integrated into speech to provide emphasis Pointing?* Yes No Unusual eye contact?* Yes No If yes, give examples belowFacial expressions* Directs a range of facial expressions Limited direction of facial expressions Does not direct appropriate facial expressions Provide examples below*Responsive social smile?* Yes No Unusual sensory interest(s)?* Yes No Provide examples below*Hand and finger or other complex mannerisms?* Yes No Provide examples below*Excessive interest or references to unusual or highly specific topics/objects/repetitive behaviors?* Yes No Provide examples below*Compulsions or rituals?* Yes No Provide examples below*Overactivity/agitation?* Yes No Provide examples below*Tantrums, aggressions, negative or disruptive behavior?* Yes No Provide examples below*Refusal to complete partial/entire tests?* Yes No Provide examples below*Overall quality of rapport* Comfortable Comfortable but not sustained One-sided or unusual Markedly uncomfortable ADHD SupplementActivity level* Hyperactive/excessively restless Well-modulated Hypoactive/slow moving Activity level: check all that apply* Fidget and squirm in seat Talk nonstop Move around Touching or playing with anything in sight Constantly in motion Difficulty with attention/distractibility?* Yes No Attention/distractibility: check all that apply* Cannot attend or maintain focus Inability to sustain focus over time Easily distracted Missed details Careless mistakes Forgot items Bored with task Easily confused with tasks or instructions Provide examples of attention/distractibility below*Level of impulsivity* Low Moderate High Intervention needed to slow child down and process test stimuli before a response?* Yes No If yes, provide examples below*Examinee interrupts explanation directions?* Yes No If yes, provide examples below*Frustration tolerance* Low Moderate High Frustration tolerance: check all that apply* Child's sensitivity to known deficits Reaction to being forced to perform in difficult areas Aggressiveness Poor emotional regulation Excessive need to be successful None of the above Frustration tolerance: provide examples below*Mood: predominately negative mood with tantrums?* Yes No Mood: crying?* Yes No Mood: check all that apply* Temperamental issues Other behavioral problems Oppositionality Mood: provide examples below*Test refusal: declines to respond to some items?* Yes No If yes, provide examples below*Test refusal: refuses more difficult items?* Yes No If yes, provide examples below*Test refusal: stops responding to all items?* Yes No If yes, provide examples below*Additional NotesSignature*Date* MM slash DD slash YYYY
