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* Date Format: MM slash DD slash YYYY Were there multiple days of testing?*YesNoSecond day of testing (if multiple days) Date Format: 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?*YesNoWho accompanied the patient?* Alone Mother Father Grandmother Grandfather Other family member Separation*EasilyNormalDifficultAppearanceDress*CasualFormalDisheveledInappropriateGrooming*NeatAppropriateUnkempt (e.g., hair not combed, spills)Assistive DevicesCheck all that apply* Glasses Contacts Hearing aid AAC (device) None HandednessSelect below:*RightLeftAmbidextrousHearing & VisionVisual acuity*AdequatePoorDid child hold materials close to face to see them?*YesNoHearing: Was examiner required to use a loud voice?*YesNoMotor SkillsWere the child's motor skills/gait perceptually judged as typical?*YesNoIf no, provide more details below.Was the child's ambulation perceptually judged as typical?*YesNoIf no, provide more details below.Did the child present with any unusual mannerisms?*YesNoIf yes, provide more details below.Level of ArousalSelect below*AlertLethargicNon-responsiveInterpersonal StyleSelect below*Easily engagedGuardedSelect below*ActivePassiveSelect below*FriendlyHostileSelect below*AppropriateDisinhibitedProvide examples of interpersonal style below*Attitude Towards TestingSelect below*Relaxed (confident)Tense (lacks confidence)Distrust (threatened)IrritableFears failureApathyCooperation LevelSelect below*Full (cooperative - interested/involved)Less than full (Uncooperative - uninvolved or resistant)FluctuatingProvide examples of cooperation level below*Effort LevelPut forth good effort:*ConsistentInconsistent (variable)MinimalImproves as assessment progressesProvide examples of effort level below*Work HabitsResponse time*SlowMediumFastMovements*NeatClumsyCarelessPersistence*PersistentGives up easilyPlanning/thought process*Trial and errorPlanned and deliberateImpulsive?*YesNoPerseverative?*YesNoEasily distracted?*YesNoLost set?*YesNoProvide examples of work habits below*Self-MonitoringDoes child self-monitor work?*YesNoIs child aware of failure?*YesNoReaction to failure*InsightfulDisinterestFrustrationNegative self-talkInappropriateProvide examples of self-monitoring below*EncouragementResponse to encouragement*No changeIncreasedDecreasedNeeds frequent encouragementDirectionsAble to understand directions?*YesExplNoAble to remember?*YesNoAble to follow directions?*YesNoRequires prompts/redirection?*YesNoIf yes, explain frequency of prompts/redirectionProvide examples of following directions below*Expressive LanguageSpontaneous*YesNoFluency*FluentHaltingNon-fluentVolume*LoudSoftPace*FastSlowArticulation*ArticulateReduced articulationOther 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?*YesNoWas the evaluation assessing signs of ADHD?*YesNoAutism SupplementSpeech abnormalities associated with autism?*YesNoIf yes, check all areas that are atypical Intonation Volume Rhythm Rate Describe examples of each of these areas belowEcholalia?*YesNoIf yes, give examples belowOffers information?*YesNoIf yes, offers information:SpontaneouslyOccasionallyRarelyGestures?*YesNoIf 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?*YesNoUnusual eye contact?*YesNoIf yes, give examples belowFacial expressions*Directs a range of facial expressionsLimited direction of facial expressionsDoes not direct appropriate facial expressionsProvide examples below*Responsive social smile?*YesNoUnusual sensory interest(s)?*YesNoProvide examples below*Hand and finger or other complex mannerisms?*YesNoProvide examples below*Excessive interest or references to unusual or highly specific topics/objects/repetitive behaviors?*YesNoProvide examples below*Compulsions or rituals?*YesNoProvide examples below*Overactivity/agitation?*YesNoProvide examples below*Tantrums, aggressions, negative or disruptive behavior?*YesNoProvide examples below*Refusal to complete partial/entire tests?*YesNoProvide examples below*Overall quality of rapport*ComfortableComfortable but not sustainedOne-sided or unusualMarkedly uncomfortableADHD SupplementActivity level*Hyperactive/excessively restlessWell-modulatedHypoactive/slow movingActivity 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?*YesNoAttention/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*LowModerateHighIntervention needed to slow child down and process test stimuli before a response?*YesNoIf yes, provide examples below*Examinee interrupts explanation directions?*YesNoIf yes, provide examples below*Frustration tolerance*LowModerateHighFrustration 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?*YesNoMood: crying?*YesNoMood: check all that apply* Temperamental issues Other behavioral problems Oppositionality Mood: provide examples below*Test refusal: declines to respond to some items?*YesNoIf yes, provide examples below*Test refusal: refuses more difficult items?*YesNoIf yes, provide examples below*Test refusal: stops responding to all items?*YesNoIf yes, provide examples below*Additional NotesSignature*Date* Date Format: MM slash DD slash YYYY