Read each item carefully. Score each item for the previous month only
Problem Behaviors - Directed to others (Include behavior that is directed to other persons).
Do not include behavior directed towards self or behavior primarily directed at property or other behaviors. Rate risk as it is currently perceived.
4: No behavioral problems directed to others during the period rated.
3: Mild Irritable: Quarrelsome, occasional verbal abuse.
2: Moderate: Frequent verbal abuse, verbal threats, occasional aggressive gestures, pushing or pestering (harassment).
1: Severe Risk: Occurrence of physical aggression resulting in injury to others requiring simple first-aid.
0: Very severe risk: Occurrence of physical aggression producing injury to others serious enough to need treatment.
Behavioral problems – directed at self (self-injury)
Include all forms of self-injurious behavior. Do not include behavior directed towards others
4: No self-injurious behavior during the period rated.
3: Mild: Occasional self-injurious behavior (e.g. face tapping)
2: Moderate: Frequent self-injurious behavior not resulting in tissue damage e.g. redness, soreness, wrist-scratching.
1: Severe: Risk or occurrence of self-injurious behavior resulting in reversible tissue damage (e.g. cuts, bruises, hair loss).
0: Very Severe: Risk or occurrence of self-injurious behavior resulting in irreversible tissue damage (e.g. permanent scarring)
Other behavioral problems. This is a global rating to include behavioral problems not described above
Do not include behavior directed towards others, or self-injurious behavior. Include: a) Behavior destructive to property b) Problems with personal behaviors (e.g. spitting, eating trash, self-induced vomiting, continuous eating or drinking, hoarding trash, inappropriate sexual behavior) c) Rocking, stereotyped and ritualistic behavior d) Anxiety, phobias, obsessive, compulsive behavior.
4: No behavioral problem(s) during the period rated.
3: Mild: Occasional behavioral problem(s) that are out of the ordinary or socially unacceptable.
2 Moderate: Behavior(s) sufficiently frequent and severe to disrupt and impact own or other’s functioning.
1: Severe: Behavior(s) sufficiently frequent and severe to significantly disrupt and impact own or other’s functioning
0: Very Severe: Severe behavior(s) producing major disruption of and impact on functioning supervision or physical intervention
Attention and concentration
Include problems that may arise from underactivity, overactive behavior, restlessness, fidgeting or inattention etc.
4: Can sustain attention and concentration in activities/programs independently during the period rated
3: Can sustain attention and concentration in activities/programs with occasional prompting and supervision.
2: Can sustain attention and concentration in activities/programs with regular prompting and supervision.
1: Can sustain attention and concentration in activities/programs briefly with constant prompting and supervision.
0: Cannot participate in activities and programs even with constant prompting and supervision.
Include all types of responses to verbal, gestural and signed communication, supported if necessary with environmental cues.
4: Able to understand first language (mother tongue) about personal needs and experience during the period rated.
3: Able to understand groups of words/short phrases/signed communication about most needs.
2: Able to understand some signs, gestures and single words about basic needs and simple commands (food, drink, come, go, sit, etc.).
1: Able to acknowledge and recognize attempts at communication with little specific understanding (pattern of response is not determined by nature of communication).
0: No apparent understanding or response to communication.
Communication (problems with expression)
Include all attempts to make needs known and communicate with others (words, gestures, signs). Rate behavior under Scales 1, 2 and 3.
4: Able to express needs and experience during the period rated.
3: Able to express needs to familiar people.
2: Able to express basic needs only (food, drink, toilet, etc.).
1: Able to express presence of needs, but cannot specify (e.g. cries or screams when hungry, thirsty or uncomfortable).
0: Unable to express need or presence of need.
Problems associated with mood changes
Include problems associated with low mood, elated mood, mixed moods and mood swings (alternating between unhappiness, weeping and withdrawal on one hand and excitability and irritability on the other).
4: No evidence of mood change during period rated.
3: Mood present but with little impact
2: Mood change producing significant impact on self or others (e.g. weeping spells, decrease in skills, withdrawal and loss of interest).
1: Mood change producing major impact on self or others (e.g. severe lack of interest and unresponsiveness, severe agitation and restlessness).
0: Depression, sadness or mood swings producing severe impact on self and others (e.g. agitation too severe to allow time to be engaged in meaningful activity).
Activities of daily living at home
Include skills such as household chores and/or involvement in activities household tasks.
4: Performs or contributes towards activities of daily living at home.
3: Some limitations in performing or contributing towards household tasks.
2: Significant limitations in performing or contributing towards household tasks
1: Major limitations in performing or contributing towards household tasks
0: Unable to make a contribution to daily living activities
Problems with relationships
Include effects of problems with relationships with family, friends, staff and therapy providers etc. Measure what is occurring regardless of cause, for example, somebody who is known to have good relationships may still display problems.
4: Positive and frequent contact with family or friend and staff etc.
3: Generally positive relationships, but some strain or limitations in contact.
2: Some positive relationships, but current disruptions of contact or worsening of relationships.
1: Difficulties in relationships with risk of breakdown or infrequent contact.
0: Significant relationships broken down with no current contact.
Level of self-care
Rate the overall level of functioning in activities of self-care such as eating, washing, dressing and toileting. Rate the current level achieved with the existing support. Rate appearance not motivation.
4: Appearance and personal hygiene maintained.
3: Some deficits in personal appearance, personal hygiene or attention to health
2: Significant deficits in personal appearance, personal hygiene or attention to health causing a problem with social acceptability, but not sufficient to pose a health risk (e.g. body odor, unkempt hair or nails).
1: Major deficits in personal appearance, personal hygiene or attention to health posing a health risk (e.g. skin rashes, gum infection, not fully dressed).
0: Gross self-neglect with severe difficulties relating to appearance, hygiene and diet posing a major health risk
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