YOUR CHILD'S DEVELOPMENT IN COMMUNICATIONS & LEARNING SKILLS
Name of Child:
Date of Birth:
Date of Rating:
Circle the description which best describes your child's behavior on the following scale and bring this form to your next appointment with your child's pediatrician.
1. Your child's disposition is usually:
Cheerful and pleasant.
Sad or despondent
Good natured and sociable.
Irritable or angry.
2. When seeking out a toy, your child:
Points or leads you to it.
Wanders around aimlessly.
Goes and gets it him/herself.
Looks puzzled or disoriented.
3. When family or other children are around, your child:
Enjoys the attention of others
Appears aloof and detached
Show joy and excitement
Seems overly interested in "things" or own self, rather than other people
4. When playing games such as peek-a-boo, funny faces or looking at pictures in a book, your child:
Imitates gestures; is interested in visual play
Appears highly distracted.
Responds happily and enjoys this time
Reacts initially but can only focus for a few seconds with you.
5. How many of these organized emotions - curiosity, assertiveness, responsiveness, pleasure, excitement, separation, fear, worry and caution does your child exhibit?
All of the above
One to three of the above.
Most of the above
None of the above.
1. Does your child:
Have his or her own ideas of fun?
Seem listless or bored most of the time?
Frequently display happiness, but at times also sadness, anger or fright?
Never seems to be happy or to be having fun?
2. When at play, your child:
Spends time on a few favorite toys
Does one thing over and over again
Has many interests but does each activity well
Cannot concentrate on one activity formore than a few seconds
3. When having fun, your child:
Is careful not to hurt self or others.
Frequently breaks things or hurts others.
Plays rough at times, but is also able to slow down to be careful.
Becomes a daredevil, jumps from high places, often getting hurt
4. When wanting something, your child:
Takes your hand and leads you to it.
Becomes quiet and withdrawn.
Goes and gets it on own.
Gets upset but won't say why.
5. If you ask your child to get something, your child:
Looks at you and does what you ask.
Often looks puzzled.
Looks at you but shakes head "no"
Usually ignores you
1. Does your child:
Interested in own body and your body, sometimes showing it off?
Always touching or trying to touch self
Curious about what different parts of the body are called.
Constantly rubbing on or up against things or people?
2. When your child gets angry, your child:
May have a tantrum, but won't hurt others.
Often hits or bites children, adults or animals.
May get frustrated and push, but seems careful not to hurt anyone.
Takes other children's toys without regard for their feelings or rules.
3. When you give your child directions, your child:
Follows them with no problem.
Looks at you knowingly but refuses to obey either by word or gesture.
Doesn't appear to understand eitheryour words or your "body language."
4. When you are talking with your child,your child:
Disagrees with you, but obviously understands what you've said.
Ignores you or doesn't appear tounderstand what you are saying.
Uses words, phrases or sentences logically makes conversation
Repeats words and phrases without purpose.
If you circled any items on the right hand column, your child might have an early communication and learning problem. It is vital to have your child evaluated by a developmental specialist as soon as possible. If all your answers appeared on the left hand column and you still have concerns, for your child's sake, please get an evaluation.