| | Developmental Assessment of Young Children PROFILE/EXAMINER SUMMARY SHEET Seo Equi, lle Cognitive score Child's Mame Male Female Parent/Guardian School/Daycare Respondent's Name Relationship to Child Length of Time Respondent Has Known Child Examiner's Name and Title Year Month Day Date of Testing Date of Birth Age Age in Months Score Equivalent Communiation Sociai-Emotional Physical Development ‘Adaptive Behavior ‘Sum of Standard Scores General Development Quotient BSG3xBR33!BNO Developmental Assessment of Young Children COGNITIVE SUBTEST SCORING FORM Section |, Identifying information Child's Name Male Female__ Parent/Guardian School/Daycare _ Respondent's Name __ Relationship to Child Length of Time Respondent Has Known Child Examiner's Name and Title Year Month = Day Date of Testing Date of Birth Age — ‘Age in Months ‘Section i, Record of Scores Raw Score Age Equivalent ___ Percentile Standard Score Rating Section Ill. Summary of Other Test Results ave Testlame Date Test Scoro——_—Score Equivalent 1 2. 3. 4 5. Section IV. Administration Conditions ‘A. Testing conducted in: fone session _ ‘Administration time —__ ‘two sessions Administration time three or more Administration time _ B. Testing Location . Describe administration (individual, arena, observa- tion, interview, andlor direct) in detail. D. Environmental Characteristics Interfering Noninterfering Noise level Interruptions Distractions Lighting Temperature Other E. Personal or physical characteristics that may affect the child's test results. BEE ____ Section v. Interpretation and Recommendations te 6 ate (© 1998 by PRO-ED, Inc 785 10 G7 06 05 Os ‘Additional copies of this for (98733) may be purchased rom 'PRO-ED, 8700 Shoal Creek Bla, Austin. TX 78737-6097 10097-3202, Fax 600387763, ww-proecinc comInstructions: ; ose items thatthe child can do right artng points are determined bythe childs age. Score 1 fr tl y now benning tod, rad when he ov se was younger but has outgrown Sore O Yor these items that the child cannot do, ion, interview, or direct, Basal and Ceiling: Begin at the suggested starting point. Continue items (by observation, interview, or direct adminis- iid does not receive «sore of ration um 3 of sem receive a score of Be, celing) Ifthe cid des notre f ‘on 3 camecatve tems, administer oy observation, tere, or diet administration the tems in reverse unt a basal ot 3 cores of reached trem | Score # | toro | tem Start Age: Birth 1 moves hand to mouth 2 watches an object moved slowly through his or her ine of sight 3 looks back and forth between 2 objects 4 |_ holes toy placed in hand for 10 to 15 seconds 5 ‘alternatively glances from hand to an object or from one hand to another lr ‘epeats arm or leg movernents to cause an action to occur again (e.g, shakes arm with Fate attached to “wrist kicks leg to’ move mobile attached to crib) z mouths toys 8 exper object ina variety of ways visually turning it around feeling all surfaces, banging and shaking ° pills doth from face 10 imitates familar actions after observing caregiver doing that action (e.g, claps hanes) " finds an object that is partially hidden 2 intentionally drops an object and watches it fal 3 ‘retrieves an object seen hidden under or behind a single barrier “ fouehesadut to have that person start or continue interesting game or acon Start Age: 12 months 15 “rsirsn objet from one hand tothe other pick up second object 16 hands an objec to an adult to have that person repeat i have that person repeat or tart. a desired action (e., start windup toy) 7 imitates seribbling demonstaies understanding of funcional ralationa 18 ane 'sonshis(@, uls person in ear and putes GG GOuEy Fa 9 attempts to start toy if he or she has 1eone seen someon sie make it work (3, a windup toy) Start Age: 24 months 20 demonstrates use of everyday items (e toy tems (6. pretends to erink from a cap) 2 Places @ small object into small container i sine (¢9. a raisin into a small botiey 2 ‘olls wheeled toys Page 2 Totalttem | Score a | fore | tem B |_manages 3 to 4 toys by setting one side when given a new toy x os 2 spontaneously names object Eg ratches an object to is picture — 27_|__|_ seauences related action in pay @ 9, fees dol with bottle, pats on the bac, puts to bed) 28 uses pretend objects in play 2 Lnderstands concept of “one” (¢.., “Give me one block") and “al” (eg, “Give me al the locks") Start Age: 36 months 30 stacks 6 10 7 blocks n matches simple shapes, such a cic, square, triangle 2 responds to “one” and “one more” (eg, “Give me one block “Give me one more") 3 ts graduate sizes inorder (e.g, nests four boxes or stack ings on peg inorder of siz) Fa matches object by colo shape, and size 35 | repeats Finger plays with words and actions 36 counts by rote to 5 7 matches objects that have the same function (e, comb and brush) 38 tells if an object is “heavy” or “light” 2 courts up to 5 objects 7° bul bridge wing 3 bok eat mous dS 4a understands “same” and “eifferent” (eg, “Are these two colors the same or ctferent”) Tors objec by one Gtr (Give cd pictures or Objects acrom’ a Teast two categorie 2G, ape, = color—and state, “Put these into groups that are alike.") a understands concept ofthe number 3 (9, "Give me three blocks.) “4 understands “more,” "les," "same" (@. "Which pile has more?*) Start Age: 48 months a imitates drawing ofa face Joris objets into categories (Give Gd pictures or Objecs—e a, tov, atnal—and Hate, “PLR hese Ino * {groups that are alike.");may not be able to label the categories 47 identifies objects that donot belong in a group (eg. recognizes that dog does not belong with food items) “ knows sequence of reading a book, from lft to right top to bottom Zoris groups of objects n more than one way (Give child pictures or abjecs acromsat Teast two categorie— = 3 clo, shaped ate, “Pt thee nto grope hat are lke Now them anther wan) 50 builds pyramid of 6 blocks; adult models -53- 51 Identifies “fis,* “ls,” *middle* (e.g, "Point to the child who ifs inline.) Page 3 Totaltrem | Score # | 10r0 | item 2 retels story from picture book wit reasonable accuracy 3 | Identifies the larger of two number (e9., “Which is moe, 2 oF 37") | se draws tik fue == ‘Sec ae carci ea rel and ae eee Ting a nog a, “He WO 6 copies own name; may use lage, irregular eters 37 Predicts what may happen next (eg, child predicts what wil happen next in a stor) 8 Points to “half* or “whole” objects 58 names mast letters ° puts three pictures in a sequence to tell a story 6 matches the number of items ina set tothe correct numeral 6 understands concept of "zero" (eg, “Which cup has zero cubes?") 8 draws person with 6 recognizable parts « Prints frst name legibly without a model 6 draws identifiable objects without a model a counts up to 20 objects 7 ‘ells month and day of birth 6 arranges numbered ties oF card in proper sequence ® tells own street name and town 70 names the days of the week in order n States preceding and following days of the week (e.g, “What day comes after Sunday?) n Points to coins when named (ie, penny, nickel, dime, quarter) a States preceding and following numbers (eg, “What number comes before 197°) 4 writs first and last name from memory 8 Calculates single-digit addition and subtraction problems 6 counts by rote from 1 to 100 7 writes numerals 1 to 19 without model 78 ‘ads 10 printed words Page 4 Total Page 3 Total Page 2 Total ‘Total Subtest Raw Score (Page 2+ 3+ 4)DNC Developmental Assessment Section |. Identifying information Child's Name Male __ Female _ Parent/Guardian School/Daycare Respondent's Name __ of Relationship to Chl gth of Tine Respondent Has Known Child Young Children crenrs Hane nde Year Month Day SOCIAL-EMOTIONAL SUBTEST | acorns — SCORING FORM Age _— Age in Months i Section Il. Record of Scores Section Ill. Summary of Other Test Results one Terhine oases Sorat Raw Score ‘Age Equivalent _ Percentile Standard Score _ Rating Section IV. Administration Conditions A. Testing conducted in: ‘Administration time __ one session _ ‘two sessions ___Administration time three or more Administration time 2, Testing Location . Describe administration (individual, arena, observa- tion, interview, and/or direct) in detail. . Environmental Characteristics Interfering Noninterfering Noise level Interruptions Distractions Lighting Temperature Other E, Personal or physical characteristics that may affect the child's test results. "Section V. Interpretation and Recommendations {© 1988 by PRO-ED, Inc. 78/3 10 07 05 05 08 03 ‘Adsitional copies ofthis form (#8736) may be purchased from 'RO-ED, 8700 Shoal Creek Bid. Austin, TX 78757-6887 ‘8008573202, Fox 800/397-7633, vwproedinc comee Le ‘Section Vi. Social-Emotional Subtest 1 those items that the child can do right ‘ for Instructions: Starting points are determined by the child's age. Score 7 att ‘now, is beginning to do, or did when he or she was younger but has outgrown. Score 0 for those items that the child cannot do. Basal and Ceiling: Begin at the suggested starting point. Continue to administer items (by observation, ierview, oF direct administration) until 3 of 5 items receive a score of 0 (ie. a ceiling). the child does not receive a score of 1 on 3 consecutive items, administer (by observation, interview, or imine tration) the items in reverse until a basal of 3 scores of 1 is reached. tem | score # | toro | item Start Age: Birth 1 stops crying when talked to, picked up, or comforted 2 looks at adult face for several seconds 3 |_ interacts by smiling and cooing z ‘ecagnizes familar faces and objects (eg, parent, bot) reais By waving arms and legs Or squealing with excitement 5 ‘expresses feelings such as anger, tiredness, excitement, or hunger 6 comforts self (i, quits fussing by himself or herself) S Trnows the diference between caregivers and sirangers (eg, smiles at loved ones, stares, quiets, or refuses ‘0 smile with stranger) 8 plays alone for short periods (ie, 5 to 10 seconds) ° when someone cals the chle's name, he or she looks atthe person and vocalizes, Start Age: 12 months 10 ‘extends arms to familar persons 1 responds differently to children and adults 2 imitates facial expressions, actions, and sounds B recognizes self in the mirror 4 plays simple games (e9.. peek-a-boo, pat-a-cake) 15 shows anxiety at separation from caregiver (eg, refusal to explore the environment, crying, searching) 16 expresses affection (e.g, hugging, patting, special looks, resting head) v7 “shows special dependence on primary caregiver (e.g, wants only that person to feed, dress, change, and comfort him or her) 18 laughs at incongruous events (e.., wearing @ bow as a hat) 19 purposefully refuses to comply with requests (e.g, says “no,” shaking head) Start Age: 24 months 20 beginning to function on his or her own; may periodically return to the parent for reassurance and attention 2 brings toys to share with caregiver 2 has difficulty sharing with other children Page 2 Totaltem | Score # | 10r0 | item 2 has temper tantrums when frustrated 2 insists on trying to do many things without help (e.g, eating with spoon, putting on a coat) 25 shown independence (9. runs ahead of parent outdoors, refuses to have hand held) 26 Plays well for brief time in groups of two or three children 2 _attempts to comfort others in distress (@9,convors a child who is hurt or distressed) 28 enjoys simple make believe says “please” and “thank you"; may need to be reminded Start Age: 36 months 30 separates trom parent in fama surroundings without cying x Sings familiar songs with adult 32 ‘spontaneously greets familiar person by ugging 7 2 Willy takes urs » spends most group tne in solar activity, watching other chien 35 laughs at combinations of incongruous events and we of words (e., milking a dog) 36 asks for assistance when having difficulty. a 7 shows rie in accomplishments 38 ‘ates whether he or he isa boy ora gi » lays group games with simple rules Start Age: 48 months 40 plays dress-up a shows off by repeating rhymes, songs. or dances for others 42 talks about ovn feelings 3 changes from one activity to another when required by teacher or parent “ selects own friends 4s ‘waits for turn when playing in group games (e.g, red rover, steal the bacon) “6 iknows and follows clasroom rules a ‘ins attention from peers in appropriate ways “6 “understands rules of fir play 9 likes competitive games 50 has bestfriend of same sex 31 ‘explains rules of a game to others Page 3 Totaltem | Score © [toro | tem 2 ks before sing anothers Belongings 3 Accepts mild, rend teasing without becoming too agitated - sa works alone at chore for 2010 20 minutes s ‘xpress anger with nonaggressive words rather than with physi action | tes goa for hime or herself and carries out acy 7 accepts valid criticism without crying, pouting, o refusing to continue ss newer the phone, remembers a simple mesage, and delivers it othe corec person Page 4 Total - Page 3 Total Page 2 Total ‘Total Subtest Raw Score (Page 2 +344)DAYC Developmental Assessment of Young Children Section |. Identifying information Child's Name Male Female Parent/Guardian - School/Daycare Respondent's Name Relationship to Child Length of Time Respondent Has Known Child Examiner's Name and Title Year Month Day PHYSICAL DEVELOPMENT =| vcore, —_ SUBTEST SCORING FORM | age = = Age in Months i Secon i: Record of Scores Section il Summary of Other Test Results ome ow Score Twttane ose ete Se eutet Age Equivalent = Percentile Standard Sore 7 Rating A Testing conducted in D. Environmental Characteristics one session Adminstration time Interfering Noninterfering two sessions Noi level tiree or more Adminstration time Inweruptions ie Distractions C. Describe administration (individual, arena, observa- comes tion, interview, and/or direct) in detail. ‘Temperature other E. Personal or physical characteristics that may affect, ‘the child's test results. Section V. Interpretation and Recommendations (© 1998 by PROD, In. 6789 10 O7 06 05 % a3 Adtional copes ofthis form (18735) may be purchased from 'PRO-ED, 8700 Shoal Creek Boulevard, Austin TX 18751-6897, ‘S145 13245, Fax 51251-8568‘Section Vi. Physical Development Subtest E Starting points are determined by the chile’ age. Score 1 for those items that the child can do ‘now, is beginning to do, or did when he or she was younger but has outgrown. Score 0 for those items that the child cannot do. Begin at the suggested starting point. Continue to administer items toy observation, interview, of direct administration) until 3 of 5 items receive a score of 0 (i.e., a ceiling). If the child does not receive a score of 1 on 3 consecutive items, administer (by observation, interview, or direct adminis. tration) the items in reverse until a basal of 3 scores of 1 is reached. tem 1 ‘extends both legs when lying on stomach 2 closes fingers when light pressure is applied on open pal 3 kicks reciprocally (e.. one lg, then the other) when lying on back 4 |_ rots rom side to back [os when held upright, will bar some weight on legs 6 when lying on stomach, lifts head with support of forearms 7 when pulled to sitting, holds head inline with body (ie, no head lag) |e reaches for, but may net actually touch, an abject 8 |_ holds objects between fingers and palm of hand ; 10 brings hands together when ving on back " sits with support 2 rolls from back to sie 3 holds a small object in each hand at one time 14 reaches for and grasps an object, 5 ‘opens hand in anticipation of contact 6 rolls rom back to stomach 7 when on stomach, extends arms and legs off mattress 18 when on stomach, reaches with one hand while bearing weight on other forearm 19 When on back, brings feet to mouth 20 twansfersan object from one hand to the other 2 holds an object between fingers and opposed thumb and palm of hand 2 ‘bounces in standing when supported by adult 2 Sits alone for 30 seconds while playing with toy 7 pulls self to sitting while grasping adult fingers 25 moves body forward to get an object 26 ses raking oF scooping motion to pick up a small object Page 2 TotaItem ses arms to move forward on belly Sits alone steadi initially with wide base of support Stands slone by holding on to something 30 ‘rom sitting positon, turns 90 degrees to retrieve an object 3” walks 3 oF more steps with assistance 2 Pulls self to standing position 33 when falling forward, extends arms to catch self 34 bangs 2 objects together ‘Start Age: 12 months 5 "moves from back to sitting without stance 36 ieks up a smal object using thumb and forefinger 7 walks sideways while holding on to furniture 38 $e00%s toward an object while maintaining sting potion 3» ‘moves from standing to siting in controlled feshion a pokes with index finger a walks with one hand held 4a Pushes or pulls toys while walking - “a walks without holding on, may fal easily “4 Stars and stops in waking Start Age: 24 months when standing, stoops, then stands again without losing balance 45 46 holds erayon, penl, and 0 on, in fist with thumb up a7 creeps backward down steps a squats during play “3 runs (may be a hurried walk) 30 es spontaneously 31 throws a ball verhand with relative accuracy 2 walks up and down stars pacing both feet on each step, without assistance 3 holds crayon with fingers, hand on top, forearm turned so thumb is directed downward 4 uses hand to hold paper in place when drawing Start Age: 36 months 55 walks backward 56 ses one hand consistently in most activities 7 Walks up stairs, alternating feet, in adult fashion while holding on Page 3 TotalScore Toro tem climbs low play equipment imitates circular, vertical, and horizontal strokes holds pencil between first 2 fingers and thumb (ve, adult grasp) ses vertical, horizontal, and circular motions when drawing walks swinging arms and legs freely in cross pattern similar to adult walk pattern catches ball from straight arm position, trapping ball against chest item « 5 9 © a z= e A makes several snips on paper using scissors Start Age: 48 months a hops on 1 foot few steps o tums somersaut 7 walks forward heel to toe without losing balance =e ee copies 8 rom @ balances on one foot for Sto 10 seconds without support 70 jumps over objects up to 6 inches high lands with both feet together 7” {ts with cor following a ine rR copies a square 7 _ B copies a rectangle ve 7 gallops leading with one foot and tansering weight smoothly and evenly 75 swings on swing maintaining own momentum; Uses legs to propel %6 bounces and catches tennis ball or any bal of similar size) 7 colors within ines 7 cuts out simple geometric shapes with sciors 79 skips, alternating feet, maintaining balance ~ * ‘apidy touches each finger to thumb a1 hops in straight line on one foot without losing balance 2 places paper clips on paper a tins 3 consecutive somersauls “ pases o glues neatly 5 Copies a ciamond with straight, connected ines % rop5 a ball and kicks it forward befor it hits the floor 7 {ums rope by self Page 4 Total Page 3 Total Page 2 Total “Total Subtest Raw Score (Page 2+ 3-+ 4)Child’s Name Male Female Parent/Guardian School/Daycare Respondent's Name __ Relationship to Child Length of Time Respondent Has Known Child Examiner's Name and Title Developmental Assessment of Young Children Date of Testing Date of Birth Age ‘Age in Months COMMUNICATION SUBTEST SCORING FORM Raw Score ‘Age Equivalent Percentile Standard Score ‘A. Testing conducted in: D. Environmental Characteristics one session Administration time Interfering Noninterfering ‘two sessions ____ Administration time _ Noise level ~ three or more Administration time Interruptions B. Testing Location Distractions Lighting . Describe administration (individual, arena, observa- tion, interview, and/or direct) in detail, Temperature Other E. Personal or physical characteristics that may affect the child's test results, (© 1986 by PRO-ED, ‘Additional copies ofthis form (8738) may be purchased fom 6789 10 OF 605 'PRO-ED, 8700 shoal Creek Boulevard, Aun Tx 1757-6857 SYRMS1 3246, Fax 51214518540mined by the child's age. Score 1 for those items that the child can do right Instructions: Starting poy tooo ad when he of she was younger But has outgrown Score O for those items thatthe child cannot do basal and Ceiling: Begin atthe suggested starting point. Continue to administer items (by observation, interview, or sea etiminatation) unt 3 of 5 tems receive a score of 0 (ie. a ceiling) If the child does not sees tore of fon 3 consecutive items, administer (by observation, interview, or direct admin tration) the items in reverse until a basal of 3 scores off is reached. Trem ] Score |] | ford | tem Star Age: Birth 1 reac to loud noe by Blinking, moving arms or legs, o stoping movement 2 Turns head foward voice when someone speaks to him or her 3 makes nies other than eying (9, «009, guating) a aries at pein whe staking oF gertiing 5 produces vocal gual in response to soathing voice € has ferent ries for pin, hunger and comfort, 7 produces single vowel sounds (ah, eh, uh) 8 laughs out oud ° produces vome consonants uch ask or hd 0 tur and oaks toward nose 1 produces two-plable, one-consonant sound sings repetively(e, aba) 2 | ops activity when name i clled - 3 produces consonants sucha of if 4 responds with propriate gestures to “up” “bye-bye,” o ther routines Start Age: 12 months 8 briefly op activity when oi “0° 16 produces string of consonants and wordike double consonant (e9., baba, da-da) 7 ser inflection patterns when vocalizing (eras pitch if asking @ question) 8 moves body to musi ® $275 “Mama” or "Bada" discsiminately 2 Tecate falar objects on equest (9, “Whereis your blanket?™) 2 follows simple spoken commands, “Give Mory the ep") 2 when aske, wil point to familiar pesos animas an toys 2 responds to “where” questions (eg, "Where ithe bal") Page 2 Totala mrs Item * follows directions about pacing one tem “in® oF "on* another B has a word oF sound for drink - : “ena 7 neg nts | carries out 2-8 rections e: a [pam esteo eet - Says one word that conveys entire thought mea; *cookie™ 7 e Paes Dee ‘thought; meaning depends on context (eg, “cookie” may mean “wants ‘tart Age: 24 months Uses at least 5 words (vocabulary is similar to age peers) 7 identifies familiar characters or items seen on TV (eg, Big Bird) a refuses by saying “no” 2 indicates “yes” or "no" (or appropriate head movement) in response to question® aa knows names of playmates understands possesives ("mine,” “yours,” and “his e.g, "Whereis your ball?" “Whose bali this?") % produces some Z-word phrases (eg, more cookie) 7 points to 6 body parts when asked = points to 15 or more pictures of common objects when they are named 39 Uses 10 to 15 words spontaneously (vocabulary is similar to age peers) 0 whispers a names 8 or more pictures of familiar objects a points to common objects described by their use (e.g, "Show me what you eat with”) “a knows “big” and “little* (e.g, “Throw the big ball to me.) “4 carries out 2step unrelated commands (e.., “Put the bal on the shelf and then clap your hands") Start Age: 36 months 6 {follows directions about placing one item “beside” or “under” another 6 ‘uses at least 50 different words in spontaneous speech (vocabulary is similar to age peers) a ses 3-word sentences 6 demonstrates understanding of passive sentences (e.g, “Show me the train was pushed by the ca.”) cd describes what he or she is doing (e.g. responds to "What are you doing?) Start Age: 48 months 50 ‘asks “what” or “where” questions (e.g. "Where is my ball?") 51 uses some plurals Page 3 Totaltem Score | toro | tem 2 tells whether two words thyme — 3 responds to "who" and "whose" questions 9, “Who hat ona red shirt today?") Z [ ve full name on request, "What is your name?*) 38 asks questions beginning with “When,” "Who," “Why,” "How many” (e.g. “When will we eat?") se understands “infront of* and “behind” ("What is behind the sreen?®) 7 changes speech depending on istener (eg, talks diferently to babies than to adults) 38 "uses 300 to 1,000 words in spontaneous speech (vocabulary i similar to age peers) 9 uses contractions (eg, “FL ean") @ Ses Fe omar tat are notre eg, “Pe al onthe abe, athe do aT er completes simple verbl analogies 9, “Daddy is 3 man; Mommy ia e ues comparative (9, “big “bigger” “biggest”; “Which one i bigge™") e | efines 2 simple words (e.g, “What is 2 cat?") «| rakes statements about cause and effet eg, “i wort rol because the wheel i of") | 6 | answers question, “What happens i...“ (9, "you drop an €9a”) % defines 5 simple word (ea, "What ia block?) 7 ‘els familiar stores without picture cues « answers comprehension questions when tld a short story oe defines 10 simple words (e.g. “What isa_____?") 70 understands seasons of the year and what you do in each (e.g, “What do we do in the summer?") n es irregular plurals (9, footeet) 2 responds to questions involving time concepts (eg, “When do we eat lunch?) 7 ates saris ("Wow are shoe and Books aKa?) and aeTence eg, How ae II and water different") between objects 74 responds to “Tellme the opposite of 7s ‘tells simple jokes 6 identifies eft and right on own body “Raise your righthand”) 7 ses iepularcomparatives correctly (€., “good,” “better “bes 78 es “yesterday" and “tomorrow” meaningfully Page 4 Total age 3 Total Page 2 Total Total Subtest Raw Score Page 2+ 3+ 4