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