Form No number No number Behavior Rating Preschool Version

ATTACHMENT AD Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Behavior Rating Inventory of Executive Function- Preschool Version

Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P)

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Behavior Rating Inventory of Executive Function Preschool Version

Scale:

0= Never

1= Sometimes

2= Often

Items Included:

Inhibit

Is unaware of how his/her behavior affects or bothers others

Does not stop laughing at funny things or events when others stop

Has to be more closely supervised than similar playmates

Acts wilder or sillier than others in groups (such as birthday parties, play groups)

Is fidgety, restless, or squirmy

Is impulsive

Does not notice when his/her behavior causes negative reactions

Does not realize that certain actions bother others

Gets out of control more than playmates

Talks or plays too loudly

Acts too wild or out of control

Has trouble putting the brakes on his/her actions even after being asked

Completes tasks or activities too quickly

Gets easily sidetracked during activities

Becomes too silly

Plays carelessly or recklessly in situations where he/she could be hurt (such as playground, swimming pool)

Shift

Becomes upset with new situations

Has trouble adjusting to new people (such as babysitter, teacher, friend, or day care worker)

Is upset by a change in plans or routine (for example, order of daily activities, adding last minute errands to schedule, change in driving route to store)

Takes a long time to feel comfortable in new places or situations (such as visiting distant relatives or new friends)

Is bothered by loud noises, bright lights, or certain smells

Is disturbed by changes in the environment (such as new furniture, things in room moved around, or new clothes)

Has trouble changing activities

Has trouble “joining in” at unfamiliar social events (such as birthday parties, picnics, holiday gatherings)

Resists change of routine, foods, places, etc.

Acts overwhelmed or over stimulated in crowded, busy situations (such as lots of noise, activity, or people)

Emotional Control

Overreacts to small problems

Has explosive, angry outbursts

Becomes upset too easily

Has outbursts for little reason

Mood changes frequently

Small events trigger big reactions

Angry or tearful outbursts are intense but end suddenly

Reacts more strongly to situations than other children

Is easily overwhelmed or over stimulated by typical daily activities

After having a problem, will stay disappointed for a long time

Working Memory

When given two things to do, remember only the first or last

Has trouble carrying out the actions needed to complete tasks (such as trying one puzzle piece at a time, cleaning up to earn reward)

Has trouble concentrating on games, puzzles, or play activities

Repeats the same mistakes over and over even after help is given

Makes silly mistakes on things he/she can do

Has trouble with activities or tasks that have more than one step

Needs help from adults to stay on task

Forgets what he/she is doing in the middle of an activity

Has trouble finishing tasks (such as games, puzzles, pretend play activities)

Cannot stay on the same topic when talking

Has trouble getting started on activities or tasks even after instructed

Does not try as hard as his/her ability on activities

Unable to finish describing an event, person, or story

Is unaware when he/she does well and not well

Has trouble remembering something, even after a brief period of time

Has a short attention span

Is unaware when he/she performs a task right or wrong

Plan/Organize

When instructed to clean up, puts things away in a disorganized, random way

Needs to be told to begin a task even when willing to do it

When sent to get something, forgets what he/she is supposed to get

Cannot find clothes, shoes, toys, or books even when he/she has been given specific instructions

Has trouble following established routines for sleeping, eating, or play activities

Has trouble thinking of a different way to solve a problem or complete an activity when stuck

Leaves messes that others have to clean up even after instruction

Gets caught up in the small details of a task or situation and misses the main idea

Cannot find things in room or play area even when given specific instructions

Does not complete tasks even after given directions