Sensory, Attachment and Survival Behaviour Questionnaire
Compiled by Éadaoin Bhreathnach MSc.
Child’s Name: _________________________________
DOB: _______________ Age: ___________________
Address: __________________________________________________________ Tel: ___________________
GP:__________________________________________
School/Nursery: ______________________________
Completed By: _______________________ Relationship to Child: __________________ Date: ______________
Instructions
The purpose of this questionnaire is to help us to gain a more detailed picture of your child in terms of their
sensory, attachment and developmental needs.
When using the tick system, please tick the description which best describes the frequency with which your child displays the
following behaviours. Please answer all of the questions. If you feel the question does not apply to your child tick ‘never’.
Please write comments about your child’s behaviour in the comments section at the end of each question. This will help us to
begin to work out why these behaviours occur.
Use the following key to mark your responses
Always
Your child always responds in this manner 100% of the time
Frequently Your child frequently responds in this manner about 75% of the time
Occasionally Your child occasionally responds in this manner about 50% of the time
Seldom
Your child seldom responds in this manner about 25% of the time
Never
Your child never responds in this manner about 0% of the time
Comments Explain the context in which the behaviour occurs i.e. when does it happen, write your observations of the
child’s behaviour.
This profile may not be reproduced without the written permission of the author. É. Bhreathnach November 2002 ©
Background:
Reasons for Fostering/Adoption ( i.e. the child’s birth/early history, previous placements if any)
___________________________________________________________________________________________________
What age was child when s/he first came to live with you?
___________________________________________________________________________________________________
Summarise behaviour when the child first came to live with you?
___________________________________________________________________________________________________
Summarise the current behaviour of the child
___________________________________________________________________________________________________
Has the child had any previous therapy/counselling? (please give details)
Section 1 - Survival Strategies
Questions
Is your child tense or constantly vigilant
when in the company of others?
Easily Startled?
Clingy, reluctant to separate?
Finds it difficult to go to bed?
Finds it difficult to get to sleep
Constantly on the go?
Fidgety / Agitated?
Acts Before Thinking?
Attacks Others (describe behaviours such
as kicking, biting, hitting etc.)?
Self-Abusive, e.g. head banging, biting,
cutting self, etc. Describe behaviour?
Overly compliant, obedient?
Totally freezes in certain situations?
Resistant Stubborn (e.g. digs heels in,
won’t change mind, quietly goes own
way)?
Resistant Defiant (e.g. digs heels in,
cheeky and/or openly resists)?
Day Dreams, goes into world of their
own?
Sleeps after access visit, court hearing,
other (please circle & specify other)?
Always
Frequently Occasionally Seldom
100% time 75% time
50% time
25% time
Never
0% time
Comments
Section 2 - Attachment Behaviour
Questions
Takes on caring role towards parents or
brothers and sisters?
Child is the “too good child”?
Is obedient with adults but bullies other
children?
Is too independent (e.g. does not look for
help)?
Makes you feel unneeded as a parent?
Always says “I’m fine” even when they
are not?
Hides feelings, Doesn’t say when they
feel unhappy?
Avoids rows, dislikes getting into
arguments?
Is a very organised child?
Withdrawn or shy (please circle)?
Is a loner, socially isolates self?
Is child disorganised e.g. muddled or
messy ?
Becomes hyperactive or over-excited or
aggressive during play (please circle)?
Can quickly change response e.g. from
being charming, to being threatening, or
feeling victimised when the child wants
something from you or others?
Always wants to be the centre of
attention?
Dislikes change in routine?
Looks for help a lot, is overly dependent?
Is unable to accept responsibility for own
actions?
Always
Frequently Occasionally Seldom
100% time 75% time
50% time
25% time
Never
0% time
Comments
Questions
Always
Frequently Occasionally Seldom
100% time 75% time
50% time
25% time
Never
0% time
Comments
Blames others?
Is jealous of others?
Deliberately taunts others, starts rows?
Engages in risk taking behaviours (e.g.
climb onto roof, run into traffic)?
Idealises both birth parents (e.g. puts
them on pedestal) ?
Idealises one birth parent and is
dismissive of the other (state which
parent)?
Angry with one set of parents (birth or
foster) and defends the other (birth or
foster)?
Better relationship with Foster Father or
Foster Mother?
Overly obedient with certain adults and
not others ? (specify)
Aggressive with certain adults (specify)?
Stress triggers a change in behaviour e.g.
court, access visits? (specify)
Stays close but does not want to be
physically held?
Threatens to self harm, put self at risk?
Tries to hide self-abusive behaviour?
(Name the behaviour)
Section 3 – Developmental History and Sensory Processing
Question
Do you have any information on the pregnancy and
child’s birth history?
(e.g. medical problems during birth/pregnancy, delayed
labour, born more than 2 weeks early or late, child’s birth
weight)
Yes /
This applies
No /
This does not apply
Comments:
Question
Yes /
This applies
No /
This does not apply
Comments:
Did the child have any difficulty feeding in the first
year of life?
Did s/he suffer much from colic?
Was the child extremely demanding as an infant?
Was the child extremely passive as an infant?
Did s/he feel tense when being held?
Did s/he feel floppy when being held?
In the first three years of life did the child suffer
from any illnesses involving extremely high
temperature, delirium, or convulsions?
Did the child have a history of frequent ear, nose,
throat or chest infections in the first three years of
his/her life?
Does the child suffer from allergies?
Was, or is, there a problem with wetting the bed
after the age of 5 years?
Date and Result of Last Eye Test:
Date and Result of Last Hearing Test:
Proprioceptive-Vestibular Processing: (Body Position and Body Movement Sensation)
Question
Did the child dislike being placed on his/her
stomach to play?
Did the child have difficulty raising his or her head
and pushing up on extended arms in this position?
Did the child miss out on stages of crawling on
his/her tummy and creeping on hands and knees?
When did the child learn to walk?
Yes /
This applies
No /
This does not apply
Comments:
Question
Did the child have difficulty learning to use pedals
on a trike?
a)Was it because s/he lacked the strength to push?
b)Was it because s/he did not know how to
organise his or her feet to push the pedals?
Did the child have difficulty learning to ride a bike
without stabilisers?
Is the child inclined to crash into obstacles, on the
bike/trike, before coming to a halt
Does the child have difficulty catching a ball?
a)Does the ball drop through his or her hands?
b)Does the ball hit him/her on the body before
s/he reacts?
c) Other –please specify
Please tick which of below, applies for your child:
a) Can the child kick a ball when s/he is still and
the ball is still?
b) Can the child kick a ball when s/he is running
and the ball is still?
c) Can the child kick a ball when it is moving
towards him/her and s/he is still?
d) Can the child kick a ball when s/he is running
and the ball is moving?
Does the child tire easily, tend to slump in the
chair?
Does the child constantly shift about when sitting
on a chair?
Yes /
This applies
No /
This does not apply
Comments:
Question
Yes /
This applies
No /
This does not apply
Comments:
Yes /
This applies
No /
This does not apply
Comments:
Is s/he fearful of playground equipment?
a)swing
b)slide
c)climbing frame
d)roundabout
Does the child have the tendency to use too much
or too little force when playing with an object or
using a pencil? (circle which of the above)
Does the child seek out rough and tumble play, the
rougher the better or does the child actively avoid
rough and tumble play?
Does the child constantly seek out movement e.g.
run, jump, spin, tilt self upside down, (circle which
of the above)?
Is the child right or left handed or does s/he
continue to use either hand?
Did the child have problems learning to dress
him/herself? Describe current difficulties:
Does the child suffer from car sickness?
Does the child have balance difficulties?
Tactile Processing:
Question
Does s/he dislike being touched unexpectedly?
Is s/he easily irritated or angry when touched by
others?
Does touch have to be on his or her terms only?
Question
Does s/he tend to rub or scratch the spot where
someone has touched her/him?
Does s/he have difficulty waiting in line or standing
in a queue?
Is s/he easily irritated if someone accidentally
pushes into him or her.
Is s/he tentative in his or her approach to touching
objects?
Does s/he tend to use the tips of his/her fingers to
grasp objects?
Does s/he dislike having his or her hands dirty?
Does s/he dislike the feel of paint, sand, pottery
clay? (Please circle which of these applies)
Does s/he avoid walking barefoot?
Does s/he dislike the feel of tight fitting clothing?
Does s/he dislike the feel of labels on the clothes?
Does s/he dislike having a shower or bath?
(please circle which of these applies)
Does s/he dislike having his or her hair washed,
brushed, cut? (Please circle which of these applies)
Does s/he dislike having his or her nails cut?
Does s/he over or under react to cuts and bruises?
Does s/he constantly trying to touch people and
objects i.e. can’t keep their hands to themself?
Does s/he frequently drop/fumble with objects?
Does s/he seem unaware of food/liquids on their
face, hands or body?
Yes /
This applies
No /
This does not apply
Comments:
Mouth/Taste:
Question
Yes /
This applies
No /
This does not apply
Comments:
Does s/he frequently chew or mouth non-food
objects e.g. clothes, pencils or toys?
Does s/he frequently grind his/her teeth? When
does this occur?
Does s/he fail to notice if face is dirty or if there is
food dribbling down chin?
Does s/he dislike the feel of the toothbrush in his
or her mouth?
Is s/he a picky eater?
Does s/he like sweet foods?
Does s/he like salty foods?
Does s/he like sour/citrus/spice foods?
Does s/he like bitter/smoke foods?
Describe likes and dislikes e.g. does s/he like crunchy or chewy foods or does s/he tend to mash his/her food with lots of gravy.
Visual Form and Space Perception and Visual Construction:
Question
Does s/he avoid, or have difficulties, building with
Lego?
Did s/he have difficulty learning to recognise
shapes, size, and colours?
Does the child have problems in learning to draw
basic shapes such as a straight line, a circle, a
square etc.?
Does the child have any writing difficulties?
(please specify)
Does the child have difficulty copying down from
the blackboard?
Does the child have reading difficulties?
Does the child have spelling difficulties?
Yes /
This applies
No /
This does not apply
Comments:
Does the child struggle with jigsaw puzzles and
spot the difference games? (please circle which)
Does the child struggle to find objects/toys in a
cupboard?
Does the child get lost easily, in a familiar place
e.g. nursery/school or friends house?
Auditory Processing:
Question
Yes /
This applies
No /
This does not apply
Comments:
Yes /
This applies
No /
This does not apply
Comments:
Does the child have problems remembering
sequences of instructions?
Does the child find it difficult to carry out tasks on
verbal instructions only?
Does the child need to shown what to do, before
s/he can carry it out?
Does s/he have difficulty paying attention where
there are other sounds nearby?
Is the child fearful of any sounds? (please specify
which sounds)
Describe his/her behavioural response to sounds
that s/he dislikes or fears
Does the child ever appear to ‘switch off’ from
listening? Describe his/her behaviour.
Does the child make noises to himself/herself
when working or playing?
Does the child cover his/her ears in any context?
(please specify)
Play:
Question
If left to his/her own devices what sort of activities
will s/he engage in?
What type of activities does s/he enjoy?
Will s/he amuse himself/herself for long periods
with an object/game?
Does s/he enjoy imaginary play? Describe the play.
Question
Yes /
This applies
No /
This does not apply
Comments:
Will s/he physically construct an imaginary world
for cars or figures etc., or does the child just talk to
figures, make sound effects etc.?
Does the child rely on someone else to come up
with play ideas?
Does s/he tend to watch how others play before
joining in?
Does s/he seek to be entertained by others
Does s/he prefer to be passively entertained by
watching television or videos?
Is s/he disorganised in his play? S/He knows what
s/he wants to do but cannot organise how to do it
successfully.
Additional Comments:
Summarise you child’s main strengths:
Summarise you main concerns regarding your child
Your key goal for the child
References:
This profile was complied from the following resources:
1.
2.
3.
4.
5.
6.
7.
8.
Ayres Clinic Developmental History for Occupational Therapy
Bhreathnach, É. Long and Short Profile Forms.
Blythe, S. G. & Hyland, David. (1998). Screening for the Neurological Dysfunction in the Specific Learning Difficulty Child. BJOT 61, 10 459-464.
Dunn, Winnie. (1994) Performance of Typical Children on the Sensory Profile: An Item Analysis. AJOT 48, 967-974.
Evaluation of Sensory Integration and Praxis
OTA Preschool Checklist for Occupational Therapy
Knickerbocker, Barbara M. (1983). A Holistic Approach to the Treatment of Learning Disorders. Slack.
Perry, Bruce D., Pollard, Ronnie A., Blakley, Toi L., Vigilante, Domenico. (1995) Childhood Trauma, the Neurobiology of Adaptation, and "Use-dependent" Development of the
Brain: How "States" Become "Traits". Infant Mental Health Journal, Vol. 16, No. 4, Winter Edition.
Éadaoin Bhreathnach MSc Dip COT
Consultant Occupational Therapist November 2002 ©