merrell hcsbs sample.pdf

Community Social Behavior Scales

To Be Completed by Parent, Guardian, or Supervisor of Children or Adolescents Ages 5–18

Identifying Information

Name of child or adolescent:_____________________________________________________________________________
School: ________________________________________________________________________________________________
Grade: __________________ Age: years: _______ months: _______ Sex: Male ❑ Female ❑

Name of person completing form:________________________________________________________________________
Date form completed:___________________________________________________________________________________
Relationship of rater to child/adolescent:_________________________________________________________________
List the settings in which you observe or interact with this child or adolescent: ________________________________

Directions

After you have completed the Identifying Information section, please rate this child or adolescent’s behavior using all of the items on pages 2 and 3 of this rating form. Ratings should be based on your observations of this child or adolescent’s behavior during the past three months. The rating points after each item are based on the following format: Never If the child or adolescent does not exhibit a particular behavior, or if you have not had an opportunity to observe a particular behavior, circle 1, which indicates Never. Frequently If the child or adolescent often exhibits a particular behavior, circle 5, which indicates Frequently. Sometimes Circle the numbers 2, 3, or 4, (which indicate Sometimes) if the child or adolescent exhibits the behavior somewhere in between the two extreme rating points, based on your judgment of how frequently it occurs. The rating points after each item appear in the following format:

NEVER SOMETIMES FREQUENTLY

1 2 3 4 5

Please complete all items, and do not circle between numbers. If you have any additional comments about this child or adolescent, write them in the space provided at the top of page 4.

Scale A Never Sometimes Frequently Scoring Key
1. Cooperates with peers 1 2 3 4 5
2. Makes appropriate transitions between different activities 1 2 3 4 5
3. Completes chores without being reminded 1 2 3 4 5
4. Offers help to peers when needed 1 2 3 4 5
5. Participates effectively in family or group activities 1 2 3 4 5
6. Understands problems and needs of peers 1 2 3 4 5
7. Remains calm when problems arise 1 2 3 4 5
8. Listens to and carries out directions from parents or supervisors 1 2 3 4 5
9. Invites peers to participate in activities 1 2 3 4 5
10. Asks appropriately for clarification of instructions 1 2 3 4 5
11. Has skills or abilities that are admired by peers 1 2 3 4 5
12. Is accepting of peers 1 2 3 4 5
13. Completes chores or other assigned tasks independently 1 2 3 4 5
14. Completes chores or other assigned tasks on time 1 2 3 4 5
15. Will give in or compromise with peers when appropriate 1 2 3 4 5
16. Follows family and community rules 1 2 3 4 5
17. Behaves appropriately at school 1 2 3 4 5
18. Asks for help in an appropriate manner 1 2 3 4 5
19. Interacts with a wide variety of peers 1 2 3 4 5
20. Produces work of acceptable quality for use or usability level 1 2 3 4 5
21. Is good at initiating or joining conversations with peers 1 2 3 4 5
22. Is sensitive to the feelings of others 1 2 3 4 5
23. Responds appropriately when corrected by parents or supervisors 1 2 3 4 5
24. Controls temper when angry 1 2 3 4 5
25. Enters appropriately into ongoing activities with peers 1 2 3 4 5
26. Has good leadership skills 1 2 3 4 5
27. Adjusts to different behavioral expectations across settings 1 2 3 4 5
28. Notices and compliments accomplishments of others 1 2 3 4 5
29. Is assertive in an appropriate way when he or she needs to be 1 2 3 4 5
30. Is invited by peers to join in activities 1 2 3 4 5
31. Shows self-control 1 2 3 4 5
32. Is “looked up to” or respected by peers 1 2 3 4 5
Scale B Never Sometimes Frequently Scoring Key
1. Blames others for his or her problems 1 2 3 4 5
2. Takes things that are not his or hers 1 2 3 4 5
3. Is defiant to parents or supervisors 1 2 3 4 5
4. Cheats on schoolwork or in games 1 2 3 4 5
5. Gets into fights 1 2 3 4 5
6. Is dishonest; tells lies 1 2 3 4 5
7. Teases and makes fun of others 1 2 3 4 5
8. Is disrespectful or “sassy” 1 2 3 4 5
9. Is easily provoked; has a “short fuse” 1 2 3 4 5
10. Ignores parents or supervisors 1 2 3 4 5
11. Acts as if he or she is better than others 1 2 3 4 5
12. Destroys or damages others' property 1 2 3 4 5
13. Will not share with others 1 2 3 4 5
14. Has temper outbursts or tantrums 1 2 3 4 5
15. Disregards feelings or needs of others 1 2 3 4 5
16. Is overly demanding of attention from adults 1 2 3 4 5
17. Threatens others; is verbally aggressive 1 2 3 4 5
18. Swears or uses offensive language 1 2 3 4 5
19. Is physically aggressive 1 2 3 4 5
20. Insults peers 1 2 3 4 5
21. Whines and complains 1 2 3 4 5
22. Argues or quarrels with peers 1 2 3 4 5
23. Is difficult to control 1 2 3 4 5
24. Bothers and annoys others 1 2 3 4 5
25. Gets into trouble at school or in the community 1 2 3 4 5
26. Disrupts ongoing activities 1 2 3 4 5
27. Boasts and brags 1 2 3 4 5
28. Is not dependable 1 2 3 4 5
29. Is cruel to other persons or to animals 1 2 3 4 5
30. Acts impulsively without thinking 1 2 3 4 5
31. Is easily irritated 1 2 3 4 5
32. Demands help from peers 1 2 3 4 5

Additional Information

Please use the following space to provide any additional information about this child or adolescent that you believe would be useful for understanding his or her social behavior:

HCSBS Score Summary (for scorer use only—refer to Appendix A or B in User’s Guide)

Raw Percentile Social
HCSBS Scales Score T-Score Rank Functioning Level

Scale A: Social Competence Peer Relations (PR) Self-Management/Compliance (SMC) Social Competence Total Scale B: Antisocial Behavior Defiant/Disruptive (DD) Antisocial/Aggressive (AA)

Higher Social Competence scores indicate greater levels of social adjustment. Higher Antisocial Behavior scores indicate greater levels of social behavior problems.