SESSION 1 OF 6 Kathleen Ellen

APPENDIX A

Teacher Questionnaire (to be administered before and after the completion of all group sessions)
1. Which of the following most accurately describes the student’s frustration tolerance and
emotional regulation skills?
a. Student is able to control emotions with minimal outbursts or disruptions to classroom
or learning activities.
b. Student has occasional outbursts or challenges with frustration tolerance but is able to
self-regulate in order to avoid negative impacts on classroom or learning activities.
c. Student often has emotional outbursts and difficulty regulating emotions, which
typically leads to significant disruptions to classroom or learning activities.
d. Student is unable to regulate emotions at all, causing complete disruption to classroom
or learning activities.
2. Select the most appropriate statement about this student’s peer interaction skills.
a. Student has very little difficulty interacting with peers and makes friends easily.
b. Student occasionally has trouble interacting with peers but does have a few friends.
c. Student often has a hard time interacting with peers and has few friends, though peers
seem accepting of the student.
d. Student has extreme difficulty interacting with peers, has little to no friends, and other
students tend to avoid him/her.
3. Choose the most accurate description of this student’s social skills, in the area of eye contact.
a. Student typically maintains eye contact during conversations.
b. Student occasionally maintains eye contact during conversations.
c. Student rarely maintains eye contact during conversations.
d. Student never maintains eye contact during conversations.
4. Which of the following best describes this student’s communication skills?
a. Student always engages in turn taking with conversational partner, demonstrates
patience, and uses appropriate tone and inflection of words.
b. Student usually allows conversational partner a chance to speak, can be slightly
impatient, and generally uses appropriate tone and inflection of words.
c. Student rarely allows conversational partner a chance to speak, is often impatient, and
has difficulty with tone and inflection of words.
d. Student monopolizes conversation, is very impatient, and has poor use of appropriate
tone and inflection of words.
5. Select the statement that most accurately summarizes the impact these areas have on the
child’s classroom performance, daily routines, and overall ability to participate in occupations.
a. Student is typically successful in all classroom and learning activities, exhibiting
minimal interference from emotional regulation, peer interaction, social, and
communication skills.
b. Student has difficulty in 1 or 2 areas, which occasionally interferes with classroom
performance, daily routines and overall ability to participating in occupations.
c. Student has difficulty in 3 or more areas, which often interferes with classroom
performance, daily routines and overall ability to participating in occupations.
d. Student has significant difficulty in 3 or more areas, which interferes with classroom
performance, daily routines and overall ability to participating in occupations; student’s
challenges also impact the classroom performance of his/her peers.
SESSION 1 OF 6 Kathleen Ellen
APPENDIX A

Student Rating Scale 1 (to be administered before and after the completion of all group sessions)
1. When I am mad or upset I can calm myself down and get back to work. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
2. It is easy for me to tell people how I am feeling and why I am feeling that way. 1 2 3 4 5
* 1= very hard, 2= pretty hard, 3= it’s okay, 4= pretty easy, 5= very easy
3. I look at my friends when I am talking to them or when they are talking to me. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
4. I can understand how someone else feels, even if I do not feel the same way. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
5. I take turns talking when I am having a conversation with someone. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
6. I can wait my turn during games and activities with my friends and peers. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
7. I do well in school and don’t let anything stop me from doing my work. 1 2 3 4 5
* 1= never, 2= rarely, 3= sometimes, 4= most of the time, 5= always
8. It is easy for me to make friends and I have a lot of friends in my class. 1 2 3 4 5
* 1= never true, 2= rarely true, 3= sometimes true, 4= usually true, 5= always true

Student Rating Scale 2 (to be administered before and after the completion of all group sessions)
1. When I am mad or upset I can calm myself down and get back to work.

2. It is easy for me to tell people how I am feeling and why I am feeling that way.

3. I look at my friends when I am talking to them or when they are talking to me.

4. I can understand how someone else feels, even if I do not feel the same way.

5. I take turns talking when I am having a conversation with someone.

6. I can wait my turn during games and activities with my friends and peers.

7. I do well in school and don’t let anything stop me from doing my work.

8. It is easy for me to make friends and I have a lot of friends in my class.