Parent,/Caregiver

Checklist
.tr.unlocking potential

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Developrrler"ltal Proti le 4
Gerald D. Alpern, PhD

Child's narne Year Month

Parent,r'Caregiver's narne I Relationship to child (e.g., Motlrer)

Child's age

Where to Start
First fill in the information requested on the upper portion of thls page. Then read and answer all of the questions
on the following pages i:y circling Yes if it describes your child or No if it does not.

When to Stop
Do not stop until you have answered all questions on the following pages, even if they ask about skills or
behaviors typical of a child nruch older or younger than your child.
Scoring Tips
Most of the questions ask whether your child does perform a task. To score Yes, your chilcl must not only be able
to perform the task, he or she rnust actually perforrn it some of the tinre. However, some questions ask whether
your child can perform a task. For these questions, a Yes means that your chiid has shown the ability to perform
the task at least once.
Some questions ask about skills or behaviors that your child mastered long ago and does not do anymore; for
example, "Does ycur child sornetimes imitate spoken words, such as saying'da-da'or'ma-ma'?" Your child may
have imitated words when younger and now uses more advanced speech. You would answer Yes to this question
because your child successfully did so in the past.

Please answer Yes or lVo to the question exactly as it is written. For example, if your child cannot speak but uses
sign language, you must still respond ,Vo to questions about speaking words, even if your child can sign them.
However, you may respond Yes to questions that ask about communication and don't specify speaking.
lf you are not sure whether to answer Yes or /Vo, please make yor:r best guess.

The DP-4 is available online at platform.wpspuhlish.com.

Additional ccpaes of this form (W-703B) may be purchased from WPS. Please contact us at 8OO.648.8857 or wpspublish.com.
Copyright O 202O by Wesaern Psychological Services. Not to be reproduced, adapted, and./or translated ,n whole or in part
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 P1"" When lying face down, does your child hold up his or her head for at least 1 minute without help? Yes No

P2. Can your child push his or her arms up to a push-up position and hold it for 5 seconds? Yes No

P3. Can your child roll from his or her stomach onto his or her back without help? Yes No

P4. Can your child roll from his or her back onto his or her stomach without help? Yes No

P5. Does your child sit without support for at least 30 seconds? Yes No

P5. Does your child move forward from one place to another by creeping (stomach touching floor), No
Yes
e rawling (stonrach off floor), or by any other means (except rolling)?

P7. While standing alone or holding onto something (such as furniture), does your child bend over
Yes No
and pick something up without falling down?

P8. Does your child pull up on anything (except people) to get from a sitting to a standing position? Yes No

P9. Does your chiid walk at least four steps independently, without holding onto anything (such as No
Yes
people or furniture) for support?

P1O. Does your child walk well enough, without support, to go through a room without repeatedly
Yes No
falling or bumping into objects?

F11"" Does your child rnake a stack of at least three small objects, such as blocks? Yes No

P12. Does your child walk (not crawi) upstairs using a wall, handrail, or person's hand for support?
Yes No
Putting Lroth feet on a step is acceptable"

FL3. Can your child pick up and carry a small chair (or something else of equivalent size and weight)
Yes No
across the room?

P14. Can your child use a twisting hand motion to accomplish something such as unscrewing a loose
Yes No
lid or winding up a toy?

P}5. Can your child kick a ball at least 5 feet in the desired direction? Yes No

FL6. Can your child carry a smartphone or tablet carefully enough to be trusted not to let ii fall? Yes No

Pi.7. Can your child throw a ball of any size to an adult who is standing 5 feet away? The adult must No
Yes
usually be able to catch the ball without having to move"

PL8- Does your child make a circular arm and hand movernent to copy a circle with a pencil, marker,
Yes No
or crayon?

P19. Can yourr child carry an open container of liquid (for example, a cup of water) without much spilling? Yes No

P20. Does your chlld usually walk upstairs and downstairs by putting only one foot on each stair? Yes No
A wall or raillng can be used for support.

? DP-A Physical Scale

 P21.. Can your child copy an up-and-down straight line, using a pencil, crayon, marker, or paintbrush?
No
Your child must be able to show eye-hand coordination, not just scribble.

P22. Does your: child build a bridge using three blocks? A bridge must have a top block resting on two
Yes No
bottom blocks, with space between the bottom blocks.
P23. Does your child copy two intersecting lines to make a cross or "X"? Yes No

P24. Does your child catch a ball (any size) thrown by an adult who is standing 5 feet away?
Yes No
Your child must catch the ball at least half of the time.

P25. Does your child use child-safe scissors with one hand to cut paper or cloth? The other hand can
Yes No
hold the material. He or she must be able to actually cut the material, not tear it.

P26. Can your child balance on one foot for at least 10 seeonds? Yes No

P27. Does your child jump over at least three things in a row without stopping? The "things" should be
Yes No
at least 8 inches high.

P28. Does your child use a bat, racket, or paddle of any kind to hit a gently thrown ball? Your child must
No
make contact with the ball at least once every four swings.

P29. Does your child use leg and body motion ("pumping") to swing by hirnself or herself on a swing,
No
without being pushed?
P30. Does your. child draw or copy a square? The square must have right-angled corners, and the sides
No
of the square should be of about equal length.

P3L. Does your child cut out simple shapes like a circle or square, staying close to the lines
No
. (within l/2inch of the Iines)?

P32. Can your child roller-skate, skateboard, ride a scooter, ski, snowboard, or ice-skate? There
can be occasional falls, but most of the time the child can travel at least 1O feet without faliing, Yes No

P33. Can your child use a key or open a padlock to unlock and open a typical door? Yes No

P34. Can your child tie shoelaces or any other string into a bow? Yes No

P35. Can your child catch a tennis-size ball with one hand when thrown genily from at least 6 feet away?
(Your child must catch it at least half of the time") Yes No

P35. Can your child ride a two-wheeled bike (without training wheels) without falling most of the time? Yes No

P37. Can your child type sentences or ideas on a computer? Yes No

,]
:-

Physical Scale DP-4Parent/CaregiverChecklist 3

 A1. Does your child intentionally swat away something that is in his or her way? For example,
a blanket over the eyes or hair in the face.

A2. Does your child shcw he or she is hungry cr thirsty? For example, opening his or her nrouth
Yes irlo
or moving toward a bottle or breast.

A.3. Does your child try to get things that are just out of reach? Vcc No

A4. Does your child flinch at unexpected things, such as ioud noises? Yes No

A5. Does your child pick up an object or toy that has eiropped from his or her hantls? Yes t\o

A5. Can your chiid drink frorn a cup, sippy cupl, or slraw? Yes No

A7. Does your child look for and find a toy that is at least 2 feet away and has been covered or hidden? Yes No

A8" Does your child help with putting on a shirt or jae ket by holding r:ut his or her arms for the sleeves? Yes No

A9. Does your child take off shoes or socks without help? This must be part of undressing, not just playing Yes No

Al"O. Can your child use a fork for eating solid foods? Yes No

Al. L. Does your child use a spoon without help and with very liitle spilling? Yes No

A1.2. Does your child undo ai least two of ihe following fasteners: large buttons, snaps, shoelaces,
Yes t\o
zippers, Velcro?

,&13. Does your child drink from a child-sized cup or glass without help and usually without spilllng? Yes No

A1"4. Does your child undo and take off his or her buttoned or zippered lackets? Yes No

A15. Does your child use a computer, tablet, phone, or other digital device to play a simple game
Yes No
or use basic educational software?

4.L6. Does your child put on shoes wlthout help? (Shr:es untied or on ihe wrong feet is acceptable.) Yes No

AL7. Does your child ask permission appropriately? For example, "Can I please get a drink?" or
No
"Can I get another rnarker?"

AL8. Does your child use a mouse, touch pad, touch screen, or other digitai clevice to point and click
Yes t\o
on objects cn a screen?

A39. Does your child wipe his or her hands and face without help after eating, well enough to look clean? Yes N0

4,20. Does your chilc! take off a shirt over his or her head without help? Yes No

4 Dp-4 Adaptive Behavior Scale

A2L. Does yoLrr child urinate in ihe toilet without help? This includes taking down and pulling up
Yes No
clothing, and flushing the toilet.

A22. Does your child dress himself or herself completely, except for shoelace tying? Yes NIo

A23. Can your child locate and play a TV program, movle, or video? This can be through a DVR or Nln
Yes
digital streaming.

A24. Can your child be trusted to carry scissors safely? Yes No

A25. Does your child independently choose what to eat at a restaurant, cafeteria, or at home? Yes No

A26. Does your child take care of his or her own bowel movements without help? This means
Yes No
undressing, wiping, dressing, and flushing the toilet.

A27. Does your child use coping skills appropriateiy at ieast some of the time when mad or upset? For
Yes No
example, taking deep breaths, walking away, or using other means to control himself or herself?

A28. Does your child choose the correct clothing to wear based on weather and destination?
Yes No
For example, a jacket when it's cold.

A29. Does your child use the lnternet or application store to locate and play games? Yes No

A3O. Can your child interact with strangers appropriately when necessary? For instance, asking where
Yes No
the bathroom is.

A3L. Does your child wash himself or herself acceptably without help? This means getting the bath or
Yes No
shower ready and washing and drying completely.

A32. Does your chiid know how to interact with a cashier to buy something at a store? \bs No

A33. Does your child use a knife correctly for cutting ground meat, fruit, or similar foods? (Help may
Yes No
still be needed to cut tougher foods such as steak.)

A34. Can your child recite a parent's phone number and his or her home address for use in case of
Yes No
an emergency?

A35. Does your child care for a minor cut or scrape independently? This includes washing the injury
Yes No
and using antibiotic ointrnent and/ar bandages.

A36. Has your child prepared at least two simple foods (for example, eggs, popcorn, pasta) using a
Yes No
microwave, stove, toaster, or oven?

A37. Does your child know how to look up something on the lnternet successfully? Yes No

A38. Does your child complete homework independently without constant reminders? Yes No

A39. Does your child manage money (from savings or allowance) well enough to buy small items
Yes No
independently?

A4O. Does your child manage and prioritize school assignments so that the most important are
Yes No
completed first?

A41". Does your child contact friends to make plans without parental assistance? Parental permission
Yes No
may still be needed.

Adaptive Behavior Scale DP"4 Parent,/Caregiver Checklist 5

 S1" Does your child look at an adult who is ialking, as if trying to fcllsw whal ihe aclult is saying? Yes No

52. When your child is upset, does human contact frequently have a positlve, calming effect? Yes l(o
33. Dces your child react differentiy to differe nt people? Far example, smiling at a caregiver,
YES Ncl
or lor:king away fronr a stranger.

54. Does your chiid show interesl in other people? For instance, by moving toward them or gesturing
Yes No
tc get their attentron.

55. ls your child interested in ioys or games that cther children are piaying? YCS No

56. Does your child show negative reactions (fclr example, anger, refusal, fear, withdrawal) to things
Yes No
he or she does not like, sueh as strangers or disliked food?

57. Does your child express fondness for an adult who is seen less than weekly (such as a grandparent
who lives elsewhere or a specialist teacher who only comes to school monthly)? Yes No

S8. Does your child wave bye-i:ye at the right times? Yes No

59. Does your child usually like to play with other children instead of playing alone? Yes l.,lc

S1"0. Does your child respond more readily to the instructions of a familiar aelult, as opposed tr: an
Yes No
unfamiliar adult?

SLl". Does yor:r child want to play (at least weekly) with classmates or other children? Yes No

512. Does your child show he or she knows what my means? This means that your child Lrnderstands
when someone says "nry truck" or "my rnomrny." Yes Nc

SL3" Does your child somet,mes seek out other children to play wlth? For exampie, walk over to thenr,
or ask "Will you play with me?" Yes t\o

SL4. Does your child do one of the following things for at least 15 mlnutes without needing constant
Yes Nt't
atlult attention: coloring. writing, building, looking at pictures?

S1.5. Does your child show awareness of how others feel by correctly saying things like "He is mad,"
"She is angry," "He is afraici." or "You are cranky"? No

S1"6. Does your child change his or her behavjor appropriately for the setiing? For example,
Yes No
being quiet and calm at the library or classroom but active and loud at the park or playgroLlnd?

S17. Does your child frequently say "l'm sorry" or try to make it up to a person that he c;r she has hurt
or insulted? Yes No

S1"8. Does your child ask permission to play with a toy that belongs to someone else, rather than just
Yes Ncl
taking it?

S1.3. Can you;- child t:arry cn a conversation for at leasi 5 minutes with peers, taking turns in speaking? Yes \IN

S20" ls your child able to keep working for af leasf 30 minufes with a similar-aged child on a sing/e Nask,
such as block building; sand or mud play; or playing store, school, or house? Yes t\o

6 DP4 Social*Enrotional Scale

$21. Does your ehild eooperate with others for a group project by contributing to the group?

S23. Can your child instruct or teach another child to playa board game orvideo game?

S25. Does your child understand why one person would be a good friend and ansther wouldn't? For
example, that a nice and caring person would make a good friend, but someone who calls people
names might not be.

S27.ls your child usually a good sport? For example, not having a tantrum or a fit when losing a game.

S29. Does your child react to others' misbchavior? Forexample, anger when others cheat or shock
about a crirne reported on the news.

S31. Does your child seek out adult advice with friendship problems?

S33. Does your child know that sorne adult jobs pay more money than other jobs?

S35. Does your child talk to peers for at least L hour on most days? The eonversation can be on the
phone, via text, social media, or the lnternet, or during nonschool "hang-out" tirnes.

Social-Emotional Scale DP-4 ParentlCaregiver Checktist 7

 GL. Do yaur chilcl's eyes follow sornething be ing moved in front of his or her face? Yes No

G2. Does your child usually look or turn toward the source of a new scund, such as a person who is
Yes No
beginning to talk?

G3. Willyour chiid turn toward a noise and then change direction when the source of that noise is moved? No

G4. Does your child laugh, clearly showing joy? Yes No

G5. When a toy is placed in your child's hands, does he or she seem clearly aware of the object for at
Yes No
least 5 seconds?

G6. Does your child usually look err turn his or her body toward the right person or thing when asked
Yes No
where that person or thing is?

G7. When a toy is moved out of sight, does your child look for it in the right place? For example, if a toy is
moved from a table and hidden under a pillow, would your child search for it under the pillow and not Yes I\U
just seern to forget it?

G8. When asked, does your child point to at least one body part an himself or herself or on a doli? Yes No

G9. Does your child ever give or take one mare of something when askeC to do so? For exanrple,
Yes No
taking another bite of food.

G1"0. Does your child use pencils or crayens to make marks on any writing surface? Yes No

Gi. 1. When asked to identify or describe an object in a book or magazine, dces your child point to, lock at,
Te5 No
or otherwise indicate recognition of the object?

G12. When piaying with a doll or stuffed animal, does your child demonstrate understanding that it
No
represents a living thing? This would include pretending to feed or dress it, or put it to bed.

G13. Does your child identify at least 20 things when they are named? For example, pointing to or v,eS No
describing images in a book.

G 14. When asked, does your child correctly identify at least two colors? Your child does not need to
Yes No
name them.

G15. Dces your child correctly classify things using size words (large or big, and little or small)? Yes No

G1.6. Can your child correctly count up to six objects? ic5 ldo

GL7. Does your child ever sort things by color, shape, or size? Yes No

GL8. Does your child understand the concept of three? For example, when asked to give three crayons,
Yes No
would your child do so?

G 19. When asked, does your child correctly place an object between, under. and oyer other objects?
Your child must do all three placements.

G2O. Does your child know the difference between living and nonliving things? For example, does your
child correctly name things that are living (such as dogs, bugs, horses) and things that are not
living (such as chairs, blankets, toysX

8 DP.4 Cognitive Scale

G21. Can your child count up to 15? Yes No

G22. Does your child recognize a printing of his or her: first and last name? Yes No

G23. Does your child understand that cartoon characters or superheroes in television programs, books,
Yes lrlo
or movies are not real?

G24. Does your child write recognizable numbers and letters? They can be reversed but must be readable. Yes Ns

G25. Does your child sometimes use logic about cause and effect? Words such as because or srnce may be
Yes No
used. For example, "l should be able to watch TV later tonight because there is no school tomorrowl'

G25. Does your child understand the concepts of yesterday, today, and tomorrow? For example, Nt^
if you say "There wili be a party tomorrow," would your child know it is on the following day?

Q27 . Can your child name at least three sets of rhyming words? For exampie, "red" and "headl"'toes"
Yes No
and "nose," "house" and "mousel'

G28. Can your child print his or her first and last name? Yes No

G29. Can your child read at least five wrltten words and understand what they mean? Your child must
actually read the words, not just name something, such as recognizing a cereal box and naming No
the cereal.

G30" Can your child name the seven days of the week and answer which day comes before and after any
No
given day? For example, your child must be able to tell you what clay comes before and after Thursday.

G3 L. Does your child answer correctly when asked to subtract one single-digit number from another?
Yes No
For example, "What is 9 minus 4?" Counting on objects or fingers is acceptable.

G32. Does your child read a simple story aloud so that someone who is only listening can follow the story? Yes No

G33. Can your child relay accurate information learned about a historical figure or scientific principle
(for example, George Washington or the water cycle) at least several hours after learning it? No
The information must contain at least two facts.

G34" Does your child write or print frorn rnernory at ieast 2O words with correct spelling? Yes No

G35. Can your child perform single-digit addition calculations in his or her head, without counting on
Yes No
anything?

G36. Does your child use a keyboard or touch screen to type at least one line of text (at least four words)? Yes No

G37. Does your child answer with the correct day, month, and year when asked for the daie? All three
Yes No
must be correct.
G38. Can your chilcl perform single-digit subtraction calculations in his or her head, without counting
No
on anything?

G39. Does your child use a computer word-processing program or a tablet to complete assignments
Yes No
for school?

G4O. Does your child know how to use the shift key to capitalize lettefs on a keyboard? Yes No

G4L. Does your child answer correctly when asked to multiply single-digit numbers by two (such as Bx 2)?
Yes No
Counting on objects or fingers is acceptabie.

&42^ Can your child do multiplication problems through the sixes with only a few errors? For example, your
No
child will know the answers lo 6 x 9,5x 8, and 4 x 3from memory, without using counters or fingers.

Cognitive Scale D?-4Parent/Caregiver Checklist I

 [,4 ]". Does your child use apprcpriate facial expressions
la convey his or her moocj? [65 sx6plnlo
Yes t\o
smiling when happy and pouting or frowning when sad.

l\,!2. Does your child show likes or dislikes for some people, places, or things (other than fcod)? Yes No

M3. Does your ehild imitate something that someone else does, sueh as a physical gesture or
Yes No
repeating a sounC?

futA. Dces your chilci raise his or her arrns (or make a similar gesture) when about to be pickecl up? Yes No

M5. When an adult points to sonrething, dces your chilel usually look where the adult has pointed? Yes No

M6. Does your chiid answer an adult's words with gestures, such as waving bye-bye when an adult
says "good-bye," or shaking his or her head up and derwn foryes and side to side for no when Yes No
answe ring an adult's question?

M7. Does your child sometinres imitate spoken words, such as saying "Ca-da" or "ma-rra"? Yes No

M8. Does your child express wanting more or anather by using specif ic words or by signing or gestur!ng? Yes No

M9" Doe: your chiiC ciearly understand the meaning of "no"? Yes Nc

l\f i.0. Does your child nod, smile, or use other nonverbal cues to show that he or she is lisiening when
son']eone is talking?
Yes l\o

MLl". Does ycur child usually follow instructions of three or more words? Examples are "Find your shoe,"
"Bring the boitle," or "Put the book cn the table." No

M12. Does your child u:e words, word-iike sounds, or sign langr"rage tr: express a want or need?
No
For example, saying "wa-wa" fcr wate r.

&tI13. Dces your child co:'rectly follow two-step verbal instructions? [xamples are "Take off your clothes
No
and get into the tub" or "Pick r-ip the washclcth and wash your face."

M14. Does your child imitaie a sentence of two or rnore words? [xanrples are "Daddy goes," "Doggie
Yes Nr.l
drinks," or "Baby walks."

[I]"5. Does your child repeat parts of famillar shows, books, or scngs, or join in when others say them? Yes I\U

Ivll"6. Does your child understand at least two of the following three nonverbal gestures: 1) shoulder
shrug to cornmunicate I don'f knorv or I'm nof sure; 2) touching index f inger to lips to indicate be Nc
qulet; 3) thurnbs-lrp as an indication af okay?

M17. Does your child name or olherwise conrmunicate (not lust repeat) at least 20 things seen in pictur-es? Yes l.lo

M18. Does your child speak ai least 50 difierent words? v^-

IC5
\t^
I\U

hil19. Can your child tell people (by speaking cr hclding up fingers) horv old he or she is? Yes No

M20. Does your child show, by asking or gesturing, ihe need to go to the toilet? The gestures must be
Yes No
more than just acting jumpy.

10 DP-4 Comrnunrcalion Scale

 M2L. When asked, does your child sometimes give his or her first and last name?

M?Z.Can your child tetl a story by looking at the pictures in a book? The story must match what
is'pictured, although parts of the story not shovrn by the pictures may be left out.

M2].. Has sung a song of at.least30 words wltn1ul.nel1?. No

1ou.1cnlla
It2:4;Soagys.y,r..ohild understEndfosai!a,p'.,9 gp
"uorisis"y$ti,aslrxe*].91ffi,b*kflsayr$laan
M25. Can your child use negotiation and cornpromise to solve a conflict? For example, agreeing to
trade for a toy that another child wants.
Yes No

M26.lt your child were told a short story of approximately 10 sentences, could he or she answer simple
,.,,.r '1,q1rgstlons about the story, such as the names of the main c*a;iactdts;qnd{hg,Spp-err6l.iagu ,.:

M27. Can your child retell (in about 5 minutes) the plot of a story, play, video, or TV show? Your child
Yes No
must be able to tell the whole story.

M28. Can your child make up a story that has a beginning, middle, and end, and at least six to eight
sentences or complete thoughts? The story can be spoken or written.

M29. Can your child carry on a back-and-forth conversation about a current event or issue for at least
No
5 minutes?

M3O. Does your child change his or her communication style depending on the situation? For example,
using slang and informal speech with friends, but speaking more formally with teachers.
'uu"Js
ur3;.;;r;rurli o u,u", o."r""iri", tiuirurt *inrt"rz No

M32. When sending texts or other digital messages, does your child use shorthand? For example,
Ns
ii,{OL :,tnstded of taugll d:iit'taud
M33. Does your child gather and/or share information on the lnternet? For example, on social media,
Yes No
discussion boards, etc.

M34. Does your child use social media? Yed f,llo

rI

Communication Scale DP-4 Parent,rCaregiverChecklist 11