asd program

Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

1

Appears to be unresponsive to others (e.g., unaware of presence of others)

2

Does not use sustained and purposeful eye contact or watch faces intensely

3

Does not respond to others’ attempts to share attention through eye gaze or pointing

4

Shows little curiosity about or interest in the immediate environment-appears to be in “own world”

5

Shows little interest in or response to positive social communication/initiations (e.g., cheerful/playful voice or baby-talk)

6

Does not calm or quiet in response to a familiar adult’s face or voice

7

Does not respond to the emotional expressions of familiar others

8

Has difficulty imitating simple movements and sounds

9

Does not use movement, sound, or gestures to gain attention of caregivers

10

Responds in an unusual manner to affection (e.g., resists hugs, or overreacts when others offer comfort)

11

Has difficulty using and perceiving nonverbal communication (e.g., tone of voice, gestures, facial expressions)

12

Treats others as if they were objects/solely to gain assistance or a desired object (e.g., pulls parent to door)

13

Has difficulty taking turns in play or social activities-social reciprocity (e.g., peek-a-boo, pat-a-cake)

14

Isolates self from others or chooses solitary play consistently and across settings

15

Does not exhibit fear of unfamiliar people-fails to display “stranger anxiety”

16

Does not seek others’ attention in order to share an experience (e.g., bring an object to show or point out an item or person)

17.

Has difficulty joining an activity with peers

18.

Makes no attempt to comfort others who are in obvious distress

19.

Does not show interest or shows little interest in interacting with peers

20.

Displays unusual eye contact (e.g., looks out of corner of eye or away from speaker)

21.

Has little or no interest in assuming “roles” in play interactions with others (e.g., “cooking” play pizza for peer at table) or between play objects (e.g., conversations between mom and dad dolls)

22.

Other:

Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

23

Seems unmotivated by customary rewards or social approval (e.g., stickers, praise, hug, smile)

24

Stares intensely and for long periods of time at objects that move (e.g., stares at fan or rolling credits of television show/movie)

25

Attached to objects in an unusual manner (e.g., refuses to leave the house without a block, goes to bed while holding a plastic letter of the alphabet)

26

Uses objects in repetitive, atypical manner (e.g., meticulously lines up object, spins objects repeatedly)

27

Has intense preoccupations (e.g., trains, letters, shapes, electronics, doors)-to the exclusion of play or family activities-and is difficult to distract

28

Displays atypical repetitive motor movements (e.g., flaps hands, rocks body side-to-side, flicks fingers)

29

Displays difficulty engaging in activities other than intense special interests

30

Has excessive difficulty transitioning from a preferred activity

31

Has strong need for closure or difficulty stopping a task before it is completed

32

Repeats specific sounds, words, phrases, or music frequently (e.g., repeats parts of movies or phrases from books)

33

Becomes upset easily with interruption to routines or unanticipated changes in events (e.g., taking a different route to a destination, moving a familiar object from “its place,” using a different color plate for meals

34

Other:

Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

35

Has current speech delay (e.g., no sounds of content, vowel-like sounds between 2-3 months; no babbling at 8 months; no single words by 12 months; no phrase speech by 24 months)

36

Atypically quiet; does not produce a variety of sounds other than crying (e.g., cooing)

37

Displays absence of a social smile or displays a “vacant” smile

38

Does not imitate sound produced by a caregiver

39

Does not use varied voice intonation to express joy and pleasure

40

Does not respond or shows delayed response when name is called

41

Does not use turn-taking when vocalizing/verbalizing with a partner that includes a comfortable to-and-fro

42

Has difficulty using basic gestures, facial expressions of “body language” to communicate feelings

43

Fails to respond to verbal greetings or nonverbal gestures (e.g., wave bye-bye, raise arms to be picked up)

44

Has difficulty or makes no attempt to make clear requests (e.g., does not lift arms to be picked up, only labels objects-does not request by name)

45

Has difficulty understanding labels or names for common objects/people (e.g., does not point to picture in book upon request)

46

Has difficulty following a variety of routine one-step directions

47

Demonstrates unusual voice or speech qualities (e.g., hums, grunts; uses “sing-song” or mechanical speech

48

Fails to respond to verbal or nonverbal greetings by giving a verbal response (e.g., by saying “hi” or “bye”)

49

Communicates wants and needs through tantrums that appear more extreme in frequency and/or intensity than those of other children of the same age

50

Makes sounds or states the same words or phrases repeatedly

51

Talks to self excessively in place of communicating with others

52

Frequently uses “gibberish” with few recognizable words

53

Does not spontaneously comment or share experiences-may speak only when asked a direct question

54

Has difficulty with basic rules of conversation (e.g., asks inappropriate questions, makes poor eye contact, has difficulty maintaining conversation, wants to talk about own interests exclusively)

55

Displays immediate or delayed echolalia (e.g., repeats another person’s questions or statements, recites lines from a favorite book or movie repeatedly)

56

Uses words in odd or idiosyncratic manner (e.g., calling yellow objects “cheesy”)

57

Asks repetitive questions

58

Makes frequent mistakes in use of pronouns (e.g., reverses you and me or refers to self by name)

59

Other:

Item

Description

Notes on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

60

Often responds in a developmentally unusual manner to sounds (e.g., reacts as if has no hearing, ignores some sounds, turns up volume on tv, bangs toys and objects, or overreacts to noises such as crowds or sirens)

61

Often responds in a developmentally unusual manner to pain (e.g., overreacts or seems unaware of an illness or injury)

62

Often responds in a developmentally unusual manner to temperature (e.g., prefers or avoids certain temperatures or fails to respond to temperatures)

63

Often responds in a developmentally unusual manner to smells (e.g., may comment on smells that others do not notice or fails to notice strong smells)

64

Often shows an unusually strong desire to do activities that provide touch or pressure (e.g., tight swaddling; crashing body into bed, sofa, or people; banging toys together)

65

Often shows an unusually strong desire to do activities that provide movement (e.g., swinging, rocking, spinning body, running; or being rocked or bounced by others)

66

Often shows an extreme overreaction to activities that provide touch or pressure (e.g., resists diaper changes, strongly dislikes hair washing or cutting, nail cutting, and/or tooth brushing; avoids touching foods or walking on grass)

67

Often shows an extreme overreaction to activities that provide movement (e.g., avoids swinging, climbing, rocking, or pacing)

68

Often responds in a developmentally unusual manner to visual input (e.g., focuses on shiny items and reflections; ignores faces; shows preference for or strong dislike of certain colors; overreliance on salient visual features such as glasses and hair)

69

Has had difficulty learning feeding skills and/or transitioning to more advanced feeding skills (e.g., from breast/bottle feeding to spoon feeding with smooth, thin purees and then to mixed textures)

70

Often responds in a developmentally unusual/rigid manner to taste (e.g., avoids many textures, foods, and flavors)

71

Frequently preoccupied with sensory exploration of objects (e.g., mouths, licks, chews, sniffs, holds close to eyes, rubs, squeezes, or uses object to make sounds)

72

Frequently makes noises such as humming, singing, or throat-clearing vocalizations

73

Other:

Item

Description

Notes on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

74

Takes longer to learn new skills or learns some skills much earlier than same-age peers (e.g., may be able to identify letters or numbers or read words at unusually young age)

75

Does not generalize learned skills to new settings or demonstrate them consistently upon request

76

Demonstrates inconsistent recall of information or routines (e.g., seems to forget what was previously learned)

77

Has difficulty engaging in adult-initiated activities

78

Has difficulty maintaining engagement in meaningful self-directed activities (e.g., persists with activities but only within preferred interests or remains engaged only in areas of restricted interests)

79

Recites, signs, lists, or labels with limited purpose or understanding (e.g., displays excellent memory for songs or stories)

80

Has difficulty following new or unfamiliar directions

81

Displays little or no pretend and imaginative play-only uses objects for intended purpose (e.g., banana as food not telephone)

82

Other:

Item

Description

Notes on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

83

Demonstrates awkward motor movements (e.g., head flops backwards when placed into sitting position, crawls, walks or runs atypically age, walks on toes)

84

Displays atypical activity level (e.g., overactive/hyperactive, underactive/very passive, or unusual stamina)

85

Displays variability in gross-motor skills (e.g., able to engage in some age-appropriate physical activities but not others, may climb furniture but seeks support climbing stairs)

86

Has difficulty maintaining hold or actively resists grasping objects or a tool (e.g., chalk, crayon, marker, pencil, paintbrush for purposeful activities)

87

Displays unusual facial expressions or grimacing

88

Has extreme difficulty starting or stopping actions (e.g., difficulty feeding self, moving through environment, or playing with objects)

89

Has difficulty independently moving through environment and appropriately maneuvering around objects and people (e.g., difficulty crawling, moving room to room, walking on uneven surfaces, moving on/off a chair)

90

Has difficulty using hands for fine-motor tasks (e.g., holding a crayon, using eating utensils, turning a single page, fastening, buttoning, and zipping)

91

Displays variability in fine-motor skills (e.g., can accomplish some tasks, but not others, may use one hand in a very precise manner to manipulate small objects, but does not use hands together for combined stabilizing and skill)

92

Displays unusual or repetitive body postures and movements (e.g., hand flapping, rocking, finger flicking, moving fingers in front of face, and spinning)

93

Other:

Item

Description

Notes on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

94

Exhibits more extreme emotional responses, in duration and/or intensity, than other children of the same age

95

Demonstrates unusual fear response-lacks appropriate fears or is overly fearful

96

Emotional responses are not related to the situation (e.g., laughs for no apparent reason)

97

Displays great difficulty being comforted by parents/caregivers when upset-is not easily calmed

98

Has more difficulty expressing and/or controlling emotions than other same-age children

99

Does not find pleasure in activities and interactions similar to children the same age; seems withdrawn

100

Appears to purposefully injure self (e.g., bangs head, picks skin, bites nails until finger bleeds, bites self)

101

Becomes stressed when presented with a new task or situation (e.g., does not initially attempt new things)

102

Shows persistent aggressive behaviors with people and/or objects that do not readily respond to typical developmental interventions (e.g., persistently harms others or breaks objects)

103

Has low frustration tolerance

104

Other