Autism Spectrum Disorder Evaluation Template
EVALUATION RESULTS AND/OR EXISTING DATA:
Autism Specialist
Autism Behavior Checklist (ABC)
Autism Diagnostic Observation Scale (ADOS)
Childhood Autism Rating Scale (CARS)
Gilliam Asperger Disorder Scale (GADS)
Gilliam Autism Rating Scale-2 (GARS-2)
Short Sensory Profile
The Autism Social Assessment for School Planning
School Assessment Rating Scale for Asperger’s Syndrome
School Function Assessment
Autism Spectrum Structured Student Interview
Systematic Classroom Observation
Autism Behavior Checklist (ABC)
The Autism Behavior Checklist (ABC) is a checklist of non-adaptive behaviors; capable of providing how an individual “Looks” in comparison to others. This checklist reflects an individual’s challenges to respond appropriately to daily life situation. XXX’s parents and the educational team at XXX School completed the check lists.
XXX received a total score of XX from his parents which was indicating that there MAY / may NOT be a presence of autism.
XXX received a total score of XX from his educational team which was indicating that there MAY / may NOT be a presence of autism.
Differences in behaviors were noted in the following areas:
Sensory Behaviors:
ü Poor use of visual discrimination when learning
ü Seems not to hear, so that a hearing loss is suspected
ü Sometimes shows no “startle response” to loud noise”
ü Sometimes painful stimuli such as bruises, cuts, and injections evoke no reaction
ü Often will not blink when bright light is directed toward eyes
ü Covers ears at many sounds
ü Squints, frowns, or covers eyes when in the presence of natural light
ü Frequently has no visual reaction to a “new” person
ü Stares into space for long periods of time
Relating Behaviors:
ü Frequently does not attend to social/environmental stimuli
ü Has no social smile
ü Does not reach out when reached for
ü Not responsive to other people’s facial expressions/feelings
ü Actively avoids eye contact
ü Resists being touched or held
ü Is flaccid when held in arms
ü Is stiff and hard to held
ü Does not imitate other children at play
ü Has not developed any friendships
ü Often frightened or very anxious
ü “Looks through” people
Body and Object Use Behaviors:
ü Whirls self for long periods of time
ü Does not use toys appropriately
ü Insists on keeping certain objects with him/her
ü Rocks self for long periods of time
ü Does a lot of lunging and darting
ü Flaps hands
ü Walks on toes
ü Hurts self by banging head, biting hand, etc…
ü Twirls, spins, and bangs objects a lot
ü Will feel, smell, and/or taste objects in the environment
ü Gets involved in complicated “rituals” such as lining things up, etc…
ü Is very destructive
Language Behaviors:
ü Does not follow simple commands given once
ü Has pronoun reversal
ü Speech is atonal
ü Does not respond to own name when called out among two others
ü Seldom says “yes” or “I”
ü Does not follow simple commands involving prepositions
ü Gets desired objects by gesturing
ü Repeats phrases over and over
ü Cannot point to more than five named objects
ü Uses 0-5 spontaneous words per day to communicate wants and needs
ü Repeats sounds or words over and over
ü Echoes questions or statements made by others
ü Uses at least 15 but less than 30 spontaneous phrases daily to communicate
Language Behaviors:
ü Learns a simple task but “forgets” quickly
ü Strong reactions to changes in routine/environment
ü Has “special abilities” in one area of development, which seems to rule out mental retardation
ü Severe temper tantrums and/or frequent minor tantrums
ü Hurts others by biting, hitting, kicking, etc…
ü Does not wait for needs to be met
ü Difficulties with toileting
ü Does not dress self without frequent help
ü Frequently unaware of surroundings, and may be oblivious to dangerous situations
ü Prefers to manipulate and be occupied with inanimate things
ü A developmental delay was identified at or before 30 months of age
Autism Diagnostic Observation Scale (ADOS)
The Autism Diagnostic Observation Scale (ADOS) is a semi-structured, standardized assessment of communication, social interaction, play, and imaginative use of materials for individuals who have been referred because of a possible autism spectrum disorder. Specific tasks were presented because they were likely to induce particular behaviors relevant to autism spectrum disorders.
During the session, XXX displayed brief hand and finger mannerisms including
The assessment, observation, and scoring was completed by XXX and XXX, a team of XXX from Lakes XXX. The following scores were obtained:
Communication Total XX (met criteria - Autism Cut-Off 5)
Reciprocal Social Interaction XX (met criteria – Autism Cut-Off 6)
Total XX (met criteria – Autism Cut-Off 12)
In the area of communication, XXX met/did not meet the cut-off score for Autism Spectrum due to
In the area of social interaction, XXX met/did not meet the cut-off score for Autism Disorder due to
When the scores are totaled, XXX meets/does not meet eligibility for Autism.
He/She displays symptoms and needs in the areas of communication, social interaction, and stereotyped behaviors and restricted interests.
Childhood Autism Rating Scale (CARS)
The Childhood Autism Rating Scale (CARS) is a 15 item behavioral rating scale developed to identify children with autism and to categorize these behaviors from mild to moderate to severe. The total CARS score may range from a low of 15 (obtained when the child¹s behavior is rated as falling within normal limits on all 15 scales) to a high of 60 (obtained when the child¹s behavior is rated as severely abnormal on all 15 scales). The score represents placement on a continuum: the lower the score, the fewer autistic behaviors the child exhibits; the higher the score, the more autistic behaviors the child exhibits.
School Rating Completed by XXXX. The results were as follows:
Relating to People XX
Emotional Response XX
Imitation XX
Body Use XX
Object Use XX
Adaptation to Change XX
Listening Response XX
Taste, Smell, Touch XX
Visual Response XX
Fear or Nervous XX
Verbal Communication XX
Activity Level XX
Nonverbal Communication XX
Level & Consistency of Intellectual Response XX
General Impression XX
Total Score XX
The Childhood Autism Rating Scale was completed utilizing information provided by XXXXX. Based on his/her observations and evaluation, XXXXX received an overall rating score of XX, placing him within the XXXX autistic range.
XXXXdisplays a marked difference in his/her social skills (including), his/her communication skills (including) and his/her repertoire of interests and activities (including) as well as his/her sensory responses (including).
Gilliam Asperger’s Disorder Scale (GADS)
The Gilliam Asperger’s Disorder Scale (GADS) is used for the assessment of individuals ages 3 through 22 who present unique behavioral problems. It’s purpose is to help professionals identify Asperger’s Disorder characteristics within the school setting. It is used to help educational teams determine whether a child may meet MN State Educational Criteria for receiving special education services under the Autism Spectrum Disorder category. The GADS provides information about four categories of behavior – social interaction, restricted patterns of behavior, cognitive patterns, and pragmatic skills. Even if the person is not diagnosed with Asperger’s Disorder, the GADS provides information that is usefully in the diagnosis and treatment of other behavioral disorders. Educational staff at XXXX School and XXXX’s parents completed the GADS.
The results were as follows:
HOME Rating
Rater: XXX Name Stand. Score %ile Rater: XXX Name Standard Score %ile
Social Interaction XX XX% XX XX%
Restricted Patterns of Behavior XX XX% XX XX%
Cognitive Patterns XX XX% XX XX%
Pragmatic Skills XX XX% XX XX%
Sum of Standard Scores XX XX
Asperger’s Disorder Quotient XX XX% XX XX%
Asperger’s XXXX Probable Asperger’s XXXX Probable
SCHOOL Rating
Rater: XXX Name Stand. Score %ile Rater: XXX Name Standard Score %ile
Social Interaction XX XX% XX XX%
Restricted Patterns of Behavior XX XX% XX XX%
Cognitive Patterns XX XX% XX XX%
Pragmatic Skills XX XX% XX XX%
Sum of Standard Scores XX XX
Asperger’s Disorder Quotient XX XX% XX XX%
Asperger’s XXXX Probable Asperger’s XXXX Probable
The following items were rated frequently observed in each of the following categories:
Social Concerns Identified:
· Is inattentive to social/environmental stimuli
· Has difficulty cooperating in a group
· Has difficulty playing with other children
· Seems unaware of social conventions or codes of conduct
· Lacks empathy (Understanding how others feel)
· Needs an excessive amount of reassurance if things are changed or go wrong
· Lacks subtlety in expression of emotion (shows distress or affection out of proportion to the situation)
· Requires specific instruction to begin tasks
· Becomes frustrated quickly when unsure of what is required
Restricted Patterns of Behavior Subscale:
· Stares or looks unhappy or unexcited when praised, humored, or entertained
· Is unaware of or insensitive to the needs of others
· Demonstrates eccentric forms of behavior
· Has preoccupation with specific subjects or objects that is abnormal in intensity or focus
· Requires extensive directions from others
· Expresses feelings of empathy inappropriately
· Displays clumsy or uncoordinated gross motor movements
· Exhibits unusual, uncoordinated movements when walking or running
Cognitive Patterns Subscale:
· Talks about a single subject excessively
· Displays superior knowledge or skill in specific subjects or activities
· Uses exceptionally precise or pedantic speech
· Attaches very concrete meanings to words
· Has difficulty understanding jokes or humor
· Shows excellent memory
· Shows an intense, obsessive interest in certain intellectual subjects
Pragmatic Skills Subscale:
· Has difficulty understanding slang expressions
· Has difficulty identifying when someone is teasing
· Has difficulty understanding when he or she is being ridiculed, put down, or made fun of
· Has difficulty understanding what causes people to dislike him or her
· Fails to predict probable consequences in social events
· Has difficulty making believe or pretending
· When confused, doesn’t ask for clarification but switches to a familiar topic
Gilliam Autism Rating Scale (GARS-2)
The Gilliam Autism Rating Scale-2 (GARS-2) is a 42 item norm referenced screening instrument used for the assessment of individuals ages 3-22 who have severe behavioral problems that may be indicative of autism. Its purpose is to help professionals identify Autism Spectrum Disorders, but in a school setting, it is used to help educational teams determine whether a child may meet MN State Educational Criteria for receiving special education services under the Autism Spectrum Disorder category. It is important to clarify that this is not a medical diagnosis, but rather a category to receive special education services. The GARS-2 gathers information about specific characteristics typically noted in children with autism spectrum disorders in three areas (Stereotyped Behaviors, Communication, and Social Interaction) and it contains a developmental history. The GARS-2 was normed entirely of individuals diagnosed as autistic. Standard scores and percentiles are provided and the likelihood of autism can be determined.
Educational staff at XXXX School and XXXX’s parents completed the GARS-2.
The results were as follows:
HOME Rating
Rater: XXX Name Standard Score %ile Standard Score %ile
Stereotyped Behaviors XX XX% XX XX%
Communication XX XX% XX XX%
Social Interaction XX XX% XX XX%
Sum of Standard Scores XX XX
Autism Index XX XX% XX XX%
Probability of Autism is Unlikely, Possibly, Very Likely.
SCHOOL Rating
Rater: XXX Name Standard Score %ile Standard Score %ile
Stereotyped Behaviors XX XX% XX XX%
Communication XX XX% XX XX%
Social Interaction XX XX% XX XX%
Sum of Standard Scores XX XX
Autism Index XX XX% XX XX%
Probability of Autism is Unlikely, Possibly, Very Likely.
Note: On this tool, if the subject’s Autism Index is 85 or above, the person is very likely autistic, and if the Autism Index is 70-84, the person is possibly autistic. Autism Indexes of 69 or less indicate that the person is unlikely to be autistic.
The following items were rated frequently observed in each of the following categories:
Stereotyped Behaviors Identified:
· Avoids establishing eye contact, looks away when eye contact is made
· Stares at hands, objects, or items in the environment for at least 5 seconds
· Rapidly flicks fingers or hands in front of eyes for periods of 5 seconds or more
· Eats specific foods and refuses to eat what most people will usually eat
· Licks, tastes or attempts to eat inedible objects
· Smells or sniffs objects
· Whirls, turns in circles
· Spins objects not designed for spinning
· Rocks back and forth while seated or standing
· Makes rapid lunging, darting movement when moving from place to place
· Prances (walks on tiptoes)
· Flaps hand or fingers in front of face or at sides
· Makes high-pitched sounds or other vocalizations for self-stimulation
· Slaps, hits, or bites self or attempts to injure self in other ways
Communication Behaviors Identified:
· Repeats (echoes) words verbally or with signs
· Repeats words out of context
· Repeats words or phrases over and over
· Speaks or signs with flat tone or with dysrhythmic patterns
· Responds inappropriately to simple commands
· Looks away or avoids looking at speaker when name is called
· Does not ask for things he or she wants
· Does not initiate conversations with peers or adults
· Uses “yes” and “no” inappropriately
· Uses pronouns inappropriately
· Uses the word “I” inappropriately
· Repeats unintelligible sounds over and over
· Uses gestures instead of speech or signs to obtain objects
· Inappropriately answers questions about a statement or brief story
Social Interaction Behaviors Identified:
· Avoids eye contact; looks away when someone looks at him or her
· Stares or looks unhappy or unexcited when praised, humored, or entertained
· Resists physical contact from others
· Does not imitate other people when imitation is required or desirable, such as in games or learning activities
· Withdraws, remains aloof, or acts standoffish in group situations