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Saint Paul Public Schools
ASD MINI-GUIDE APPENDIX
ASD Parent Interview/Developmental History
(A 1-4)
ASD Parent Interview- Reevaluation
(B 1)
ASD Parent Interview/Developmental History- Example
(C 1)
ASD Teacher Interview and Questionnaire- Preverbal Students
(D 1-2)
ASD Teacher Interview-Elementary
(E 1-4)
ASD Teacher Interview and Questionnaire- Secondary Students
(F 1-4)
ASD Structured Student Interview
(G 1-2)
ASD Observation Form 1
(H 1)
ASD Observation Form 2
(I 1)
ASD Observation Form 3
(J 1-2)
ASD Observation –Examples
(K 1)
ASD ESR Example
(L-1)
Saint Paul Public Schools
ASD Parent Interview/Developmental History-Initial Evaluation
Student: ______________________________________________Birthdate:_______________
Parent/Caregiver:__________________________________________________
CURRENT CONCERNS: What are your current concerns?
DEVELOPMENTAL HISTORY:
1. Is there a family history of developmental or learning issues?
2. Did you have any concerns during your pregnancy (toxemia, seizures, diabetes)?
3. Any health concerns or hospitalizations during infancy or early childhood (feeding issues, respiratory
distress, seizures, failure to thrive, jaundice, etc)?
4. Does your child have a medical diagnosis? Hospitalizations? Any current health concerns (seizures,
asthma, allergies, lead poisoning, etc)? Medications?
5. When did you first notice that your child’s development seemed different from other children?
Describe any concerns you had prior to age four.
6. At what age did your child
______ Use single words?
______ Speak in short sentences?
_____ Walk independently?
_____ Become toilet trained?
7. Did your child ever stop talking? If yes, at what age? For how long?
8. Did you notice concerns regarding your child’s vision? (general vision problems, eye contact,
intense interest in mirrors/lights, holds objects close to eyes, stares off into space, unusual visual
interest such as spinning or studying objects)
9. Did you notice concerns regarding your child’s hearing? (failed screening, ear fluid/infections,
concern about hearing impairment/deafness, covers ears when hearing everyday sounds, seems to
hear better on some days)
10. Have you had any concerns regarding his or her motor skills? (awkward, delays in gross motor
skills/ fine motor tasks, repetitive motor behaviors/spinning and finger posturing)
A-1
SOCIAL INTERACTION:
1. Do you currently have any concerns about your child’s behavior or social skills? If yes, what are your
concerns? At what age did you first have concerns about your child’s social skills?
2. How would you describe your child’s ability to play/interact with other children his or her age?
(initiating, playing parallel, perseverative interests)
3. Does your child have more difficulty making and keeping friends when compared to other children of
your child’s same age?
4. What types of activities does your child enjoy participating in? Does your child show an interest in
being with other children? Does your child prefer interacting with adults?
5. How does your child express his/her emotions and feelings? Does your child use a typical range of
facial expressions that are appropriate for the situation?
6. What calms your child down? Does your child seek you out for comfort when tired, upset or sick?
7. Does your child understand basic safety rules and concepts for his/her age? Does your child need
more or the same amount of supervision than other children his/her age need?
COMMUNICATION
1. Is your child currently able to use their finger to point to something or to request something?
2. If you give your child one direction at a time, can he/she follow the direction? Can he/she follow a
series of directions? Give examples.
3. How does your child communicate at home?
4. How does your child initiate conversations with family members? With adults? With other children?
5. Does your child
_____ greet others
_____ respond to greetings
_____ make requests,
_____ describe events
_____ comment on activities
_____ share information about thoughts/interests/feelings
_____ ask for help
A-2
6. Does he or she appropriately carry on back-and-forth conversation with other people?
7. Does your child changes intonation and pitch appropriately during conversations?
8. Does your child’s voice sound like it lacks emotion or sounds monotone or has a melodic vocal (singsong) intonation? Speak using an unusual volume or pitch?
9. What gestures does your child use? (nod, wave, point, etc.)
10. Does your child have difficulty understanding nonverbal cues such as facial expressions or changes
in vocal tone? Give an example.
11. Does your child repeat phrases or sentences heard in the past that have little or no relationship to
the current situation?
12 Does your child ever pull you to a desired item or use your hand as a tool instead of talking?
13. Do you notice anything unusual about your child’s language skills? (mixing up pronouns, persisting
on certain topics, repeating scripts from television shows, etc.)
RESTRICTED, REPETITIVE, OR STEREOTPYED BEHAVIOR/INTERESTS/ACTIVITIES:
1. Have you noticed differences in how he or she responds to touch, sound, smells, or light? (licks,
smells, sniffs inedible objects)
2. Do you have any concerns about your child’s eating? (unusual cravings, picky eater, restricted
preferences?
3. Are there unusual behaviors that seem different from other children? (flapping arms, walking on tiptoes or in circles, rocking, rapid lunging, obsessed with routines, self-abusive behavior)?
4. Describe your child’s favorite activities. What holds your child’s attention? Does your child initiate
these activities independently?
5. Do you have concerns about your child’s activity level or attention span?
A-3
6. Does your child have any interests that seem unusual for his/her age or seem unusual in intensity?
7. Are there any unreasonable fears or unusual reactions to situations?
8. How does your child react to changes in daily routine or schedule? (appears anxious, easily upset,
adjust if prepared ahead of time, responds negatively or with tantrums when given
commands/requests/directions)
9. Does he or she appear overly concerned with order and routine in his/her play or daily activities (i.e.,
lining things up, needing things in a certain order)
10. Does he or she seem more interested in the parts of toys or objects than the actual toy?
11. Does your child frequently engage in one-sided conversations about favorite topics?
12. What kind of assistance does your child need in performing daily tasks? (dressing, bathing, taking
care of belongings, playing with friends)
SKILL ACQUISITION: Does your child have difficulty learning new skills?
Does your child demonstrate any unusual or seemingly advanced skills?
OTHER: Is there any other information that might be helpful to share?
Source: 2006 Supplement to “Promising Practices for the Identification of Individuals with Autism Spectrum Disorders”.
A-4
Saint Paul Public Schools
ASD Parent Interview- Reevaluation
Student: _________________________________________________Birthdate:_______________
Parent/Caregiver:__________________________________________________
Tell me about your child and any current concerns:
SOCIAL INTERACTION:
1. Describe your child’s current social interaction skills.
2. How would you describe your child’s ability to play/interact with other children? Adults?
3. What activities does your child enjoy participating in?
COMMUNICATION:
1. Tell me about your child’s current communication skills.
2. Does your child use gestures? Understand nonverbal cues?
3. Do you notice anything unusual about your child’s language skills?
BEHAVIORS/INTERESTS/ACTIVITIES:
1. Describe any behaviors that are different from other children (flapping/toe walking/unusual
interests/unusual fears).
2. How does your child react to changes in routine or schedule?
3. Does your child seem overly concerned with order and routine?
4. Any concerns about how your child reacts to touch, sound, smells, or light?
OTHER:
Is there any other information that might be helpful to share?
Source: 2006 Supplement to “Promising Practices for the Identification of Individuals with Autism Spectrum Disorders”.
B-1
Saint Paul Public Schools
ASD Parent Interview/Developmental History –Example
(Student)’s mother was interviewed regarding (Student)’s early development and current functioning
related to behaviors consistent with an Autism Spectrum Disorder. There is a family history of learning
difficulties and attention problems. His mother’s main concerns include (Student)’s social interaction,
language delay, and repetitive behavior.
Developmental History:
In the area of prenatal and early development, no concerns were noted during pregnancy or early
infancy. He seemed to enjoy being held as an infant. (Student) did not “try out his voice” or babble
like other infants. He began speaking in single words at age 5 and in phrases at age 6. No regression
in language skills was noted. (Student) used gestures to try to communicate, and his parents tried to
figure out what he wanted. His parents were concerned about his hearing and vision at a young age,
but screening results were normal. (Student) tended to appear clumsy as a young child, and he began
walking at age 18 months. In addition, (Student) would line up his toys and was overly interested in
toys that fly. He had significant difficulty with changes in routine as a preschooler.
Social Interaction:
In the area of social interaction, concerns were first noted at age 2 years. (Student) did not attempt to
engage or please parents as a young child. His mother describes him as a loving child, although he
does not express a wide range of facial expressions. He has a history of difficulty relating to others and
developing friendships. His interaction with peers is limited, and he is able to play next to peers, but not
with them.
Communication:
In the area of communication, (Student) currently speaks in phrases and short sentences. He has
difficulty finding the right word. He is able to follow a one step direction. He has difficulty engaging in
conversations with peers and is better able to engage adults in conversation. He tends to speak in a
monotone voice. She noted that (Student) sometimes gets too close to peers and say something from
a movie. He seems to have difficulty understanding the nonverbal cues of others. He shares little
information about his thoughts and feelings.
Restricted Patterns of Behavior:
In the area of restricted and stereotyped behavior, interests, and activities, (Student) likes to watch the
same videos over and over again. He repeats sections that are very scary or interesting. He is
sensitive to loud noises and may cover his ears. (Student) continues to have difficulty with changes in
routine, and he becomes anxious. He started to memorize written words at 5 years of age, but did not
seem to learn the meanings. His mother also noted that (Student) has difficulty learning new things,
such as learning how to ride a bike.
Summary:
Results from the parent interview indicate an early pattern of concerns related to social interaction,
communication skills, and repetitive behavior. The parent reported continued concerns in the areas of
peer interaction, conversational skills, sensory sensitivities, difficulty with changes in routine, and
restricted interests.
C-1
Saint Paul Public Schools
ASD Teacher Interview and Questionnaire
Preverbal Students
Student: _______________________________________
Date: ______________
Teacher: ______________________________________
Qualitative Impairment in Social Interaction:
1. When others approach the student how does he/she react? Does he attempt to involve others
when he/she is playing? Does the student ever actively avoid other children or adults? Does the
student watch you as you walk into the room?
2. Does he show preferences for certain adults or children? Does student show enjoyment of
these interactions?
3. Does he/she ever show you things? Does the student ever want you to share in his/her
enjoyment of something? What kinds of things may make the student excited?
4. Does the student’s facial expressions/emotional reactions usually seem appropriate to the
particular situation as far as you can tell? How does the student show feelings? Does the
student ever seek out comfort from others if he is sad, hurt, or ill?
5. How does the student let you know he/she wants help or to gain your attention?
Qualitative Impairment in Communication:
1. Does the student spontaneously point/reach at things around him? How about other common
gestures? (shake head yes or no, etc.)
2. Does student wave goodbye or any other common gestures? (e.g. clapping, blowing kiss, etc.)
3. Any examples of imitation of adult actions?
4. Does student make any sounds to be sociable or friendly, rather than because he/she wants
something?
D-1
Restricted, Repetitive, or Stereotyped Patterns of Behavior:
1. Are there things that the student seems to have to do in a particular away or order? How does
the student react if unable to complete a whole sequence or is disrupted during the course of
his/her actions?
2. Does the student have any odd ways of moving his/her hands or fingers? Do they interfere with
getting things done and what happens if you try to get him/her to stop? Any circumstance in
which this behavior increases?
3. Are there any complicated movements of the whole body (e.g. spinning, arm flapping, bouncing,
rocking)? Does this interfere with other activities and what happens if you try to stop him/her?
4. How does the student play with toys and objects? Are objects used as they are intended or is
the focus on parts of the object? Does the student ever collect or gather certain sorts of objects?
Does he/she ever line things up or do the same thing over and over with them?
5. Does the student seem particularly interested in the sight, feel, sound, taste, or smell of things?
6. Does the student have any sensitivity to certain clothing, textures or temperatures?
Related Questions:
1. How does the student handle transitions throughout the day? Do transitions need to be
announced?
2. How does the student handle changes in the daily routine? What if the environment is changed
or imperfect?
3. What is motivating to the child? Any particular likes and dislikes?
Source: 2006 Supplement to “Promising Practices for the Identification of Individuals with Autism Spectrum Disorders”.
D-2
Saint Paul Public Schools
ASD Teacher Interview –Elementary Students
Student: ________________________________________________
Date: ______________
Teacher: _______________________________________________
Qualitative Impairments in Social Interaction
1. How does ____ interact/ play with other students his own age when there are more than two
together? What does the interaction look like? Is imaginative play present? Would he/she ever
initiate the contact? Engage in parallel play (plays near or next to other children, but not actively with
other children)?
2. When others approach ____ how does he/she react? Does he/she ever actively avoid other
children? Does he/she appear uninterested in other children? Does he/she prefer to play alone?
3. Does ___ have any particular friends or a best friend? Does he/she have more difficulty making and
keeping friends when compared to other children the same age?
4. Does ____ show you things that interest him/her? Offer to share things with you or other children?
Does ____ever seem to want you to share in his/her enjoyment (smile to show pleasure)?
5. Does ____’s facial expressions/ emotional reactions usually seem appropriate to the particular
situation? How does he/she show feelings? Does he/she show a limited range of facial expressions?
Does he/she ever try to comfort others if they are sad, hurt, or ill? Does he/she appear not to
understand the feelings of other people? Does he/she understand nonverbal communication (ie,
gestures, facial expressions of emotion)?
6. How does _____let you know he/she wants to gain your attention? Does he/she ask for help
appropriately? Does he/she look directly at a person when someone is trying to attract his/her
attention? Does he/she look you directly in the face when doing things with you or he/she is talking
with you?
E-1
Qualitative Impairment in Communication:
1. Does _____spontaneously point at things around him/her? How about other common gestures (to
elicit help or attention)? Shakes head yes and no? Does he/she avoid looking at others when his/her
name is called? How does ____ask for things he/she wants (or does he/she avoid doing this)?
2. Does _____engage in pretend games or play? How about imaginative play or his/her ability to make
up stories?
3. Would _____ever talk with you just to participate in some form of conversation? Does he/she
initiate conversation with peers or adults? If not asked a direct question will he/she build on the
conversation? Does he/she carry on a back and forth conversation with other people?
4. Can____bring up appropriate / variety of topics in conversation? Does he/she engage in one sided
conversations about his/her favorite topics? Are there times when he/she uses socially inappropriate
questions or statements (i.e., asking personal questions or making comments at awkward times)?
5. Has___ever tended to use rather odd phrases or say the same thing over and over in almost the
same way? If yes, what happens if you interrupt him/her or refuse to comply?
Any examples of echolalia or delayed echolalia (repeating what you or others say, or repeating what
he/she has heard from a movie, song) ?
6. Does ____ ever use words that he/she seems to have invented or make up by himself/herself?
Does he/she ever put things in odd, indirect ways or have “idiosyncratic” ways of saying things such as
“hot rain” for “steam”?
7. Has ____ever got his personal pronouns the wrong way around (i.e., “you want a drink” instead of “I
want a drink”)?
8. Does____understand figurative language, idioms, inferences?
9. Is there anything unusual about his/her speech or intonation? Please describe.
____speaks consistently too loud or too soft
____speaks in an unusual rate or rhythm
____speaks with an odd intonation or pitch, or in a monotone
_____repeats sentences or phrases in a monotone or same tone of voice
E-2
Restricted, Repetitive or Stereotyped Patterns of Behavior:
1. Does ____have any special hobbies/interests that are unusual in their intensity? Does he/she share
this interest with others? Does it seem at all compulsive? Does it interfere with his/her doing things?
2. Are there things that ___seems to have to do in a very particular way or order, that is, rituals that
he/she has to do or has to have you do (i.e., putting things in special places/order)? How does he/she
react if unable to complete whole sequence or is disrupted during the course of his/her actions?
3. Does____have any odd ways of moving his/her hands or fingers (i.e., flicking fingers in front of eyes,
flapping hands)? Do they interfere with getting things done and what happens if you try to get him/her
to stop? Any circumstances in which this behavior increases (i.e., stress)?
4. Any complicated movements of his/her whole body (i.e., spinning, repeatedly bouncing, arm flapping
while rocking)? Does this interfere with other activities and what happens if you attempt to stop
him/her?
5. How does ___ play with his/her toys or objects around him? Are objects used as they are intended
or is the focus on parts of the objects? Does he/she ever collect or gather together certain sorts of
objects? If yes, what does he/she do with them? Does he/she ever line things up or do the same thing
over and over with them?
6. Does ___ seem particularly interested in the sight, feel, sound, taste, or smell of things or people?
Examples may include: sniffing objects, feeling the texture of things, looking at things for long periods
of time, licking or tasting objects to see how they feel or taste. Any hypersensitivities to the
environment/clothing?
E-3
School Related Questions:
1. How does ____handle transitions throughout the school day (i.e., activity to activity, room to room)?
What if transitions are announced? Can he/she follow the daily schedule? Is a visual needed?
2. How does ____follow verbal directions? Do you need to often repeat directions and visually show
him/her what needs to be done? How is his/her ability to attend during school? Is he/she able to
quickly shift attention to new task?
3. What is motivating to ____? Any particular likes and dislikes? Unusual fears?
4. Is ___ able to complete tasks (i.e., at her/skill level) independently? Any advanced skill areas?
5. Are there any significant behavioral concerns? Safety concerns?
Source: 2006 Supplement to “Promising Practices for the Identification of Individuals with Autism Spectrum Disorders”.
E-4
Saint Paul Public Schools
ASD Teacher Interview and Questionnaire-Secondary Students
Student: ________________________________________________
Date: ______________
Teacher: _______________________________________________
Directions: Many questions can be answered with a YES or NO. Feel free to give specific behavior
examples. Please check all that apply when given multiple-choice answers.
Qualitative Impairment in Social Interaction:
1. When interacting with other students his/her own age does the student initiate the contact?
2. During passing times between classes or before class starts, does the student converse with peers?
What does his/her behavior look like during this time?
3. When asked to work within a small group on an assignment is the student able to actively participate
with peers?
4. Does the student offer to help peers?
5. Does the student have a best friend or does he/she associate with a peer group? Does the student
“hang out” and socialize with others?
6. Are they any concerns with the student being teased by peers or difficulties with being accepted by
his/her peer group? Is the student typically alone or with peers? Are there any behaviors that interfere
with developing same-age friendships?
7. Does the student share his/her interests with others or share enjoyment with peers or teachers? Has
the student been able to share humor with others?
8. When interacting with others do the student’s facial expressions match the social situation?
9. Can you identify by the student’s facial expression and nonverbal behaviors when he/she is happy,
angry, anxious?
10.Does the student appear aware of the moods of others around him/her by reading the nonverbal
cues of others?
F-1
Qualitative Impairment in Communication:
1. When approached by peers and adults does the student respond to direct questions? Does the
student ask another question to keep the conversation going?
2. How does the student let you know he/she wants help in the classroom?
a.
b.
c.
d.
e.
____ Raises hand
____ Move to where the adult is to seek out help
____ Sits passively and waits for the adult to address them
____ Verbal request without raising hand
____ Other (please describe)
3. Which of the following nonverbal behaviors does the student consistently use:
a.
b.
c.
d.
____ Spontaneously points at items in the environment
____ Shakes his head to indicate “yes” and “no”
____ Establishes eye contact when speaking to others
____ Uses hands while talking (gestures)
4. When asked to write a creative story or to use imagination within an assignment is the student
successful?
5. Does the student demonstrate understanding of the following?
a.
b.
c.
d.
____ Figurative language
____ Idioms
____ Inferences
____ Have not observe/not enough information
6. Is the student able to talk about a variety of topics in conversations?
7. Is the student able to stay on topic during class discussions?
8. Is there ever a need to interrupt the student from continuing to talk because they have missed
the cue to stop?
9. Does the student use any of the following speech and language patterns?
a. ____Tending to use odd phrases or saying the same thing over and over in almost the
same way
b. ____ Echolalia (exact repetition speech)
c. ____ Delayed echolalia (exact repetition speech produced at a later time)
d. ____ Idiosyncratic speech
e. ____ Use of formal speech or unusual advanced vocabulary
f. ____ Inconsistent or incorrect pronouns
F-2
Restricted, Repetitive, or Stereotyped Patterns of Behavior:
1. Does the student have any special hobbies or interests that are unusual in their intensity or
unusual for his/her age? Does he/she share this interest with others? Does it seem at all
compulsive or does it interfere with his/her doing things? Please describe.
2. Are there things that the student seems to have to do in a very particular way or order, that is,
rituals that he/she has to do? Are there things that he/she insists YOU as the teacher do in a
specific way or order? How doe the student react if he/she is unable to complete the whole
sequence or is disrupted during the course of his/her actions? Please explain the behavior.
3. Any odd ways of moving hands or fingers?
4. Any complicated movements of his/her whole body (spinning, rocking, flapping)?
5. Does the student ever collect or gather certain objects? Does he/she ever line things up or do
the same thing over and over with them?
6. Does he/she seem particularly interested in the sight, feel, sound, taste, or smell of things?
a.
b.
c.
d.
e.
f.
g.
h.
i.
____ Sniffing objects
____ Feeling the texture of things
____ Looking at things for long periods of time
____ Licking or tasting objects to see how they feel or taste
____ Hypersensitivities to the environment/clothing
____ Comments on changes in the environment
____ Dislike of being too close to others
____ Frequently fidgeting
____ Staring
School Related Questions:
1. What is the student’s ability to handle transitions throughout the school day?
a.
b.
c.
d.
e.
____ Same as peers
____ Occasionally needs additional time
____ Occasionally needs additional cues
____ Consistently needs warning of upcoming transitions
____ Needs significant adult support
2. Is the student distressed by changes during the school day? What might cause the student
distress?
a.
b.
c.
d.
____ Pop quiz
____ Substitute teacher
____ Changes in the room arrangements
____ Working in new groups
F-3
e. ____ Unpredictable change in schedule
f. ____ Favorite items not available
3. Which of the following describes the student’s ability to follow directions?
a.
b.
c.
d.
e.
____ Same as peers
____ Requires directions repeated
____ Requires visual demonstrations
____ Needs directions to be broken down
____ Additional processing time needed
4. Is the student able to complete tasks within the classroom (at skill level) independently?
5. Able to complete homework assignments at a passing grade level?
6. Any differences between the student’s performance on tests versus written assignments?
7. Is the student able to independently use and follow organizational strategies for your class?
8. Does the student manage materials required for class?
*Adapted Minneapolis Citywide Autism Services—9/06
F-4
Saint Paul Public Schools
ASD Structured Student Interview
Student: ________________________________________________
Date: ______________
Directions: This is an interview designed to elicit response from a student that may help an evaluator
understand how the student thinks about things. This is not a diagnostic tool; it is an informal interview.
If used for initial evaluation purposes, this tool should be accompanied by teacher and parent
interviews, as well as additional standardized ASD checklists.
(When interviewing, note any odd speech patterns)
1. What is your favorite thing to talk about?
2. Do you have a best friend?
3. What is one thing you really like about your best friend?
4. What do you do with your best friend? Do you two talk on the phone, text message or email each
other? Ever sleep over?
5. Name one thing your best friend thinks is really important. One thing he/she thinks is really funny.
(Is the student using emotional language? Are his thoughts about friendship at age level or younger?)
6. What is an important rule in your school? Why do you think school needs rules?
7. Tell me something that really makes your teacher mad. Why do you think that would make her/him
mad?
8. How can you tell when your teacher is mad?
9. What is the best thing about school?
10. What is the worst thing about school?
(Remember to share something about yourself and wait for the student to ask you more about it or
expand on what you say)
G-1
11. Who do you usually eat lunch with?
12. Have you ever had trouble getting along with other people?
13. Have you ever tried to make things go better for you with other people? How did it work?
14. What is the most frustrating thing about adults? What about people your own age?
15. Do you ever want to get married? Why do you think people would want to get married?
16. What would you like to be when you grow up, or what kind of job would you like to have? What are
some of the things you will need to do to make that happen?
17. Have you ever been teased? What kind of things have you been teased about?
18. What kind of things make you really mad at school? What do you usually do when you get mad?
Does that work?
19. Why do you think it is important to look at someone when you are talking to them? What is the
hardest thing about doing that?
20. If you had 3 wishes for your friends (classmates) for things that they would really want, what would
they be?
21. Solve this situation: You come home from school and you go into the kitchen and you find your
mother crying. What would you do? Why would you do that?
Notes about the interview:
G-2
Saint Paul Public Schools
ASD Observation -Form 1
Student: ___________________________________ Observer: _________________________
Date: _____________________________________ Time: ____________________________
Setting:____________________________________ Students Present: ___________________
Activities:__________________________________ Adults Present: _____________________
Social Interaction: (Watching, responding, initiating & maintaining interaction with others; use of eye
contact; facial expressions directed toward others; joint attention; understanding of social situations;
showing/bringing things to others to express interest; etc.)
Communication: (Use of gestures, facial expression, and vocalization; language directed towards
others and for what purpose; shared enjoyment; unusual use of language; ability to maintain
conversation; etc.)
Restricted Range of Interests & Behaviors: (Choice of activity- solitary or social; unusual use of
objects; unusual use of body; imaginary play; reaction to sensory stimuli, response to change; etc.)
H-1
Saint Paul Public Schools
ASD Observation Form-2
Child_______________________________________ Parent/Caregiver ____________________
Date______________ Place________________________ Time____________________
Observer__________________________________________________
Activity observed_________________________________________________________
0-5
minutes
6-10
minutes
11-15
minutes
16-20
minutes
TOTAL
Target behaviors:
Notes:
I-1
Saint Paul Public Schools
ASD Observation -Form 3 (pg. 1 of 2)
Student: ____________________________
Observation Date and Time: ___________________
Location (in school) of observation: _______________________
Review the following behavioral examples prior to completing the observation. Check behaviors
observed and include comments regarding other behaviors noted. This is not an exhaustive list and is
to be used only in conjunction with a comprehensive educational evaluation.
SOCIAL INTERACTION
_____Fails to look at people when conversing
_____Avoids eye contact when walking by people
_____Fails to look up when addressed
_____Watches people out of corner of his/her eye
_____Touches others inappropriately
_____Stands too close or too distant from others when interacting
_____Enters private spaces or joins groups (lunch, recess) without permission
_____Facial expressions do not fit emotional state
_____Face is blank when being reprimanded
_____Does not smile back when smiled at
_____Appears unable to empathize
_____Uses poor manner when eating or drinking
_____Has difficulty understanding social rules and etiquette
_____Lacks common sense in peer interactions
_____Seems tactless
_____Does not seem to follow the, “hidden social curriculum”
_____Avoids other students, withdraws from the group, isolates self
_____Minimal participation in group activities
_____Does not imitate others when unsure of what to so in a social setting
_____Difficulty learning and following rules of games
Other observations related to social interaction:
COMMUNICATION
_____No verbal communication
_____Uses other’s hand to gesture or communicate
_____Lack of eye contact with others
_____Does not point to express interest
_____Inattentive to voices
_____Does not read cues regarding desire of other people to converse or not
_____Does not pick up, “your turn” to talk signals
_____Speaks too fast or too slowly for situation
_____Choice of conversation topics is inappropriate to situation
_____Speaks too softly to be heard easily
_____Speaks too loudly for situation
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ASD Observation -Form 3 (pg. 2 of 2)
COMMUNICATION (continued)
_____Tone of voice does not fit emotional state or situation
_____ Hand gestures are poorly timed with speech content
_____Mumbles when speaking or speaks in monotone; flat affect
_____Lacks understanding of abstract language (sarcasm, idioms, humor)
_____Thinks in concrete terms, interprets information literally
_____Immediate or delayed echolalia
_____Confuses word order
_____Difficulty processing language, following directions
_____Difficulty maintaining a topic
_____Limited range of conversational topics
_____Difficulty initiating conversation with adults
Other observations related to communication:
RESTRICTED, REPETITIVE OR STEREOTYPED BEHAVIOR PATTERNS/INTERESTS
____Repetitive hand or finger movements
____Staring
____Hypo- or hyper sensitive to touch, sounds, light, tastes
____Unreasonable fears or unusual reactions to situations
____Intolerant of changes in types of clothing
____Smelling, licking or touching objects
____Learns skill in one situation but unable to use skill in another
____Fascination with watching spinning or moving objects
____Distress over changes in environment or schedule
____Insistence on following routines in precise detail
____Persistent discussion about favorite topics
____Unusual/repetitive motor behavior (e.g., hand flapping, toe walking, self-injury)
____Lines up objects (for example, when playing)
____Unusual fixation on parts of objects/toys, rather than on object/toy itself
____Limited use of imaginary play
____Anxiety associated with transitions
____Difficulty with unstructured time
____Walks too fast/too slowly for situation; bolts to leave when class is over
Other observations related to restricted, repetitive or stereotyped behaviors
Sources: Addendum to Promising Practices Manual, Minnesota Department of Children, Families and Learning, 2006;
Dyssemia Rating Scale – edited by Kari Dunn Buron, adopted from the work of Nowicki and Duke; Early Identification and
Intervention for the Spectrum of Autism, developed by the Minnesota Low Incidence Projects .
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Saint Paul Public Schools
ASD Observations -Examples
Observation: Lunchroom
LEARNER was observed in the lunchroom on (date). The focus of observation was on LEARNER’s
social interaction, social communication, and range of interests and activities. In the area of social
interaction, LEARNER was not observed to interact with peers while in the lunch line. After getting his
lunch, he was observed to sit off to the side by himself. LEARNER’s communication skills were also
observed. LEARNER was asked by a staff member if he would like to move over to another table to
join his classmates. He turned away from the adult and did not say anything. He did not initiate any
interactions with peers during the observation. In the area of restricted interests and activities,
LEARNER was observed to follow the routine in the lunchroom appropriately. LEARNER ate his food
from his tray in order from left to right. He appeared to be very particular about peeling his banana and
getting all of the strings off of the banana before eating it. He was able to move through the lunch line
independently, clean up his lunch when finished, and wait at his table to be dismissed. In summary,
results from the observation indicate that LEARNER isolated himself from peers in the lunchroom and
had difficulty initiating and responding in conversation.
Observation: Classroom
LEARNER was observed in his classroom on the afternoon on (date). The focus of observation was on
his social interaction, social communication, and repetitive interests and behaviors. Both large group
instruction and a small group activity were observed. LEARNER’s social skills were observed
throughout the lesson. During the math lesson, the teacher told a story and most of the students were
laughing. LEARNER did not laugh or change his facial expression. During a small group activity,
LEARNER looked away from the peers. In the area of communication skills, LEARNER was observed
to raise his hand. He answered the teacher when called on. He used a monotone voice and varied his
pitch very little when speaking. During the observation, LEARNER was not observed to use gestures.
During the small group activity, LEARNER was observed to initiate and respond to the teacher, but he
did not initiate any interactions with the peers in his group. When a peer initiated an interaction with
him, LEARNER looked away and did not respond. In the area of restricted range of interests and
behaviors, LEARNER was observed to follow the classroom routine during the structured lesson in
math. He got up to turn his assignment into the basket at the front of the room. Results from the
observation indicate that LEARNER has difficulty initiating and responding to peers in conversation.
He also has difficulty using gestures, facial expression, and eye contact to modulate social interaction.
Observation: Home Visit
LEARNER was observed during an activity/home visit from his service provider. The identified
behaviors that were being observed included social interaction skills (shares an activity with an adult,
response to praise, and ability to imitate), communication skills (speech intelligibility, response to verbal
directions, spontaneous speech), and cognitive skills (imaginative play, attention to tasks). At the
beginning of the observation, LEARNER sat on his mother's lap, with his face turned into her. After
several minutes, during which time the adults were talking, LEARNER came over to the service
provider and sat on the floor next to her. He then began to play with various items presented.
LEARNER did not stay with any activity presented for more than one minute. When items were not
preferred, LEARNER turned away and screamed loudly (4 times). LEARNER did copy simple hand
movement games presented by the service provider. When he was given praise, such as "good job!"
and a smile, LEARNER responded with a return smile in 5 of 10 opportunities. LEARNER did not
initiate any speech or conversations, but did respond to verbal interaction with one-word phrases in
4 of 8 opportunities. His speech was only intelligible in context with the activity.
K-1
Saint Paul Public Schools
ASD ESR- Example
Emotional, Social and Behavioral Development Summary:
On the ADOS, LEARNER met the cut off score for an autism spectrum disorder. On the ASRS parent and
teacher rating scale, LEARNER’s behaviors were rated very elevated in the total score area, and in the composite
score areas of social communication and unusual behavior. Previous evaluation resulted in a diagnosis of
Pervasive Developmental Disorder, Not Otherwise Specified. Two observations, parent and teacher interviews,
and developmental history support these results. See the discussion of the core features below which describe
LEARNER’s unique pattern of social emotional skills.
CORE FEATURES OF AUTISM SPECTRUM DISORDERS
In the area of social interaction, LEARNER demonstrates significant impairment. (List examples of indicators
specific to student here) He demonstrated inconsistent eye contact, had limited facial expressions, and has
difficulty maintaining friendships.
In the area of communication, LEARNER demonstrates significant impairment. (List examples of indicators
specific to student here) He frequently shared information about his topics of interest, with little interest in back
and forth conversations. He had difficulty staying on topic and sequencing stories. He demonstrated limited
understanding of nonverbal communication, not recognizing or using facial expressions or body language. He
demonstrated limited creativity and imagination, primarily playing with toys in functional ways only.
In the area of restricted, repetitive stereotyped patterns of behavior, LEARNER demonstrates impairment. (List
examples of indicators specific to student here) He had definite difference in sensory-seeking behaviors per
parent report, and at school, his teacher reported concerns in visual attending. He also has difficulty with
transitions, becomes upset if routines change, and can be obsessed with certain topics or details.
Overall Summary of Results:
LEARNER demonstrates significant impairments in his social-emotional skills, in the areas of social interaction,
communication, and restricted stereotypical behavior patterns. LEARNER demonstrates overall average to low
average ability, with less developed verbal skills. He continues to demonstrate delays in his communication and
in his articulation skills. His fine motor skills, while improved, are still delayed and he demonstrates sensory
processing difficulties.
The student’s educational disability affects his/her involvement in and progress in the general curriculum
or, for preschool children, to participate in appropriate activities in the following ways:
(Include a statement of whether any additions or modifications to the special education and related
services are needed to enable to the student to meet the measurable annual goals set out in the IEP)
LEARNER’s social emotional delays impact his ability to interact with peers and adults to make progress in the
general curriculum. LEARNER’s disability in language will impact his progress in understanding directions,
participating, and answering questions in the classroom.
The student will receive special education services with additions and modifications to meet the following
special education needs: (Tie these needs to the indicators in the core features listed under the social
emotional summary).
1. LEARNER needs to improve his social interaction skills, such as developing and maintaining friendships,
learning to identify a range of facial expressions and understanding the social cues of others.
2. LEARNER needs to develop his communication skills, including following directions containing concepts, story
retell, answering/asking questions, topic maintenance/eye contact/turn-taking, voice volume, rate/sound
production, and sentence structure.
3. LEARNER needs to develop strategies to address sensory needs, such as self-calming techniques and to
increase sustained attention to task.
4 .LEARNER needs to develop skills to accept changes in routines and activities
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