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Checklist for Autism Spectrum Disorder (Susan Mayes, PhD, Penn State College

of Medicine)
Check each item that applies to your child now or in the past. Symptoms 1-30 are checked if any
box under
the symptom is checked. Childs Name
PRO!"MS #$%& SOC$A! $'%"RAC%$O'
!1" Social isolation
withdrawn# aloof# a$oids contact with others# or prefers to play alone rather than with peers
parallel play alon% side but not with peers
difficulty establishin% friendships
!&" 'imited reciprocal interaction
limited social smile or eye contact !looks away# looks throu%h people# looks at speakers mouth#
needs to
be prompted to make eye contact# or does not make eye contact when communicatin%"
limited sharin% and showin% !e.%.# does not show a toy to an adult# seek reco%nition# or share an
experience or accomplishment with others"
excessi$ely ri%id play with peers !dictates play accordin% to his(her peculiar and repetiti$e
interests and rules"
en)oys physical or sensory play with others !e.%.# ticklin%# chasin%" but has limited reciprocal
social
interaction !e.%.# does not play social %ames or %ames in$ol$in% turn takin%"
!3" Self-absorbed
self-absorbed or in own world !e.%.# en%a%es in self-stimulatin% beha$iors# talks to self# or
fantasi*es
excessi$ely about thin%s such as mo$ies or cartoons"
obli$ious to the presence of others or unresponsi$e to the social o$ertures of others
!+" Socially indiscriminate beha$ior
inappropriately talks to or hu%s stran%ers
in$ades personal space !%ets too close to or touches others"
no stran%er(separation anxiety when youn% !not wary of stran%ers or upset if separated from
parents"
socially inappropriate# insensiti$e comments or beha$iors !picks nose in public# asks personal
,uestions"
!-" .roblems with social skills
does not appropriately initiate or sustain peer interaction thou%h may interact well with adults
poor social reasonin% !difficulty understandin% social cues(comments# facial expressions# body
lan%ua%e"
wants to ha$e friends but does not know how to make friends
P"RS"("RA%$O'
!/" Narrow or unusual ran%e of interests and play beha$iors
obsessi$e preoccupations or extreme fixation on thin%s such as certain mo$ies or 01 shows
!reenacts or
watches the same mo$ies o$er and o$er"# computer %ames# letters# shapes# numbers# countin%#
ob)ects
or topics !e.%.# trains# dinosaurs# N2SC23# maps# planes# electricity# 4u-5i-6h# cartoon characters#
etc."
unusual attachment to and holdin% or hoardin% ob)ects !e.%.# small fi%ures# strin%# other"
!7" Stereotyped and repetiti$e play
repetiti$e play !e.%.# excessi$ely lines up# sorts# spins# or throws ob)ects8 opens and closes thin%s
repeatedly8 plays with the same toys without $ariation8 draws the same pictures repeatedly8
other"
disinterest in toys or lack of normal and $aried ima%inati$e play
unusual preoccupation with parts of ob)ects !e.%.# repetiti$ely spins wheels on a toy"
!9" :pset with chan%e
distressed by chan%e !e.%.# chan%e in routine or schedule# parent takes a different car route home
from
school# furniture or childs toys are mo$ed# seasonal chan%e in clothin%# other"
difficulty with transitions !e.%.# from one acti$ity to another"
extreme need to finish what he(she starts
idiosyncratic or rituali*ed patterns !e.%.# drinks only from a certain cup# wears only certain
clothes# insists
that food be arran%ed a certain way on a plate# other"
insists that thin%s be in a certain location or a certain way !e.%.# doors must be closed# coats
*ipped# etc."
insists on doin% thin%s the same way e$ery time
o$erly precise and inflexible# upset if someone breaks a ;rule#< ri%id and literal thinkin%
!=" Stereotypies !unusual repetiti$e mo$ements such as hand flappin% when excited# toe walkin%#
body
rockin%# head shakin%# body tensin%# teeth clenchin%# teeth %rindin% while awake# fin%er
mo$ements# facial
%rimacin%# repeatedly runnin% back and forth# twirlin% or spinnin%# pacin%# playin% with sali$a# sk
in pickin%"
SOMA%OS"'SOR) D$S%*RA'C"
!10" >xcessi$e atypical cra$in% and lo$e of spinnin%# ticklin%# climbin%# rockin%# swin%in%#
bouncin%# )umpin%
!11" :nresponsi$e at times to $erbal input !not react when name called or spoken to# hearin%
,uestione d"
!1&" ?ypersensiti$ity
unusual hypersensiti$ity to some sounds !e.%.# distress or co$erin% ears in response to loud noise#
motors# $acuum cleaner# hair dryer# baby cryin%# sirens# clappin%# alarms# toilet flushin%# people
sin%in%"
unusual hypersensiti$ity to smell# li%ht# or temperature
!13" @istress with commotion or crowds !uncomfortable(anxious in lar%e %roups# theatres#
cafeterias# parties"
!1+" >xtreme fascination with spinnin% or repetiti$e mo$ements !e.%.# re$ol$in% fans# Aheel of
Bortune#
runnin% water"# linear patterns !e.%.# credits on 01# window blinds"# minute details# li%hts# shiny
surfaces
!1-" 2bnormal sensory inspection
excessi$ely smells# mouths# chews# licks# or rubs inanimate ob)ects or surfaces
repetiti$ely $isually scrutini*es ob)ects or fin%er mo$ements close to eyes
places ears a%ainst thin%s that $ibrate or hum or presses ob)ects a%ainst face to an unusual de%ree
!1/" 0actile defensi$eness or extreme dislike ofC
bein% touched or hu%%ed
touchin% certain thin%s or %ettin% hands dirty or sticky
water on self or clothes
ha$in% face washed# teeth brushed# hair combed# or nails cut
walkin% in bare feet
clothin% that is ti%ht# seams in clothes# or certain textures of clothin%
!17" ?i%h tolerance for pain !e.%.# does not cry when hurt or does not respond normally to painful
stimuli"
!19" Sleep disturbance !e.%.# difficulty fallin% asleep# wakin% durin% the ni%ht# wakin% early in the
mornin%"
!1=" Beedin% problems
$ery picky eater# limited food preferences# insists on eatin% only a few foods
hypersensiti$ity to textures !e.%.# lumps in food"
retains food in mouth without swallowin%
eats inedible substances
other peculiar eatin% patterns !e.%.# eats only one brand# color# or shape of a food# other"
A%)P$CA! COMM*'$CA%$O' A'D D"("!OPM"'%
!&0" 'an%ua%e re%ression or slowin% at approximately 1 to & years of a%e !e.%.# speakin% a few
words at one
year but then losin% speech or normal early lan%ua%e de$elopment and later lan%ua%e is delayed"
!&1" 1isual-motor skills !e.%.# assemblin% pu**les# buildin% with 'e%os# operatin% the 1C3"
si%nificantly hi%her
than lan%ua%e skills durin% the preschool years or walkin% at a much earlier a%e than talkin%
!&&" Communication impairment
absent or limited communicati$e speech but %estures to communicate !e.%.# pulls an adult by the
hand
and leads to what wants# hands an ob)ect to an adult for assistance# brin%s a cup to an adult for a
drink"
communicates $erbally with others only when stressed or needin% somethin%
difficulty with reciprocal con$ersational speech !initiatin% and sustainin% con$ersations# listenin%
and
respondin% to what others say"# talks at people# or one-sided con$ersations on topics of interest to
self
!&3" 2typical $ocali*ations or speech
unusual $oice ,uality or modulation !e.%.# hi%h pitch# sin% son% $oice# lack of intonation# etc."
screeches or makes other odd noises !e.%.# %rowls# hums# etc."
unusual repetiti$e $ocali*ations and sounds
idiosyncratic )ar%on as if talkin% in own lan%ua%e
echolalia !inappropriately mimics what others say# such as repeatin% instead of answerin% a
,uestion"
sporadic speech !says a word or phrase once and rarely or ne$er says it a%ain"
excessi$ely recites from mo$ies# cartoons# commercials# etc.
uses rote or memori*ed phrases that are excessi$e# out of context# or not rele$ant
makes pronoun substitutions !e.%.# says ;you< when meanin% ;D<"
excessi$ely repetiti$e speech and ,uestions
idiosyncratic thou%hts and speech !makes up words# nonsensical speech# uni,ue $iews and
perceptions"
!&+" Special abilities that are si%nificantly hi%her than other abilities
exceptional rote memory !e.%.# at an unusually youn% a%e# identifies numbers# letters# shapes#
lo%os# and
colors8 sin%s or hums tunes8 memori*es car routes8 counts8 recites the alphabet8 reads8 spells8 etc."
phenomenal $ocabulary or ability to memori*e mo$ies# books# or factual information
remarkable ability to mimic mo$ie or cartoon characters
outstandin% $isual-mechanical skills !e.%.# at an unusually youn% a%e# assembles pu**les# matches
shapes# operates a computer or 1C3# fi%ures out how thin%s work# complex constructions with
'e%os"
remarkable artistic or musical talent
extremely well-de$eloped %ross motor skills with delayed de$elopment in other areas !in contrast
to hi%h-
functionin% children with autism who often ha$e writin% or coordination problems"
MOOD D$S%*RA'C"
!&-" 6$erreacti$ity# irritability# low frustration tolerance# a%itation# tantrums# meltdowns#
explosi$eness#
a%%ression# or self-in)urious beha$ior !distressed by minor e$ents or occurrences most children can
tolerate# such as intrusions# acti$ity interruptions# proximity# confinement# performance demands#
writin%
tasks# or when thin%s are not the way the child thinks they should be"
!&/" Eoodiness and emotional lability !the cause for mood chan%es may not always apparent#
such as
lau%hter or distress for no apparent reason"
!&7" @ifficulty showin% and reco%ni*in% emotions# emotionally unresponsi$e in some situations#
lack of
empathy or emotional reciprocity !e.%.# does not respond appropriately or pro$ide comfort when
someone is hurt or sad"# or misinterprets the emotions or responses of others
!&9" :nusual fears# such as fear of ele$ators# steps# toilets# balloons# $acuums# tornadoes#
other
PRO!"MS #$%& A%%"'%$O' A'D SA+"%)
!&=" Selecti$e attention# ability to hyperfocus on acti$ities# ob)ects# or topics of interest to self
!e.%.# lines up
toys# spins wheels# watches the same mo$ie# assembles pu**les# builds with 'e%os# or draws
pictures
for lon% periods of time"# but is inattenti$e# impulsi$e# and fid%ety at other times
!30" 'imited safety awareness# fearless# or obli$ious to dan%er !e.%.# unsafe climbin%# wanders
about house at
ni%ht# runs off by self# %oes into traffic or water# walks off with stran%ers"