A Deaf-Appropriate American Sign Language-Based Autism Spectrum Disorder Clinical Diagnostic Tool

Running head: DEAF-APPROPRIATE AUTISM DIAGNOSTIC TOOL 1
A Deaf-Appropriate, American Sign Language-Based Autism Spectrum Disorder Clinical
Diagnostic Tool
Ryanne K. Reddick and Kiersten B. Washburn
Central Michigan University

DEAF-APPROPRIATE AUTISM DIAGNOSTIC TOOL 2
Table of Contents
Disclaimer 3
How to Use This Document 3

Module Selection 3
Working with an Interpreter 4
Adaptation Categories 6
Communication and Lingual 6
Sensory and Medical 6
Cultural 6
Module 1 8
Module 2 11
Module 3 15
Appendix 18
Appendix A - Glossary 18
Appendix B - Visual Appendix 20
Disclaimer
This document and the following ADOS-2 module modifications are not a formalized,
clinically-approved autism diagnostic test. Scoring as it exists in the unadapted ADOS-2 does not
apply to our tool. As such, we emphasize that this is just that: a tool. Our work is intended to be
used to aid administrators in making clinical judgments regarding the diagnosis of autism in Deaf
and native signing children. We understand that, in following our modifications and foregoing
the scoring and standardization of the ADOS-2 as originally created, the test is no longer
technically clinically valid. However, we argue that using the ADOS-2 as-is for testing Deaf and
native signing children, as well as the lack of an appropriate test as a whole, leads to invalid
results, despite however clinical they may be. We would thus prefer for the results to be accurate
and non-scorable than inaccurate but quantifiable. Unless the clinician is certifiably fluent in
American Sign Language, a certified interpreter must be present to aid in administering the test.
We also recommend that all modules be administered by observing and using manual signs in
place of vocalizations for all test takers using a sign system as their primary language. For more
information please refer to our Guideline.
How to Use This Document
Module Selection
Before an ADOS assessment is given, one of five modules must be chosen to be administered.
The selection of standard ADOS modules is based partially on age but primarily on speech
ability (Mood & Shield, 2014). Typically Developing (TD) Deaf children very rarely have
speech capacities equal to TD hearing children, and that disparity may only worsen when
looking at autism in either population (Mood & Shield, 2014). For this adapted version, module
selection will be based on the testee’s American Sign Language (ASL) fluency rather than
speech ability. If a child only signs at a single word level, they should be administered the first
module. Those who sign in simple ASL phrases without a strong demonstrated ability to produce
their own thoughts should be administered the second. Children who sign fluently with
intentional and individual thoughts should be administered the third, and the fourth to
adolescents who do the same (Mood & Shield, 2014). This can be determined using a
combination of resources such as parents, interpreters, and a clinician's own observations during
free play. A modified Social Communication Questionnaire (SCQ) may be used to bolster these
observations and to gain insight into a child’s language patterns that may be indicative of autism
spectrum disorder (ASD) (Shield, 2014). However, the SCQ should not be used as a sole
determinant of ASD in a Deaf child due to its focus on spoken language; modifying the words
“s ay” or “talk” for the word “sign” can be useful for examining linguistic behaviors, but it
undermines the accuracy of the SCQ when used to determine ASD (Shield, 2014, p. 311;
Szarkowski, Mood, Shield, Wiley, & Yoshinaga-ltano, 2014, p. 252). The modified ADOS-2
assessment must not begin until a module has been chosen based on a child’s signed language
proficiency. To determine if the correct module has been chosen, the clinician and interpreter
must work together during the first few activities to decide if the client is being tested at an
appropriate language level.
Working with an Interpreter
An interpreter is tasked with conveying accurate information from an English speaker to a Deaf
client and vice versa. Interpreting is not a mere word-for-word translation from one language to
the other, but instead requires the efficient and correct translation of grammar, context, and
meaning between the two languages. When working with an interpreter, the interpreter should be
positioned next to the English speaker so the ASL user can see both the interpreter, to receive the
language, and the English speaker, to discern body and facial expressions (How to Use an
Interpreter, n.d.). Additionally, interpreters are expected to maintain confidentiality (Leigh &
Andrews, 2017, p. 163; How to Use an Interpreter, n.d.); as such, you can and should provide
information about the evaluation beforehand, including the materials you will be using and, if
allowed, the name of the Deaf client to ensure there is no relational bias (Kirkpatrick, n.d.; How
to Use an Interpreter, n.d.; Working with Interpreters, n.d.). When conducting an evaluation,
speak directly to the Deaf client, not to the interpreter. Speak in your typical manner, using a
first-person perspective (Kirkpatrick, n.d.). Avoid telling the interpreter what to do, such as
asking not to interpret everything you said or saying Tell him or Explain this; the role of the
interpreter is to portray everything you say to the Deaf client as you said it as accurately as
possible (Kirkpatrick, n.d.). Expect the Deaf client to sign back to you rather than turning toward
and signing to the interpreter. Speak at your normal rate, but be sure to allow time for the
language to be properly translated from person to person without rushing into your next topic or
activity (Working with Interpreters, n.d.). Additionally, do not assume that the client inherently
understands what is being signed by the interpreter. Having an interpreter present does not
eliminate confusion or misunderstanding on behalf of the Deaf client, just as speaking to a
hearing person does not mean that person is guaranteed to understand what you are saying
(Working with Interpreters, n.d.). Remember that the interpreter is the lingual connection
between you as a clinician and the Deaf client, and the evaluation should proceed as normally as
possible.
Adaptation Categories
Communication and Lingual
Communication/Lingual adaptations encompass modifying the testing material from
standard verbal English to grammatically and manually correct American Sign Language (ASL).
Simply translating the test from English to ASL is not advised nor entirely accurate, as each
language has its own grammar, syntax, pragmatics, and vocabulary and is not directly reflective
of the other (Shield, Cooley, & Meier, 2017). Translating the English test in ASL also
technically invalidates the test and its results (Shield, Cooley, & Meier, 2017; Brenman,
Hiddinga, & Wright, 2017; Mood & Shield, 2014). Nevertheless, administering the test in the
child’s native language will provide a much more comprehensive picture of the child’s
development if it is used as a clinical tool rather than a test.
Sensory and Medical
Sensory/medical adaptations involve situations where the participant would not be able to
fully complete the task, or the task would be unfair to the participant due to their hearing loss.
Situations may include, but are not limited to, spoken instruction, vocalizations, and materials
that make sound.
Cultural
Cultural adaptations are used when a difference in cultural norms may result in an
incorrect understanding of the task or results. Deaf culture is a full and complete culture that has
its own customs, heritage, artforms, and niceties. Mere translation of the ADOS-2 from English
to ASL does not account for the cultural differences that contribute to differences in
psychopathology among various populations (Brenman et al., 2017). In other words, diagnosing
autism in Deaf children through a lens explicitly built for the oral, hearing world ignores the
linguistic and cultural norms of the signing, Deaf world (Mood & Shield, 2014). Professionals
must understand that there are norms that are unique to the Deaf community that are not standard
in the hearing community. Hearing clinicians may overgeneralize habits in Deaf children,
assuming some behaviors to simply be associated with their hearing loss rather than noticing
when a characteristic is abnormal for a Deaf child to exhibit (Brenman et al., 2017).
Module 1
Activity Suggested Modification Appendix Reference Adaptation Category
Replace the music box with the Glitter Roll

and Music Base/Switch from Enabling
Devices, as it provides both visual and
1 auditory stimulation Sensory/Medical
https://enablingdevices.com/product/glitter
-roll-and-music-baseswitch/
Adjusting the Hierarchy of Presses
Clinician/Interpreter: Sign child's name

sign, first at their peripheral edge, then
moving toward the center of their vision
with each repeated sign, UP TO 4 times
(Mood & Shield, 2014)
Clinician/Interpreter: Use culturally Appendix A

appropriate mode of attention-getting (such Name sign
as waving; tapping on something the child Attention getters
2 is in contact with to create vibrations; Sensory/Medical,
flicking the lights on/off; or stomping with Appendix B Cultural
one foot to create a vibration on the floor; Tapping (Attention Getter)
etc.). Do so without using any physical Waving (Attention Getter)
contact (Mood & Shield, 2014)
Parent/Caregiver: Use culturally

appropriate mode of attention-getting
without using any physical contact
Parent/Caregiver: Do whatever
necessary, including touching the child, to
get him or her to look at the
parent/caregiver
Pay particular attention to the direction of

the eyes and body, as well as to any body
movements to determine if joint attention
has been achieved
Consider using a toy such as the Vibrating

Fiber Optic Light
https://enablingdevices.com/product/vibrati
ng-fiber-optic-light/
• Orient the child’s body toward your

face, if possible
• Up to five attempts should be made to Appendix A
attract the child’s attention toward your Name sign
face (without touching the child) using a Communication/
3 culturally-appropriate attention-getter Appendix B Lingual,
before administering the activity THAT (Directional) Sensory/Medical
• If the child’s attention is NOT obtained, THAT ( Nondirectional)
you should still proceed through the
hierarchy of presses, including activation
of the toy
• Sign “(Child’s name sign), look!” Use
the sign for SEE w ith an exaggerated head
turn. Do not use a directional SEE ( Mood
& Shield, 2014)
• Sign “(Child’s name sign), look at that!”
Use the sign for SEE a nd non-directional
THAT f ollowed by a head turn, UP TO two
Use the sign for SEE f ollowed by a head
turn and directional THAT ( Mood &
Shield, 2014)
• Activate the toy
All prompts, encouragement, and Communication/

4 instruction should be given both visually Lingual,
and auditorily by clinician and interpreter Sensory/Medical



Instead of clapping, use Deaf applause with

a happy expression on face (reinforcement
of celebration) Communication/
8 Appendix B Lingual,
Clinician and interpreter should display Deaf Applause Sensory/Medical
animal noises and actions using a
combination of signs, fingerspelling, and
facial expressions

of celebration) Appendix B Communication/
9 Deaf Applause Lingual,
All prompts, encouragement, and Sensory/Medical
instruction should be given both visually
and auditorily by clinician and interpreter

Module 2

Clinician/Interpreter: Sign child's name

sign, first at their peripheral edge, then
moving toward the center of their vision
with each repeated sign, UP TO 4 times
Clinician/Interpreter: Use culturally Appendix A

appropriate mode of attention-getting (such Name sign
as waving; tapping on something the child Attention getters
2 is in contact with to create vibrations; Sensory/Medical,
flicking the lights on/off; or stomping with Appendix B Cultural
one foot to create a vibration on the floor; Tapping (Attention Getter)
etc.). Do so without using any physical Waving (Attention Getter)
contact (Mood & Shield, 2014)
Parent/Caregiver: Use culturally

appropriate mode of attention-getting
without using any physical contact
Parent/Caregiver: Do whatever
necessary, including touching the child, to
get him or her to look at the
parent/caregiver

4 No suggested modification

Pay particular attention to the direction of

the eyes and body, as well as to any body
movements to determine if joint attention
has been achieved
Consider using a toy such as the Vibrating

Fiber Optic Light
https://enablingdevices.com/product/vibrati
ng-fiber-optic-light/
• Orient the child’s body toward your

face, if possible
• Up to five attempts should be made to Appendix A
attract the child’s attention toward your Name sign
face (without touching the child) using a Communication/
6 culturally-appropriate attention-getter Appendix B Lingual,
before administering the activity THAT (Directional) Sensory/Medical
• If the child’s attention is NOT obtained, THAT ( Nondirectional)
you should still proceed through the
hierarchy of presses, including activation
of the toy
• Sign “(Child’s name sign), look!” Use
the sign for SEE w ith an exaggerated head
turn. Do not use a directional SEE ( Mood
& Shield, 2014)
Use the sign for SEE a nd non-directional
THAT f ollowed by a head turn, UP TO two
Use the sign for SEE f ollowed by a head
turn and directional THAT ( Mood &
Shield, 2014)
• Activate the toy
Layout a variety of Applied Behavior

Analysis (ABA) approved picture cards,
including all the potential objects that the
child may use to get ready for the day (bed,
toothbrush, shoes, backpack, breakfast,
etc.), as well as several other common
objects that should be well known but
likely not used in a daily morning routine
(television, dinner, shower, playground,
etc.). Ask the child to arrange the objects
they use to get ready in the morning for
school/daycare/work. Once they have
7 arranged their routine, ask them to walk Appendix A Communication/
you through the routine step-by-step, Classifiers Lingual, Cultural
explaining what they are doing and how
they use each object to get ready. Examine
their use of classifiers as placeholders and
use of ASL as their linguistic explanations.
Through a combination of grammar
(including miming with classifiers),
vocabulary, and facial expressions, assess
the complexity of the child’s use of various
and overlapping explanation skills. The
focus is less on the accuracy of their
routine and more on their ability to think
about and describe what they do regularly.


Replace the music box with the Glitter Roll

and Music Base/Switch from Enabling
Devices, as it provides both visual and
10 auditory stimulation Sensory/Medical
https://enablingdevices.com/product/glitter
-roll-and-music-baseswitch/

of celebration) Appendix B Communication/
11 Deaf Applause Lingual,
All prompts, encouragement, and Sensory/Medical
instruction should be given both visually



Module 3


Layout a variety of Applied Behavior

Analysis (ABA) approved picture cards,
including all the potential objects that the
child may use to get ready for the day (bed,
toothbrush, shoes, backpack, breakfast,
etc.), as well as several other common
objects that should be well known but
likely not used in a daily morning routine
(television, dinner, shower, playground,
etc.). Ask the child to arrange the objects
they use to get ready in the morning for
school/daycare/work. Once they have
4 arranged their routine, ask them to walk Appendix A Communication/
you through the routine step-by-step, Classifiers Lingual, Cultural
explaining what they are doing and how
they use each object to get ready. Examine
their use of classifiers as placeholders and
use of ASL as their linguistic explanations.
Through a combination of grammar
(including miming with classifiers),
vocabulary, and facial expressions, assess
the complexity of the child’s use of various
and overlapping explanation skills. The
focus is less on the accuracy of their routine
and more on their ability to think about and
describe what they do regularly.


Be familiar with Deaf storytelling norms as

differing from vocalized storytelling, Appendix A
focusing specifically on facial expressions Storytelling in ASL Communication/
7 as grammar Lingual,
Appendix B Sensory/Medical,
All prompts, encouragement, and Role Shifting Cultural
instruction should be given both visually (Storytelling)





Be familiar with Deaf storytelling norms as

differing from vocalized storytelling, Appendix A
focusing specifically on facial expressions Storytelling in ASL Communication/
14 as grammar Lingual,
Appendix B Sensory/Medical,
All prompts, encouragement, and Role Shifting Cultural
instruction should be given both visually (Storytelling)
Appendix
Appendix A - Glossary
Term Meaning
Autism Diagnostic The most commonly used diagnostic tool in modern autism
Observation Schedule 2 evaluations (Mood & Shield, 2014)
(ADOS-2)
American Sign Language The linguistic mode of communication for the Deaf community
(ASL) in the United States with its own grammar, syntax, pragmatics,
and vocabulary distinct from English (Paul, 2009, p. 220-221)
Autism Spectrum Disorder A broad variety of neurodevelopmental variances that contribute

(ASD) to challenges in communication and human interaction (What Is
Autism?, n.d.)
Attention getters Culturally appropriate ways of getting the attention of a Deaf

individual, such as waving, tapping his/her shoulder, lightly
slapping a shared table, stomping your feet, flashing the lights in
the room, or asking a person closer to the Deaf individual to help
you get his/her attention (Vicars, n.d.-c)
Classifiers A grammatical feature of ASL that constitutes specific

handshapes that are used for a general purpose, such as denoting
shape, arrangement, size, and the animation or stationary position
of an object or person (Paul, 2009, p. 229, 231-232)
deaf Spelling used for the audiological diagnosis of a profound

hearing loss (Community and Culture, 2016)
Deaf Spelling used for the cultural and linguistic community aspects of
being deaf, which includes, in the United States, the use of
American Sign Language (Berke, 2019)
Echolalia The repetition of words, sounds, noises, or phrases (Rudy, n.d.)
● Mitigated signed A signed echo that involves changes in movement and direction
echolalia which often result in echoes without clear formation or a clear
object or subject; an indication of imitation more than
comprehension (Shield et al., 2017)
● Partial signed A signed echo that maintains the directionality of the original
echolalia phrase, thus changing the meaning of the sign from its original
intent (Shield and Meier, 2012)
● Pure signed A signed echo that maintains the exact meaning of the original
echolalia phrase, generally by mirroring the original directionality (Shield
and Meier, 2012)
Manual communication Signed or manually-coded gestures utilized as a form of

communication which varies from the official language rules of
ASL (Paul, 2009)
Name sign A signed identifier of a person, typically given to and by an

individual who is involved in the Deaf community (Callis, 2017)
Neologism An invented or made-up sign or phrase, or a family-specific home

sign that is not a true ASL sign (Shield, 2014)
Neurotypical Refers to the population without Autism Spectrum Disorder or

other neurologically atypical diagnoses (Rudy, L. J., 2019)
Palm reversal Occurs when a sign is produced with the palm of the hand facing
opposite from the normal sign position (Shield, 2014)
Storytelling in ASL A visually represented story that utilizes role shifting, classifiers,
facial grammar and more to successfully convey concepts and
details, including characters, a setting, rising events, a climax,
and a resolution (Rayman, 1999, p. 65; Cook, 2011, p. 37)
Theory of Mind The developmental concept that other people have different
thoughts, perspectives, experiences, and plans compared to
everybody else (Mood & Shield, 2014)
Typically developing (TD) Refers to the population without any developmental delays or
diagnoses that may interfere with standard projections of child
development
Appendix B - Visual Appendix
Title Image Description
Deaf Applause A positive facial

expression combined
with hands waving
back and forth
I GIVE YOU (Standard) The sign GIVE

moving from the
signer to the receiver
to accurately say I
GIVE YOU
I GIVE YOU (Echolalic) The sign GIVE

moving from the
receiver to the signer
to say YOU GIVE ME
as an inaccurate
partially signed echo
Palm Orientation (Tuesday) A T handshape with

the palm facing the
signer
Palm Orientation (Bathroom) A T handshape with

the palm facing the
receiver
Role Shifting (Storytelling) A shift in body

position to represent
two different
characters or
perspectives; a role
shift may not be this
exaggerated and may
instead be represented
by a slight shift in eye
gaze or facial
direction or
expression
Tapping (Attention Getter) A

culturally-appropriate
attention getter that
involves tapping the
receiver lightly on the
shoulder or arm
THAT ( Standard) The sign LOOK

followed by the sign
THAT t hat is fully
oriented toward the
desired object with an
extended arm
movement,
accompanied by an
eye gaze in the same
direction
THAT (Nondirectional) The sign LOOK

followed by the sign
THAT that is slightly
oriented toward the
desired object without
an extended arm
movement,
accompanied by an
eye gaze in the same
direction
Waving (Attention Getter) A

culturally-appropriate
attention getter that
involves noticeably
waving the hand up
and down to catch the
attention of the
receiver
WH- Questions Facial The sign HOW

Grammar accompanied by
furrowed brows to
indicate that further
information is being
requested
Yes/No Questions Facial The sign WELL

Grammar accompanied by
raised brows to
indicate that a yes or
no answer is being
requested

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Running head: DEAF-APPROPRIATE AUTISM DIAGNOSTIC TOOL 1

A Deaf-Appropriate, American Sign Language-Based Autism Spectrum Disorder Clinical

Ryanne K. Reddick and Kiersten B. Washburn

Central Michigan University

How to Use This Document 3

information please refer to our Guideline.

How to Use This Document

appropriate language level.

Working with an Interpreter

eliminate confusion or misunderstanding on behalf of the Deaf client, just as speaking to a

Communication and Lingual

Communication/Lingual adaptations encompass modifying the testing material from

development if it is used as a clinical tool rather than a test.

Sensory and Medical

that make sound.

Activity Suggested Modification Appendix Reference Adaptation Category

Replace the music box with the Glitter Roll

Adjusting the Hierarchy of Presses

Clinician/Interpreter: ​Sign child's name

Clinician/Interpreter:​ Use culturally Appendix A

Parent/Caregiver​: Use culturally

Activity Suggested Modification Appendix Reference Adaptation Category

Pay particular attention to the direction of

Consider using a toy such as the Vibrating

Adjusting the Hierarchy of Presses

• Orient the child’s body toward your

All prompts, encouragement, and Communication/

Activity Suggested Modification Appendix Reference Adaptation Category

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

Instead of clapping, use Deaf applause with

Instead of clapping, use Deaf applause with

All prompts, encouragement, and Communication/

Activity Suggested Modification Appendix Reference Adaptation Category

All prompts, encouragement, and Communication/

Adjusting the Hierarchy of Presses

Clinician/Interpreter: ​Sign child's name

Clinician/Interpreter:​ Use culturally Appendix A

Parent/Caregiver​: Use culturally

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

Activity Suggested Modification Appendix Reference Adaptation Category

Pay particular attention to the direction of

Consider using a toy such as the Vibrating

Adjusting the Hierarchy of Presses

• Orient the child’s body toward your

Activity Suggested Modification Appendix Reference Adaptation Category

Layout a variety of Applied Behavior

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

Replace the music box with the Glitter Roll

Activity Suggested Modification Appendix Reference Adaptation Category

Instead of clapping, use Deaf applause with

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

Activity Suggested Modification Appendix Reference Adaptation Category

All prompts, encouragement, and Communication/

All prompts, encouragement, and Communication/

Layout a variety of Applied Behavior

Activity Suggested Modification Appendix Reference Adaptation Category

All prompts, encouragement, and Communication/

Clinician/Interpreter: Sign child's name

Clinician/Interpreter: Use culturally Appendix A

Parent/Caregiver: Use culturally

Clinician/Interpreter: Sign child's name

Clinician/Interpreter: Use culturally Appendix A

Parent/Caregiver: Use culturally

All prompts, encouragement, and Communication/

I GIVE YOU (Standard) The sign GIVE

I GIVE YOU (Echolalic) The sign GIVE

Palm Orientation (Tuesday) A T handshape with

Palm Orientation (Bathroom) A T handshape with

THAT ( Standard) The sign LOOK

THAT (Nondirectional) The sign LOOK

WH- Questions Facial The sign HOW

Yes/No Questions Facial The sign WELL