Module 2 DSM-5 Checklist | ID: _____________________ Date: ____________________ Age: ___________________ Examiner: ☐ Parent/Caregiver ☐ Therapist

Language Level: A1. Overall Level of Nonechoed Spoken Language: _________

BOSA Version: PSYF
DSM-5 Checklist for Module 2
A. Impairment in Social Communication & Social Interaction B. Restricted and Repetitive Behaviors
ADOS Recode BOSA Parent Other ADOS Recode BOSA Parent Other
1. Deficits in Social-Emotional Reciprocity 1. Repetitive and Stereotyped Behavior
Score Rule Score Report Info Score Rule Score Report Info
0-1→0 0→0
A5. Conversation A2. Speech Abnormalities Associated with Autism
2-3→1 1-2→1
0→0 0-1→0
*B3. Shared Enjoyment in Interaction A3. Immediate Echolalia
1-3→1 2-3→1
0→0 0→0
*B5. Showing *A4. Stereotyped/Idiosyncratic Use of Words or Phrases
1-2→1 1-3→1
0→0 0→0
v*B6. Spontaneous Initiation of Joint Attention *D2. Hand and Finger and Other Complex Mannerisms
1-2→1 1-3→1
0→0 0→0
*B8. Quality of Social Overtures D3. Self Injurious Behavior
1-3→1 1-2→1
0→0
B9b. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
1-3→1
0-1→0
B10. Quality of Social Response 2. Excessive Adherence to Routines and Ritualistic Behavior
2-3→1
0→0 0→0
*B11. Amount of Reciprocal Social Communication (D5 from M3). Compulsions/Rituals
1-3→1 1-2→1
0→0
v(A5 from M3). Offers Information Other (Specify):_______________
1-2→1
0-1→0
v(A6 from M3). Asks for Information 3. Restricted, Fixated Interests
2-3→1
0-1→0
Other (Specify):_______________ *D4. Unusually Repetitive Interests or Stereotyped Behaviors
2-3→1
2. Deficits in Nonverbal Communication used for Social Interaction Other (Specify):_______________
0→0
*B1. Unusual Eye Contact 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
2→1
0→0 0→0
*B2. Facial Expressions Directed to Others *D1. Unusual Sensory Interest in Play Material/Person
1-2→1 1-3→1
0→0
(B3 from M3). Language Production & Linked Nonverbal Communication Other (Specify):_______________
1-2→1
Other (Specify):_______________ Other Behaviors (E Codes)
ADOS Recode BOSA Parent Other
3. Deficits in relationships
Score Rule Score Report Info
0-1→0 0→0
(B15 from M1). Level of Engagement E1. Overactivity
2-3→1 1-3→1
0→0 0→0
C1. Functional Play With Objects E2. Tantrums, Aggression, Negative or Disruptive Behavior
1-3→1 1-3→1
0-1→0 0→0
vC2. Imagination/Creativity E3. Anxiety
2-3→1 1-2→1
Clinical Notes on Observations or Outside Information:
Other (Specify):_______________
Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9 should be
converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if symptom present
based on additional gathered or observed information.
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence or language too limited to code 0-3
Select codes from ADOS-2 reprinted by author C. Lord, for authorized use within the work now known as BOSA, under written permission from WPS. No
additional use, including and not limited to adaptation or translation, is permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved
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(rights@wpspublish.com).