Autism Spectrum Disorder Checklist-Dsm-5 Criteria

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South   B end   C ommunity   S chool   C orporation  
Special   E ducation   S ervices  
 
Autism   S pectrum   D isorder   C hecklist-­‐DSM-­‐5   C riteria  
 
Student   N ame:     _ ____________________________________   SBCSC   I D#:   _ ________________           S TN#:     _ _______________________________  
 
School:     _____________________________________________  
Grade:   _ _____________________             D ate:   _ _________________________________  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent   d eficits   i n   s ocial   c ommunication   a nd   s ocial   i nteraction   a cross   m ultiple   c ontexts,   a s   m anifested   b y   a ll   t hree  
of   t he   f ollowing,   c urrently   o r   b y   h istory   ( examples   a re   i llustrative,   n ot   e xhaustive):  
 
_____     D eficits   i n   s ocial-­‐emotional   r eciprocity   ( ranging,   f or   e xample,   f rom   a bnormal   s ocial   a pproach   a nd   f ailure   o f  
normal   b ack-­‐and-­‐forth   c onversation;   t o   r educed   s haring   o f   i nterests,   e motions,   o r   a ffect;   t o   f ailure   t o   i nitiate   o r  
respond   t o   s ocial   i nteractions.)  
 
_____   D eficits   i n   n onverbal   c ommunicative   b ehaviors   u sed   f or   s ocial   i nteraction   ( ranging,   f or   e xample,   f rom  
poorly   i ntegrated   v erbal   a nd   n onverbal   c ommunication;   t o   a bnormalities   i n   e ye   c ontact   a nd   b ody   l anguage   o r  
deficits   i n   u nderstanding   a nd   u se   o f   g estures;   t o   a   t otal   l ack   o f   f acial   e xpressions   a nd   n onverbal   c ommunication.)  
 
_____     D eficits   i n   d eveloping,   m aintaining,   a nd   u nderstanding   r elationships   ( ranging,   f or   e xample,   f rom  
difficulties       a djusting   b ehavior   t o   s uit   v arious   s ocial   c ontexts;   t o   d ifficulties   i n   s haring   i maginative   p lay   o r   i n  
making   f riends;   t o   a bsence   o f   i nterest   i n   p eers.)  
 
 
Restricted,   r epetitive   p atterns   o f   b ehavior,   i nterests,   o r   a ctivities,   a s   m anifested   b y   a t   l east   t wo   o f   t he  
following,   c urrently   o r   b y   h istory   ( examples   a re   i llustrative,   n ot   e xhaustive)  
 
_____     S tereotyped   o r   r epetitive   m otor   m ovements,   u se   o f   o bjects,   o r   s peech   ( e.g.   s imple   m otor   s tereotypes,   l ining  
up   t oys   o r   f lipping   o bjects,   e cholalia,   i diosyncratic   p hrases)  
 
_____     I nsistence   o n   s ameness,   i nflexible   a dherence   t o   r outines,   o r   r itualized   p atterns   o f   v erbal   o r   n onverbal  
behavior   ( e.g.   e xtreme   d istress   a t   s mall   c hanges,   d ifficulties   w ith   t ransitions,   r igid   t hinking   p atterns,   g reeting  
rituals,   n eed   t o   t ake   s ame   r oute   o r   e at   f ood   e veryday).  
 
_____     H ighly   r estricted,   f ixated   i nterests   t hat   a re   a bnormal   i n   i ntensity   o r   f ocus   ( e.g.   s trong   a ttachment   t o   o r  
preoccupation   w ith   u nusual   o bjects,   e xcessively   c ircumscribed   o r   p erseverative   i nterest).  
 
_____   H yper-­‐   o r   H ypo   r eactivity   t o   s ensory   i nput   o r   u nusual   i nterests   i n   s ensory   a spects   o f   t he   e nvironment  
(e.g.   a pparent   i ndifference   t o   p ain/temperature,   a dverse   r esponse   t o   s pecific   s ounds   o r   t extures,   e xcessive  
smelling   o r   t ouching   o f   o bjects,   v isual   f ascination   w ith   l ights   o r   m ovement).  
 
Symptoms   m ust   b e   p resent   i n   t he   e arly   d evelopmental   p eriod   ( but   m ay   n ot   b ecome   f ully   m anifest   u ntil   s ocial  
demands   e xceed   l imited   c apacities,   o r   m ay   b e   m asked   b y   l earned   s trategies   i n   l ater   l ife)  
 
Symptoms   c ause   c linically   s ignificant   i mpairment   i n   s ocial,   o ccupational   o r   o ther   i mportant   a reas   o f   c urrent  
functioning.  
 
These   d isturbances   a re   n ot   b etter   e xplained   b y   i ntellectual   d isability   o r   g lobal   d evelopmental   d elay.    
Intellectual   d isability   a nd   a utism   s pectrum   d isorder   f requently   c o-­‐occur;   t o   i dentify   b oth,   s ocial  
communication   s hould   b e   b elow   t hat   e xpected   f or   g eneral   d evelopmental   l evel.  
 
M-­‐Team   M embers:  
 
 
 
 
 
 
Agree    
Disagree  
 
Psychologist  
 
______________________________________________________  
___________  
____________  
Autism   C onsultant                           _ _____________________________________________________  
___________  
____________  
Special   E d   T eacher                         _ _____________________________________________________  
___________  
____________  
General   E d   T eacher  
______________________________________________________  
___________  
____________  
SLP  
 
 
______________________________________________________  
___________  
____________  
 
Parent    
 
______________________________________________________  
___________  
____________  
Other    
 
______________________________________________________  
___________  
____________  
 
 
 
 
 
 
 
 
 
 
 
 
 

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