Autism Behavior Checklist Template
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1
2Autism Behavior Checklist
From Krug, Arick, and Almond (1978)
Patient _____________________________
Birth Date: ______________________
Examiner___________________________
Test Date______________________
Circle the number for those items most accurately describing the child:
1
Whirls self for long periods of time
4
2
Learns a simple task but “forgets” quickly
2
3
Frequently does not attend to social/environmental cues
4
4
Does not follow simple commands (sit down, come here, stand up) given once
1
5
Does not use toys appropriately (spins wheels, etc.)
2
6
Poor use of visual discrimination when learning (fixates on parts of objects such as
2
size, color, position…)
7
Lacks a social smile (may smile out-of-context)
2
8
Exhibits pronoun reversal (you for I…)
3
9
Insists on keeping certain objects with him/herself
3
10 Seems not to hear (despite normal hearing tests)
3
11 Speech is atonal and arrhythmic
4
12 Rocks self for long periods of time
4
13 Does not (or did not as a baby) reach out when reached for
2
14 Strong reactions to minor changes in routine/environment
3
15 Does not respond to own name when called out among two or more other names
2
16 Lunges and darts about, interrupted by spinning, toe walking, hand flapping…
4
17 Not responsive to other people’s facial expressions or feelings
3
18 Seldom uses “yes” or “I”
2
19 Has special abilities in one area – seems to rule out mental retardation
4
20 Does not follow simple prepositional commands (e.g., “put the ball in the box”)
1
21 Sometimes shows no “startle response” to a loud noise
3
22 Flaps hands (or other self-stimulating behavior)
4
23 Severe temper tantrums and/or frequent minor tantrums
3
24 Actively avoids eye contact
4
25 Resists being touched or held
4
26 Sometimes, painful stimuli (cuts, injections, bruises) evoke no reaction
3
27 Is (or was as a baby) stiff and hard to hold
3
28 Is flaccid (doesn’t cling) when held in arms
2
29 Gets desired objects by gesturing
2
30 Walks on toes
2
31 Hurts others by biting, hitting, kicking…
2
32 Repeats phrases over and over again
3
33 Does not imitate other children at play
3
34 Often will not blink when a bright light is directed toward eyes
1
35 Hurts self by biting hand, banging head…
2
36 Does not wait for needs to be met (wants things immediately)
2
37 Cannot point to more than five named objects
1
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