LOI2-QUEX-8 - ASD Scheduled Assessment Summary Sheet

Attachment 3 LOI2-QUEX-8 – Scheduled Assessment Summary Sheet

NCS Scheduled Assessment Summary

SECTION 1: This section should be completed by staff familiar with developmental assessment – but DOES NOT need to be completed by the diagnosing clinician

Name of person completing this section: ___________________________________________________________

Information in this box is for site use only, and is not to be entered into data system.

Subject ID #: _____________

Child Name: ____________________________________ Child Date of Birth: _____/_____/______

Date of Assessment: _____/_____/______

Scheduled Assessment Type (answer both questions):

Research or Clinical (check one) ASD Suspicion or Other Developmental Issue (check one)

□ for a research study □ because of suspect ASD

□ done as a clinical assessment □ because of other concern (no ASD suspected a priori)

Reported Major Comorbidities: Check if any of the following comorbidities were documented in record at the time of behavioral assessment.

□ Tuberous sclerosis	□ Constipation
□ Down syndrome	□ Feeding problems
□ Rett syndrome	□ Other GI: __________________________________
□ Fragile X
□ Neurofibromatosis	□ Hypotonia
□ Angelman;s	□ Seizure DO
□ NF-1	□ Other neurologic: ____________________________
□ Other genetic: _____________________________

Summary results from any ASD screeners (if available):

M-CHAT Standard ____________________ Date of administration: _____/_____/______

Best of 7 ____________________

SRS Summary (raw) ______________ Date of administration: _____/_____/______

Summary (t-score) ___________

PDDST-II ____________________________ Date of administration: _____/_____/______

SCQ ____________________________ Date of administration: _____/_____/______

ASSQ ____________________________ Date of administration: _____/_____/______

ESAT ____________________________ Date of administration: _____/_____/______

FYI ____________________________ Date of administration: _____/_____/______

Tool Score Date of administration

Other ____________________________ ____________ _____/_____/______

Other ____________________________ ____________ _____/_____/______

Cognitive Functioning: Include available results from the most recent test that was appropriate for the child’s age, and indicate whether the score was from a test administered during the scheduled assessment or from a prior visit.

Prior During Scheduled

Test administered: Visit Assessment Date .

□ Mullen □ □ _____/_____/______

□ Wechsler □ □ _____/_____/______

(any of the following: WISC, WAIS, WASI, WPPSI)

□ Stanford-Binet (SB-IV, SB-V) □ □ _____/_____/______

□ Differential Abilities Scale (DAS) □ □ _____/_____/______

□ Kaufman (either KABC or KBIT) □ □ _____/_____/______

□ Leiter □ □ _____/_____/______

□ Merrill-Palmer-Revised (2005 revision) □ □ _____/_____/______

□ Other: _________________________ □ □ _____/_____/______

Scores:

Guidelines for translating scores from tests to the following summaries will be provided.

Nonverbal score: _______

Verbal score: _______

Composite score: _______

ADOS Scores: Please ONLY report results from assessment performed at the scheduled assessment visit.

Check one:

□ ADOS not performed this visit (skip to past ADOS question)

□ ADOS performed (complete module, scoring, reliability, and past ADOS questions)

Module: □ 1 □ 2

Complete scoring information for at least one algorithm- if information from both algorithms are available, complete both.

Score - Original Algorithm

Communication domain score: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Social domain score: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Summary score: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Score – New Algorithm

Social Affect: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Restricted, Repetitive Behaviors: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Summary score: _______

□ Met for ASD □ Met for Autism □ Did not meet for ASD/Autism

Assessor reliability: Please indicate whether the assessor completing the ADOS was research-reliable.

□ Yes

□ No

Past ADOS: Is there any indication that the child was evaluated with an ADOS prior to this visit.

□ Yes Date: ___/ _____ (mos/yr)

□ No

ADI Scores: Please ONLY report results from assessment performed at the scheduled assessment visit.

Check one:

□ ADI not performed this visit (skip to past ADI question)

□ ADI performed (complete scoring, reliability, and past ADI questions)

Complete scoring information:

Social Interaction: __________

Communication and language: __________

Restricted and repetitive behaviors: __________

Assessor reliability: Please indicate whether the assessor completing the ADI was research-reliable.

□ Yes

□ No

Past ADOS: Is there any indication that the child was evaluated with an ADI prior to this visit.

□ Yes Date: ___/ _____ (mos/yr)

□ No

SECTION 2: This section must be completed within 24 hours of the scheduled assessment visit by a clinician who saw the child during the scheduled assessment visit and who is qualified to make ASD diagnoses.

Name of person completing this section: ___________________________________________________________

If the child was seen at the scheduled assessment because of suspect ASD (as recorded above) complete Part A below. If the child was seen at the scheduled assessment other developmental concerns with no a priori ASD suspicion complete Part B below.

PART A: Complete for subjects being evaluated for suspect ASD:

ASD DSM Diagnosis (check one):

 Child meets criteria for an ASD (autistic disorder, Asperger’s disorder, PDD-NOS)

 Child does not meet criteria for an ASD

Confidence Ratings: How certain are you that the above determination about an ASD diagnosis is accurate?

□ 1 (extremely certain)

□ 2

□ 3

□ 4

□ 5 (extremely uncertain)

Before completing your own assessment, but after reviewing the child’s records and preparing for the visit, how confident were you that he or she would receive this ASD diagnostic determination? Remember, this question is specific to your feelings before meeting the child, based only on the available records and visit preparation.

□ 1 (extremely certain)

□ 2

□ 3

□ 4

□ 5 (extremely uncertain)

Other DSM Diagnoses: Please list any other DSM diagnoses assigned based on this evaluation

1) _______________________________________________________________

2) _______________________________________________________________

3) _______________________________________________________________

4) _______________________________________________________________

PART B: Complete for subjects being evaluated for other developmental concerns with no a priori ASD suspicion:

DSM Diagnoses: Please list any DSM diagnoses assigned based on this evaluation

1) _______________________________________________________________

2) _______________________________________________________________

3) _______________________________________________________________

4) _______________________________________________________________

Confidence that the subject DOES NOT have ASD:

How certain are you that the subject does not have an ASD:

□ 1 (extremely certain)

□ 2

□ 3

□ 4

□ 5 (extremely uncertain)

Was this subject referred for further ASD assessment:

□ Yes

□ No

Was this subject diagnosed with an ASD (autistic disorder, Asperger’s disorder, PDD-NOS)

□ Yes

□ No