Form 1.4 LO12 QUEX-8 Autism Diagnostic Screener (ADI-S)

Attachment 4 – LOI2-QUEX-8 – Autism Diagnostic Interview Screener (ADI-S) OMB #: 0925-0661

Expiration Date: June 30, 2015

Demographic information
This next section has some general questions about your background.
DE01.	Were you born in the United States?		no (SKIP to DE03) 0 Yes 1 REFUSED (SKIP TO DE03) 97 DON’T KNOW (SKIP TO DE03) 98
DE02.	In which State were you born?		SPECIFY: REFUSED (SKIP TO DE05) 97 DON’T KNOW (SKIP TO DE05) 98
DE03.	In which country were you born?		SPECIFY: REFUSED (SKIP TO DE05) 97 DON’T KNOW (SKIP TO DE05) 98
DE04.	When did you come to live in the United States?		YEAR REFUSED 97 DON’T KNOW 98
DE05.	What language do you speak at home?		ENGLISH 1 OTHER (SPECIFY) 2 REFUSED 97 DON’T KNOW 98
DE07.	Are you Hispanic, Latino/Latina, or Spanish origin? (One or more categories may be selected) (READ ANSWERS)		No, not of Hispanic, Latino/a, or Spanish origin 1 Yes, Mexican, Mexican American, Chicano/a 2 Yes, Puerto Rican 3 Yes, Cuban 4 Yes, Another Hispanic, Latino/a or Spanish origin 5 REFUSED 97 DON’T KNOW 98
DE08.	HAND R SHOW CARD A. What is your race? (One or more categories may be selected)		WHITE 1 BLACK or AFRICAN-AMERICAN 2 AMERICAN INDIAN or ALASKAN NATIVE 3 ASIAN ASIAN INDIAN 4 CHINESE 5 FILIPINO 6 JAPANESE 7 KOREAN 8 VIETNAMESE 9 OTHER ASIAN 10 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER NATIVE HAWAIIAN 11 GUAMANIAN OR CHAMORRO 12 SAMOAN 13 OTHER PACIFIC ISLANDER 14 REFUSED 97 DON’T KNOW 98
DE09.	HAND R SHOW CARD B. What is the highest degree or level of education you have completed?		Less than a high school diploma or ged 01 high school diploma or ged 02 some college but no degree 03 associate degree 04 bachelor’s degree (for example, ba, bs) 05 post graduate degree (for example, masters or doctoral) 06 DON’T KNOW 97 REFUSED 98
DE10.	I want to get a rough estimate of your total household income before taxes in 2011? Would you say it was (READ ANSWERS)?		Below $4,999 1 $5,000-$9,999 2 $10,000-$19,999 3 $20,000-$29,999 4 $30,000-$39,999 5 $40,000-$49,999 6 $50,000-$74,999 7 $75,000-$99,999 8 $100,000-$199,999 9 $200,000 or more 10 REFUSED (SKIP TO DE12) 97 DON’T KNOW (SKIP TO DE12) 98
DE11.	At that time, how many people were supported by that income, including both adults and children?		NUMBER OF PEOPLE DON’T KNOW 97 REFUSED 98
DE12.	I’d like to ask you about your marital status. Are you:		MARRIED 1 NOT MARRIED BUT LIVING TOGETHER WITH PARTNER 2 NEVER BEEN MARRIED 3 DIVORCED 4 SEPARATED, OR 5 WIDOWED? 6 DON’T KNOW 97 REFUSED 98

Autism Screening Interview (ASI) Preschool Version (2-4 Years)

Now we will do a brief interview about (CHILD).

BACKGROUND

First I would like to ask you a few background questions about (CHILD).

AS00

RECORD STUDY CHILD’S GENDER

MALE 1 FEMALE…………………………… 2

AS01

What is (CHILD)’s date of birth? So that makes (him/her) how old?

Age in months REFUSED 97 DON’T KNOW…………………………… 98

AS02

What is your relationship to (CHILD)? READ ANSWERS APPROPRIATE TO RESPONDENT’S GENDER.

Biological Mother 1 Stepmother 2 Adoptive Mother 3 Foster Mother 4 Grandmother 5 Biological Father 6 Stepfather 7 Adoptive Father 8 Foster Father 9 Grandfather 10 Other Legal Parent/Guardian 11 OTHER (SPECIFY): 12 REFUSED 97 DON’T KNOW 98

AS03

Does (CHILD) live in your home right now?

no …………………..………… 0 Yes (SKIP TO AS06) 1 refused (SKIP to AS06) 7 don’t know (SKIP to AS06) 8

AS04

With whom does (he/she) live?

SPECIFY: ______________________________________________________

AS05

How many days in the month do you see (CHILD)?

DAYS PER MONTH REFUSED 97 DON’T KNOW 98 [SKIPPED 99]

AS06

Does (CHILD) have any serious problems with (his/her) vision that are not corrected with glasses or other assistive technology?

no 0 Yes 1 REFUSED 7 DON’T KNOW 8

AS07

Does (CHILD) have any serious problems with (his/her) hearing that are not corrected with hearing aids or other assistive technology?

no 0 Yes 1 REFUSED 7 DON’T KNOW 8

AS08

Is (CHILD) able to walk on (his/her) own now? MAKE SURE THAT RESPONDENT DOES NOT COUNT TEMPORARY DIFFICULTIES, SUCH AS A SPRAINED ANKLE, AS “NOT WALKING”.

no 0 Yes (SKIP TO AS09) 1 REFUSED 7 DON’T KNOW 8

AS08A

Was there ever a period of time when (CHILD) could walk on (his/her) own without holding on?

no (SKIP to AS10) 0 Yes 1 REFUSED (SKIP TO AS10) 7 DON’T KNOW (SKIP TO AS10) 8

AS09

How old was (he/she) when (he/she) first started walking without holding on?

Age IN MONTHS REFUSED 97 DON’T KNOW 98

AS10

Currently, does (CHILD) receive any special educational services, such as speech therapy, a one-to-one aide, or time in a special education or resource classroom?

NO 0 YES 1 REFUSED 7 DON’T KNOW 8

Now I have some questions about how (CHILD) uses speech to communicate.

AS11

How old was (CHILD) when (he/she) first started using single words besides “mama” and “dada” to communicate?

Age in months not using single words yet 88 REFUSED 97 DON’T KNOW 98

Please answer Yes or No to the following questions.

AS12

Currently, do you think that (CHILD)’s language is at the same level as other children (his/her) age? MAKE SURE THAT THE RESPONDENT UNDERSTANDS THAT THIS QUESTION REFERS TO AMOUNT AND COMPLEXITY OF LANGUAGE, NOT ARTICULATION/PRONOUNCIATION.

NO 0 YES 1 REFUSED 7 DON’T KNOW 8

AS13

Does (CHILD) use at least 5 words on a daily basis?

no (SKIP to AS16) 0 Yes 1 REFUSED (SKIP TO AS16) 7 DON’T KNOW (SKIP TO AS16) 8

AS14

Does (CHILD) put words together to make phrases, such as “want more cookies” or “me no go” on a daily basis?

no (SKIP to AS16) 0 Yes 1 REFUSED (SKIP TO AS16) 7 DON’T KNOW (SKIP TO AS16) 8 [SKIPPED 9]

AS15

Does (CHILD) use complex sentences on a daily basis, such as: “Can we go to the park after we eat lunch?” or “I didn’t get any candy because I was late”? IF NECESSARY, CLARIFY THAT SENTENCES DO NOT NEED TO BE GRAMMATICALLY CORRECT. THE FOCUS OF THIS QUESTION IS WHETHER OR NOT THE CHILD CAN COMMUNICATE MORE THAN ONE IDEA IN THE SAME SENTENCE.

no 0 Yes 1 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS16

What kinds of things does (CHILD) say during a typical day? Can you give me some specific examples? IF EXAMPLES INCLUDE PHRASES, GO BACK TO AS13 AND CHANGE ANSWER TO YES, AND THEN RECORD YES FOR AS14 AND ASK AS15.

EXAMPLE1: EXAMPLE2: EXAMPLE3:

Now I am going to ask you several specific questions about (CHILD)’s current behavior. HAND SHOW CARD A. Each question will have four answer choices of not at all, occasionally, often or very frequently. It is important to note that not every item will apply exactly to your family’s situation. You should select the best response for each question. When I can, I will clarify any items that are confusing. The idea is to quickly get a sense of (CHILD)’s current behavior.

SOCIAL COMMUNICATION

this first section is about how (CHILD) communicates with you. Please focus on behaviors that you have observed in the past 3 months. Respond based on what (CHILD) typically does.

AS17

DIRECT GAZE When (CHILD) is doing things with you or talking with you, how often does (he/she) make eye contact? Would you say (READ ANSWERS)? MARK “Not at all” IF RESPONDENT SAYS CHILD DOES NOT INITIATE/PARTICIPATE IN INTERACTIONS OF ANY KIND.

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS18

RESPONSE TO NAME If you call (CHILD)’s name, how often does (he/she) respond by looking at you? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS19

WHERE’S MOMMY/DADDY If someone says, “Where’s daddy or dad?” or “Where’s mommy or mom?” how often does (CHILD) look at the correct person? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS20

INITIATIONS How often does (CHILD) come to get you just because (he/she) wants you to play with (him/her)? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS21

USE OF OTHER’S BODY Does (CHILD) ever use your hand like a tool to make it do something, such as putting your hand over a door handle or bottle top, in order to get it open? How often? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

IF AS13 = NO, RF, OR DK SKIP TO AS32

The next few questions are about (CHILD)’s talking.

AS22

OFFERING INFORMATION How often does (CHILD) tell you about something that happened to (him/her), such as if (he/she) fell down at the playground? Would you say (READ ANSWERS)? (PROBE: IF THE CHILD TELLS ABOUT THEIR EXPERIENCES ONLY WHEN ASKED, SAY: And how often does (CHILD) spontaneously offer information about something, without being asked?)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS23

SOCIAL CHAT How often does (CHILD) use (his/her) language for social purposes, such as chatting or making comments just to be friendly? Would you say (READ ANSWERS)? (PROBE: This item is asking about how often (CHILD) talks or chats for social purposes. It does not include talking because (he/she) wants to get something or wants to find out about something.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS24

RESPONDING TO QUESTIONS When you ask (CHILD) a question, how often does (he/she) respond to what you asked? Would you say (READ ANSWERS)? (PROBE: IF CHILD RESPONDS BY REPEATING THE QUESTION, SAY: Other than just repeating what you said, how often does (he/she) give an answer?)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS25

RESPONDING TO CONVERSATIONAL LEADS If you make a comment to (CHILD) without asking a direct question, how often does (he/she) respond to what you said? Would you say (READ ANSWERS)? (PROBE: IF CHILD RESPONDS BY REPEATING WHAT IS SAID, SAY: Other than just repeating what you said, how often does he/she respond when you make a comment without asking a direct question?)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS26

STARTING CONVERSATIONS How often does (CHILD) start a conversation with you? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS27

ASKING FOR INFORMATION How often does (CHILD) ask you questions about your interests or experiences? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS28

ODD PHRASES How often does (CHILD) say things that others think are unusual or strange? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT ASKS WHAT IS MEANT BY “OTHERS”, SAY: For example, neighbors or extended family members.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS29

FORMAL SPEECH Some children use words or phrases that seem overly formal and can sound like a “little adult” or “a little professor”. How often does (CHILD) sound overly formal? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS30

STEREOTYPED PHRASES Some children have their own way of saying something that they say in the same way every time. For example, a child might say “3, 2, 1, blast off!” to mean that they want to go outside, or “How can I help you, sir?” whenever they meet a new person. How often does (CHILD) use phrases like this in a similar way? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS31

SOCIALIZING WITH PEERS How often does (CHILD) verbally express an interest in getting together to play with another child, such as asking if a child can come over to play? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

Now I have some more questions about the ways that (CHILD) interacts with you and other people. Remember to choose the response that best describes (CHILD)’s behavior during the past 3 months.

AS32

SHOWING When (CHILD) sees something interesting, how often does (he/she) hold it up or bring it over just to show you? Would you say (READ ANSWERS)? THIS DOES NOT INCLUDE BRINGING THINGS OVER FOR THE PURPOSE OF GETTING HELP.

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS33

POINTING (TO EXPRESS INTEREST) Some children point to request things. Others also point to show something of interest, such as pointing to an airplane in the sky. How often does (CHILD) use (his/her) finger to point out something of interest? Would you say (READ ANSWERS)? THIS MUST INCLUDE USING A FINGER TO POINT. IT DOES NOT INCLUDE USING ONLY WORDS TO “POINT” SOMETHING OUT.

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS34

GESTURES Now I am interested in hearing about other gestures. How often does (CHILD) use simple gestures, such as waving good-bye or blowing a kiss, without being told to do so? Would you say (READ ANSWERS)? (PROBE: Gestures are hand movements used to communicate, such as making a beckoning motion to mean “come here”.).

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS35

NODDING How often does (he/she) nod (his/her) head to mean yes without being told to do so? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS36

RESPONSE TO JOINT ATTENTION What if you point out something for (CHILD) to see? How often does (he/she) respond by looking at what you point at? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS37

SMILING AT PEOPLE How often does (CHILD) smile at people? Would you say (READ ANSWERS)? THIS CAN INCLUDE SMILING AT FAMILIAR PEOPLE OR UNFAMILIAR PEOPLE.

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS38

SOCIAL SMILING If (CHILD) is not smiling already, and you smile at (him/her) without touching (him/her), how often does (he/she) smile back at you? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS39

INAPPROPRIATE FACIAL EXPRESSIONS Some children show facial expressions that do not match the situation, such as laughing when it is not clear what is funny. How often does (CHILD) show facial expressions that do not match the situation? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS40

FAVORITE THINGS Now I would like to hear about the kinds of things that (CHILD) enjoys. What are (his/her) favorite things to do?

Specify_1: SPECIFY_2: SPECIFY_3:

AS41

SHARING ENJOYMENT When (CHILD) is excited about something, how often does (he/she) seem to want to get you to be excited too? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS42

SHARING How often does (CHILD) offer to share food or other things with people, without being asked or told to share? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS43

RESPONSE TO DISTRESS When someone else is hurt or sick, how often does (CHILD) notice that something is wrong? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS44

APPROPRIATE SOCIAL RESPONSES When an adult outside of the family talks to (CHILD), how often does (he/she) respond appropriately, such as by smiling, saying “Hi!”, or talking to the other person? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT INDICATES THE CHILD DOES NOT HAVE CONTACT WITH NON-FAMILY ADULTS SAY: What about responding to teachers, bus drivers, cashiers or other adults?)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS45

INAPPROPRIATE SOCIAL RESPONSES On the other hand, does (CHILD) ever respond inappropriately to an adult outside of the family, such as by ignoring the person? How often does this happen? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS46

SOCIAL DISINHIBITION In social situations, such as when eating in a restaurant or visiting someone’s home, how often does (CHILD) show behaviors that are not appropriate to that situation? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT SAYS THAT CHILD’S INAPPROPRIATE BEHAVIORS SEEM TYPICAL FOR THE CHILD’S AGE, SAY: Not taking into account (CHILD)’s age, how often does (he/she) show behaviors that are not appropriate given the situation.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

PEER INTERACTION

Some of these next questions are about how (CHILD) gets along with other children. Do not include brothers or sisters or other children living in the home when answering questions about how (CHILD) interacts with other children.

AS47

TIME ALONE Does (CHILD) prefer to spend time by (himself/herself)? How often? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS48

INTEREST IN CHILDREN How often does (CHILD) show interest in other children, such as by watching them or pointing them out to you? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS49

RESPONSE TO CHILDREN If another child tries to interact with (CHILD), how often does (he/she) respond positively and do something to try to keep the interaction going? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS50

GROUP PLAY WITH PEERS When groups of children are playing games such as hide- and -seek or duck-duck-goose, how often does (CHILD) join in on (his/her) own and play? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 UNKNOWN (E.G., RESPONDENT INSISTS THAT HE OR SHE HAS NOT OBSERVED INTERACTIONS WITH OTHER CHILDREN) 5 REFUSED 7 DON’T KNOW 8

AS51

BIRTHDAY PARTY QUESTION When there are other children around, such as at a birthday party or during free time at preschool or daycare, how often does (CHILD) stay outside of the group instead of interacting with the other children? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 UNKNOWN (E.G., RESPONDENT INSISTS THAT HE OR SHE HAS NOT OBSERVED INTERACTIONS WITH OTHER CHILDREN) 5 REFUSED 7 DON’T KNOW 8

AS52

IMAGINATIVE PLAY WITH PEERS How often does (CHILD) play pretend games with other children, such as playing house or school? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 UNKNOWN (E.G., RESPONDENT INSISTS THAT HE OR SHE HAS NOT OBSERVED INTERACTIONS WITH OTHER CHILDREN) 5 REFUSED 7 DON’T KNOW 8

AS53

IMAGINATIVE PLAY How often does (CHILD) make up (his/her) own stories using action figures or small dolls, such as pretending that the figures are going somewhere or doing something? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS54

RITUALIZED PLAY Some children have very particular or ritualized ways of playing. They do not like to change from “their way” of playing with something and might get upset if others try to get them to play in a different way. How often does (CHILD) insist on playing in a very particular way? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS55

EXCESSIVE IMAGINATIVE PLAY Some children spend an unusual amount of time playing the same pretend game, such as spending a lot of time pretending to be one character or pretending to have imaginary friends. Does (CHILD) spend an unusual amount of time playing this way? How often? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

RESTRICTED AND REPETITIVE BEHAVIORS

Now I have some other questions about behaviors that you may have observed during the past 3 months. (PROBE: IF PARENT IS DISTRACTED BY THE SPECIFIC EXAMPLES IN THIS SECTION, SAY: Remember that these are just examples that may not exactly describe your child. Does (CHILD) have any (behavior in question) that you think might fit here?)

AS56

INITIATION OF APPROPRIATE ACTIVITIES During free time, how often does (CHILD) seem to get stuck on doing the same activity for a long period of time? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS57

REPETITIVE USE OF OBJECTS Some children seem more interested in playing with the parts of an object instead of using the whole object as it was intended. For example, when playing with a toy car, they might turn it over and spin the wheels rather than using it as a car. How often does (CHILD) focus (his/her) attention on specific parts of toys or objects rather than using them as they were intended? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS58

SENSORY AVERSIONS Some children are overly sensitive to loud noises or are upset by certain sounds, sights, tastes, or feels of things. Is (CHILD) bothered by any of these things? How often? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often ………… 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS59

UNUSUAL SENSORY INTERESTS On the other hand, some children have sensory interests and like to seek out certain sensations. This might include looking at things in unusual ways, sniffing objects, or repeatedly touching certain textures. How often does (CHILD) show sensory interests? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT STARTS TALKING ABOUT SENSORY AVERSIONS (I.E., DISLIKES), SAY: This item is about (CHILD) seeking out sensations that (he/she) likes.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS60

UNUSUAL PREOCCUPATIONS Some children have unusual interests such as elevators, spoons, or people’s home addresses, or they might be unusually interested in a specific aspect of something, such as the letter A of the alphabet. Does (CHILD) have unusual interests like this?

NO (SKIP TO AS63) 0 YES 1 REFUSED (SKIP TO AS63) 7 DON’T KNOW (SKIP TO AS63) 8

AS61

Please specify (CHILD)’s unusual interests.

SPECIFY:

AS62

How often does (CHILD) do (or say) things related to this unusual interest? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS63

CIRCUMSCRIBED INTERESTS Does (CHILD) have any overly intense interests or intense hobbies, such as in trains or geography or other special interests, that take up an unusually large amount of (his/her) time?

NO (SKIP TO AS66) 0 YES 1 REFUSED (SKIP TO AS66) 7 DON’T KNOW (SKIP TO AS66) 8

AS64

Please specify these intense interests.

SPECIFY:

AS65

How often does (CHILD) spend time (talking about or) doing things related to this intense interest? Would you say (READ ANSWERS)?

Not at all 1 A little 2 Pretty much 3 Extremely 4 REFUSED 7 DON’T KNOW 8 [SKIPPED 9]

AS66

HAND/FINGER MANNERISMS Some children show repetitive hand movements, such as flicking their fingers or flapping their hands. How often does (CHILD) move (his/her) hands or fingers in these ways? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT SAYS THE CHILD ONLY DOES WHEN EXCITED, SAY: This item is asking about whether (CHILD) shows repetitive hand movements in any type of situation. You should think about different situations and choose the response that best describes (CHILD)’s behavior during the past 3 months.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS67

OTHER COMPLEX MANNERISMS Some children show unusual repetitive whole body movements, such as hopping while waving their arms. How often does (CHILD) move (his/her) body in these ways? Would you say (READ ANSWERS)? (PROBE: IF RESPONDENT SAYS THE CHILD ONLY DOES WHEN EXCITED, SAY: This item is asking whether (CHILD) shows these repetitive whole body movements in any type of situation. You should think about different situations and choose the response that best describes (CHILD)’s behavior during the past 3 months.)

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS68

ROUTINES Some children are bothered by minor changes in their daily routine. For example, a child might become upset if a different route to school is taken or if lunch happens 30 minutes earlier than usual. How often does (CHILD) react negatively to changes like this in (his/her) day? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

AS69

COMPULSIONS AND RITUALS Some children need to do things in a very particular way or sequence. For example, a child might insist on touching the mailbox before going into the house or insist on closing all doors that are open. How often does (CHILD) insist on doing things in a very particular way or order? Would you say (READ ANSWERS)?

Not at all 1 Occasionally 2 Often 3 Very frequently 4 REFUSED 7 DON’T KNOW 8

Diagnostic history

we are coming to the end of the interview, and I just have a few more questions:

AS70

Have you ever had concerns about (CHILD)’s behavior or development?

nO (skip to as74) 0 yES …. 1 REFUSED (SKIP TO AS74) 7 DON’T KNOW (SKIP TO AS74) 8

AS71

What concerns you the most right now about (CHILD)’s behavior or development?

SPECIFY: ______________________________________________________

AS72

How old was (CHILD) when you first wondered if there might be something different or not quite right about (his/her) behavior or development?

Age in months REFUSED 97 DON’T KNOW 98 [SKIPPED 99]

AS73

What was it that gave you concern at that time?

sPECIFY:

AS74

Did (CHILD) lose any language or social skills during the first few years of life after (he/she) first gained them? DO NOT INCLUDE LOSSES THAT OCCURRED AFTER AGE 3 YEARS

nO (skip to as77) 0 yES …. 1 REFUSED (SKIP TO AS77) 7 DON’T KNOW (SKIP TO AS77) 8

AS75

What type of skills did (he/she) lose?

sPECIFY:

AS76

How old was (he/she) when (he/she) lost those skills?

Age in months REFUSED 97 DON’T KNOW 98 [SKIPPED 99]

AS77

Has a medical, mental health or school professional ever expressed concerns that (CHILD) has an autism spectrum disorder or ASD, like autism, Asperger syndrome, or PDD-NOS?

nO (skip to as80) 0 yES …. 1 REFUSED (SKIP TO AS80) 7 DON’T KNOW (SKIP TO AS80) 8

AS78

What type of professional was this (READ ANSWERS)?

Pediatrician 1 Developmental Pediatrician 2 Neurologist 3 Psychiatrist 4 Psychologist 5 Other (SPECIFY): __________________________ 6 REFUSED 7 DON’T KNOW 8

AS79

Did that professional tell you this after an assessment done as part of a research study (CHILD) was participating in?

nO 0 yES …. 1 REFUSED 7 DON’T KNOW 8

AS80

Has a medical, mental health or school professional ever told you that (CHILD) may have an autism spectrum disorder or ASD, like autism, Asperger syndrome, or PDD-NOS?

nO (skip to as83) 0 yES …. 1 REFUSED (SKIP TO AS83) 7 DON’T KNOW (SKIP TO AS83) 8

AS81

What type of professional was this (READ ANSWERS)?

Pediatrician 1 Developmental Pediatrician 2 Neurologist 3 Psychiatrist 4 Psychologist 5 Other (SPECIFY): __________________________ 6 REFUSED 7 DON’T KNOW 8

AS82

Did that professional tell you this after an assessment done as part of a research study (CHILD) was participating in?

nO 0 yES …. 1 REFUSED 7 DON’T KNOW 8

AS83

Has a medical, mental health or school professional ever told you that (CHILD) does not have an autism spectrum disorder or ASD, like autism, Asperger syndrome, or PDD-NOS?

nO (skip to as86) 0 yES …. 1 REFUSED (SKIP TO AS86) 7 DON’T KNOW (SKIP TO AS86) 8

AS84

What type of professional was this (READ ANSWERS)?

Pediatrician 1 Developmental Pediatrician 2 Neurologist 3 Psychiatrist 4 Psychologist 5 Other (SPECIFY): __________________________ 6 REFUSED 7 DON’T KNOW 8

AS85

Did that professional tell you this after an assessment done as part of a research study (CHILD) was participating in?

nO 0 yES …. 1 REFUSED 7 DON’T KNOW 8

AS86

Is there anything else important about (CHILD)’s behavior or development that I should have asked you?

sPECIFY:

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