LOI2-QUEX-8 - ASD Scheduled Assessment Summary Sheet

Attach 3 LOI2-QUEX-8 - ASD Scheduled Assessment Summary Sheet.docx

Neuropsychosocial Measures Formative Research Methodology Studies for the National Childrens Study (NICHD)

LOI2-QUEX-8 - ASD Scheduled Assessment Summary Sheet

OMB: 0925-0661

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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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleADULT BLOOD DRAW INFORMATION FORM
AuthorChildren's Hospital of Philadelphia
File Modified0000-00-00
File Created2021-01-26

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