Questionnaire for Parents/Teachers of 2- to 4-year-olds with Autism Spectrum Disorder
These questions are about your child or student - the questions aim to identify early indicators of behavioural difficulties (and the form of the difficulty present), to evaluate communication skills & social functioning, and to identify the presence/absence of the 13 preschool life skills (as described by Hanley et al. 2007).

***PLEASE ANSWER ONLY IF YOU ARE THE PARENT OF A CHILD WHO IS CURRENTLY 2 - 4 YEARS 11 MONTHS OLD WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDER (ASD) OR IF YOU ARE A TEACHER/TUTOR/STAFF MEMBER WORKING A CHILD WHO IS CURRENTLY 2 - 4 YEARS 11 MONTHS OLD WITH A DIAGNOSIS OF ASD***

If you have any questions please contact Carolyn Ritchey (ritcheyc@tcd.ie).

Relationship to Child *
Child's Gender *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age at Diagnosis *
Years, Months
Your answer
City/Country of Residence *
Your answer
Geographic Area *
Required
Any Co-occuring Diagnosis?
For each item, please mark the box for Not True, Somewhat True or Certainly True. *
Please give your answers on the basis of the child's behaviour over the last six months or this school year.
Not True
Somewhat True
Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children (treats, toys, pencils etc.)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset, or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations
Kind to younger children
Often argumentative with adults
Picked on or bullied by other children
Often volunteers to help others (parents, teachers, other children)
Can stop and think things out before acting
Can be spiteful to others
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span
For each behaviour listed below, please choose the answer that describes the extent to which it is has been a concern WITHIN THE PAST MONTH. *
No Concern
Mild Concern
Moderate Concern
Serious Concern
Language use and understanding (doesn't use words, has difficulty initiating conversations, etc.)
Compulsive behaviours (completes routines always in the same manner)
Anxiety (shows distress from new situations or crowds, etc.)
Sensory issues (reacts to lights, sounds, textures, etc.)
Sleep disturbance (does not fall asleep easily, wakes often, etc.)
Aggression (intentionally hits, bites others, etc.)
Hyperactivity (is constantly moving, running, jumping etc.)
Attention span (has difficulty finishing a task, etc.)
Mood swings (has unpredictable changes between emotions)
Eating habits (eats few foods/certain types of foods, etc.)
Social interactions (prefers to be alone, has few friends, etc.)
Self-stimulatory and repetitive behaviours (rocks, spins, flaps hands, etc.)
Self-injurious behaviour (bangs head, pinches, bites, hits oneself, etc.)
Please answer each question by choosing yes or no. A few questions ask about several related types of behaviour; please circle yes if any of these behaviours were present during the past 3 months. Although you may be uncertain about whether some behaviours were present or not, please answer yes or no to every question on the basis of what you think.
1. Is she/he now able to talk using short phrases and sentences? *
If no, skip to question 8.
2. Do you have a to and fro "conversation" with her/him that involves taking turns or building on what you have said?
3. Does she/he ever used odd phrases or say the same thing over and over in almost exactly the same way (either phrases that she/he hears other people use or ones that she/he makes up)?
4. Does she/he ever use socially inappropriate questions or statements? For example, does she/he ever regularly ask personal questions or make personal comments at awkward times?
5. Does she/he ever get her/his pronouns mixed up (e.g., saying you or she/he for I)?
6. Does she/he ever use words that she/he seems to have invented or made up her/himself, put things in odd, indirect ways; or use metaphorical ways of saying things (e.g. saying hot rain for steam)?
7. Does she/he ever say the same thing over and over in exactly the same way or insist that you say the same thing over and over again?
8. Does she/he ever have things that she/he seems to have to do in a very particular way or order or rituals that she/he insists that you go through? *
9. Does her/his facial expression usually seem appropriate to the particular situation as far as you can tell? *
10. Does she/he ever use your hand like a tool or as if it were part of her/his own body (e.g., pointing with your finger, putting your hand on a doorknob to get you to open the door)? *
11. Does she/he ever have any interests that preoccupy her/him and might seem odd to other people (e.g. traffic lights, drainpipes, or timetables)? *
12. Does she/he ever seem to be more interested in parts of a toy or an object (e.g. spinning the wheels of a car), rather than using the object as it was intended? *
13. Does she/he ever have any special interests that are unusual in their intensity but otherwise appropriate for her/his age and peer group (e.g. trains, dinosaurs)? *
14. Does she/he ever seem to be unusually interested in the sight feel, sound, taste, or smell of things or people? *
15. Does she/he have any mannerisms or odd ways of moving her/his hands or fingers, such as flapping or moving her/his fingers in front of her/his eyes? *
16. Does she/he ever have any complicated movements of her/his whole body, such as spinning or repeatedly bouncing up and down? *
17. Does she/he ever injure her/himself deliberately, such as by biting her/his arm or banging her/his head? *
18. Does she/he have any objects (other than a soft toy or comfort blanket) that she/he has to carry around? *
19. Does she/he have any particular friends or a best friend? *
20. Does she/he ever talk with you just to be friendly (rather than to get something)? *
21. Does she/he ever spontaneously copy you (or other people) or what you are doing (such as vacuuming, gardening, or mending things)? *
22. Does she/he ever spontaneously point at things around her/him just to show you things (not because she/he wants them)? *
23. Does she/he ever use gestures, other than pointing or pulling your hand, to let you know what she/he wants? *
24. Does she/he nod her/his head to indicate yes? *
25. Does she/he shake her/his head to indicate no? *
26. Does she/he usually look at you directly in the face when doing things with you or talking with you? *
27. Does she/he smile back if someone smiles at her/him? *
28. Does she/he ever show you things that interest her/him to engage your attention? *
29. Does she/he ever offer to share things other than food with you? *
30. Does she/he ever seem to want you to join in her/his enjoyment of something? *
31. Does she/he ever try to comfort you if you are sad or hurt? *
32. If she/he wants something or wants help, does she/he look at you and use gestures with sounds or words to get your attention? *
33. Does she/he show a normal range of facial expressions? *
34. Does she/he ever spontaneously join in and try to copy the actions in social games, such as The Mulberry Bush or London Bridge is Falling Down? *
35. Does she/he play any pretend or make-believe games? *
36. Does she/he seem interested in other children, of approximately the same age whom she/he does not know? *
37. Does she/he respond positively when another child approaches her/him? *
38. If you come into a room and start talking to her/him without calling her/his name, did she/he usually look up and pay attention to you? *
39. Does she/he ever play imaginative games with another child in such a way that you can tell that each child understands what the other is pretending? *
40. Does she/he play cooperatively in games that need some form of joining in with a group of other children, such as hide-and-seek or ball games? *
Read the description of each skill and examples of situations where the child might demonstrate the skill. Choose the answer which best describes the child.
SKILL 1: RESPONDING APPROPRIATELY TO NAME. Within 2 seconds, the child stops the competing behaviour and turns toward the speaker. *
Examples of situations where the skill may be used: adult calls child's name while he/she is involved in an activity that he/she enjoys or while the child is moving from one activity/location to another, etc.
SKILL 2: COMPLYING WITH SIMPLE INSTRUCTIONS. Within 3 seconds of being told to do something, the child starts working on the task and completes the task in a timely manner. *
Examples of situations where the skill may be used: the child is instructed to wipe his/her mouth or to throw away an empty container, etc.
SKILL 3: COMPLYING WITH MULTI-STEP INSTRUCTIONS. Within 3 seconds of being told to do something, the child starts working on the task and completes the task in a timely manner. *
Examples of situations where the skill may be used: the child is instructed to take off his/her coat AND hang it up, or to walk to [area] AND pick up [item], etc.
SKILL 4: REQUESTING ASSISTANCE: Child requests assistance by saying "help me," "I need help," or similar phrase within 45 seconds of being told to do something and in the absence of inappropriate behaviour. (The child may also demonstrate this skill through the use of signs or pictures.) *
Examples of situations where the skill may be used: the child is instructed to put [items] on a shelf that he/she cannot reach, to open a tightly closed container or to tie his/her shoes, etc.
SKILL 5: REQUESTING ATTENTION. Child gets an adult's attention by calling the person's name or by saying "excuse me" or similar phrase in the absence of inappropriate behaviour. (The child may also demonstrate this skill by tapping adult on shoulder in the absence of inappropriate behaviour.) *
Examples of situations where the skill may be used: an adult's back is turned to the child while the adult talks on the phone; an adult helps another child with something, etc.
SKILL 6: FRAMED REQUESTING TO ADULTS: Child recruits adult's attention as described in skill 5 (calling adult's name, saying "excuse me", or tapping adult on shoulder), waits for a response, and then requests access to an item/activity in the form of "May I --", "Can I --", "I want --", "I would like --", or similar phrase. (The child may also demonstrate this skill by tapping adult on shoulder and showing pictures or signs.) *
Examples of situations where the skill may be used: an adult is holding an item that the child needs for a favourite activity or an adult delays passing the food/drink to the child during meals, etc.
SKILL 7: FRAMED REQUESTING TO PEERS. Child recruits peer's attention as described in skill 5 (calling child's name, saying "excuse me", or tapping child on shoulder), waits for a response, and then requests access to an item/activity in the form of "May I --", "Can I --", "I want --", "I would like --", or similar phrase. (The child may also demonstrate this skill by tapping child on shoulder and showing pictures or signs.) *
Examples of situations where the skill may be used: a peer is holding an item that the child needs for a favourite activity or a peer delays passing the food/drink to the child during meals, etc.
SKILL 8: TOLERATING DELAYS IMPOSED BY ADULTS. Child waits patiently for 30 seconds for the adult-mediated event. *
Examples of situations where the skill may be used: an adult tells the child to wait for something and delays providing the requested item or event for about 30 seconds.
SKILL 9: TOLERATING DELAYS IMPOSED BY PEERS. Child waits patiently for 30 seconds for the peer-mediated event. *
Examples of situations where the skill may be used: peer tells the child to wait for something and delays providing requested item or event for about 30 seconds.
SKILL 10: SAYING "THANK YOU." Within 5 seconds of receiving an item from someone, the child orients to the giver and says "thank you." (The child may also demonstrate this skill through the use of signs.) *
Examples of situations where the skill may be used: a child is given food/drink during meals or a peer shares an item with the child, etc.
SKILL 11: ACKNOWLEDGING OR COMPLIMENTING OTHERS. Within 10 seconds of a newcomer's arrival to an area, the child greets ("hello" or similar phrase) or compliments ("I like --" or similar phrase) the newcomer. (The child may also demonstrate this skill through the use of signs or gestures, such as waving.) *
Examples of situations where the skill may be used: a peer enters the classroom or play group, etc.
SKILL 12: OFFERING OR SHARING. Within 10 seconds of a newcomer's arrival, the child offers some of the toys or materials within reach. *
Examples of situations where the skill may be used: a peer is without toys or activity materials, etc.
SKILL 13: COMFORTING OTHERS IN DISTRESS. Within 10 seconds of an event, the child approaches the victim and asks "Are you okay?" or similar phrase. (The child may also demonstrate this skill through the use of signs, or by offering a hug or similar gesture.) *
Examples of situations where the skill may be used: another person bumps into something, trips, etc., and shows signs of pain or distress
Please provide an email address so that I may contact you in relation to this study. **Contact details and questionnaires will be stored separately to protect anonymity. *
Your answer
I consent to taking part in this study. I understand that agreeing to take part means that I am willing to answer questions and provide information about my child to allow the information collected to be used anonymously in this research project. I agree to provide my contact details and I understand that no personally identifiable information will be included in the research reports. Personally identifiable information will not be published or made available to anyone except for the study supervisor and student. All information will be stored in a locked filing cabinet or as encrypted files on password-protected computers. I understand that I have the right to access my personal data at any time under the Freedom of Information Act (1997). The information I provide will be stored at Trinity College Dublin for a period of 10 years. I may request access to my information at any time of the study or at any point during the 10-year period. I understand that there is a risk that I could become upset by the issues raised during the research project and the researchers will provide support or find the relevant support for me in this instance. I understand that participation in this study is voluntary. I understand that I am free to withdraw my consent at any time. I may also request that data related to my child/student or myself be removed from the study prior to analysis of results and submission/publication (i.e. July 29th, 2015). *
Please fill in your name below if you agree to take part in this research project. (Note: You are not required to give your full name.)
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