SCHOOL VERSION RATING FORM
Tamara J. Arthaud
Kerri Duncan
PROFILE
SHEET
Name of student:
Gender: Male
Andrew Thomas
Grade: 7
State: PA
Midvale
Date of rating:
2007
1
(year)
23
(month)
1998
Date of birth:
Raw
Score
Subscales
School: Midvale
Science
Class:
City:
SUMMARY OF SCORES
(day)
9
7
(Appendix A)
(Appendix C)
136
6
1.01
Reciprocal Communication
50
8
1.37
Restricted Range of Interest &
Repetitive Behavior
Interpretation of Sensory Experiences:
26
9
1.50
Reciprocal Social Interaction & Play
(year)
(month)
(day)
Auditory
10
10
2.01
12
(years)
9
(months)
11
(days)
Visual
9
11
12
9
1.73
1.42
1.60
1.73
10
1.68
Rated by (observer's name): M. Jackson
Kinesthetic
26
14
7
22
Dates during which observation of student occurred:
Fear, Anxiety, & Nervousness
10
Age at rating:
Standard Standard Score
Score
SEM
Tactile
Olfactory & Gustatory
From: 09/04/2006
E
R
CO N
S
K IO
C
I
U VER LE
Q
P
S OL
E
M
AD HO E SA
SC FIL
O
R
P
To: 11/29/2006
Amount of time spent with stude
Per day 50 min
Sum of
Subscale SS
Per week 250 min
Total Score
Quotient
(Appendix B)
84
Percentile
(Appendix B)
93
33
Quotient
SEM
(Appendix C)
Confidence
Interval
2.73
99%
Percentiles
Percentile
Rank
Subscales
Standard
Score
Restricted
Interpretation of Sensory Experiences
Reciprocal
Range of
Social Reciprocal Interest &
Olfactory
Interaction Communi- Repetitive
&
& Play
cation
Behavior Auditory Visual Tactile Gustatory
Kinesthetic
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
ADES SV
X
X
Copyright (c) 2008
Hawthorne Educational Servces, Inc.
X
X
X
X
Fear
Anxiety, &
Nervousness
X
X
X
Quotients
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
Quotient
> 99
X
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
<1
X
The Reciprocal Social Interaction & Play subscale assesses verbal and nonverbal social behaviors that occur when
engaging in conversation or play activities jointly performed with others. This subscale includes such items as
avoiding eye contact, playing alongside others without interacting with them, unusual facial expressions, lack of facial
expression, preferring to play alone, inability to understand others' viewpoints, and inappropriate or lack of response to
verbal and nonverbal communicative attempts by others. It also includes unusual activities or mannerisms during play
such as spinning toys, lining toys up, playing with unusual items (e.g., strings, lids, paper, etc.), or development of
predictable routines with toys.
Andrew scored more than one standard deviation below the mean on the Reciprocal Social Interaction & Play
subscale.
22.
23.
24.
25.
38.
Avoids looking directly into others’ eyes or cannot hold eye contact for appropriate amount of time
Does not accept an item presented to him/her by others
Prefers inanimate objects over interaction with people
Does not exhibit awareness of social “codes of conduct” or does not learn appropriate behavior from observing such behaviors (e.g., saying,
“please/thank you,” turn taking, sharing, etc.)
Is unable to understand others’ view points
Does not realize how his/her actions affect others
Does not communicate for the purpose of sharing positive affect (e.g., joint attention)
Does not use other’s emotional responses to guide behavior (i.e., social referencing)
Does not respond to social praise, is not motivated by social praise
BE A
SC H D
H AV ES
O I Q
O O U
L R IC
V S
ER O K S
SI F C CO
O O R
N N E
SA CE
M RN
PL
E
1.
7.
11.
21.
The Reciprocal Communication subscale assesses verbal communicative attempts by the student or his/her responses
to verbal communication. This subscale includes such items as the inability to participate in conversation turn-taking,
interpreting comments literally, unusual voice tones or speech patterns, inappropriate use of language in unfamiliar
situations, and difficulties with personal space.
Andrew scored within one standard deviation below the mean on the Reciprocal Communication subscale.
46. Interprets comments literally
55. Has difficulty understanding or accepting others’ point of view
The Restricted Range of Interest & Repetitive Behavior subscale assesses repetitive, stereotyped behavioral patterns
exhibited in a continued, inflexible, orpersistent manner. These items include such behaviors as rocking one's body,
flapping hands, unusually intenseinterest in specific topics or activities, repeated verbalizations (e.g., phrases or
words), perseveration on words or tasks, and difficulty accepting changes in routine.
Andrew scored within one standard deviation below the mean on the Restricted Range of Interest & Repetitive
Behavior subscale.
66. Engages only in activities which focus on personal topics of interest
ADES SV Copyright (c) 2009 Hawthorne Educational Services, Inc.
Page 2 of 5
The Interpretation of Sensory Experiences: Auditory subscale involves overly sensitive responses to auditory
information and includes such items as overreacting to environmental sounds (e.g., vacuum cleaner, blender, bells,
etc.), covering ears when hearing distant or barely audible sounds, not responding to loud noises very close to him/her,
and humming or using vocal stimulations to tune out surrounding noises.
Andrew scored at the mean on the Interpretation of Sensory Experiences: Auditory subscale.
The Interpretation of Sensory Experiences: Visual subscale involves overly sensitive reactions to visual information
and includes such items as staring off into space, inability to look others in the eye, preoccupation by visual stimuli
(e.g., lights, mirrors, shiny objects, spinning objects, etc.), moving body in a manner to create visual stimulus (e.g.,
hand flapping, spinning toys/materials, etc.), and fear of certain visual stimuli (e.g., large rooms, small rooms, specific
objects, etc.).
Andrew scored within one standard deviation below the mean on the Interpretation of Sensory Experiences: Visual
subscale.
BE A
SC H D
H AV ES
O I Q
O O U
L R IC
V S
ER O K S
SI F C CO
O O R
N N E
SA CE
M RN
PL
E
83. Needs to be reminded to look at objects or tasks
84. Stares off into space
The Interpretation of Sensory Experiences: Tactile subscale involves heightened or unusual responses to touch or
tactile sensations and includes such items as overreacting to being lightly touched (e.g., slight bumps with others, feels
pain with normal clothing textures or touching, etc.), difficulty tolerating different textures normally found in clothing,
fabrics or food; resisting changing to seasonal clothing, unresponsive to pain, reacting inappropriately to pain (e.g.,
laughing when injured), eating inedible materials (e.g., dirt, pebbles, paper), limiting one's diet to certain foods or food
textures, and craving deep pressure (e.g., deep hugs, weighted objects, etc.).
Andrew scored within one standard deviation above the mean on the Interpretation of Sensory Experiences: Tactile
subscale.
The Interpretation of Sensory Experiences: Olfactory & Gustatory subscale involves overly sensitive reactions to
smells and includes such items as seeking out different smells, inappropriately smelling objects/people as a means of
exploring the environment, craving particular food tastes (e.g., sour or spicy), and eating only bland foods.
Andrew scored within one standard deviation above the mean on the Interpretation of Sensory Experiences: Olfactory
& Gustatory subscale.
The Interpretation of Sensory Experiences: Kinesthetic subscale involves overly sensitive or heightened reactions to
bodily movement and includes such items as seeking out movement activities (e.g., swinging, jumping on a
trampoline, sit-n-spin, etc.), self-stimulatory behaviors, seeking out unusual risk-taking activities (e.g., climbing to
high places, walking across high beams, etc.), difficulty with fine or gross motor skills, and walking with an unusual
gait.
Andrew scored within one standard deviation below the mean on the Interpretation of Sensory Experiences:
Kinesthetic subscale.
115. Demonstrates difficulty with fine motor skills (e.g., unable to hold a crayon, pencil, or cut with scissors, etc.)
116. Refuses to participate in paper/pencil activities
The Interpretation of Sensory Experiences: Fear, Anxiety, & Nervousness subscale involves heightened or lack of fear
and anxiety to common events or activities and includes such items as lacking awareness of safety concerns, showing
no fear of hazardous situations such as walking out into a busy street, persistent fear of harmless events or objects
(e.g., fear of a family cat, fear of hats, fear of doorbell at home, etc.), and unusual fear of such places as noisy,
crowded areas or big, open spaces.
Andrew scored at the mean on the Interpretation of Sensory Experiences: Fear, Anxiety, & Nervousness subscale.
ADES HV Copyright (c) 2009 Hawthorne Educational Services, Inc.
Page 4 of 5
HOME VERSION RATING FORM
Tamara J. Arthaud
Kerri Duncan
PROFILE
SHEET
Name of student: Andrew Tomas
School: Midvale Elementary
Class:
City:
Gender: Male
State: PA
2007
1
(year)
Age at rating:
23
(month)
1998
Date of birth:
Raw
Score
Subscales
Grade: 3
Midvale
Date of rating:
SUMMARY OF SCORES
(day)
9
7
Standard Standard Score
Score
SEM
(Appendix A)
(Appendix C)
Reciprocal Social Interaction & Play
75
10
0.52
Reciprocal Communication
35
10
0.60
Restricted Range of Interest &
Repetitive Behavior
Interpretation of Sensory Experiences:
29
8
0.79
(year)
(month)
(day)
Auditory
12
8
1.10
8
(years)
4
(months)
16
(days)
Visual
19
13
11
23
10
12
10
7
0.83
0.99
1.07
9
10
1.03
Olfactory & Gustatory
Rated by (observer's name): M. Jackson
Relationship to Child: Mother
Tactile
E
R
CO
S
K ON
C
I
U ERI LE
Q
P
V
S
E
M
E
AD OM E SA
H FIL
O
R
P
Kinesthetic
Fear, Anxiety, & Nervousness
Total Score
Quotient
Percentile
Quotient
SEM
(Appendix B)
(Appendix B)
(Appendix C)
Sum of
Subscale SS
85
95
37
1.08
Confidence
Interval
1.57
68%
Percentiles
Percentile
Rank
Subscales
Standard
Score
Restricted
Interpretation of Sensory Experiences
Reciprocal
Range of
Social Reciprocal Interest &
Olfactory
Interaction Communi- Repetitive
&
& Play
cation
Behavior Auditory Visual Tactile Gustatory
Kinesthetic
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
ADES HV
Fear
Anxiety, &
Nervousness
X
X
X
Copyright (c) 2008
Hawthorne Educational Servces, Inc.
X
X
X
X
X
X
Quotients
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
Quotient
> 99
X
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
<1
X
The Reciprocal Social Interaction & Play subscale assesses verbal and nonverbal social behaviors that occur when
engaging in conversation or play activities jointly performed with others. This subscale includes such items as
avoiding eye contact, playing alongside others without interacting with them, unusual facial expressions, lack of facial
expression, preferring to play alone, inability to understand others' viewpoints, and inappropriate or lack of response to
verbal and nonverbal communicative attempts by others. It also includes unusual activities or mannerisms during play
such as spinning toys, lining toys up, playing with unusual items (e.g., strings, lids, paper, etc.), or development of
predictable routines with toys.
Andrew scored at the mean on the Reciprocal Social Interaction & Play subscale.
The Reciprocal Communication subscale assesses verbal communicative attempts by the child or youth or his/her
responses to verbal communication. This subscale includes such items as the inability to participate in conversation
turn-taking, interpreting comments literally, unusual voice tones or speech patterns, inappropriate use of language in
unfamiliar situations, and difficulties with personal space.
BE A
H H DE
O AV S
M I Q
E OR UI
V
ER S O CK
SI F SC
O CO O
N
R
N
SA C E
M ER
PL N
E
Andrew scored at the mean on the Reciprocal Communication subscale.
The Restricted Range of Interest & Repetitive Behavior subscale assesses repetitive, stereotyped behavioral patterns
exhibited in a continued, inflexible, or persistent manner. These items include such behaviors as rocking one's body,
flapping hands, unusually intense interest in specific topics or activities, repeated verbalizations (e.g., phrases or
words), perseveration on words or tasks, and difficulty accepting changes in routine.
Andrew scored within one standard deviation below the mean on the Restricted Range of Interest & Repetitive
Behavior subscale.
The Interpretation of Sensory Experiences: Auditory subscale involves overly sensitive responses to auditory
information and includes such items as overreacting to environmental sounds (e.g., vacuum cleaner, blender, bells,
etc.), covering ears when hearing distant or barely audible sounds, not responding to loud noises very close to him/her,
and humming or using vocal stimulations to tune out surrounding noises.
Andrew scored within one standard deviation below the mean on the Interpretation of Sensory Experiences: Auditory
subscale.
The Interpretation of Sensory Experiences: Visual subscale involves overly sensitive reactions to visual information
and includes such items as staring off into space, inability to look others in the eye, preoccupation by visual stimuli
(e.g., lights, mirrors, shiny objects, spinning objects, etc.), moving body in a manner to create visual stimulus (e.g.,
hand flapping, spinning toys/materials, etc.), and fear of certain visual stimuli (e.g., large rooms, small rooms, specific
objects, etc.).
Andrew scored at the mean on the Interpretation of Sensory Experiences: Visual subscale.
The Interpretation of Sensory Experiences: Tactile subscale involves heightened or unusual responses to touch or
tactile sensations and includes such items as overreacting to being lightly touched (e.g., slight bumps with others, feels
pain with normal clothing textures or touching, etc.), difficulty tolerating different textures normally found in clothing,
fabrics or food; resisting changing to seasonal clothing, unresponsive to pain, reacting inappropriately to pain (e.g.,
laughing when injured), eating inedible materials (e.g., dirt, pebbles, paper), limiting one's diet to certain foods or food
textures, and craving deep pressure (e.g., deep hugs, weighted objects, etc.).
Andrew scored within one standard deviation above the mean on the Interpretation of Sensory Experiences: Tactile
subscale.
ADES HV Copyright (c) 2009 Hawthorne Educational Services, Inc.
Page 2 of 5
The Interpretation of Sensory Experiences: Olfactory & Gustatory subscale involves overly sensitive reactions to
smells and includes such items as seeking out different smells, inappropriately smelling objects/people as a means of
exploring the environment, craving particular food tastes (e.g., sour or spicy), and eating only bland foods.
Andrew scored at the mean on the Interpretation of Sensory Experiences: Olfactory & Gustatory subscale.
The Interpretation of Sensory Experiences: Kinesthetic subscale involves overly sensitive or heightened reactions to
bodily movement and includes such items as seeking out movement activities (e.g., swinging, jumping on a
trampoline, sit-n-spin, etc.), self-stimulatory behaviors, seeking out unusual risk-taking activities (e.g., climbing to
high places, walking across high beams, etc.), difficulty with fine or gross motor skills, and walking with an unusual
gait.
Andrew scored at one standard deviation below the mean on the Interpretation of Sensory Experiences: Kinesthetic
subscale.
The Interpretation of Sensory Experiences: Fear, Anxiety, & Nervousness subscale involves heightened or lack of fear
and anxiety to common events or activities and includes such items as lacking awareness of safety concerns, showing
no fear of hazardous situations such as walking out into a busy street, persistent fear of harmless events or objects
(e.g., fear of a family cat, fear of hats, fear of doorbell at home, etc.), and unusual fear of such places as noisy,
crowded areas or big, open spaces.
Andrew scored at the mean on the Interpretation of Sensory Experiences: Fear, Anxiety, & Nervousness subscale.
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