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. ADES QUICK SCORE BEHAVIORS OF CONCERN HOME VERSION SAMPLE ADES HV Copyright © 2008 Hawthorne Educational Services, Inc. Page 5 of 5
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