ADES QUICK SCORE SCHOOL VERION PROFILE SAMPLE

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1 SCHOOL VERSION RATING FORM PROFILE SHEET Name of student: Andrew Thomas Gender: Male SUMMARY OF SCORES Raw Standard Standard Score School: Midvale Score Score SEM Class: Science Grade: (Appendix A) (Appendix C) City: Midvale State: PA Reciprocal Social Interaction & Play Reciprocal Communication Date of rating: (year) (month) (day) Restricted Range of Interest & Repetitive Behavior Date of birth: 18 Interpretation of Sensory Experiences: (year) (month) (day) Auditory 2.01 Age at rating: Rated by (observer's name): (years) (months) (days) M. Jackson Dates during which observation of student occurred: From: 0/04/2006 To: /2/2006 Amount of time spent with stude Per day 0 min Per week 20 min Visual Tactile Olfactory & Gustatory Kinesthetic Sum of Subscale SS Quotient (Appendix B) Total Score Quotient Percentile SEM (Appendix B) (Appendix C) > <1 ADES SV Copyright (c) 2008 Hawthorne Educational Servces, Inc. Tamara J. Arthaud Kerri Duncan Fear, Anxiety, & Nervousness SCHOOL VERION PROFILE SAMPLE Confidence Interval 2.3 % Restricted Interpretation of Sensory Experiences Reciprocal Range of Social Reciprocal Interest & Olfactory Fear Standard Interaction Communi- Repetitive & Anxiety, & Percentile Score & Play cation Behavior Auditory Visual Tactile Gustatory Kinesthetic Nervousness Quotients Quotient Percentiles Rank 3

2 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 1. 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 21. 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.) 22. Is unable to understand others view points 23. Does not realize how his/her actions affect others 24. Does not communicate for the purpose of sharing positive affect (e.g., joint attention) 2. Does not use other s emotional responses to guide behavior (i.e., social referencing) 38. Does not respond to social praise, is not motivated by social praise 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 46. Interprets comments literally. 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. SCHOOL VERSION SAMPLE Andrew scored within one standard deviation below the mean on the Restricted Range of Interest & Repetitive Behavior 66. Engages only in activities which focus on personal topics of interest

3 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 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 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 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 SCHOOL VERSION SAMPLE 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. Demonstrates difficulty with fine motor skills (e.g., unable to hold a crayon, pencil, or cut with scissors, etc.) 6. 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

4 HOME VERSION RATING FORM PROFILE SHEET SUMMARY OF SCORES Name of student: Andrew Tomas Gender: Male Raw Standard Standard Score School: Midvale Elementary Score Score SEM Class: Grade: 3 (Appendix A) (Appendix C) City: Midvale State: PA Reciprocal Social Interaction & Play Reciprocal Communication Date of rating: (year) (month) (day) Restricted Range of Interest & Repetitive Behavior Date of birth: 18 Interpretation of Sensory Experiences: (year) (month) (day) Auditory 8 1. Age at rating: Visual (years) (months) (days) Tactile Rated by (observer's name): M. Jackson Relationship to Child: Mother Sum of Subscale SS Total Score Quotient Quotient Percentile SEM (Appendix B) (Appendix B) (Appendix C) > <1 ADES HV Copyright (c) 2008 Hawthorne Educational Servces, Inc. Tamara J. Arthaud Kerri Duncan Olfactory & Gustatory Kinesthetic Fear, Anxiety, & Nervousness HOME VERION PROFILE SAMPLE Confidence Interval 1. 68% Restricted Interpretation of Sensory Experiences Reciprocal Range of Social Reciprocal Interest & Olfactory Fear Standard Interaction Communi- Repetitive & Anxiety, & Percentile Score & Play cation Behavior Auditory Visual Tactile Gustatory Kinesthetic Nervousness Quotients Quotient Percentiles Rank 1.03

5 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 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. Andrew scored at the mean on the Reciprocal Communication 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 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 HOME VERSION SAMPLE 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 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

6 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 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 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 HOME VERSION SAMPLE