ASD Assessment Scale Grading and Scoring

Grading for Assessment Questions in General:

(Bolded questions are graded differently. See detailed descriptions below.)

• No (0 points): Perfectly normal, never had such problem.
• Resolved (1 point): Perfectly normal, but used to belong to one of the below categories.
• Mild (2 points): Feature present minimal, whether improved or was always just rarely noted or skill (speech) only minimally impaired. Must be clearly different from other children.
• Moderate (3 points): Feature present frequently or skill significantly impaired.
• Severe (4 points): Feature present almost all the time or skill almost absent. (no speech or no eye contact)

Grading for Social Interaction Difficulties

Social impairments are a fundamental aspect of autism, Asperger’s syndrome or PDD NOS.

Scoring for bolded question:

• No (0 points): Normal.
• Resolved (0 points): Anyone who qualified for the below descriptions but now has completely normal social skills.
• Mild (8 points): Are people (or children) who appear almost normal in their interaction with others, yet do have some subtle “strange behavior” or an inability to “read” social cues. For example, not understanding when they are boring to others, continuously perserverating about the same subject or thinking that others like them when it’s clear to all that this is not the case. (Frequently being made fun of.)
• Moderate (12 points): Have significant, very noticeable problems interacting. May be interested in social interaction, but will appear awkward, extremely shy, or eccentric. They may stand too close during conversation, touch others inappropriately or speak in a tone that doesn’t fit the situation. (Socially isolated, have very few friends.)
• Severe (16 points): Is reserved to those who have no interest to interact with others and seem irritated or anxious when coming in social contact. For younger children 2-3 this will manifest with a desire to play on their own, cry, have tantrums or seem upset around other kids.

1. Poor eye contact, or staring from unusual angle
   • No: Perfectly normal, never had such problem.
   • Resolved: Eye contact is now perfectly normal, but was clearly abnormal previously.
   • Mild: Almost normal eye contact, but some subtle unusual way of looking at others exists. This may be present in children with PPD NOS who start with very poor eye contact that gradually improves over time.
   • Moderate: Eye contact may be present for extended period but is obviously abnormal, may be gazing too long at one spot, appears “very shy” or establishing eye contact by turning the eyes to the side.
   • Severe: Almost never capable of establishing eye contact, when eye contact is present, it’s very short and clearly abnormal.
2. Ignores when called, pervasive ignoring, not turning head to voice
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal reaction to calling, but formerly met one of the below categories
   • Mild: Almost normal reaction to calling of the name, but there is a subtle delay in reaction and a mildly (but clear) noticeable difference from other people.
   • Moderate: Significant abnormality in reaction to calling, but clearly reacts at times.
   • Severe: Hardly ever turns when his/her name is called, appears to be deaf, yet when his favorite sound, music or video plays, even very quietly, there may be an immediate reaction.
3. Excessive fear of noises (vacuum cleaner); covers ears frequently
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal reaction to sounds, but used to belong to one of the below categories.
   • Mild: Occasionally (more than normal) bothered by sounds.
   • Moderate: Frequently bothered by sounds.
   • Severe: Inability to tolerate certain noises or sounds, covering the ears and going into temper tantrums as soon as exposed to the trigger sound.
4. In his/her own world (aloof)
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal but used to belong to one of the below categories.
   • Mild: Occasionally aloof, clearly different, but almost normal interaction with the outside world.
   • Moderate: Frequently in his own world.
   • Severe: Constantly in his own world, hardly any ability to interact with the outside world.
5. Lack of curiosity about the environment
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal but used to belong to one of the below categories.
   • Mild: Some lack of reaction to event, almost normal but clearly different.
   • Moderate: Significant lack of interest.
   • Severe: Not at all interested in people, situations or events, completely ignores noises (a fire truck passing by) or other events that interest others, unless it involves a noise that irritates him.
6. Facial expressions don’t fit situations
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal but used to belong to one of the below categories.
   • Mild: Almost normal, but subtle inappropriateness detected.
   • Moderate: Frequently unable to fit appropriate facial expression to situation.
   • Severe: Never able to have an expression of the fact that is interpreted by others as appropriate to the situation. May be lacking affect (poker face). May be smiling frequently without a reason or appearing constantly anxious even when calm.
7. Inappropriate crying or laughing
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal but used to belong to one of the below categories.
   • Mild: Almost normal, but clearly different.
   • Moderate: Occasionally
   • Severe: Very frequently occurring
8. Temper tantrums, overreacting when not getting his/her way
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal but used to belong to one of the below categories.
   • Mild: Occasional temper tantrums, almost normal but clearly different.
   • Moderate: Frequent tantrums, may be controlled somewhat by giving in to the child’s demands (which is not recommended).
   • Severe: Very frequent temper tantrums, occurring almost always when needs to change between activities or engage in any situation that is requested by others, such as stopping with a game or sitting for dinner. The tantrums are difficult to control.
9. Ignores pain (bumps head accidentally without reacting)
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Almost normal reaction, but decreased.
   • Moderate: Occasionally ignores pain (“forgets” to cry when bumps his head).
   • Severe: Hardly ever reacts to pain.
10. Doesn’t like to be touched or held (body, head)
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal but used to belong to one of the below categories.
    • Mild: Almost normal, may be touched, but expresses discomfort or being discontent with the tactile sensory input.
    • Moderate: Clearly unhappy when touched, moves away, but doesn’t react with tantrums.
    • Severe: Extreme reaction to being touched on skin, head, or hair. May react with temper tantrums or violent behavior.
11. Hates crowds, difficulties in restaurants and supermarkets
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Almost normal, but more likely to overreact and have tantrums in crowded areas.
    • Moderate: Frequent difficulties in crowded areas, very sensitive, but at times capable of tolerating the situation.
    • Severe: Almost impossible to leave the regular protected environment. Whenever in a restaurant, supermarket or other crowded areas, goes into severe temper tantrums to the point that caretakers dread to leave the house with the individual.
12. Inappropriately anxious, scared
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: More anxious than the average person.
    • Moderate: Very anxious, but may be consoled.
    • Severe: Extreme, severe fear from relatively minor situations. Having phobias to noises (thunder), sounds (vacuum cleaner), objects, animals, bugs, or people, leading to severe temper tantrums and out of control behavior.
13. Inappropriate emotional response (not reaching to be picked up)
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Almost normal, but clearly different in a subtle way.
    • Moderate: Frequent inappropriate emotional response.
    • Severe: Never exhibit any appropriate emotional response. When parents reach with hands, to pick up the child, he won’t understand to lift his arms to facilitate being picked up.
14. Abnormal joy expression when seeing parents
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Almost normal, but clearly different expression of joy.
    • Moderate: The child may come to see the parent entering the house, but will have a very inappropriate joy expression.
    • Severe: Never expresses joy as expected. When parents get into the house, this child will not even acknowledge the situation.
15. Lack of ability to imitate
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Almost normal, but some subtle limitations in the ability to imitate are clearly evident.
    • Moderate: Some limited ability to imitate.
    • Severe: When children play and interact, they imitate and mimic each other as part of a social situation in order to be “cool” or to make a joke. These individuals have no ability at all to imitate.

Grading for Speech and Language Delay

Scoring for bolded question:

• No (0 points): Normal.
• Resolved (0 points): Perfectly normal, but used to belong to one of the below categories.
• Mild (8 points): Almost normal, but some comprehension of speech difficulties persist.
• Moderate (12 points): A very significant delay in speech (40-70% from age required skills).
• Severe (16 points): Nonverbal, or single words in an adult. If dealing with a young child (1-4 years), this may be evaluated with a developmental assessment by a behavioral or medical professional.

1. Loss of acquired speech
   • No: Perfectly normal, never had such problem.
   • Resolved: Not applicable.
   • Mild: Any loss of any (even minimal) acquired speech.
   • Moderate: Was able to say many words that were lost.
   • Severe: Was able to communicate in sentences and became nonverbal.
2. Produces unusual noises or infantile squeals
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Occasional, more frequent than normal, production of these sounds.
   • Moderate: Very frequent production of these sounds.
   • Severe: No other sound production other than screeching and squealing.
3. Voice louder than required
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Voice occasionally sound inappropriate, clearly different than normal.
   • Moderate: Voice frequently inappropriate.
   • Severe: Voice constantly very loud (but may be also inappropriately quiet such as whispering). Never sound appropriate.
4. Frequent gibberish or jargon
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Rare gibberish
   • Moderate: Very frequent gibberish and jargon.
   • Severe: Almost constantly producing, unintelligable speech-like sounds, as if imitating speech, but unable to say anything that could be understood by others. (It is my theory that this is an attempt of children with autism to repeat speech sounds the same way they repeat heard words, TV commercials and other sounds.
5. Difficulty understanding basic things (“just can’t get it”)
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Subtle difficulties to get to the point, “can’t get a joke.”
   • Moderate: Significant inability to understand abstract concepts.
   • Severe: Complete lack of understanding.
6. Pulls parents around when wants something
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Occasionally does it.
   • Moderate: Frequently does it.
   • Severe: Always pulls parents or people around, manipulating their position/taking them to where he wants as an abnormal means of communication.
7. Difficulty expressing needs or desires, using gestures
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Occasionally using gestures.
   • Moderate: Frequently using gestures.
   • Severe: Always using gestures; never speech.
8. No spontaneous initiation of speech and communication
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Almost normal, but shy and hesitating with regards to initiative of social interaction.
   • Moderate: Rarely initiates.
   • Severe: Never initiates.
9. Repeats heard words, parts of words or TV commercials
   • No: Perfectly normal, never had such problem.
   • Resolved: Perfectly normal, but used to belong to one of the below categories.
   • Mild: Rarely repeats.
   • Moderate: Frequently repeats.
   • Severe: Will almost always repeat some word or communication when addressed or spoken to.
10. Repetitive language (same word or phrase over and over)
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Rarely.
    • Moderate: Occasionally having repetitive language
    • Severe: Frequent or continuous rambling and repeating a word, phrase, sentence or entire movies out of context to a social situation.
11. Can’t sustain conversation
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Some difficulties.
    • Moderate: Significant difficulties sustaining conversation.
    • Severe: Completely unable to initiate or respond to a sentence as part of a conversation.
12. Monotonous speech, wrong pausing
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Some subtle difficulties.
    • Moderate: Significant difficulties with the flow of speech.
    • Severe: Speech sounds “robotic.” There is absolutely no indication when a sentence starts or stops.
13. Speaks same to kids, adults, objects (can’t differentiate)
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Subtle difficulties.
    • Moderate: Will have significant difficulties.
    • Severe: Complete lack of ability to adjust the tone, flow or intensity of the speech in relation to a specific situation.
14. Uses language inappropriately (wrong words or phrases)
    • No: Perfectly normal, never had such problem.
    • Resolved: Perfectly normal, but used to belong to one of the below categories.
    • Mild: Subtle difficulties, rarely uses wrong words or phrases.
    • Moderate: Occasionally makes language errors.
    • Severe: Very commonly uses the wrong word, wrong phrase or wrong expression, completely out of context.

Grading of Speech Related Skills

(features 9-14 in the Speech and Language questions)

When no language is present, these questions 9-14 must all be graded severe if ASD is diagnosed based on the entire assessment. When language delay is moderate or mild, features 9-14 must be graded accordingly, if the language impairment prevents these features from being manifested.

Grading for Abnormal Symbolic or Imaginary Play

Scoring for bolded question:

• No (0 points): Perfectly normal, never had such problem.
• Resolved (0 points): Perfectly normal, but used to belong to one of the below categories.
• Mild (8 points): Plays almost normally but has subtle inappropriateness and “clumsiness” in using imagination or being “creative” while playing.
• Moderate (12 points): May be interested in toys, or even want to play with them, but has a clearly abnormal or inappropriate use of the toys. Doesn’t understand to feed the doll and has no ability to use imagination or make believe as part of playing.
• Severe (16 points): No interest in age-appropriate toys. If interested in something, may be in order to bang it, twist it, hold or arrange it.

1. Hand or finger flapping; self stimulation
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely flaps.
   • Moderate: Frequently flaps, mostly when excited, happy, upset or nervous.
   • Severe: Almost constantly engaged in same self stimulatory behavior, frequently will involve flapping of the hands, as if trying to fly, but may also involve flapping of the finger, tapping on the ear or using an object for such stimulatory behavior.
2. Head banging
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely bangs the head.
   • Moderate: Occasionally bangs, mostly during temper tantrums or when upset.
   • Severe: Frequently bangs the head, usually against a hard surface.
3. Self mutilation, inflicting pain or injury
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely.
   • Moderate: Occasionally inflicting self pain, mostly when upset or excited.
   • Severe: Poses danger to self, needs to be frequently supervised to prevent him/her from biting, hitting his/her own face or causing damage in any other way.
4. Toe walking, clumsy body posture
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely
   • Moderate: Frequently
   • Severe: Almost always toe walking. Clumsiness present in coordination of movements. A typical example would be, despite walking on time at age 1, being unable to pedal a tricycle until 4 or 5 due to an inability to coordinate the movements.
5. Arranging toys in rows
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely arranging objects compulsively.
   • Moderate: Frequently arranging objects as a form of playing.
   • Severe: Very frequently arranging toys or objects in patterns, getting extremely upset, going into temper tantrums if the pattern is disrupted.
6. Smelling, banging, licking or other inappropriate use of toys
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Almost normal play skills, but occasional bizarre use of objects and toys.
   • Moderate: Frequent unusual use of toys and objects, intermixed with some appropriate play skills.
   • Severe: No evidence of any appropriate use of toys. May smell, spin, bang, lick, shake repetitively, but not having any imaginary use of toys.
7. Interest in toy parts, such as car wheels
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely drifts into playing repetitively with a toy part.
   • Moderate: Able to play with toys correctly, but drifts frequently into focusing on a part of the toy, repetitively manipulating it.
   • Severe: Very frequent engagement with toy parts (can’t see the entire picture). Spinning a wheel of a car, never being able to make use of a toy the way it’s meant to be used.
8. Obsessed with objects or topics (trains, weather, numbers, dates)
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely, but clearly abnormally talking about their obsessions out of context.
   • Moderate: Frequently obsessed with the same objects or topics.
   • Severe: Almost always preocccupied with talking on a specific topic or being busy with doing the same obsessive activity over and over. May be interested in numbers or letters (before even saying the first word such as “dada.”) May be reading books before being able to talk. May be interested in the weather, the calendar (remembering dates and days over a span of many years). May be interested in mechanical objects (washing machines or other spinning tools). Leaving very little time to other activities.
9. Spinning objects, self, or fascination with spinning objects
   • No: Perfectly normal, never had such problem.
   • Resolved: Normal, but used to belong to one of the below categories.
   • Mild: Rarely but clearly abnormally engaged in spinning or fascinatoin with spinning activities.
   • Moderate: Frequently engaged in spinning.
   • Severe: Almost constantly and continuosly spinning objects or spinning oneself. May be also very fascinated with fans, ceiling fans or toys that have spinning parts.
10. Restricted interest, (watching the same video over and over)
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: Rarely, but clearly inappropriately, engaged in the same repetitive behavior.
    • Moderate: Frequently engaged in the same activity. May stop without temper tantrums.
    • Severe: Constantly engaged in the same repetitive behavior or interest, watching the same video over and over, talking about the same thing, getting extremely angry if gets interrupted.
11. Difficulty stopping repetitive “boring” activity or conversation
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: May be able to stop repetitive behavior, but with some difficulty.
    • Moderate: Frequently talking about topics that clearly do not interest the listeners without being able to realize that they are boring. Activities may include some mechanical repetitive playing with strings or more complex tasks. Topics may include history, science, going into extreme fine details.
    • Severe: Continuously rambling with inappropriate bits and pieces of conversation.
12. Attachment to unusual objects, (sticks, stones, strings, or hair)
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: Rarely, but clearly abnormally attached to objects.
    • Moderate: Frequently attached to unusual objects, not going into tantrums if removed.
    • Severe: Always holds an unusual object (string, rock, stick, pen, colors, toy, bottle, part of the toy and others). Goes into severe temper tantrums if removing the object.
13. Stubborn about rituals and routines; resists to change
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: Tends to follow routines and compulsive rituals, but is aware of them and is capable of controlling them on his/her own.
    • Moderate: Frequently follows a schedule and has some rituals. Is able to change, but has a difficult time with it.
    • Severe: Always follows the same schedule, same pattern and engages in frequent ritualistic (compulsive, illogical) activity. Severe temper tantrums result from trying to change this schedule.
14. Restricted taste by consistency, shape or form (refuses solids)
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: Almost normal, but has some “strange choices” when it comes to food, based on taste, shape or consistency.
    • Moderate: Agrees to eat some foods, but has a very limited repertoire of things they are willing to eat.
    • Severe: Unable to eat certain food; refuses solids. May be over 10 years and insists on drinking milk or eating only one type of food. Choice may be related to taste consistency or sensory sensation to the oral cavity.
15. Savant ability, restricted skill superior to age group (reads early, memorizes books)
    • No: Perfectly normal, never had such problem.
    • Resolved: Normal, but used to belong to one of the below categories.
    • Mild: Some superior ability in a restricted field of interest.
    • Moderate: Very clear superior ability in a restricted area.
    • Severe: Superior ability (genius), knowledge of extreme details, in a very restricted area (math, literature, history, weather) in a person who is very limited in the ability to communicate with others (reading before speaking).

Grading for Behavioral Difficulties

• No (0 points): Normal.
• Resolved (0 points): Perfectly normal, but used to belong to one of the below categories.
• Mild (8 points): Almost normal but occasional tantrums, inappropriate outbursts of difficult behavior.
• Moderate (12 points): Severe, potentially dangerous, behavioral outbursts, yet may be predictable and, therefore, controlled.
• Severe (16 points): Behavior so difficult they can’t be left alone for any minimal time because they become wild, “out of control,” and may hurt self or others.

Scoring

To diagnose infantile autism based on the DSM IV criteria, one must have features from each group, associated with a significant level of dysfunction, indicated by a score of at least “moderate” or “severe.”

The DSM IV criteria requires onset before 3 years of age, the associated autistic features as above and a significant impairment observed, involving one of the following:

1. Social interaction
2. Language
3. Symbolic or imaginative play

If the above requirements are met then the following scores may be suggestive of the corresponding definitions:

• 0 – 49 = no ASD
• 50-100 = Mild ASD
• 100-150 = Moderate ASD
• > 150 = Severe ASD

The above numbers are arbitrary estimates and must be confirmed with a large scale population study that hasn’t been performed yet.

The total score may not indicate ASD unless there is a feature present in each of the 3 sections. However, if there are no features present in the second section, Speech and Language Delay, but the overall score is above 60, consider Asperger’s Syndrome.

Interpretation of the ASD Assessment scale questionnaire: Best performed by an experienced physician with both parents present during the information intake. Interpretation of data acquired by parents filling the forms without proper instructions and explanation of the features, may lead to diagnostic errors.

Final diagnostic determination: Must take into account the examiner’s clinical experience in conjunction with the above collected data.

For the diagnosis of specific syndromes, such as Asperger’s or Rett, one has to apply the collected data to the specific DSM IV criteria.