GARS=-2 Cruse ens il sasiee eee iat etna Mae ee cng Date of Rating Date of Birth Age Subscales Stereotyped Behaviors, Communication Individuat's Nome Social Interaction ‘Sum of Standard Scores Section I. identifying Information Yeor Month Dey Section H. Score Summary Raw Standard Score Score Autismindex (| fo 4 Section Ill. Interpretation Gui Subseale Standard Autism Probability of Score Index Autism Tor Higher 85 ot Higher Very Likely Atob 70to 84 Possibly 1to3 69 or Less Unlikely (©1095, 206 4 FRO-£0 4&6 Teo eo Male Female Grode School Rater’s Name aminer’s Name Examiner's Title Section IV. Profile of Scores Subseales d Behaviors Social Interaction Stereotype utism Index Adeiionel copes ofthis form (#12263) are avilable rom PAO-E0, 8760 Shoal rack B., Asin, 12 78737-4897 206/897-3202, Fx BON/$97-1655, wm peoede omeSection V, individuc! item Respon! Directions: Rate th lowing items ace! ing to the frequency of occurrence. Use the following guidelines for your rati Never Observed~You have never seen the individual behave in this manner L_ Seldom Observed—Individual behaves in this manner 1-2 times per 6-hour period s s Observed~Individuat behaves in this manner 3-4 times per 6-hour per 3 Frequently Dbserved~individual behoves in this manner at least §-€ times per 6 Circle the number that best describes your observations of the individual's typical behavior under cumstances (j.e., in most places, with familiar people, and in usual daily activities), Remember to ro m If you are uncertain about how to rate an item, delay the rating and observe the individual for a 6-ho determine your rating. REMEMBER, EVERY ITEM SHOULD RECEIVE A SCORE 1. fivoids establishing eye contact; looks away when eye contact is made. 0 1 2 3 2, Stares at hands, objects, or items in the environment for at least § se o 1 2 3 3. Flicks fingers rapidly in front of eyes For period onds or more 6 1 a i 4. Eats specific foods and refuses to eat what most people usually will e a \ a 3 5. Licks, tastes, or attempts to eat inedible objects (e.g., person's hand, toys 2 3 books) 6. Smells or sniffs objects (e.g., toys, person's hand, hair) Q 1 2 3 7. Whirls, turns in circles. 0 1 2 8. Spins objects not designed for spinning (e.g., saucers, cups, glasses) ° L 2 3 9. Rocks back and forth while seated or standing. 0 L 2 3 10. Makes rapid lunging, darting movements when moving from place to place. 0 L 2 3 11. Prances (i.e., watks on tiptoes) 0 l 2 3 12. Flaps hands or fingers in front of face or at sides. 0 l 2 3 13. Makes high-pitched sounds (e.g., ece-eee-eee-eee) or other 0 1 2 3 vocalizations for self-stimulation. 14. Slaps, hits, or bites self or attempts to injure self in other ways 0 3 Subtotals a en Stereotyped Behaviors Total Raw ScoreDirections: f ig items according to the frequency of occurrence. Use the follawing guidelines for 1 Observed--You have never seen the individual behave in this manner J Seldom Gbserved—individual behaves in this manner 1-2 times per 6-haur period. 2 jetimes Observed—Individual behaves in this manner 3-4 times per 6-hour period. 3 Frequently Observed~Individual behaves in this manner at least 5-6 times per é-hour perio ircle the number that best describes your observations of the individual's typical behavior under ordinary cir cumstances (i.e., in most places, with familiar people, and in usual daily activities), Remember to rate every item If you are uncertain abaut how to rate an item, delay the rating and observe the individual for a 6-hour period to determine your rating. REMEMBER, EVERY ITEM SHOULD RECEIVE A SCORE How does this individual communicate? Talks —— Signs —— Does not Talk or Sign If the individual does not talk, sign, or use any other form of communication, omit this subscale. 15, Repeats (echoes) words verbally or with signs 0 2 3 16. Repeats words out of context (i.e., repeats words heard at anearliertime; 0 2 3 €-g., repeats words heard more than | minute earlier) 17. Repeats words or phrases over and over. 0 1 2 4 18, Speaks or signs with flat tone, affect, or dysrhythmic patterns 0 1 2 3 19. Responds inappropriately to simple commands (e.g., “sit down’ 0 1 2 3 ‘stand up") 20. Looks away or avoids looking at speaker when name is called. 0 1 2 i 21. Does not ask for things he or she wants 0 1 2 3 22. Does not initiate conversations with peers or adults 0 1 2 3 23. Uses “yes” and “no” inappropriately. Says “yes” when asked iFhe or she 0 1 2 3 wants an aversive stimulus, o¢ says “no” when asked if he or she wants a favorite toy or treat 24. Uses pronouns inappropriately (e.g., refers to selfas “he,” “you,” “she”). 0 1 2 25. Uses the word I inappropriately (e.g., does not say “I” to refer to self). a 1 2 3 26. Repeats unintelligible sounds (babbles) over and over 0 1 2 3 27. Uses gestures instead of speech or signs to obtain objects. 0 1 2 3 28, inappropriately answers questions about a statement or brief story. a 1 2 3 Subtotals — te tite Communication Total Raw ScoreSection V. Continued. Directions: Rate the fallow your ratings: ig items according to the frequency of occurrence. Use the following guidelines for 1 Never Observed—You have never seen the individual behave in this manner Seldom Observed—Individual behaves in this manner I-2 times per é-hour period Sometimes Observed—individual behaves in this manner 34 times per 6-haur period 3 Frequently Observed—individual behaves in this manner at least §-6 times per 6-hour period. Circle the number that best describes your observations of the individual's typical behavior under ordinary cir cumstances (i.e., in mast places, with familiar people, and in usual daily activities). Remember to rate every item. f you are uncertain about how to rate an item, delay the rating the individual for a 6-hour period te determine your rating. REMEMBER, EVERY ITEM SHOULD RECEIVE A z 29. Avoids eye contact; looks away when someone looks at him or her i 1 2 3 30. Stares or looks unhappy or unexcited when praised, humored, ar entertained. 0 1 2 3 31. Resists physical contact from others (e.g., hugs, pats, being held 5 1 2 3 affectionately) 32. Does not imitate other people when imitation is required or desirable a 1 2 5 such as in games or learning activities 33. Withdraws, remains aloof, or acts standattish in group situations. 0 3 34. Behaves in an unreasonably fearful, frightened manner. 0 1 2 3 35. Is unaffectionate; does not give affectionate responses (e.g.,hugsand 0 1 2 3 kisses) 36. Shows no recognition that a person is present (i.e, looks through people) 1 2 3 37. Laughs, giggles, cries inappropriately. 0 1 2 3 38. Uses toys or objects inappropriately (e.g., spins toy cars, takes action Q 1 2 3 toys apart). 39. Does certain things repetitively, ritualistically. 6 1 2 3 40. Becomes upset when routines are changed. a 1 2 5 41, Responds negatively or with temper tantrums when given commands, 4 1 2 5 requests, oF direction: 42. Lines up objects in precise, orderly fashion and becomes upset when a 1 2 3 the order is disturbed. Subtotals — tote +e Social Interaction Total Raw ScoreSection Vi, Parent inter who have direct, sustained contact with the in This section e completed by parents or other caregive dividual. Porent and caregiver interview eptable. Answer each question by recording either yes ot no Complete every item Social Interaction During the child's First 3 years of ie ithe eld reach nthe povent attempted to itt the cil the chil er hb ne adult to ont Language Used in Social Communicat 1 During the child’ first 3 years of ite: i ld use single words by 16 months of . ch ofanguage (i.e, coving, babbling, and spenking without en interruption or egression 4. Gidthe citd follow directions (ie, oppear to understand what ta do whe fo something the child oppear tohave \ Social Interaction Yes, During the child's frst 3 years of life we chill smile at pavents or ab layed with? we child ry when approached by unfamiliar persons during the first yeor © Did the child engage in imitative play before age 3 (eg. eect Did the child proferto spend time nthe company Language Used in Social Communication Yes No During the child's Fest 3 years of ite a, Did the child respone to his or her nome when called (eg, turn and look a the perso . [ b. Did the child ask for things or use gestutes to communicate what he or she wonted? sme hee “give me a hug,” *wave bye-b Did the child Follow simple directions ( Did the child appear to understand what todo whan told to do something © Didthe child indicate (show facial concern} when a parent o sibing cred or was distressed Symbolic or Imaginative Play Yes No During the cil’s fist 3 years of life: W ploy fe. play with dolls, acto appropriately)? Di the child engage in pret nd he or she was someone else (e.g, Mammy or Daddy, action hero)? amething else? For example, did the child pre Between his or her legs and pretend tobe viding Di th hicomstiek was @ horse an place te Bro: child pretend that an object wos 4. Did the child pretend that he or she had an imaginary Friend or animal i Dic the child play with dols pretending that they were real persone? AV-TR. tf you checked Ns to any question i Aocurent whether the mlvidual meets «set of diagnostic erteria fram D pose of Section Vis vets criteria for delays or abnormal functioning. section, the individual