Childhood Language Disorders

Assessment tools

Submitted by – Deeksha Abrol

Subject expert – Dr. Veena KD

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 INDEX

S.No Topic abbreviation Page. No

1. Introduction 1-5
2. Screening tools :
a. Checklist for Autism in toddlers CHAT 7-8
b. Modified Checklist for Autism in toddlers M-CHAT 9-11
c. Social Communication Questionnaire SCQ 12-13
d. Screening tool for autism in toddlers and STAT 14-16
young children
e. Autism Spectrum Screening ASSQ 17-18
Questionnaire
f. Autism Spectrum Questionnaire test AQ TEST 19
g. Indian Autism Screening Questionnaire IASQ 21
3. Assessment tools:
a. Indian Scale for Assessment of Autism ISAA 21-22
b. INCLEN Diagnostic tool for ASD IDT-ASD 23-24
c. Malin’s Intelligence Scale for Indian MISIC 25-28
Children
d. Differential Diagnosis checklist for ASD DDC-ASD 29
e. Autism Diagnostic interview – Revised ADI-R 30-31
f. Autism Diagnostic Observation Schedule ADOS-2 32-33
–2
g. Childhood autism rating scale CARS 34-36
h. Gilliam Autism rating scale GARS 37-39
i. Autism behaviour checklist ABC 40
4. Feeding assessment tools
a. Brief autism mealtime behaviour BAMBI 41
inventory
b. Parent Mealtime Action scale PMAS 41
5. Article – Telehealth assessment 42
6. References 43-45

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Introduction

A comprehensive assessment for individuals suspected of having autism spectrum disorder

(ASD) should be functional, sensitive, and multidisciplinary. It requires collaboration among
families, caregivers, classroom teachers, speech-language pathologists (SLPs), special
educators, and psychologists to ensure a holistic understanding of the individual's needs.

The SLP plays a crucial role in incorporating the family's perspective, gathering valuable
insights about their beliefs and concerns. It is essential to communicate assessment findings
with clarity, empathy, and sensitivity, as the diagnostic process can be a stressful and
emotional experience for families (Marcus et al., 2005).

Comprehensive ASD Assessment will include -

1. Case History and Medical Background

 Detailed review of the child's health, developmental milestones, and behavioral
history
 Current medical status and any coexisting conditions
 Family medical and mental health history, including any siblings diagnosed with ASD
2. Medical Evaluations
 General physical and neurodevelopmental examination
 Vision and hearing screenings to rule out sensory impairments
3. Speech-Language and Communication Assessments (Conducted by an SLP)
 Language assessment (expressive and receptive language skills, pragmatic
communication)
 Speech assessment, including motor speech abilities
 Feeding and swallowing evaluation, if needed
 Augmentative and Alternative Communication (AAC) assessment, if required to
enhance functional communication
4. Additional Assessments
 Audiological evaluation (by an audiologist) to assess hearing function
 Genetic testing (if there is a family history of intellectual disability, genetic syndromes
like Fragile X or Tuberous Sclerosis, or physical features suggestive of a genetic
disorder)

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  Metabolic testing (if symptoms such as lethargy, cyclic vomiting, pica, or seizures are
present)

The results of a thorough ASD assessment may lead to:

✅ A formal diagnosis of ASD

✅ A detailed description of communication challenges and symptom severity
✅ Personalized recommendations for intervention, therapy goals, and necessary supports.
✅ Referral for an AAC assessment (if not conducted during the initial evaluation)
✅ Additional referrals to specialists for further evaluation and confirmation of diagnosis

By taking a comprehensive and collaborative approach, this assessment ensures that

individuals with ASD receive accurate diagnoses, effective interventions, and the support
they need to thrive.

SPEECH AND LANGAUGE ASSESSMENT

A speech and language assessment for individuals with Autism Spectrum Disorder (ASD)
evaluates their ability to understand and use language effectively. It includes assessing
expressive and receptive language skills, pragmatic (social) communication, speech sound
production, and overall communicative intent. Since individuals with ASD may have unique
communication profiles—ranging from being nonverbal to highly verbal but struggling with
social communication—both formal and informal assessments are used.

A few formal assessment tools are –

1. Receptive Expressive Emergent Language Scale (REELS)

2. Receptive Expressive Language Test (RELT)
3. Assessment of language development (ALD)

FEEDING ASSESSMENT

Feeding problems are common among children with autism spectrum disorders (ASD), but
the assessment of feeding behavior in this population has received little attention. Behavioral
assessments of feeding problems include:

(a) indirect questionnaires,

(b) direct-observation,

(c) functional assessments, and

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(d) functional analyses.

Currently, two of the most psychometric assessments of feeding problems in children and
adolescents with promising ASD are the Brief Autism Mealtime Behavior Inventory
(BAMBI) and the Parent Mealtime Action Scale (PMAS).

AAC ASSESSMENT

To:

 Determine an individual's current profile of social communication skills.

 Identify high-priority learning objectives within natural communication contexts.

 Examine the influence of the communication partner and the environment on

communication competence.

 As part of the ongoing assessment process, clinicians can use dynamic assessment
procedures to identify skills that an individual has achieved, those that may be
emerging, and the contextual supports that enhance communication skills.

AUDIOLOGICAL ASSESSMENT

 It is also possible for an individual to have both ASD and hearing impairment
(Easterbrooks et al., 2008).

 Some characteristic behaviors associated with ASD can make it challenging to obtain
valid and reliable hearing assessment results.

These include:

a. comfort with sameness and aversion to novel situations

b. hypersensitivity and negative responses to sensory input

c. communication differences, such as receptive language deficits and unreliable

pointing gestures (Davis et al., 2010).

SCREENING ASSESSMENT TOOLS

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Developmental screening can be done by a doctor or nurse, but also by other professionals in
healthcare, early childhood education, community, or school settings.

The tools used for developmental and behavioral screening are formal questionnaires or
checklists based on research that ask questions about a child’s development, including
language, movement, thinking, behavior, and emotions.

The American Academy of Pediatrics (AAP) recommends developmental and behavioral

screening for all children during regular well-child visits at these ages:1

 9 months

 18 months

 30 months

In addition, AAP recommends that all children be screened specifically for ASD during
regular well-child visits at:

 18 months

 24 months

In 2006, AAP the recommendation was expanded to screen at 24 to 30 months of age to

identify those who may regress after 18 months of age

SCREENING ASSESSMENT TOOLS

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 I. Checklist for Autism in Toddlers (CHAT)

The CHecklist for Autism in Toddlers (CHAT) is a screening tool developed in the early
1990s by Simon Baron-Cohen, Jane Allen, and Christopher Gillberg to assess the risk of
autism spectrum disorder (ASD) in children aged 18–24 months. It evaluates key
developmental behaviors, particularly joint attention and pretend play, which are critical
indicators of early autism risk.

Validation and Use

A population-based screening study conducted by Baron-Cohen et al. (1996) in the UK

demonstrated the CHAT’s potential for early autism detection. The tool is typically
administered during the 18-month developmental check-up by primary healthcare workers,
such as health visitors or general practitioners. However, it is not recommended for use
before 18 months due to the risk of false positives. Although some regions administer it at 24
months, data on its validity for older children remain limited.

The CHAT (see appendix I) consists of two sections:

 Section A (Parent-Report): Nine questions answered by parents, focusing on the

child's behaviors and play habits.

 Section B (Clinician-Observed): Five items assessed by a healthcare professional,

evaluating the child's response to specific stimuli during a clinical visit.

Each item is answered in a yes/no format, with a structured order to minimize bias.

Interpretation of Results

The CHAT identifies children at different levels of autism risk based on their responses to
five key items (A5, A7, B2, B3, and B4; see appendix I), which assess joint attention and
pretend play:

 High Risk for Autism: Failing all five key items suggests the child is at the greatest
risk.

 Medium Risk for Autism: Failing A7 and B4, but not all key items, places the child
in the medium-risk category.

 Low Risk for Autism: Children who do not fall into the high- or medium-risk groups
are considered low risk.

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Limitations of CHAT

Despite its usefulness, the CHAT has several shortcomings:

1. Many children who later receive an autism diagnosis may initially pass the CHAT
screening at 18 months.

2. The tool primarily assesses joint attention and pretend play, potentially overlooking
other early autism-related behaviors.

3. The CHAT is designed for 18-month-old children, making it unsuitable for screening
younger or older age groups.

4. Section B must be completed by a healthcare professional, limiting accessibility

compared to fully parent-report tools.

5. The CHAT identifies children at risk but does not provide a definitive diagnosis,
requiring further assessments.

6. Since the CHAT was developed in the UK, its applicability across diverse populations
may require adaptations.

7. Some children with ASD who present different early symptoms may not be identified
by the CHAT.

Due to these limitations, the Modified Checklist for Autism in Toddlers (M-CHAT) was
developed to improve sensitivity and broaden autism screening. The M-CHAT was
specifically adapted for the American population, addressing some of the CHAT’s
weaknesses by enhancing its ability to detect a wider range of early autism behaviors.

II. MODIFIED CHECKLIST FOR AUTISM IN TODDLERS (M-CHAT)

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The Modified Checklist for Autism in Toddlers (M-CHAT) and its revised version, M-
CHAT-R/F, are screening tools developed to identify young children at risk for autism
spectrum disorder (ASD). Both were developed by Robins, Fein, & Barton and are widely
used in the United States as part of early developmental screening.

M-CHAT (1999) M-CHAT-R/F (2009)

Developers Robins, Fein, & Barton Robins, Fein, & Barton

Age Range 16–30 months 16–30 months

Total Items 23 questions 20 questions

Screening Children failing more than 3 A two-stage process: Initial screening

Protocol items total or 2 critical items followed by a mandatory follow-up
(especially if scores remain high interview for children who screen
after follow-up) should be referred positive. Only failed items from the
for diagnostic evaluation by an initial screening are reassessed.
ASD specialist.

Scoring Failing more than 3 items or 2 For most items: "NO" response
Criteria critical items triggers a referral indicates ASD risk.
for ASD evaluation. For items 2, 5, and 12, a "YES"
response indicates ASD risk. –
Interpretation –
Risk levels:
Low Risk (0–2 points): Rescreen if
under 24 months.
Medium Risk (3–7 points): Conduct
follow-up interview; if the follow-up
score is ≥2, refer for evaluation.
High Risk (8–20 points): Immediate
referral for diagnostic evaluation.
Scoring Yes/No scoring Pass/Fail scoring
Type

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 Scoring See appendix II See appendix II
Sheet

The M-CHAT-R/F was developed to address the limitations of the original M-CHAT. It
enhances the screening process by improving specificity, reducing false positives, and
streamlining the overall assessment.

Key Improvements of M-CHAT-R/F Over M-CHAT:

1. Lower False Positive Rate:

o M-CHAT had a high false positive rate, leading to unnecessary referrals.

o M-CHAT-R/F introduced a two-stage screening process (initial screening +

follow-up interview), reducing the number of children falsely identified as at
risk.

2. Higher Specificity:

o Specificity refers to how well the tool avoids false positives.

o M-CHAT-R/F has higher specificity than M-CHAT, meaning fewer children

without autism are mistakenly flagged.

3. Mandatory Follow-Up Interview:

o M-CHAT-R/F requires a follow-up for children with a medium-risk score (3–7

points).

o This second step clarifies ambiguous cases before referring for a full
diagnostic evaluation.

o M-CHAT lacked this step, leading to over-referrals.

4. More Efficient and Streamlined Screening:

o M-CHAT-R/F reduced the number of questions from 23 to 20, making it

quicker and easier to administer.

o Some ambiguous or less useful questions were removed, improving overall

efficiency.

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 5. Refined Scoring System:

o M-CHAT used a simple pass/fail system.

o M-CHAT-R/F introduced a tiered risk assessment:

 Low Risk (0–2 points): No action needed unless concerns persist.

 Medium Risk (3–7 points): Follow-up interview required.

 High Risk (8–20 points): Immediate referral for ASD evaluation.

o This system ensures that only children who truly need further evaluation are
referred.

6. Better Detection of Autism Risk:

o M-CHAT-R/F improves accuracy by distinguishing between:

 Children who need further monitoring

 Children who require immediate evaluation

o It ensures that at-risk children are identified without overwhelming diagnostic

services with false alarms.

Hence, M-CHAT-R/F refines the original screening process by improving specificity,

efficiency, and accuracy, making it a more effective tool for identifying autism risk in
toddlers. It minimizes unnecessary referrals while ensuring that children who truly need
evaluation receive timely intervention.

III. Social communication questionnaire (SCQ) (refer drive- western screening tool)

Developed by - Rutter M, Bailey A & Lord C (2003)

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The American Academy of Pediatrics (AAP) recommends that all children be screened for
autism spectrum disorder (ASD) at both 18- and 24-month well-child visits using an autism-
specific screening tool, such as the Modified Checklist for Autism in Toddlers, Revised with
Follow-Up (M-CHAT-R/F).

Although ASD can be reliably diagnosed by age 2, the AAP also advises continued screening
at later visits when concerns arise. To address the need for an effective screening tool for
older children, the Social Communication Questionnaire (SCQ) was developed.

Social Communication Questionnaire (SCQ): Overview

 Age Range: 4 years and older

 Format: 40-item, parent-report screening measure

 Basis: Adapted from the Autism Diagnostic Interview-Revised (ADI-R)

 Scoring:

o Yes/No format

o 1 point for abnormal behavior, 0 points for normal behavior

o First item determines language ability but is not scored

o Verbal children: Score range 0–39

o Non-verbal children: Score range 0–33

Interpretation - A score of 15 or higher is often used as a cutoff to indicate a potential need

for a more comprehensive evaluation.

Versions of SCQ:

1. SCQ Current – Evaluates behaviors in the past 3 months.

2. SCQ Lifetime – Assesses developmental history; evaluates behaviors at age 4 or, if

younger, in the past 12 months.

Validity and Limitations:

 SCQ is strongly aligned with ADI-R and is a useful screening tool for ASD in older
children.

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  However, it is validated only for children aged 4+ years with a mental age of at least 2
years.

 Studies indicate that SCQ is less effective for children under 4 years, limiting its use
in younger age groups.

Overall, The SCQ bridges the gap in ASD screening for children older than 30 months,
complementing early detection tools like M-CHAT-R/F. While it provides a structured and
reliable method for ASD risk assessment, its applicability to younger children remains
limited.

IV. Screening Tool for Autism in Toddlers and Young Children (STAT)

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  The Screening Tool for Autism in Toddlers (STAT) is a standardized, interactive Level
2 screening tool designed to assess early social communication skills in young
children, particularly those at risk for Autism Spectrum Disorder (ASD).
 It was developed by Dr. W.L. Stone, Dr. E.E. Coonrod, and Dr. O.Y. Ousley, the STAT
was first published in 2000.
 It was originally designed for children aged 24 to 36 months, the tool helps identify
early signs of ASD through structured play-based interactions.
 It focuses on assessing social-communicative behaviors, play skills, communication
abilities, and motor imitation skills—all of which are core areas of difficulty for
children with ASD.

Why Early Screening is Crucial

 Although ASD can be reliably diagnosed by age 2, many children are diagnosed much
later.

 Research shows that:

o Parents often express concerns about their child's development by 18 months,

but formal diagnosis and intervention are often delayed.

o Less than 50% of children with ASD are identified before age 3.

o A significant portion (one-third to one-half) of ASD cases are diagnosed after

age 6 (Sheldrick et al., 2017).

o Many children do not receive ASD-specific services until much later, delaying
access to crucial early interventions (Rosenberg et al., 2011; Baio et al., 2018).

Assessment Process

The STAT (Screening Tool for Autism in Toddlers and Young Children) assesses four
major domains of social communication through 12 structured play-based activities. The
domains and activities are listed below –

Domain Activity Description

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 Play Turn-taking Rolls a ball or car back and forth for three consecutive
turns.

Doll Play Engages in simple functional play with a doll or stuffed

animal.

Requesting Bubbles Requests help opening a jar or asks for more bubbles
using eye contact and vocalization.

Food Requests help opening a food jar using eye contact and
vocalization.

Directing Balloon Directs the examiner’s attention to a balloon while or

Attention after it deflates.

Puppet Directs the examiner’s attention to a puppet.

Bag of Toys Directs examiner’s attention to any of the toys in a bag.

Noisemaker Directs examiner’s attention to the sound of a

noisemaker.

Imitation Shake Imitates the examiner by shaking a rattle back and forth
Rattle at least two times.

Roll Car Imitates rolling a toy car back and forth across the table.

Drum Imitates drumming hands on the table, alternating hands.

Hands

Hop Dog Imitates hopping a toy dog across the table.

Scoring and interpretation-

Each activity is rated as Pass (0), Fail (1), or Refuse (Not Scored):
✅ Pass (0): The child successfully performs the expected action.
❌ Fail (1): The child does not engage in the expected action.
🚫 Refuse (Not Scored): If the child refuses, the item is not counted against them.

 Total STAT Score = Sum of All Activity Scores (out of 12 possible points).

 Cutoff Score for ASD Risk:

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 o Less than 2.0 → Low ASD Risk

o 2.0 or higher → High ASD Risk (further evaluation recommended)

For Example:

If a child participates in all 12 activities and receives:

 Pass (0): For 8 activities

 Fail (1): For 3 activities

 Refuse (Not Scored): For 1 activity

The total score would be calculated by summing the Fail scores:

 Total Score: 3 (since Refuse is not scored)

A total score of 3 indicates a higher risk for ASD, suggesting the need for further evaluation.

Proper training is crucial for the accurate administration and scoring of the STAT. To ensure
reliability and effectiveness, training workshops are available. Detailed information about
these workshops can be found at Vanderbilt Kennedy Center – STAT Training.

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 V. Autism Spectrum Screening Questionnaire (ASSQ) (Refer drive – western
screening tool)

 The Autism Spectrum Screening Questionnaire (ASSQ), developed by Ehlers,

Gillberg, and Wing (1999), is a 27-item screening tool designed for parents and
teachers to identify developmental differences in social and behavioral functioning
among young people aged 6 to 17 years. Assesses symptoms of both Asperger
Syndrome and high-functioning autism. Also referred to as the Autism Screening
Questionnaire (ASQ), the ASSQ helps recognize traits consistent with Autism.

Factor analysis by Junttila et al. (2023) has identified four distinct domains assessed by the
ASSQ:

 Formal Style (Items 1, 2, and 6), which reflects a formal or old-fashioned way of
thinking, appearance, or communication style.

 Contextual Understanding and Routines (Items 4, 5, 7, 10, 11, 13, 23, and 24),
which reflects the ability to understand context and meaning, alongside a preference
for routines.

 Socio-Emotional Reciprocity (Items 12, 15, 16, 17, 18, 19, and 25), which reflects
engagement in social interactions and emotional exchanges.

 Vocalisation, Movement, and Appearance (Items 3, 8, 9, 14, 20, 21, 22, 26, and 27),
which reflects unique vocalisations, behaviours, and physical characteristics.

Scoring and Interpretation

The ASSQ yields a total score ranging from 0 to 54, with higher scores indicating greater
differences in social and behavioral functioning compared to peers. The total score is
expressed as a community percentile, based on normative data from the general population
(Posserud et al., 2006), and a clinical percentile, based on data from Autistic young people
(Ehlers et al., 1999).

The ASSQ provides both a total score and four subscale scores that assess different aspects
of autistic traits. Each subscale score is standardized by dividing the subscale’s total score by
the number of items within that subscale, allowing for direct comparisons between different
areas of difficulty.

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To facilitate interpretation, the scoring system uses qualitative descriptors that categorize a
child’s likelihood of autism based on cutoff thresholds. These thresholds are calculated by
dividing the total scale’s cut-off scores (27 items) to derive meaningful averages:

 Moderately Consistent with Autism → Total score ≥11 (average subscale score
0.41)

 Strongly Consistent with Autism → Total score ≥19 (average subscale score 0.70)

Each subscale score falls into one of two categories:

 Elevated (0.41–0.69) → Differences consistent with the Moderately Consistent

with Autism range.

 High (0.70–2.00) → Differences consistent with the Strongly Consistent with

Autism range.

Graphical Representation of Scores

To enhance clarity, ASSQ results are often represented in graphical form. These graphs
include:

 The child’s total ASSQ score, alongside their average subscale scores for a detailed
profile.

 A comparison of the child’s total score against normative distributions of both

autistic and non-autistic children.

 Shaded percentile areas (based on research by Ehlers et al., 1999; Posserud et al.,
2006) to contextualize the child’s results within the typical range for both autistic and
general populations.

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 VI. Autism Spectrum Quotient (AQ) Test (refer drive – western screening tools)

The Autism-Spectrum Quotient (AQ) is a self-administered questionnaire designed to

measure the degree to which an individual of normal intelligence exhibits autistic traits.
Developed by Simon Baron-Cohen and colleagues in 2001, the AQ provides an introspective
assessment of social interaction, communication patterns, imagination, attention to detail, and
tolerance for change.

Structure and Scoring

The questionnaire consists of 50 items, divided into five domains:

 Social skills (10 items)

 Attention switching (10 items)

 Attention to detail (10 items)

 Communication (10 items)

 Imagination (10 items)

Each question is scored on an ordinal scale, with responses categorized as:

 "Definitely agree" or "Slightly agree" scoring 1 point on certain items.

 "Definitely disagree" or "Slightly disagree" scoring 1 point on other items.

To minimize response bias, approximately half of the items are worded to elicit a “disagree”
response and half an “agree” response.

Interpreting AQ Scores

 0–25 → Few or no autistic traits

 26–31 → Some autistic traits, but not necessarily indicative of autism

 32+ → High likelihood of clinically significant autistic traits

A score of 32 or above suggests a strong presence of autistic traits, but does not confirm a
diagnosis. Diagnosis is only warranted if the individual experiences clinical distress due to
their traits. In such cases, referral to a specialist for a full diagnostic assessment is
recommended.

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INDIAN SCREENING TOOLS FOR AUTISM

VII. Indian autism screening questionnaire (IASQ)

 The Indian Autism Screening Questionnaire (IASQ) is a brief, standardized self-
assessment tool designed to screen for Autism Spectrum Disorder (ASD) in children.
Developed by Dr. Ousley, Dr. Smita N. Deshpande, and Dr. Satabdi Chakrabarti in 2021,
the IASQ was created as a simplified screening version of the Indian Scale for
Assessment of Autism (ISAA).
 It is available in both English and Hindi
 It consists of 10 questions with a simple Yes/No response format. Each "Yes" response is
scored as 1 point, while each "No" response is scored as 0 points
 total score ranges from 0 to 10
 Score Interpretation –
 Total Score of 2 or below: Low risk for autism
 Total Score of 2 or above: The child is at higher risk for autism and should be referred for
further comprehensive evaluation.

IASQ has been reported to be reliable and valid, showing strong correlations with established
autism assessment tools like the ISAA and CARS-2 (Chakraborty et.al., 2022)

ASSESSMENT TOOLS

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INDIAN SCALES FOR ASSESSMENT

1.Indian Scale for Assessment of Autism (ISAA) (refer drive – Indian assessment tools)

Developed by - Sharmila Banerjee Mukherjee, 2015

 The test items are based on DSM IV/ICD 10 criteria.

 It is an objective assessment tool which uses observation, clinical evaluation of
behaviour, testing by interaction with the subject and also information supplemented
by parents or caretakers in order to diagnose autism
 ISAA consists of a total of 40 items divided under six domains as given below - The
40 items of ISAA are -

Domain-I Social Relationship and Reciprocity

Domain-II Emotional Responsiveness

Domain-III Speech - Language and Communication

Domain-IV Behaviour Patterns

Domain-V Sensory Aspect

Domain- VI Cognitive Component

Scoring –

Each behavior is scored based on its frequency:

 Rarely (Up to 20%) → Score 1

 Sometimes (21 - 40%) → Score 2

 Frequently (41 - 60%) → Score 3

 Mostly (61 - 80%) → Score 4

 Always (81 - 100%) → Score 5

The total score categorizes the individual into different severity levels:

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The minimum score that can be obtained is 40 and the maximum score that can be obtained is
200

2.Inclen Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): (refer drive- Indian
assessment tools)

 Developed by: INCLEN Group, & Juneja, M., et al. (2014).

 Languages Available: English and Hindi

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  Based on: DSM-IV-TR criteria

The INCLEN Diagnostic Tool for ASD consists of two sections:

 Section A: 29 items assessing ASD symptoms

 Section B: 12 questions covering DSM-IV-TR domains B & C, including time of

onset, symptom duration, score, and diagnostic algorithm

Administration and Scoring

 Time Required: 45–60 minutes

 Scoring System:

o Responses are recorded using a trichotomous scale:

 Yes = 1 point

 No = 0 points

 Unsure / Not Applicable = 0 points

o Data Sources:

 Parental interview

 Clinician’s behavioral observations

o In case of discrepancy between parent and assessor responses, the tool

specifies which should take precedence.

Results and Interpretation

 A total score of ≥ 6 suggests ASD.

 For an ASD diagnosis, the following criteria must be met:
I. At least two symptoms from the "Impaired Communication" domain
II. At least two symptoms from the "Restricted and Repetitive Behaviors" domain

INDT-ASD has high diagnostic accuracy, adequate content validity, good internal consistency
high criterion validity and high to moderate convergent validity and 4-factor construct
validity for diagnosis Autism spectrum disorder.

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3.Malin’s Intelligence Scale For Indian Children (MISIC)

 The Indian Scale has been constructed by Dr. Arthur J. Malin of Nagpur in 1969.

 Languages available = English, Hindi, Marathi

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  It is an Indian adaption of the western tool Weschler Intelligence Scale for Children
and developed in 1966 to assess the cognitive abilities of the child.

 Age range = 6 to 15 years 11 months

 Time taken for administration = about 2 to 2-1/2 hours

 The test comprises of 11 subtests divided into two groups, Verbal and
Performance. Verbal Scale consists of 6 subtests and Performance Scale consists of 5
subtests. The score on each subtest yields an IQ score for each age group.

Verbal subtest description and scoring:

Subtest Description Scoring & Example

Discontinuation

1. Information Assesses factual 30 questions; 1 point per How many ears

Test knowledge about correct answer; do you have?
people, places, and discontinue after 5
common phenomena. consecutive failures.

2. General Measures 14 questions; scored 0-2; What should

Comprehension understanding of social discontinue after 3 you do if you
Test situations and consecutive failures. cut your
conventional finger?

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 knowledge.

3. Arithmetic Solving basic math 1 point per correct If I break this

Test calculations mentally. answer; discontinue after pencil in half,
3 consecutive failures. how many
pieces will
there be?

4. Analogy & Two subtests: Analogy Scored 0-2; discontinue Lemon is sour,
Similarity Test (complete missing after 3 consecutive but sugar is...?
word in a sentence) and failures.
Similarity (find
commonality between
two things).

5. Vocabulary Measures general 40 items; scored 0-2; Define: Cycle,

Test intelligence and discontinue after 5 Shoe.
accumulated consecutive failures.
knowledge.

6. Digit Span Recall of number Score based on longest Forward: 3-6-

Test sequences in Forward correctly repeated 2-9; Backward:
(same order) and sequence. 9-2-6-3.
Backward (reverse
order).

Performance subtests description and scoring :

Subtest Description Scoring & Discontinuation Example

1. Picture Identifying the 1 point per correct response; last Identify the

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 Completion missing part in 20 5 pictures earn a bonus if 3+ missing part in
pictures. correct; discontinue after 4 an incomplete
failures. picture.

2. Block Arranging colored 4 points per correct design + Recreate the

Design blocks into specific bonus points (varies by design); pattern shown in
geometric patterns. no points for incomplete design. the booklet
using blocks.

3. Object Arranging puzzle Points vary per item based on Assemble the
Assembly pieces into accuracy; extra points for near- pieces to form a
meaningful designs perfect arrangements. complete face.
(Man, Horse, Face,
Auto).

4. Coding Matching symbols Coding A (for <8 years): Score Pair symbols
with corresponding = total designs completed in with numbers
numbers or shapes. 120s; bonus for early quickly and
completion. Coding B (for >8 accurately.
years): 1 point per correct
response in 120s.

5. Mazes Tracing a path Mazes A, B, C: 2 points (no Navigate

through mazes error), 1 point (2 errors). Mazes through a maze
without error. 1-5: 3 points (no error), 2 points without touching
(1 error), 1 point (2 errors), 0 the boundaries.
points (exceeding max errors).

Scoring: The test yields three primary scores:

 Verbal IQ (VIQ)
 Performance IQ (PIQ)
 Full-Scale IQ (FSIQ)

Procedure of calculating scores:

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 1. The child receives a point (raw score) for each correct response in the subtest.
2. The raw scores are then converted into Test Quotients (TQs) , which act as IQ
equivalents for each subtest
3. The Verbal and Performance IQs are calculated separately before deriving the Full-
Scale IQ.
4. The Full-Scale IQ is interpreted based on standard classification:

IQ Range Classification
130 & Above Very Superior
120 - 129 Superior
110 - 119 High Average
90 - 109 Average
80 - 89 Low Average
70 - 79 Borderline
Below 70 Intellectual Disability

4.Differential Diagnosis Checklist For Autism Spectrum Disorders (DDC- ASD)

(Dr. K.C Shyamala,Mrs. Vijayashree, Mrs.Sujatha,2007, AIISH)

The Characteristic features are classified under different domains;

 Age of Onset

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  Behavior

 Sensory

 Social

 Speech and Language

There are two parts, PART –A (For autistic & asperger’s syndrome) & PART B – (Rett’s
syndrome& CDD).

5.Autism Diagnostic Interview – revised (ADI-R)

 Rutter M, LeCouteur A, Lord C (2003, 2008)

 Suitable for Individuals of any age with a developmental level of at least 2 years

 Administration Time: 1.5 – 2.5 hours.

29
  Respondent: A parent or caregiver familiar with the individual's developmental
history and behavior.

 It is used in Formal diagnosis of Autism Spectrum Disorder (ASD) and Planning

treatment and educational interventions.

 The ADI-R consists of 93 items covering different aspects of ASD. The questions are
divided into three main functional domains:

1. Language and Communication

2. Reciprocal Social Interactions

3. Restricted, Repetitive, and Stereotyped Behaviors and Interests

Scoring and Interpretation

 Each item is scored on a 0-3 scale, where:

o 0 = No abnormality

o 1 = Mildly abnormal

o 2 = Markedly abnormal

o 3 = Severely abnormal

Scores = Both "Lifetime" and "Current" Scores in the 3 domains of Social Interaction,
Communication, and Range of Restrictive, Repetitive, and Stereotyped Behaviors and
Interests are obtained. Separate Communication algorithms are available for verbal and
nonverbal individuals. In addition, scores indicating abnormal development before the age of
3 are also obtained.

 Scores are then mapped onto diagnostic algorithms based on DSM-IV-TR and ICD-10
criteria for Autism.

 A cutoff score is used to determine if the individual meets the diagnostic criteria for
ASD.

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6.AUTISM DIAGNOSTIC OBSERVATION SCHEDULE – 2 (ADOS -2) (refer drive –
Western assessment tools)

Given by - Catherine Lord et.al., 2013

The primary goal of ADOS-2 is to assess and classify behaviors associated with ASD,
focusing on communication, social interaction, play, and restricted or repetitive

31
behaviors. It provides standardized observations that contribute to an accurate diagnosis and
guide intervention planning.

Structure and Modules

ADOS-2 consists of five modules, with the appropriate module selected based on the
individual's age and language abilities:

 Toddler Module (12-30 months): Designed for very young children with minimal or
no speech.
 Module 1 (31+ months): For individuals with little or no spoken language.
 Module 2: For individuals using phrase speech but not yet fluent.
 Module 3: For children and adolescents who are fluent speakers.
 Module 4: For adolescents and adults who use fluent speech.

Each module involves a series of structured and unstructured activities designed to elicit
behaviors relevant to ASD.

Areas Assessed

 Social Communication: Eye contact, gestures, conversation skills, and joint attention.
 Social Interaction: Reciprocity, emotional expression, and response to social cues.
 Play and Imagination: Ability to engage in imaginative and reciprocal play.
 Stereotyped Behaviors and Restricted Interests: Presence of repetitive behaviors,
unusual interests, or sensory sensitivities.

Administration and Scoring

 ADOS-2 is administered by trained professionals, including psychologists,

psychiatrists, speech-language pathologists, and developmental pediatricians. The
session lasts 40-60 minutes, during which the clinician engages the individual in
structured activities while systematically observing and coding behaviors.

Scoring Process

Observation and Data Collection: During the assessment, the clinician observes the
individual’s behaviors and records responses according to predefined criteria.

32
Coding Behaviors: Each observed behavior is scored using a numerical scale (typically 0-3),
where:

 0 = No evidence of abnormality related to ASD.

 1 = Slightly atypical behavior.
 2 = Clearly abnormal behavior.
 3 = Markedly abnormal behavior.

Summation of Scores: The scores from different domains (e.g., social affect, restricted
and repetitive behaviors) are totaled to form an overall algorithm score.

Comparison to Cutoff Scores: The total score is compared to established cutoff points that
determine whether the behavior aligns with an autism diagnosis or falls within a
borderline/non-ASD range.

Toddler Module Cutoff Scores:

 Moderate-to-Severe Concern: Total score ≥ 14

 Mild-to-Moderate Concern: Total score 10-13
 Little-to-No Concern: Total score ≤ 9

Modules 1-4 Cutoff Scores:

 Autism: Score thresholds vary per module but typically range from 9-16.
 Autism Spectrum: Lower score range indicating ASD characteristics but not meeting
full autism criteria.
 Non-Spectrum: Scores below the autism spectrum cutoff.

Interpretation: The results are reviewed in conjunction with other assessments, such as
developmental history and parent interviews, to confirm or rule out an ASD diagnosis.

7.Childhood Autism Rating Scale (CARS) (refer drive – western assessment tools)

CARS was developed by Eric Schopler, Robert J. Reichler, and Barbara Rochen Renner at
the TEACCH (Treatment and Education of Autistic and Related Communication

33
Handicapped Children) program at the University of North Carolina. The original version
was published in 1980, and an updated version, CARS-2, was introduced in 2010 to enhance
its applicability across a broader range of individuals.

CARS is designed to:

 Distinguish children with ASD from those with other developmental delays.

 Determine the severity of autism symptoms (mild, moderate, or severe).

 Provide a standardized measure for clinicians, researchers, and educators.

CARS consists of 15 items, each assessing different aspects of behavior associated with
autism. These include:

1. Relating to People – Social responsiveness and interaction.

2. Imitation – Ability to mimic behaviors and sounds.

3. Emotional Response – Appropriateness of emotional expressions.

4. Body Use – Presence of repetitive or unusual motor movements.

5. Object Use – Interaction with and attachment to objects.

6. Adaptation to Change – Response to changes in routine or environment.

7. Visual Response – Reactions to visual stimuli.

8. Listening Response – Sensitivity and response to sounds.

9. Taste, Smell, and Touch Response – Reactions to sensory experiences.

10. Fear and Nervousness – Anxiety or unusual fears.

11. Verbal Communication – Speech development and use.

12. Nonverbal Communication – Gestures, eye contact, and body language.

13. Activity Level – Degree of hyperactivity or hypoactivity.

14. Level and Consistency of Intellectual Response – Cognitive abilities and

consistency of responses.

15. General Impressions – Clinician’s overall assessment based on observations.

34
Scoring System

Each item is rated based on behavioral observations:

 1 (No impairment) – Behavior is typical for the child’s age.

 2 (Mild impairment) – Slightly abnormal behavior.

 3 (Moderate impairment) – Clearly atypical behavior.

 4 (Severe impairment) – Markedly abnormal behavior.

The total score is obtained by summing all 15 items, with a possible range of 15 to 60.

Cutoff Scores and Interpretation

 Below 30: Not indicative of autism.

 30-36.5: Mild to moderate autism.

 37-60: Severe autism.

CARS 2 updates -

CARS-2 improves upon the original scale by increasing sensitivity to a broader range of
individuals, including those with high-functioning autism.

It consists of three distinct forms:

1. CARS-2 Standard Version (CARS2-ST) – Retains the original 15-item format for
assessing children under 6 years old and those with lower intellectual abilities.

2. CARS-2 High-Functioning Version (CARS2-HF) – A modified version designed

for children and adolescents 6 years and older with average or above-average
intelligence.

3. CARS-2 Questionnaire for Parents or Caregivers (CARS2-QPC) – A

supplementary parent-report form to gather additional information on the child’s
behavior in different environments.

 Scoring, cutoffs and interpretation remain similar to CARS

Feature CARS CARS-2

Year Developed 1980 2010

35
 Number of 1 3 (CARS2-ST, CARS2-HF, CARS2-
Versions QPC)

Target Age Group Primarily young children Expanded to include older children and
high-functioning individuals

Sensitivity Limited sensitivity for Improved differentiation between ASD

high-functioning autism and other conditions

Parent/Caregiver Not included Included in CARS2-QPC

Input

Advantages of CARS-2

 Assesses a wider range of individuals, including those with high-functioning autism.

 Enhances diagnostic accuracy with additional behavioral insights.

 Used globally in clinical and research settings.

 Suitable for individuals from 2 years old to adolescence.

Limitations of CARS-2

 Best used alongside tools like ADOS-2 for a complete evaluation.

8.Gilliam Autism Rating Scale (GARS) (refer drive – western assessment tools)

36
GARS is a standardized screening tool developed by James E. Gilliam to assess the
likelihood of autism spectrum disorder (ASD) in children and young adults. Over the years,
the scale has undergone multiple revisions to align with updated diagnostic criteria, improve
reliability, and enhance its ability to identify individuals with ASD.

Category GARS (1995) GARS-2 (2006) GARS-3 (2013)

Developer James E. Gilliam James E. Gilliam James E. Gilliam

Year 1995 2006 2013

Based on DSM-IV DSM-IV-TR DSM-V

Age Range 3–22 years 3–22 years 3–22 years

Total 42 items 42 items 58 items

Questions

Total Sections 9 9 9

Subscales Total 4 Subscales: Total 3 Subscales Total 6 Subscales:

• Stereotyped • Stereotyped • Restricted/Repetitive
Behaviors Behaviors Behaviors (13 items)
• Communication • Communication • Social Interaction (14
• Social Interaction • • Social Interaction items)
Developmental • Social Communication
Disturbances (9 items)
• Emotional Responses (8
items)
• Cognitive Style (7 items)
• Maladaptive Speech (7
items)
Response Yes/No Yes/No Yes/No
Format

Scoring 4-point Likert 4-point Likert 4-point Likert scale:

scale: scale: 0 - Not at all like
0 - Never observed 0 - Never observed individual
1 - Seldom observed 1–Seldom observed 1 - Not much like

37
 2 - Sometimes 2 – Sometimes individual
observed observed 2 - Somewhat like
3 - Frequently 3 - Frequently individual
observed observed 3 - Very much like
Number of times individual
behavior is observed
per 6-hour period
Interpretation Autism Quotient Autism Index (AI), Autism Index (AI),
(AQ) Standard Scores, and Standard Scores,
Percentiles Percentiles, and Severity
Levels

Outcomes Autism Quotient Autism Index (AI) AI Score Interpretation:

(AQ) Interpretation: • >54 = Unlikely ASD
Interpretation: • 85+ = Very likely • 55–70 = Probable ASD
• < 90 = Below- autism (DSM-V Level I)
average chance of • 70–84 = Possible • 71–100 = Very likely
autism presence of autism (DSM-V Level II)
• 69 or lower = • >101 = Very likely
Autism unlikely (DSM-V Level III)
Scoring Sheet See appendix IV See appendix IV See appendix IV

Key reasons for the revisions in each version of the GARS:

Revisions from GARS (1995) to GARS-2 (2006):

1. Updated to Align with DSM-IV-TR – The diagnostic criteria were refined to be

consistent with the DSM-IV-TR to improve accuracy in identifying autism.

2. Refined Subscales – The Developmental Disturbances subscale was removed,

reducing the total subscales from 4 to 3.

3. Improved Standardization – The scoring system was adjusted, and percentile ranks
were introduced to improve clinical utility.

38
 4. Introduction of Autism Index (AI) – Replaced the previous Autism Quotient (AQ) for
more reliable classification of autism likelihood.

5. Additional Clinician Considerations – New items were added to help clinicians reflect
on the diagnostic outcome beyond the raw scores.

Revisions from GARS-2 (2006) to GARS-3 (2013):

1. Updated to DSM-V Criteria – GARS-3 was revised to align with DSM-V, introducing
a classification system based on the new ASD diagnostic framework.

2. Expanded Subscales – The number of subscales increased from 3 to 6, including new

categories such as Emotional Responses, Cognitive Style, and Maladaptive Speech,
improving sensitivity to different ASD symptoms.

3. More Comprehensive Assessment – Increased total items from 42 to 58, allowing for
a broader evaluation of autism-related behaviors.

4. Severity Levels Introduced – New severity levels were mapped to DSM-V

classifications:

o Level I (55-70 AI Score) – Requiring support

o Level II (71-100 AI Score) – Requiring substantial support

o Level III (>101 AI Score) – Requiring very substantial support

5. Improved Psychometric Properties – Adjusted scoring system to reduce false

negatives and improve sensitivity while maintaining specificity.

6. Greater Differentiation Between ASD and Other Conditions – The added subscales
and expanded criteria helped differentiate ASD from other developmental disorders.

9.AUTISM BEHAVIOUR CHECKLIST (ABC)

 Developed by - Krug et al., 1980)

39
 List of questions about a child's behaviors.

 The ABC is designed to be completed independently by a parent or a teacher familiar

with the child who then returns it to a trained professional for scoring and
interpretation.

 Although it is primarily designed to identify children with autism within a population

of school-age children with severe disabilities, the ABC has been used with children
as young as 3 years of age.

 The ABC has 57 questions divided into five categories:

 (1) Sensory, (2) Relating (3) Body and Object use, (4) Language, and (5) Social and
self-help.

FEEDING ASSESSMENT TOOLS

40
 1. BRIEF AUTISM MEALTIME BEHAVIOR INVENTORY (BAMBI)

 Lukens and Linscheid (2008)

 They developed the 18-item Brief Autism Mealtime Behaviour Inventory (BAMBI)
by comparing eating behaviour of 68 children with ASD and 40 children without
ASD.

 Parents rate items using 5-point frequency Likert scales and assess their child’s
variety of foods eaten, food refusal, and their child’s demonstration of autism
features.

 Parents are to think about mealtimes with the child during the last 6 months. They are
to rate items as a “Yes” if they think the item is a problem or “No” if they think it is
not a problem.

 A major benefit of the development of the BAMBI is that it was the first assessment
to address feeding problems commonly seen in the ASD population. This is
particularly beneficial because it addresses the specific mealtime problem behaviour
seen in this population.

2. PARENT MEALTIME ACTION SCALE (PMAS)

 Hendy et al. (2009) developed the Parent Mealtime Action Scale (PMAS) to identify
both child and parent mealtime behavior and the frequency that the parents eat and
serve certain foods.

 2,988 parents involved in developing norms for this scale had children ages 2 to 12
years. A 31-item questionnaire with nine subscales was derived.

 The nine subscales of the PMAS include: snack limits, positive persuasion, daily
fruits and vegetables availability, use of rewards, insistence on eating, snack
modeling, special meals, fat reduction, and many food choices.

ARTICLE

A Randomized Trial of the Accuracy of Novel Telehealth Instruments for the

Assessment of Autism in Toddlers

41
 Corona LL (2024)

Purpose: Telemedicine approaches to autism (ASD) assessment have become increasingly

common, yet few validated tools exist for this purpose. This study presents results from a
clinical trial investigating two approaches to tele-assessment for ASD in toddlers.

Methods: 144 children (29% female) between 17 and 36 months of age (mean = 2.5 years,
SD = 0.33 years) completed tele-assessment using either the TELE-ASD-PEDS (TAP) or an
experimental remote administration of the Screening Tool for Autism in Toddlers (STAT). All
children then completed traditional in-person assessment with a blinded clinician, using the
Mullen Scales of Early Learning (MSEL), Vineland Adaptive Behavior Scales, 3rd Edition
(VABS-3), and Autism Diagnostic Observation Schedule (ADOS-2). Both tele-assessment
and in-person assessment included a clinical interview with caregivers.

Results: Results indicated diagnostic agreement for 92% of participants. Children diagnosed
with ASD following in-person assessment who were missed by tele-assessment (n = 8) had
lower scores on tele- and in-person ASD assessment tools. Children inaccurately identified as
having ASD by tele-assessment (n = 3) were younger than other children and had higher
developmental and adaptive behavior scores than children accurately diagnosed with ASD by
tele-assessment. Diagnostic certainty was highest for children correctly identified as having
ASD via tele-assessment. Clinicians and caregivers reported satisfaction with tele-assessment
procedures.

Conclusion: This work provides additional support for the use of tele-assessment for
identification of ASD in toddlers, with both clinicians and families reporting broad
acceptability. Continued development and refinement of tele-assessment procedures is
recommended to optimize this approach for the needs of varying clinicians, families, and
circumstances.

42
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