Please respond to each of the items below currently and in childhood. 

The first broad category for ASD is: Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history. 

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. [e.g. as a child having difficulty making friends, being on the periphery of friend groups, preferring adults to age peers, as an child or adult disliking “small talk,” ability to talk at length about topics of interest, difficulty engaging in uninteresting topics, developing a list of 3-4 topics to keep a conversation going and being at a loss when the list is exhausted, finding social situations emotionally draining.]  

 

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. [e.g. finding eye contact uncomfortable, looking at other features of the person’s face—eyebrows, chin—or over the person’s shoulder, observing others to establish the right amount of eye contact (e.g. 20 seconds) if you look too long you worry that the person will think you are staring and if you look to little you worry the person will think your eyes are darting. Having a “blank” face when spoken to that may be misinterpreted as “sad,” “mad,” or disinterested. Facial expression that does not match internal emotions.]  

 

 

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. [e.g. difficulty making new friends, difficulty keeping friends if no longer in geographic proximity, difficulty understanding relationships that can lead to being taken advantage of emotionally and sexually.]

 

The second broad category for ASD is: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies [twisting hair, picking at hair or skin, bouncing legs, flapping hands] lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eating the same food every day). 

 

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests [e.g. watching the same movie or TV program over and over, reading the same books, excessive interest in a particular topic).

4. Hyper-activity or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment [hypo-reactivity e.g. apparent indifference to pain/temperature, not recognizing when hungry or thirsty or when full, not recognizing when need to go to bathroom] [hyper-reactivity e.g. adverse response to specific sounds or textures or lights or being easily overwhelmed by too much sound or light, excessive smelling or touching of objects, visual fascination with lights or movement].

Have your symptoms caused significant impairment in social, occupational, or other important areas of current functioning?

 

5. Have your symptoms interfered with, or reduced the quality of, social, academic, or occupational functioning?

 

Examples/comments

 

Date: 

Name:

 

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787.