Diagnostic Interview
Patient Name:
Date of Birth
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Year
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Date of Interview:
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I. Early Development & Milestones
2. Age when you first had concerns? (Write age in months)
(enter 0 if not known, and select code below)
Age when you first had concerns?
991 - Parents were not concerned, but professional referred child
992 - Parents worried since birth (e.g., medical issues/premature)
996 - Can't recall exact age, but definitely before age 3
997 - Can't recall exact age, but definitely at 3 years or later
998 - Not applicable
999 - Not known or not asked
4. When did you first notice unusual development (looking back)?
0 - Problems present in first 12 months
1 - Problems began 12-24 months
2 - Problems began 24-36 months
3 - Problems began 3-4 years
4 - Problems began 4-5 years
5 - Problems began 5-6 years
6 - Problems began after age 6
7 - Child always seemed "different" / Personality
8 - No problems ever noted by parents
5. Age of first walking unaided? (Write age in months)
*
(enter 0 if not known, and select code below)
5. Age of first walking unaided?
995 - Still not reached
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
998 - Not applicable (e.g., physical disability)
6. Age of daytime bladder control (dry by day)? (Write age in months)
(enter 0 if not known, and select code below)
6. Age of daytime bladder control (dry by day)?
993 - Regression (Was dry, then started wetting again)
994 - Never achieved continence
995 - Still not reached
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
7. Age of nighttime bladder control (dry by night)? (Write age in months)
(enter 0 if not known, and select code below)
7. Age of nighttime bladder control (dry by night)?
993 - Regression (Was dry, then started wetting again)
994 - Never achieved continence
995 - Still not reached
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
8. Age of bowel control? (Write age in months)
(enter 0 if not known, and select code below)
8. Age of bowel control?
993 - Regression (Was dry, then started wetting again)
994 - Never achieved continence
995 - Still not reached
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
9. Age of first single words? (Write age in months)
(enter 0 if not known, and select code below)
9. Age of first single words?
993 - Regression (Had words, then lost them)
994 - Milestone not reached yet
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
10. Age of first phrases (2+ words with a verb)? (Write age in months)
(enter 0 if not known, and select code below)
10. Age of first phrases (2+ words with a verb)?
993 - Regression (Had phrases, then lost them)
994 - Milestone not reached yet
996 - Can't recall, but apparently typical
997 - Can't recall, but apparently delayed
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II. Loss of Skills (Regression)
11. Did the child ever lose language skills (after using words for 3+ months)?
0 - No (Skip to Item 20)
1 - Yes
12. Language level before loss?
0 - Strong (Used 5+ words daily, spontaneous)
1 - Limited (Used <5 words, or mostly imitation)
2 - On request only (Prompted speech)
3 - Only imitations (No spontaneous meaningful speech)
8 - N/A (No change or loss)
13. Loss of Spontaneous Words?
0 - No definite loss
1 - Probable loss
2 - Definite loss
8 - Insufficient language initially
14. Loss of Communicative Intent?
0 - No definite loss
1 - Probable loss
2 - Definite loss
8 - Insufficient language initially
15. Loss of Grammer/Syntax?
0 - No definite loss
1 - Probable loss
2 - Definite loss
8 - Insufficient language initially
16. Loss Of Articulation (Pronunciation)
0 - No definite loss
1 - Probable loss
2 - Definite loss
8 - Insufficient language
17. Age when language loss began? (Write age in months)
18. Association of loss of language with physical illness
0 - Loss of skills, but no link to any definite illness.
1 - Loss occurred during a definite illness (e.g., high fever with ear Infection), but no clear evidence of brain involvement.
2 - Loss occurred with impaired consciousness, epileptic attacks, or other definite signs of meningitis/encephalitis
8 - No loss of skills.
19. Duration of language loss? (Write duration in months)
Enter 0 if not know, and select code below
993 - Loss still present/No recovery yet
994 - Progressive Deterioration
20. Did child lose other skills (Motor, Self-Help, Play, Social)?
0 - No (Skip to Item 29)
1 - Probable loss
2 - Definite loss
For the next set of questions, mark 'Definite' if specific skills lost.
21. Hand Skills:
0 - No
2 - Definite
22. Motor Skills:
0 - No
2 - Definite
23. Self-Help:
0 - No
2 - Definite
24. Play:
0 - No
2 - Definite
25. Social:
0 - No
2 - Definite
26. Age when loss first appeared? (Record exact age in months)
(Enter 0 if unknown)
998 - Not Applicable
999 - Not known or not asked
27. Association of the skills loss with physical illness
0 = Loss, but no association with illness
1 = Loss associated with definite illness (e.g., fever with infection) but without brain involvement
2 = Loss associated with seizures, impaired consciousness, or brain involvement
8 = No loss of skills
28. Duration of the loss of skills
993 - Loss still present/No recovery yet
994 - Progressive Deterioration, skills keep declining
998 - No loss occured
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III. Language & Communication
Note: "Past" refers to Age 4.0-5.0, or the most abnormal period.
29. Current Comprehension (Understanding simple commands)
0 - Understands complex/unexpected commands
1 - Struggles with new/unexpected commands
2 - Understands many words (50+) but no complex commands
3 - Understands <50 words
4 - No comprehension
29a. Past Comprehension (Understanding simple commands)
0 - Understands complex/unexpected commands
1 - Struggles with new/unexpected commands
2 - Understands many words (50+) but no complex commands
3 - Understands <50 words
4 - No comprehension
30. Current Overall Speech Level
0 - Phrase Speech (3+ words with verbs)
1 - Some Words (5+ words daily)
2 - Very Limited (<5 words)
31. Current Use of Other's Body to Communicate
0 - No / Only if desperate
1 - Occasional + eye contact
2 - Occasional without eye contact
3 - Regular use of other's hand as a tool
31a. Past Use of Other's Body to Communicate
0 - No / Only if desperate
1 - Occasional + eye contact
2 - Occasional without eye contact
3 - Regular use of other's hand as a tool
32. Current Articulation (Pronunciation - Age 4+)
0 - Clear to everyone
1 - Hard for strangers to understand
2 - Very hard for strangers / some family
3 - Almost impossible to understand
32a. Past Articulation (Pronunciation - Age 4+)
0 - Clear to everyone
1 - Hard for strangers to understand
2 - Very hard for strangers / some family
3 - Almost impossible to understand
33. Current Stereotyped / Repetitive Speech
0 - Rare or never
1 - Repetitive but not clearly odd
2 - Frequent odd phrases / Scripting
3 - Almost entirely stereotyped
33a. Past Stereotyped / Repetitive Speech
0 - Rare or never
1 - Repetitive but not clearly odd
2 - Frequent odd phrases / Scripting
3 - Almost entirely stereotyped
34. Current Social Verbalization ("Chat")
0 - Regular social chat
1 - Some / Limited
2 - Speech used for needs/wants only
34a. Past Social Verbalization ("Chat")
0 - Regular social chat
1 - Some / Limited
2 - Speech used for needs/wants only
35. Current Reciprocal Conversation
0 - Conversation flows back-and-forth
1 - Limited flexibility / Topics
2 - Responds but does not initiate/sustain
3 - Very little spontaneous speech
35a. Past Reciprocal Conversation
0 - Conversation flows back-and-forth
1 - Limited flexibility / Topics
2 - Responds but does not initiate/sustain
3 - Very little spontaneous speech
36. Current Inappropriate Questions/Statements
0 - Rare / None
1 - Some / Not very odd
2 - Frequent / Socially embarrassing
36a. Past Inappropriate Questions/Statements
0 - Rare / None
1 - Some / Not very odd
2 - Frequent / Socially embarrassing
37. Current Pronoun Reversal (e.g., saying "You" instead of "I")
0 - None
1 - Refers to self by name
2 - Mixes up I/You
3 - Consistent use of "You" for self (question tone)
37a. Past Pronoun Reversal (e.g., saying "You" instead of "I")
0 - None
1 - Refers to self by name
2 - Mixes up I/You
3 - Consistent use of "You" for self
38. Current Neologisms (Made-up words)
0 - None
1 - Occasional
2 - Regular use
38a. Past Neologisms (Made-up words)
0 - None
1 - Occasional
2 - Regular use
39. Current Verbal Rituals
0 - None
1 - Some / Stops if asked
2 - Definite / Hard to stop
3 - Compulsive / Causes distress if stopped
39a. Past Verbal Rituals
0 - None
1 - Some / Stops if asked
2 - Definite / Hard to stop
3- Compulsive / Causes distress if stopped
40. Current Intonation / Volume / Rhythm
0 - Typical
1 - Slight difference
2- Robotic / Flat / Sing-song / Odd
3- Very peculiar
40a. Past Intonation / Volume / Rhythm
0 - Typical
1 - Slight difference
2 - Robotic / Flat / Sing-song / Odd
3 - Very peculiar
41. Current Current Communicative Speech Use
0 - Frequent / Varied contexts
1 - Limited contexts
2 - Mostly echolalia / limited purpose
3 - No communicative use
41a. Past Current Communicative Speech Use
0 - Frequent / Varied contexts
1 - Limited contexts
2 - Mostly echolalia / limited purpose
3 - No communicative use
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IV. Social Development & Play
42. Current Pointing to express interest (e.g. "Look at that plane!")
0 - Points with coordinated eye contact
1 - Points but poor eye contact
2 - No pointing to share interest
42a. Past Pointing to express interest (e.g. "Look at that plane!")
0 - Points with coordinated eye contact
1 - Points but poor eye contact
2 - No pointing to share interest
43. Current Nodding Head for "Yes"
0 - Consistent / Spontaneous
1 - Sometimes
2 - Never
43a. Past Nodding Head for "Yes"
0 - Consistent / Spontaneous
1 - Sometimes
2 - Never
44. Current Shaking Head for "No"
0 - Consistent / Spontaneous
1 - Sometimes
2 - Never
44a. Past Shaking Head for "No"
0 - Consistent / Spontaneous
1 - Sometimes
2 - Never
45. Current Conventional Gestures (Wave, Clap, etc.)
0 - Varied / Spontaneous
1 - Limited / Routine
2 - Inconsistent / Only if taught
3 - None
45a. Past Conventional Gestures (Wave, Clap, etc.)
0 - Varied / Spontaneous
1 - Limited / Routine
2 - Inconsistent / Only if taught
3 - None
46. Current Attention to Voice
0 - Looks immediately
1 - Inconsistent response
2 - Must call name / direct attention
3 - Rarely responds
46a. Past Attention to Voice
0 - Looks immediately
1 - Inconsistent response
2 - Must call name / direct attention
3 - Rarely responds
47. Current Spontaneous Imitation of Actions
0 - Wide variety
1 - Some imitation
2 - Limited / Routine only
3 - None
47a. Past Spontaneous Imitation of Actions
0 - Wide variety
1 - Some imitation
2 - Limited / Routine only
3 - None
48. Current Imaginative Play
0 - Creative / Varied
1 - Some / Limited variety
2 - Repetitive / Copied only
3 - None
48a. Past Imaginative Play
0 - Creative / Varied
1 - Some / Limited variety
2 - Repetitive / Copied only
3 - None
49. Current Imaginative Play with Peers
0 - Cooperative / Reciprocal
1 - Limited / One-sided
2 - Parallel play (No pretending together)
3 - None
49a. Past Imaginative Play with Peers
0 - Cooperative / Reciprocal
1 - Limited / One-sided
2 - Parallel play (No pretending together)
3 - None
50. Current Direct Gaze (Eye Contact)
0 - Typical / Reciprocal
1 - Brief / Inconsistent
2 - Occasional / Poor
3 - Unusual / Staring / Avoidant
50a. Past Direct Gaze (Eye Contact)
0 - Typical / Reciprocal
1 - Brief / Inconsistent
2 - Occasional / Poor
3 - Unusual / Staring / Avoidant
51. Current Social Smiling
0 - Regular / Reciprocal
1 - Some / Inconsistent
2 - Non-reciprocal / Odd
3 - Rare / None
51a . Past Social Smiling
0 - Regular / Reciprocal
1 - Some / Inconsistent
2 - Non-reciprocal / Odd
3 - Rare / None
52. Current Showing Objects (To Share Interest)
0 - Regular showing
1 - Infrequent / Unclear intent
2 - Only for help/needs
3 - None
52a. Past Showing Objects (To Share Interest)
0 - Regular showing
1 - Infrequent / Unclear intent
2 - Only for help/needs
3 - None
53. Current Offering to Share (Toys/Food)
0 - Frequent / Varied
1 - Some / Food only
2 - On request only
3 - None
53a. Past Offering to Share (Toys/Food)
0 - Frequent / Varied
1 - Some / Food only
2 - On request only
3 - None
54. Current Seeking to Share Enjoyment
0 - Frequent / Clear
1 - Limited / Unclear
2 - Rare / None
54a. Past Seeking to Share Enjoyment
0 - Frequent / Clear
1 - Limited / Unclear
2 - Rare / None
55. Current Offering Comfort
0 - Spontaneous / Empathic
1 - Partial / Indirect
2 - Rare / Odd response
3 - None
55a. Past Offering Comfort
0 - Spontaneous / Empathic
1 - Partial / Indirect
2 - Rare / Odd response
3 - None
56. Current Quality of Social Overtures
0 - Integrated (Eye gaze + Vocal)
1 - Weak integration
2 - Rare / Odd
3 - No coordination
56a. Past Quality of Social Overtures
0 - Integrated (Eye gaze + Vocal)
1 - Weak integration
2 - Rare / Odd
3 - No coordination
57. Current Range of Facial Expressions
0 - Full Range
1 - Limited / Stilted
2 - Markedly limited
3 - None / Flat affect
57a. Past Range of Facial Expressions
0 - Full Range
1 - Limited / Stilted
2 - Markedly limited
3 - None / Flat affect
58. Current Inappropriate Facial Expressions
0 - Appropriate
1 - Occasionally Odd
2 - Clearly Inappropriate (e.g., laughing at pain)
58a. Past Inappropriate Facial Expressions
0 - Appropriate
1 - Occasionally Odd
2 - Clearly Inappropriate
59. Current Appropriateness of Social Responses
0 - Appropriate
1 - Inconsistent
2 - Stereotyped / Limited
3 - Family only / None
59a. Past Appropriateness of Social Responses
0 - Appropriate
1 - Inconsistent
2 - Stereotyped / Limited
3 - Family only / None
60. Current Initiation of Appropriate Activities
0 - Spontaneous / Varied
1 - Limited range
2 - Passive (e.g., TV only)
3 - Repetitive / None
60a. Past Initiation of Appropriate Activities
0 - Spontaneous / Varied
1 - Limited range
2 - Passive (e.g., TV only)
3 - Repetitive / None
61. Current Imitative Social Play
0 - Typical / Reciprocal
1 - Limited / Familiar people only
2 - Very limited
3 - None
61a. Past Imitative Social Play
0 - Typical / Reciprocal
1 - Limited / Familiar people only
2 - Very limited
3 - None
62. Current Interest in Peers/Other Children
0 - Frequent / Approaches
1 - Watches / Indirect interest
2 - Rare / No engagement
3 - None
62a. Past Interest in Peers/Other Children
0 - Frequent / Approaches
1 - Watches / Indirect interest
2 - Rare / No engagement
3 - None
63. Current Response to Approaches by Peers
0 - Responsive
1 - Inconsistent
2 - Rare / Ignores
3 - Avoids
63a. Past Response to Approaches by Peers
0 - Responsive
1 - Inconsistent
2 - Rare / Ignores
3 - Avoids
64. Current Group Play with Peers
0 - Cooperative / Varied
1 - Some / Limited
2 - Parallel only
3 - None
64a. Past Group Play with Peers
0 - Cooperative / Varied
1 - Some / Limited
2 - Parallel only
3 - None
65. Current Friendships
0 - Reciprocal / Shared
1 - Limited reciprocity
2 - Group/Setting only (School)
3 - None
65a. Past Friendships
0 - Reciprocal / Shared
1 - Limited reciprocity
2 - Group/Setting only (School)
3 - None
66. Current Social Disinhibition
0 - Typical
1 - Bold / Naive
2 - Lacks cues / Odd
3 - Marked disinhibition
66a. Past Social Disinhibition
0 - Typical
1 - Bold / Naive
2 - Lacks cues / Odd
3 - Marked disinhibition
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V. Interests & Repetitive Behaviors
67. Current Unusual Preoccupations (Intense/Odd Interests)
0 - None
1 - Present (No disruption)
2 - Intrusive
3 - Major Interference
67a. Ever in the past - Unusual Preoccupations (Intense/Odd Interests)
0 - None
1 - Present (No disruption)
2 - Intrusive
3 - Major Interference
68. Current Circumscribed Interests (Narrow Focus)
0 - None
1 - Intense (No disruption)
2 - Intrusive
3 - Social Impairment
68a. Ever in the past - Circumscribed Interests (Narrow Focus)
0 - None
1 - Intense (No disruption)
2 - Intrusive
3 - Social Impairment
69. Current Repetitive Use of Objects (Spinning, lining up)
0 - None
1 - Some (No impairment)
2 - Definite
3 - Severe Interference
69a. Ever in the past - Repetitive Use of Objects (Spinning, lining up)
0 - None
1 - Some (No impairment)
2 - Definite
3 - Severe Interference
70. Current Compulsions / Rituals (Fixed sequences)
0 - None
1 - Fixed (No distress)
2 - Compulsive / Anxiety
3 - Severe distress
70a. Ever in the past - Compulsions / Rituals (Fixed sequences)
0 - None
1 - Fixed (No distress)
2 - Compulsive / Anxiety
3 - Severe distress
71. Current Unusual Sensory Interests (Smelling, touching)
0 - None
1 - Regular
2 - Intense / Blocking
71a. Ever in the past - Unusual Sensory Interests (Smelling, touching)
0 - None
1 - Regular
2 - Intense / Blocking
72. Current Noise Sensitivity
0 - None
1 - Slight
2 - Definite / Avoidance
3 - Major Disruption
72. Ever in the past - Noise Sensitivity
0 - None
1 - Slight
2 - Definite / Avoidance
3 - Major Disruption
73. Current Specific Sensory Negativity (Texture/Taste/Sound)
0 - None
1 - Mild
2 - Intrusive
3 - Major Interference
73a. Ever in the past - Specific Sensory Negativity (Texture/Taste/Sound)
0 - None
1 - Mild
2 - Intrusive
3 - Major Interference
74. Current Minor Routine Changes (Resistance)
0 - None
1 - Negative (No distress)
2 - Definite Distress
3 - Major Interference
74a. Ever in the past - Minor Routine Changes (Resistance)
0 - None
1 - Negative (No distress)
2 - Definite Distress
3 - Major Interference
75. Current Trivial Environmental Changes (Furniture moved, etc.)
0 - None
1 - Negative (No distress)
2 - Definite Distress
3 - Major Interference
75a. Ever in the past - Trivial Environmental Changes (Furniture moved, etc.)
0 - None
1 - Negative (No distress)
2 - Definite Distress
3 - Major Interference
76. Current Attachment to Unusual Objects
0 - Typical/None
1 - Mild/Unusual object
2 - Definite/Distress
3 - Severe Interference
76a. Ever in the past - Attachment to Unusual Objects
0 - Typical/None
1 - Mild/Unusual object
2 - Definite/Distress
3 - Severe Interference
77. Current Hand/Finger Mannerisms (Flapping, twisting)
0 - None
1 - Occasional
2 - Frequent (No distress)
3 - Marked / Distress
77a. Ever in the past - Hand/Finger Mannerisms (Flapping, twisting)
0 - None
1 - Occasional
2 - Frequent (No distress)
3 - Marked / Distress
78. Current Complex Body Mannerisms (Spinning, bouncing)
0 - None
1 - Occasional
2 - Frequent (No distress)
3 - Marked / Distress
78a. Ever in the past - Complex Body Mannerisms (Spinning, bouncing)
0 - None
1 - Occasional
2 - Frequent (No distress)
3 - Marked / Distress
79. Current Midline Hand Movements
0 - None
1 - Occasional
2 - Definite
79a. Ever in the past - Midline Hand Movements
0 - None
1 - Occasional
2 - Definite
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VI. General Behavior
80. Current Odd Gait (Walking style)
0 - Typical
1 - Somewhat Unusual
2 - Definite (e.g., Toe walking)
3 - Noticeable to others
80a. Ever in the past Odd Gait (Walking style)
0 - Typical
1 - Somewhat Unusual
2 - Definite (e.g., Toe walking)
3 - Noticeable to others
81. Current Aggression (Toward Caregivers/Family)
0 - None
1 - Mild
2 - Hitting/Biting
3 - Weapon/Implement
81a. Ever in the past - Aggression (Toward Caregivers/Family)
0 - None
1 - Mild
2 - Hitting/Biting
3 - Weapon/Implement
82. Current Aggression (Toward Non-Family)
0 - None
1 - Mild
2 - Hitting/Biting
3 - Weapon/Implement
82a. Ever in the past - Aggression (Toward Non-Family)
0 - None
1 - Mild
2 - Hitting/Biting
3 - Weapon/Implement
83. Current Self-Injury
0 - None
1 - Mild (No damage)
2 - Definite (Bruising)
3 - Severe (Serious Injury)
83a. Ever in the past - Self-Injury
0 - None
1 - Mild (No damage)
2 - Definite (Bruising)
3 - Severe (Serious injury)
84. Current Hyperventilation
0 - No
1 - Occasional
2 - Frequent
84a. Ever in the past - Hyperventilation
0 - No
1 - Occasional
2 - Frequent
85. Current Seizures / Fits
0 - No
1 - Possible
2 - Definite Epilepsy
85a. Ever in the past - Seizures / Fits
0 - No
1 - Possible
2 - Definite Epilepsy
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VII. Special Skills
86. Age Atypicality First Evident
0 - Typical
1 - Uncertain
2 - Probable <3 years
3 - Definite <3 years
4 - Autism <3 years
87. Interviewer's Judgment on Age of Onset. Code in months of age when developmental atypicalities were probably first manifest.
Age (months)
88. Visuospatial Skill
0 - No special skill
1 - Above child's general level
2 - Above population norm
89. Memory Skill
0 - No special skill
1 - Above child's general level
2 - Above population norm
90. Musical Ability
0 - No special skill
1 - Above child's general level
2 - Above population norm
91. Drawing Skill
0 - No special skill
1 - Above child's general level
2 - Above population norm
92. Reading Ability
0 - No special skill
1 - Above child's general level
2 - Above population norm
93. Computational Ability (Math)
0 - No special skill
1 - Above child's general level
2 - Above population norm
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