Sensory Assessment - Adolescent

Sensory Assessment - Adolescent
Every question should be answered, even if you have answered it previously as part of other interviews in the KiDS 0 to 18 autism diagnostic series of tests.

Completing the form can be taxing to some. It may be helpful to take a break(s) and return refreshed. Therefore, this document may be saved an unlimited number of times. However, please be sure to submit at least 24 hours prior to your appointment.

* If not completed in time, we reserve the option to reschedule your appointment to the next available testing slot. *

Demographics
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age

Introductory Question
Tell me a little about what led you to this appointment with me today.
Areas of Specific Interest/Activities
Current interests and activities
1. What types of things do you enjoy doing when you have free time?
2. When you're doing your favorite things, is it ever hard to stop and focus on something else?
3. Does doing your favorite things have a calming effect on you?
4. Does it help you block out unpleasant thoughts or feelings?

5. Does your involvement in your favorite activities ever interfere with your:
Sleep?
Work?
College/school coursework?
Household chores?
Social obligations?

6. Do the important people in your life ever tell you that you spend too much time doing your favorite things? Talking about your favorite things?
7. When you aren't doing your favorite activities, do you find yourself thinking about details related to those activities?
8. Is there anything about your current pattern of activities that you would like to change?
9. (For family members) Tell me about his/her preferred activities from your point of view.

Previous areas of interests and activities
1. Do you remember having any particular areas of passionate interest when you were a child? Any activities you liked to do for long periods of time or over and over again?
2. How did those interests change as you got older and became a teenager?
3. (For family members) What else can you add to these recollections?

Sensory Use
Let's talk about the sensory things that you prefer, as well as the things you dislike or are bothered by, or have a pronounced sensitivity to:
Attention to visual details
1. Do you notice visual details that other people may not pay attention to or notice?
2. After seeing or reading something, do you remember the details well?
3. Describe your reaction when you notice that someone has moved or rearranged something at home, in your room, or in other places.
4. How has this pattern changed since you were a child?
5. (For family members) Is there anything you would like to add?

Noises
1. What types of noises bother or distract you? How do you react?
2. What types of sounds have a soothing or calming effect on you?
3. How has this pattern changed since you were a child?
4. (For family members) Is there anything you would like to add?

Smells
1. Are there particular smells that you dislike or that bother you?
2. Do you ever find yourself smelling objects?
3. How has this pattern changed since you were a child?
4. (For family members) Is there anything you would like to add?
Touch
1. In general, are you constantly touching things, or do you actively avoid touching things?
2. Are the textures of any of these items appealing to you? Unappealing? (Reference the sensory items arranged on the table next to the adult.)
3. How has this pattern changed since you were a child?
4. (For family members) Is there anything you would like to add?

Food
1. What are some of your favorite foods?
2. What types of food don't you like?
3. Are you bothered by any particular foods—for example, their textures? Does it bother you when different foods are mixed together, or when one food touches another on a plate?
4. How has this pattern changed since you were a child?
5. (For family members) Is there anything you would like to add?

Clothing
1. Are there types of clothes you like to wear more than others?
2. Do you have any sensitivities to your clothes, such as being bothered by tags, seams in your socks, wearing shoes or not, changing from long to short sleeves, wearing jackets, or things like that?
3. How has this pattern changed since you were a child?
4. (For family members) Is there anything you would like to add?

Sleep patterns
1. Describe your sleeping habits. Do you have trouble going to sleep or staying asleep? Do you stay up late at night and then have trouble getting up during the day?
2. How has this pattern changed since you were a child?
3. (For family members) Is there anything you would like to add?
Body boundaries
1. Does it ever bother you when people stand close to you?
2. Have people ever told you that you need to stand farther away from them?
3. Which type of touch do you like better: when people use deeper pressure such as a firm handshake or deep pressure hug, when they use a light touch, or when they don't touch you at all?
4. How do you react when you are in a crowded place?
5. How has this pattern changed since you were a child?
6. (For family members) Is there anything you would like to add?

Pain tolerance
1. Would you say that you have a high threshold for pain, a low threshold, or somewhere in between? Can you give me an example?
2. How has this pattern changed since you were a child?
3. (For family members) Is there anything you would like to add?
Unpredictable events or changes in established routines
1. Tell me about what it's like for you when you are interrupted and have to stop doing something you're focused on and that you enjoy.
2. What is it like for you when someone tells you about an unexpected activity that changes your regular routine?
3. Is it helpful to know about changes in your routine in advance? In what way is it helpful?
4. How has this pattern changed since you were a child?
5. (For family members) Is there anything you would like to add?

Body movements and mannerisms
1. Describe any body movement routines you use to regulate and soothe yourself, such as:
Picking at your face or clothing?
Hand, arm, or facial movements?
Body tensing?
Pacing or rocking?
Focusing on visual details while watching video images or reading familiar material?
Sitting or lying under heavy blankets, cushions, or other sources of weight?
Listening to the same song or music over and over again, and finding that the familiarity and repetition are soothing?
Any other routines?
2. How has this pattern changed since you were a child?
3. (For family members) Is there anything you would like to add?

Degree to which sensory sensitivities and sensory needs interfere with daily life
1. At the present time, how much do your sensory sensitivities and sensory needs interfere with your quality of life? In what way?
2. (For family members) What is your perspective on the degree to which sensory sensitivities or sensory needs interfere with daily life?

Language and Communication
1. How often do you seek out other people to have conversations?
2. Do you like to be the one who starts the conversation, or do you like it when others approach you to talk?
3. Are there some topics you like talking about more than others?
4. Do the people you are closest to ever tell you they wish you would talk about something other than your areas of high interest?
5. Do you find it tiring at times to listen to conversations and to hold up your end?
6. Would you describe yourself as a careful thinker-that is, someone who needs a little extra time to think before answering questions or making comments in a conversation?
7. Some people prefer when others are literal in their use of language instead of using metaphors and figures of speech. Do you ever find yourself confused by expressions people use? (for example: "burn the midnight oil," "best thing since sliced bread," or "it takes two to tango." )
8. Do you enjoy humor when talking with others? Tell me about a time recently when you heard or said something funny.
9. Do you find yourself using the same expressions in many conversations, for example, saying "well, actually," or "I really don't know"? Do you use direct quotes from movies or shows in your conversations on a regular basis?
10. Are there any aspects of your communication style that you would like to change?
11. How has your communication pattern changed since you were a child?
12. (For family members) Is there anything you'd like to add about his/her communication style?

Social Relationships and Emotional Responses
Social relationships
1. Tell me about the people in your life with whom you are the most closely connected right now.
2. In general, do you like to spend time with other people?
3. Have you established friendships with one or more people your own age? How did you meet? What types of activities do you currently enjoy doing together? How often do you get together with people outside of your family?
4. Compared to the important people in your life, would you say your need for spending time by yourself is greater than, the same as, or less than their need for alone time?

Emotional responses
1. Tell me the types of things other people do that irritate or upset you.
2. Describe the things you typically say and do when you become irritated or upset.
3. Are there times or situations that make you nervous or anxious? Tell me about them.
4. Describe how you behave when you become highly anxious.
5. Do you take medication to help manage anxiety or agitation? Describe how the medication affects your ability to manage your emotions and behavior.
6. Do you remember how you managed your emotions when you were a child? How has this pattern changed since then?
7. Are there any aspects of your social or emotional style that you would like to change?
8. What three words or qualities would you choose to describe the type of person you are?

Health issues
1. Describe any physical health conditions you are dealing with.
2. What medications do you take, and what are they for?
3. What effects do you notice when you take your medication(s)?
4. (For family members) Is there anything you would like to add?

School competencies
Are you in school or being home schooled?
1. Tell me about school. What are you studying? Which classes do you like? Not like?
2. Are you receiving any accommodations in class, such as taking untimed tests, getting copies of the teacher's notes, or receiving tutoring or any other type of help?
3. Do you have a system to organize your assignments? Do you typically turn in your work on time? Do you typically meet deadlines?
4. If you need help and reminding to stay organized, who helps you? What do they do that is helpful?
5. What type of coursework is the best fit for your brain style? For example, math, science, creative writing, reading, history, geography, anthropology, theater, dance.
6. Do you participate in school activities that are social, such as clubs, parties, or special interest groups? Describe what you like and do not like about those activities.
1. Tell me about your school experience. Where did you go to school and what did you study?
2. Do you have a plan to go to school again? (If answer is yes) Tell me about it. (If answer is no) Tell me what you would rather be doing than going to school.
3. Would you like some guidance and help to explore the steps it will take to find a school situation that would be a good fit for your brain style?
4. What are your parent's/caregiver's thoughts about developing a school plan?

Independent living
1. Who do you live with? Tell me a little about how you get along with each person.
2. Let's talk about how much you do on your own and what things you rely on others to do for you. Do you:
Get up in the morning and get going on your own?
Make your own meals?
Shop for food? Clothes?
Clean up after yourself?
Take care of any pets?
Have a bank account?
Have a driver's license? Drive a car?
3. In five years, where would you like to be living? With whom?

Last Question
1. What, if anything, have you read or learned about autism spectrum disorder?
Date

MonthDayYear
Date
Should be Empty:

Sensory Assessment - Adolescent

Demographics

Introductory Question

Areas of Specific Interest/Activities

Current interests and activities

Previous areas of interests and activities

Sensory Use

Attention to visual details

Noises

Smells

Touch

Food

Clothing

Sleep patterns

Body boundaries

Pain tolerance

Unpredictable events or changes in established routines

Body movements and mannerisms

Degree to which sensory sensitivities and sensory needs interfere with daily life

Language and Communication

Social Relationships and Emotional Responses

Social relationships

Emotional responses

Health issues

School competencies

Independent living

Last Question