HISD
Huron Intermediate School District
1299 S. Thomas Rd., Suite 1
Bad Axe, MI 48413
(989) 269-6406 Phone
(989) 269-9218 Fax
Autism Spectrum Disorder
Evaluation Team Report
Name: Parent: Resident District:
DOB: Address: Operating District:
Age: School:
Sex: Phone: Grade:
Teacher:
Report Date
Evaluation Team Members:
, School Psychologist
, School Social Worker
, Speech/Language Pathologist
REASON FOR REFERRAL:
PREVIOUS ASSESSMENT RESULTS:
CURRENT ASSESSMENT SOURCES:
Review of School Records
Parent Interview
Teacher Interview
Observations
Administration of: Autism Diagnostic Observation Schedule (ADOS)
Bayley Scales of Infant Toddler Development- Third Edition (Bayley-III)
Vineland Parent/Caregiver Rating Form, Second Edition (Vineland-II)
Vineland Teacher Rating Form, Second Edition (Vineland-II-TRF)
Receptive One-Word Picture Vocabulary Test (ROWPVT)
Expressive One-Word Picture Vocabulary Test (EOWPVT)
Preschool Language Scale, Fourth Edition (PLS-4)
Hawaii Early Learning Profile (HELP-3)
Sensory Profile
BACKGROUND INFORMATION:
According to school records,
Mrs. was concerned that
With respect to developmental history,
In regards to medical history,
Project Find evaluation revealed
The evaluator documented observations
A hearing screen was completed on
The result of the Vision Screening Checklist was
Based on the results of the Project Find evaluation conducted on
Educational history includes
REVIEW OF EDUCATIONAL CRITERIA FOR AUTISM SPECTRUM
DISORDER (According to Rule 340.1715):
In order to be eligible for special education services under the category of Autism Spectrum Disorder (ASD)
according to Michigan Special Education Rules, a student must demonstrate behaviors in three specific areas:
impairment in reciprocal social interactions, impairment in communication, and restricted, repetitive and
stereotyped behaviors. Information relative to these three areas was gathered through parent interview, teacher
input, a review of educational records, a developmental history, standardized assessment instruments and
behavioral observations completed by all members of the team. The three critical areas are further outlined in
the body of the report below; more specific examples and additional information are contained within the
appendices of this report.
________________________________________________________________________
IMPAIRMENT IN RECIPROCAL SOCIAL INTERACTIONS
Parent Report:
Teacher Input:
Evaluation Team Report:
2
Criteria (2 of 4 Required)
Marked impairments in the use of multiple nonverbal behaviors, such as eye-to-eye gaze,
expressions, body postures, gestures
Failure to develop peer relationships appropriate to this students developmental level
Marked impairment in spontaneous seeking to share enjoyment, interests, or achievements with
other people
Marked impairment in the areas of social or emotional reciprocity
* did/did not meet criteria in this area (4 /4).
IMPAIRMENT IN COMMUNICATION
Parent Input
Teacher Input:
Evaluation Team Report:
Criteria (1 of 4 Required):
Delay in or absence of spoken language unaccompanied by an attempt to compensate through
alternative modes of communication
Marked impairment in pragmatics or the ability to initiate, sustain, or engage in reciprocal
conversations with others
Stereotyped and repetitive use of language or idiosyncratic language
Lack of varied, spontaneous, make believe play or social imitative play appropriate to this students
developmental level
* did/did not meet criteria in this area (3 /4).
RESTRICTED, REPETITIVE, AND STEREOTYPED BEHAVIORS
Parents Report:
Teacher Input:
Evaluation Team Report:
Criteria (1 of 4 Required):
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is
abnormal in intensity or focus
Apparent inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms (such as hands flapping or complex whole-body
movements)
Persistent preoccupation with parts of objects
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* did/did not meet criteria in this area (2/4).
UNUSUAL OR INCONSISTANT RESPONSE TO SENSORY STIMULI
Parent Report:
Teacher Input:
Evaluation Team Report:
Autism Diagnostic Observation Schedule (ADOS):
The Autism Diagnostic Observation Schedules (ADOS) is a semi-structured, standardized assessment of
social interactions, communication, play, and imaginative use of materials for children suspected of having
autism. This instrument also provides cut-off points for the broader Autism Spectrum Disorder diagnosis,
including pervasive developmental disorder and atypical autism. The evaluation team administered the
ADOS on -- with the following results:
The Communication Domain looks at the following: Stereotyped/idiosyncratic use of words or phrases,
reporting of events, conversation, and use of gestures. In this domain, * received a score
The Reciprocal Social Interaction Domain looks at the following: Unusual eye contact, facial expressions
directed to others, insight, quality of social overtures, quality of social response, amount of reciprocal social
communication, and overall quality of rapport. In this domain, * received a score
While other areas are looked at during evaluation (imagination/creativity and stereotyped behaviors and
restricted interests), they are not accounted for in the ASD/Autism score. In this domain, * received a score
of
DISCUSSION OF APPENDIX INFORMATION (Detailed information is found in the attached Appendices)
Additional testing was completed to
Please see Appendix A, B, C and D for detailed reports from the school psychologist, school social worker,
speech and language pathologist and occupational therapist.
SUMMARY AND RECOMMENDATIONS
Based on the results of the comprehensive team evaluation, * does not/does meet the criteria necessary
for an eligibility of Autism Spectrum Disorder under Rule 340.1715 of the Administrative Rules and
Regulations for the State of Michigan. Under this rule, all of the following must be present:
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1. Qualitative impairment in reciprocal social interaction
2. Qualitative impairment in communication
3. Restricted, repetitive, and stereotyped behaviors
The evaluation team enjoyed the opportunity to meet and work with *. Please feel free to contact any of the
evaluators listed below at (989) 269-9274 for further information or questions/concerns.
________________________ _________________________
School Psychologist School Social Worker
HISD HISD
________________________ ___________________________
Speech/Language Pathologist Occupational Therapist
HISD HISD
Report compiled by:
APPENDIX A
School Psychologist Report
Confidential Information
IDENTIFYING INFORMATION:
Name: Parent: Report Date:
DOB: Address: Assessment Date(s)
Age: School:
Sex: Phone: Grade:
COGNITIVE ASSESSMENT
The Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) was administered on . The
Bayley-III is an individually administered test to identify developmental delay in children. It assesses the
developmental functioning in infants and young children between 1 month and 42 months of age.
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The Cognitive Scale assesses motor development, development of the senses, exploration and manipulation
ability as well as memory and thinking skills. The Language Scale assesses receptive (listening and
understanding) and expressive (talking) communication skills. * obtained the following results:
Extremely Low High Very
Low=69 Borderline= 70-79 Average= 80-89 Average= 90-109 Average=110-119 Superior=120-129 Superior=130
Subtest Standard Score Percentile Rank Descriptive Rating Age Equivalent
Cognitive Composite Score........................................................................................
Language Composite Score........................................................................................
CONCLUSION
Huron Intermediate School District
Phone: 989-269-
6
APPENDIX B
School Social Work Report
Adaptive Behavior Assessment
CONFIDENTIAL
Name: Age:
Date of Birth: School:
Grade: Teacher:
Date of Report:
ASSESSMENT
Vineland- II Adaptive Behavior Scale
*s parents participated in the assessment process by completing the Vineland Adaptive Behavior Scale. The Vineland
Adaptive Behavior Scales are an individual assessment of adaptive behavior. Adaptive behavior is defined as
performance of the day-to-day activities necessary to take care of oneself and get along with others. Adaptive behavior is
age-based and is defined by the expectations and standards of others. Adaptive behavior represents the typical
performance rather than the ability of the individual what a person does as opposed to what a person is capable of doing.
The scale covers four adaptive behavior domains that include Communication, Daily Living Skills, Socialization, and
Motor Skills.
Adaptive Level Descriptions
Parent/Caregiver Rating by & Adaptive Standard Percentile
Domain Standard Percentile Rank Level Score Range Rank Range
Score High 130 and 98 and above
above
Communication
Moderately 115-129 84-97
Daily Living Skills High (above
Socialization average)
Motor Skills Adequate 86-114 18-83
(average)
Adaptive Behavior
Moderately 71-85 3-17
Composite Low (below
average)
Low 70 and below 2 and below
Subdomain Score Summary
Domain Subdomain Age Equivalent
Communication Receptive
Expressive
Written
Daily Living Skills Personal
Domestic
Community
7
Socialization Interpersonal
Relationships
Play and Leisure
Coping Skills
Motor Skills Gross Motor
Fine Motor
TEACHER INPUT Vineland- II Adaptive Behavior Scale
Mrs. #, *s ECSC Preschool Teacher completed the Vineland Adaptive Behavior Scale. The following scores indicate *s
level of functioning in Adaptive Behavior.
Mrs. #
Domain Standard Score Percentile Rank
Communication
Daily Living Skills
Socialization
Motor Skills
Adaptive Behavior
Composite
This worker is available for further assistance as needed, (989) 269-34 .
________________________________________
LMSW, SSW
School Social Worker
Huron Intermediate School District
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APPENDIX C
Speech Pathologist Report
Student: Parents:
DOB: District:
Age: Attends:
Report Date:
Reason for Referral:
LANGUAGE TEST RESULTS
PRESCHOOL LANGUAGE SCALE-4
Standard Score (SS) Percentile Rank (PR) Age Equivalents
Auditory
Comprehens
ion
Expressive Communication
Total Language Score
Receptive Strength areas from previous testing:
Receptive weakness areas that need to be worked on:
Expressive strength areas from previous testing:
Expressive weakness areas that need to be worked on:
RECEPTIVE ONE-WORD PICTURE VOCABULARY TEST- (ROWPVT)
The ROWPVT is an individually administered, norm referenced test that provides an assessment of an individuals
English hearing vocabulary. It is standardized for use with individuals ages 2y0m through 18y11m. Results for this
administration of the ROWPVT are as follows:
Obtained Test Scores
Raw Score Standard Score Equivalent Percentile Rank Stanine Age Equivalent
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EXPRESSIVE ONE-WORD PICTURE VOCABULARY TEST- (EOWPVT)
The EOWPVT is an individually administered, norm referenced test that provides an assessment of an individuals
expressive vocabulary. It is standardized for use with individuals ages 2y0m through 18y11m. Results for this
administration of the EOWPVT are as follows:
Obtained Test Scores
Raw Score Standard Score Equivalent Percentile Rank Stanine Age Equivalent
Summary
If you have any questions about the above results, please feel free to contact me at the Huron Learning Center at
269.9274 ext 34.
CCC-SLP
Speech and Language Pathologist
Huron Intermediate School District
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APPENDIX D
Occupational Therapist Report
HURON INTERMEDIATE SCHOOL DISTRICT
1299 S. Thomas Rd.
Bad Axe, Michigan 48413
Name: Date:
Birthdate: Address:
Age:
Parents: Telephone:
Therapist:
History:
Parent Report:
Observation:
Perceptual/Fine Motor:
Functional Mobility:
Range of Motion:
Strength:
Balance:
Coordination:
Perception:
Daily Living Skills:
Play:
DEVELOPMENTAL TESTING
SENSORY PROFILE CAREGIVER REPORT
Please see Summary and Interpretive Report on pages - through - .
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HELP STRANDS
Curriculum-Based Assessment Birth to Three
This assessment was given (it was originally begun by the home programmer through early intervention
services) as a way to track progress and current functioning. It covers cognitive development, language
receptive and expressive, gross motor, fine motor, social emotional and self-help. The sections of cognition,
gross motor, and fine motor development were completed only as requested during evaluation. Further
cognitive, language, social emotional and self-help were evaluated by other providers.
* Overall average taken from HELP Checklist.
Sections Emerging Skills Age Equivalents
Cognitive Development *
Gross Motor*
Walking
Jumping
Climbing
Stairs
Throwing/Catching
Riding Tricycle
Balance Beam
Fine Motor*
Visual responses & tracking
Grasp/Prehension
Bilateral and Midline Skills
Pre writing
Block construction
Foam Board
Paper activities
Summary: .
Goals:
Please feel free to contact me with any questions or concerns at: 989-269-34--.
Environmental, economic, and cultural factors have been considered in this evaluation and are not considered
to be the sole cause of this childs disability.
OTR
Occupational Therapist
Huron Intermediate School Distric
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