12 Questions for Parents:
Instructions: Read each question and then write down a few sentences that describe your child’s behavior in that area. (Don't just answer "yes" or "no"). Be honest and objective. Try not to give him the benefit of doubt – if you have not actually seen your child perform the action then do not report it as present. Be brief but try to come up with some descriptive examples in each area. The pronoun “he” is used generically and can refer to male or female. Print this questionnaire out, complete it, and bring the results to your child's physician to aid in diagnosis.
1. How does your child communicate with you nonverbally? That is, how does he get your attention, does he look you in the eye, does he respond to your nonverbal communication? How does he respond to tickling, hugging, holding?
2. How does your child react to other children? Does he play with them? Does he have friends?
3. How does your child show you that he is interested in something? Does he show you things he likes? Does he bring things to you to show you or to share with you? Does he point to things in the environment that interest him?
4. How does your child react to the social approaches of others? If someone is happy, does he act happy too? If someone is sad, does he respond appropriately? If someone hits him, how does he respond?
5. How well does your child communicate verbally? Is your child delayed in his speech?
6. How well does your child converse with others? Can your child begin a conversation appropriately? Can your child continue a conversation about a particular subject fairly well? How does your child end a conversation?
7. How does your child talk? Does he repeat words or phrases that seem unrelated to what is going on? Does he use words or phrases that only you would fully understand?
8. How well does your child pretend? Can he play make-believe games where he pretends to be an animal or pretends to be doing some action? Can he imitate your actions?
9. Does your child have very strong interests in certain toys, things, or topics that seems out of the ordinary? How easy is it for you to redirect his attention from this interest?
10. Does your child have to do things a certain way? Does he have a routine that must be followed? If you do things to interrupt his routine, how does he react?
11. Does your child engage in odd movements with his body or parts of his body? Does he rock, bang his head, flick his fingers, wave his arms or hands in the air, or make other repetitive movements?
12. Is your child fascinated with or strongly attracted to parts of objects?