1013 South US-27

St. Johns, MI 48879

(989) 224-6831

Autism Spectrum Disorder Evaluation Team

Evaluation Report

Name:
Date of Birth:
Chronological Age:
Parent(s):
Address:
Resident District:
School:
Evaluation Team Members:

Date of Report:

REASON FOR REFERRAL:

ASSESSMENT SOURCES:

Family Interview
Teacher Interview
Review of School Records
Observations
Administration of: Autism Diagnostic Observation Schedule (ADOS)

BACKGROUND INFORMATION:

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 standardized testing measures, family interview, teacher
interviews, student input, review of educational records, and behavioral observations completed
by all members of the evaluation team. The three critical areas are further outlined in the body of
the report below.

IMPAIRMENT IN RECIPROCAL SOCIAL INTERACTIONS

Marked impairments in the use of multiple nonverbal behaviors, such as eye-to-eye gaze,
expressions, body postures, gestures:

Parent Report:

Teacher Input:

Evaluation Team Report:

Failure to develop peer relationships appropriate to this student’s developmental level:

Parent Report:

Teacher Input:

Evaluation Team Report:

Marked impairment in spontaneous seeking to share enjoyment, interests, or achievements

with other people:

Parent Report:

Teacher Input:

Student Input:

Evaluation Team Report:

Marked impairment in the areas of social or emotional reciprocity:

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Parent Report:

Teacher Input:

Evaluation Team Report:

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 student’s 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

STUDENT NAME did NOT meet criteria in this area (0/4).

IMPAIRMENT IN COMMUNICATION

Delay in or absence of spoken language unaccompanied by an attempt to compensate through

alternative modes of communication:

Parent Report:

Teacher Input:

Evaluation Team Report:

Marked impairment in pragmatics or the ability to initiate, sustain or engage in reciprocal

conversations with others:

Parent Report:

Teacher Input:

Evaluation Team Report:

Stereotyped and repetitive use of language or idiosyncratic language:

Parent Report:

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Teacher Input:

Evaluation Team Report:

Lack of varied, spontaneous, make believe play or social imitative play appropriate to this
student’s developmental level:

Parent Report:

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 student’s developmental level
.
STUDENT NAME did NOT meet criteria in this area (0/4).

RESTRICTED, REPTITIVE, AND STEREOTYPED BEHAVIORS

Encompassing preoccupation with one or more stereotyped and restricted patterns of interest
that is abnormal in intensity or focus:

Parent Report:

Teacher Input:

Evaluation Team Report:

Apparent inflexible adherence to specific, nonfunctional routines or rituals:

Parent Report:

Teacher Input:
General education and special education teachers note that STUDENT NAME seems adaptable
and is “fine” with seat changes and unexpected changes to the schedule.

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Student Input:

Evaluation Team Report:

Stereotyped and repetitive motor mannerisms (such as hand flapping or complex whole-body
movements:

Parent Report:

Teacher Input:
No unusual motor mannerisms were noted by any teachers interviewed.

Evaluation Team Report:

No unusual motor mannerisms were noted by the evaluation team.

Persistent preoccupation with parts of objects:

Parent Report:

Teacher Input:
No preoccupation with parts of objects was noted by any teachers interviewed.

Evaluation Team Report:

No preoccupation with parts of objects was noted by the evaluation team.

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 hand flapping or complex
whole-body movements)
 Persistent preoccupation with parts of objects

STUDENT NAME did NOT meet criteria in this area (0/4).

UNUSUAL OR INCONSISTENT RESPONSE TO SENSORY STIMULI

While this area was removed as a required component of eligibility for ASD, it is important to
note that many children on the spectrum have great difficulty in this area. For that reason, we
continue to include this area in our report.

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Parent Report:

Teacher Report:

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 ADOS was administered to STUDENT NAME by one team member and
observed/scored by 2 other team members on DATE, 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, STUDENT
NAME received a score of SCORE; a score of 2 or more in this domain indicates autism
spectrum.

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. STUDENT NAME
received a score of SCORE in this domain; a score of 4 or more indicates autism spectrum
disorder.

While other areas are looked at during this evaluation (imagination/creativity and stereotyped
behaviors and restricted interests), they are not counted for in the ASD/Autism score.

The “Reciprocal Social Interaction” domain and “Communication + Social Interaction Total”
(STUDENT NAME score = SCORE; Autism Spectrum cutoff = 7) scores are not suggestive of
an Autism Spectrum Disorder.

SUMMARY AND RECOMMENDATIONS

Based on the results of the comprehensive team evaluation, STUDENT NAME DOES/DOES
NOT 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: Qualitative impairment in reciprocal social
interaction; Qualitative impairment in communication; Restricted, repetitive, and stereotyped
behaviors.

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