Salford Learning Support Service
IN Salford
Primary School - Years 2-6 Checklist
Possible indicators of autistic spectrum condition
Name of child:
Dob:
School:
Name of SENCo:
Year group:
Chronological age in years and months:
Date checklist completed:
Name of class teacher:
 This checklist is to help identify children who are a cause for concern with social
communication and interaction difficulties.
 This form should be completed by someone who knows the child well.
 Useful information: http://www.autism.org.uk/teacherpack
 To refer a child to the Learning Support Service please request a referral form
from: LSSreferrals@salford.gov.uk
Has this child any other known difficulties? If so – please specify:
Is this child EAL? YES/NO If yes – what is the child’s home language?
Social Communication
Has trouble taking turns in conversations, may like to do all the talking
Makes inappropriate comments in class
Finds it easier to listen when not looking at person
Has an unusual tone of voice or uses speech in an unusual way - e.g. speaks in a
monotone or with an accent
Responds to a question by repeating it, rather than answering it
Has a good vocabulary and talks in a formal, old-fashioned way
Talks a lot about a favourite topic, but finds it difficult to talk about a range of topics.
Repeats last word or phrases several times, makes verbal sounds while listening
(echolalia)
Pronouns used inappropriately e.g. "Give you a biscuit please" (instead of 'me')
Does not speak, or uses single words to communicate
Additional comments:
Social Interaction
Shows little interest in other children, struggles to maintain friendships
Stands too close to others or lacks awareness of personal space
Responds to social interactions, but does not initiate them
Difficulty understanding jokes, figures of speech or sarcasm
Difficulty reading facial expressions and body language
Seems unable to understand another's feelings
Prefers to be alone, aloft or overly-friendly
Uses facial expressions that don't match what he or she is saying
Finds unstructured social time difficult to use appropriately – for example, sit on their
own at lunchtime or try to join in games unsuccessfully at playtime
Salford learning support service - ASC
Please tick
as
appropriate:
= most of
the time
= some of
the time
O = hardly
ever/never
Makes very few gestures (such as pointing).
Unusual posture, clumsiness or eccentric ways of moving
Shows a lack of motivation or desire to please others
Additional comments:
Social Imagination/ Flexibility
Difficulty transitioning from one activity to another
Unusual attachment to objects
Difficulty transferring skills from one area to another
Perfectionism in certain areas
Difficulty predicting what will happen next, or what could happen next
Difficulty accepting changes to rules, routines or procedures
Has poor understanding of abstract concepts e.g. time – tomorrow, today etc
Difficulty with planning an task or event
Focuses on the detail rather than the bigger picture
Has poor understanding of abstract concepts e.g. time – tomorrow, today etc
Demonstrates challenging behaviour e.g. kicking, hitting, biting others
Self injurious behaviour e.g. head banging (on floors, walls or other surfaces), hair
pulling, biting.
Additional comments:
Sensory
Dislike of sudden loud noise
Dislike of crowds e.g. in corridors, hall, refectory, during PE
Becomes overwhelmed with too many verbal instructions
Makes excessive vocal sounds or excessive banging of doors, objects
Has a restricted diet
Extreme ordering of food on plate and eating order
Appears to dislike physical contact
Appears insensitive to hot/cold temperatures
Inappropriate smelling e.g. other people’s hair
Sensitive to the smell of perfume / aftershave from others
Displays self-stimulatory behaviour e.g. hand twirling, arm flapping
At times, walks on toes rather than flat footed
Quite clumsy and bumps into objects and people
Additional comments:
Salford learning support service - ASC