Salford Learning Support Service
IN Salford
Secondary School 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 form tutor:
 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 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.
Has trouble taking turns in conversations, may like to do all the talking.
Repeats last word or phrases several times, makes verbal sounds while listening
(echolalia).
Pronouns used inappropriately e.g. "Pass you a pen" (instead of 'me').
Does not speak, or uses single words to communicate.
Additional comments:
Social Interaction
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.
Finds unstructured social time difficult to use appropriately – for example, sit on their
own at lunchtime.
Uses facial expressions that don't match what he or she is saying.
Unusual posture, clumsiness or eccentric ways of moving.
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.
1
Please tick
as
appropriate:
= most of
the time
= some of
the time
O = hardly
ever/never
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.
Many and varied collections.
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.
Difficulty with managing time, finishing work, handing in or
completing homework, or getting to lessons on time;
A blurred distinction between fantasy and reality.
Additional comments:
Sensory
Dislike of sudden loud noise.
Dislike of crowds e.g. in corridors, hall, refectory.
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.
Additional comments:
2