An Autism Packet for <<Child's Name>>
Contents
An Autism Packet for <<Child's Name>> .......................................................................... 1
Contents .......................................................................................................................... 1
Introduction ..................................................................................................................... 1
Personal Information ........................................................................................................... 1
Autism Information ............................................................................................................. 1
What is Autism?.............................................................................................................. 2
Facts and Statistics ...................................................................................................... 2
What are some common signs of autism?................................................................... 2
Additional Information ............................................................................................... 3
Child Profile ........................................................................................................................ 4
Strengths and Personality Traits ..................................................................................... 4
Social/Behavioral Traits.................................................................................................. 4
Academic Strengths and Challenges ............................................................................... 6
Extracurricular Information ............................................................................................ 6
Parent Profile ...................................................................................................................... 7
Introduction
This document has been prepared to help teachers, caregivers and other professionals get
a quick snapshot of <<Child's Name>> and how his autism manifests itself. Included in
the checklist are several traits/symptoms which are commonly attributed to autism but
which he does not exhibit.
Important: the information contained in this document may not be processed,
reformatted, reproduced, stored in a retrieval system, or transmitted in whole or in part,
in any form or by any means, whether electrical, mechanical, photocopying, recording or
otherwise, without prior written permission of <<Mother's Name>>and <<Father's
Name>>.
Personal Information
Child’s Name:
Lives with Mom?
Parent’s Name:
Parent’s Name:
Academic Year:
Yes/No
Grade:
Date of Birth:
Lives with Dad?
Ph:
Ph:
School:
Yes/No
Autism Information
Following is some general information about autism as part of the larger umbrella of
Autism Spectrum Disorders. Autism manifests itself differently for each individual on the
spectrum. For additional information on developments in autism interventions, therapies,
reading materials and advocacy information, a list of books and websites is included at
the end of this section.
What is Autism?
Autism (sometimes called “classical autism”) is the most common condition in a group of
developmental disorders known as the Autism Spectrum Disorders (ASDs). Autism is
characterized by impaired social interaction, problems with verbal and nonverbal
communication, and unusual, repetitive, or severely limited activities and interests. Other
ASDs include Asperger’s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder,
and Pervasive Developmental Disorder, not otherwise specified (usually referred to as
PDD-NOS).
Facts and Statistics
Following are some facts about the incidence and impact of autism in the United States
(from the Autism Society of America website: http://www.autismsociety.org/site/PageServer?pagename=about_whatis_factsstats)
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Autism affects 1 in 110 births1
Autism affects 1 to 1.5 million Americans2
It is the fastest-growing developmental disability (10 - 17 % annual growth)
$90 billion annual cost3
90% of costs are in adult services4
Cost of lifelong care can be reduced by 2/3 with early diagnosis and intervention5
In 10 years, the annual cost will be $200-400 billion6
What are some common signs of autism?
While autism is a “spectrum disorder,” meaning that each individual’s form of the
disorder has unique characteristics and manifestations, there are three distinctive
behaviors that characterize autism. Autistic children have difficulties with
 social interaction
 verbal and nonverbal communication
 repetitive behaviors or narrow, obsessive interests
These behaviors can range in impact from mild to debilitating.
The hallmark feature of autism is impaired ability to engage in and maintain social
interaction. Parents are usually the first to notice symptoms of autism in their child. As
1
Based on prevalence statistics from the Centers for Disease Control and Prevention (2009).
Based on the autism prevalence rate of 2 to 6 per 1,000 (Centers for Disease Control and Prevention,
2001) and 2000 U.S. Census figure of 280 million Americans.
3
Jarbrink K, Knapp M, 2001, London School of Economics study: "The economic impact on autism in
Britain," 5 (1): 7-22.
4
Jarbrink K, Knapp M, 2001, London School of Economics study: "The economic impact on autism in
Britain," 5 (1): 7-22.
5
Jarbrink K, Knapp M, 2001, London School of Economics study: "The economic impact on autism in
Britain," 5 (1): 7-22.
6
ASA calculates that the annual cost of autism will increase to $200-400 billion in 10 years. February 2003
2
early as infancy, a baby with autism may be unresponsive to people or focus intently on
one item to the exclusion of others for long periods of time. A child with autism may
appear to develop normally and then withdraw and become indifferent to social
engagement.
Children with autism may fail to respond to their name and often avoid eye contact with
other people. They have difficulty interpreting what others are thinking or feeling
because they do not understand social cues such as tone of voice or facial expressions.
Some experts claim that they lack empathy, but the reality is that, while they are might be
very emotionally engaged with another person, they do not understand how to respond to
that person’s needs in a socially appropriate manner.
Many children with autism engage in repetitive movements such as rocking and twirling,
or in behavior such as biting or head-banging. They also tend to start speaking later than
other children and may refer to themselves by name instead of first-person pronoun: “I”
or “me.” Children with autism don’t know how to play interactively with other children.
Some speak in a sing-song or stilted voice about a narrow range of favorite topics, with
little regard for the interests of the person to whom they are speaking.
Many children with autism have a reduced or intensified sensitivity to pain, aural, tactile,
visual or other sensory stimulation. These unusual reactions contribute to behavioral
symptoms such as a resistance to physical contact (this includes hugs).
Additional Information
Books:
Grandin, T. and Barron, S. (2004). Unwritten Rules of Social Relationships:
Understanding and Managing Social Challenges for Those with
Asperger’s/Autism. Future Horizons, Inc. Future Horizons, Inc.
Notbohm, E. (2005). Ten Things Every Child with Autism Wishes You Knew. Future
Horizons, Inc.
Notbohm, E. and Zysk, V. (2006). Ten Things Your Student with Autism Wishes you
Knew. Future Horizons, Inc.
Shore, S. and Rastelli, L. G. (2006). Understanding Autism for Dummies. Wiley, John &
Sons, Inc.
Zysk, V. and Notbohm, E. (2004). 1001 Great Ideas for Teaching or Raising Children
with Autism Spectrum Disorders. Future Horizons, Inc.
Websites:
Autism Society of America: www.autism-society.org
Autism Society of Colorado: www.autismcolorado.org
Autism Asperger’s Digest Magazine: News and Articles on Autism, Asperger’s
Syndrome and PDD: www.autismdigest.com
Child Profile
Strengths and Personality Traits
1. What are the child’s strengths?
2. What are some of the most important things people should know about the child’s
personality?
3. How does the child respond to success?
4. How does the child respond to disappointment?
5. Does the child have any self-stimulation habits (thumb sucking, spinning, rocking) to
help focus or blow off steam? If so, please describe.
6. What activities/behaviors does the child engage in to relax or help reduce stress at
school?
7. Does the child have an aversion to sensory input? If so, please include reactions to
sensory input.
Input
Y/N/Sometimes
Reaction
Intervention Tips
Touch
Sounds
Smells
Crowds
Visual
input
Other
sensory
input
Other
sensory
input
8. Does the child have any fears or phobias? If so, please describe.
Social/Behavioral Traits
9. Does the child respond appropriately to facial queues?
Y/N
Frequently
Sometimes, with familiar people
Occasionally
Does not respond to facial queues
Additional information, explanation:
10. Does the child respond appropriately to other nonverbal queues (pointing, body
language)?
Y/N
Frequently
Sometimes, with familiar people
Occasionally
Does not respond to nonverbal queues
Additional information, explanation:
11. Does the child respond appropriately to questions?
Y/N
Frequently
Sometimes, with familiar people
Occasionally
Does not respond to questions
Additional information, explanation:
12. Does the child initiate social interactions?
Y/N
Frequently
Sometimes, with familiar people
Occasionally, with prompting
Never, unless prompted
Unwilling to engage in social interaction
Additional information, explanation:
Y
13. Does the child engage in social interactions if someone else initiates?
Y/N
Frequently
Sometimes, with familiar people
Occasionally, with prompting
Never, unless prompted
Unwilling to engage in social interaction
Additional information, explanation:
14. Does the child carry on conversations or answer questions in a classroom setting?
Y/N
Frequently
Sometimes, with familiar topics
Occasionally
Does not carry on detailed conversations
Additional information, explanation:
Academic Strengths and Challenges
15. How long can the child pay attention to the same task, activity or assignment?
5 minutes or less
Up to 10 minutes
Up to 20 minutes
More than 20 minutes
Additional information, explanation:
16. How much does the child rely on structure on a daily basis at school?
Not much
Varies by subject
Needs some help to stay organized
Relies heavily on daily structure
Additional information, explanation:
17. What kind of learner is the child?
Visual
Auditory
Tactile
Verbal
Social
Solitary
Additional information, explanation:
Extracurricular Information
18. Does the child currently receive therapies or other interventions outside school? If so,
please list therapists’/professionals’ contact information.
Therapy
Y/N Professional’s Name
Phone Number
Occupational
Physical
Speech
Psychological
Social Group
Academic Tutoring
a. If the child receives therapies or interventions outside school, how frequently?
Therapy
Frequency
Occupational
Physical
Speech
Psychological
Social Group
Academic
19. What are the child’s favorite physical activities?
1.
2. Does the child have any additional physical, medical or behavioral conditions?
Allergy, please specify:
Epilepsy
ADD/ADHD
Dyslexia
Eating disorder
Physical disability
Other, please specify:
Other: please specify:
Additional information, explanation:
3. Please list any other traits, habits, insights or information which would be helpful in
getting to know the child.
Parent Profile
Following is information about the child’s parents which would be useful for teachers
and other educational professionals to know while working in partnership to meet the
child’s needs.