Assessment Instrument

Assessment Instrument for Individuals with Autism Spectrum Disorder

By:
Melissa Duran
October 19, 2016

Assessment Instrument

I.

Introduction

This in-house Recreation Therapy assessment tool is designed for children and adolescents
with Autism Spectrum Disorder (ASD). The purpose of this assessment tool is to provide the
therapist with the clients overall social interaction, emotional control and communication skills.
This organized method would help the recreational therapist learn what the individual
weaknesses are and what strengths they have that could be used to help improve their needs. This
assessment tool includes: an initial assessment, behavioral analysis activity, and an interview
with the client and their parental guardians. The preliminary assessment form will allow the
recreational therapist to acquire the necessary information to conduct and further identify areas
that will need to be examined from the individual.

II.

Assessment Instrument Description

A. Population
This assessment instrument is designed for individuals with Autism Spectrum Disorder.

Autism Spectrum Disorder, also known as ASD, is a disorder that affects the social interaction,
emotions, verbal and nonverbal communication, and repetitive behaviors of an individual. These
disorders are characterized in a variety of degrees depending on the symptom they are
experiencing. They could have a mild form of autism while others could have a more severe
condition of autism. Since the publication of DSM-5 diagnosis Manuel, all autism disorders were
considered together under a form of one diagnosis of ASD. Previously, they were recognized as
a distinct subtypes, including autistic disorder, childhood disintegrative disorder, pervasive
developmental disorder not otherwise specified (PDD-NOS) and Asperger syndrome, (2016).

Assessment Instrument
Individuals with autism could be diagnosed as early as one year old. Recent research
confirms that appropriate screening can determine whether a child is at risk for autism as young
as one year, (2016). While each child develops in their own unique way, early treatment could
help improve their outcome dramatically. Studies show, for example, that early intensive
behavioral interventions improves learning, communication, and social skills in your children
with autism spectrum disorders (ASD), (2016). It is important that the parents or guardians of
the child learn the early signs of autism. Some examples of early signs of autism are: no words
by 16 months, no back-and-forth sharing sounds, smiles or other facial expressions by nine
months, or any loss of speech, babbling or social skills at any age.

B. Target Domain(s)
This assessment tools will be focusing on the individuals social interactions, emotional
control and their verbal and nonverbal communication skill. There are many children and
adolescents with autism that are facing barriers that effects their social interactions. According to
Autism Speaks website, both children and adults with autism tend to have some difficulty
interpreting what others are thinking and feeling (2016). Most children who develop autism
have difficulty engaging in the give-and-take of everyday human interactions, (2016). By the
time the child reaches toddlerhood, many children with autism show difficulty in several certain
areas. Some areas affected are: playing in social games, do not imitate the actions of others,
prefer to play alone instead of with peers, and may fail to seek comfort or respond to parents
displays of anger or affection in typical ways.
Another domain that is affected by autism is the individuals communication skills. One
of the most common difficulties that an individual with autism face is the inability to understand

Assessment Instrument
body language, tone of voice, and expressions that are not meant to be taken literally. The
individuals facial expressions, movements or gestures may not match what they are saying or
trying to express. The tone of their voice may not reflect the feelings that they are maybe trying
to show. This failed communication, in turn, can lead to frustration and inappropriate behaviors
(such as screaming or grabbing) on the part of the person with autism, (2016). Other difficulties
they may face is limited vocabulary, difficulty combined words to form sentences, delay in
speech, talk about their favorite subject without giving a chance for another person to speak, and
repetitive use of words.
Not only does children and adolescents with autism have difficulty with communication
and social interactions but also with regulating their emotions. This can take the form of
seemingly immature behaviors such as crying or having outbursts in inappropriate situations,
(2016). Other circumstances show that individuals with autism my feel overwhelmed or
frustrated when an individual does not understand their needs or wants. These emotional
behaviors could lead to disruptive and physically aggressive behaviors if not treated with the
proper program. This assessment will be able to observe these domains to give the recreational
therapist the information needed to help them look for a program suitable to their needs and
goals.

C. Response Mode
In order for this assessment to be completed the patient needs to participate and respond
to questions the therapist asks in the intake assessment. The individual needs to be cooperative in
allowing the recreation therapist observe the actions of the individual in their own environment.
This environment in which the recreational therapist conducts this assessment must be in a safe

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environment where the individual feels comfortable. Also, having family members participating
in some of the sections in this assessment will give the therapist more knowledge on the
individual.

D. Administration Guidelines
This assessment requires a Certified Therapeutic Recreation Specialist (CTRS) certified
by the NCTRC who has experience with children with autism to administer it. The initial
assessment form contains several different components. These components are: background
information, disability information, interests and hobbies, and social interactions and
communication skills observations. Background information will consist of previous history of
the patient and including present history. The disability information section gives the CTRS an
overall view of the characteristics that are present within the individual. The therapist will check
all that apply in the appropriate areas from reading the individuals medical history and as well as
observing their behaviors. The interest and hobbies is a section in which the therapist will ask the
patient what leisure activities interest them. This is very important for the CTRS when they need
to implement a program for the participant. This assessment is designed for children and
adolescents, the therapist needs to think of creative ways to get the person to open up about their
interest such as games, stories, and etc. Social interactions and communication skills observation
section is designed to help provide the therapist to observe the patients communication skills and
social interactions in their own environment. The therapist needs to check off areas on the social
skills and communication section of the form. This assessment should take about 30 minutes or
less per patient to administer.

Instrument Development and Trial

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III. Types of information you need and want

A. Norm-referenced or Criterion-referenced
Criterion-referenced is the testing tool used in this assessment. The Criterion-referenced
examines the content of the objects in the test comprehensively covers the area being measured
(Blaschko & Burlingame, 2010). All of the criteria elements of the task are evaluated by this test.
The clients scores are not compared against the scores of other individuals once the scoring
range has been established, (Blaschko & Burlingame, 2010). This is important characteristic of
the assessment because each individual with autism are unique and different. Some clients could
have a very mild form of autism while others could have a severe form. Having them compared
would not be useful and would not give the recreational therapist the information that they might
need.

B. Functional-environment
When a child feels safe and comfortable in an environment, then the child will be more
willing to participate and act in their own normal routine. The therapist needs to administer this
assessment in a setting in which the child feels safe and is a non-threatening environment. In
order to provide the best outcome results, the therapist needs to administer this assessment in an
environment where it is quiet and free from any distractions. With little to no distraction would
capture the individuals full attention in participating in the assessment.

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IV. Assessment report form

Autism Spectrum Disorder

Recreational Therapy Assessment
Background
Information

FIRST NAME: ___________________

______

LAST NAME: _______________________ M.I.

FEMALE/MALE: _________________ SOCIAL SECURITY NUMBER: _________________

DATE OF BIRTH: _____________________ AGE: ____________
ETHNICITY: __________________ ORIGIN: __________________
CURRENT PHYSICIAN: _______________________
PHYSICAN CONTACT: (____) _____-______
NAME OF FATHER: ______________________ PHONE NUMBER: (___) ____-_______
NAME OF MOTHER: ______________________ PHONE NUMBER: (___) ____-_______
ADDRESS: _______________________________________________________________
CITY: ______________ STATE: __________ ZIP CODE: ___________ COUNTRY: ______
HOME PHONE NUMBER: (___) ____-_____
EMERGENCY CONTACT NAME: _________________ PHONE NUMBER: (___) _________
EMERGENCY CONTACT NAME: _________________ PHONE NUMBER: (___) _________
E-MAIL: _____________________________________________________________________
*Please note: Email correspondence is not considered to be a confidential medium of
communication.

Leisure Lifestyle
Information
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HOMETOWN:
______________________________________________________________________________
CURRENT LIVING ARRANGEMENTS:
____ Parents

____ Legal Guardian

____ Group Home

____
____________________________________________________________________

Other:

Supportive Family? ___ Yes ____ No ____ Uncertain

ADDITIONAL INFORMATION:
Race: __________________ Cultural Considerations: __________________________________
Religion: __________________________________
Education: _________________________________ Grade: _________
Address: __________________________________ Zip Code: _____________ State: ________
Referred by (if any): _____________________________________________________________

POSSIBLE LEISURE BARRIERS:

____ Social Interactions
____ Communication Skills
____ Self-Esteem
____ Emotions
____ Others:
______________________________________________________________________________

*Check all that apply

Disability
Information

MEDICAL
______
Seizures
CONDITIONS

______ Sleep Deficits

______ Diabetes

______ Hyperactivity

______ Incontinence

______ Moods

____ Bowel

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____ Bladder
______ Allergies
If so:
______________________________________________________________________________

______ Others
______________________________________________________________________________

EMOTIONAL
DOMAINS
_____ Sad or Depressed

______ Anger

_____ Anxious

______ Anxiety

_____ Agitated

______ Sleep Deficits

_____ Emotional Withdrawal

______ Excessive Emotional Response

_____ Poor Self-Esteem

______ Hyperactivity

_____ Specific Fears: ____________________________________________________________

____ Other:
______________________________________________________________________________

SOCIAL
_____
Difficulty seeing things from another persons perspective
INTERACTIONS
_____ Difficulty interpreting what others are thinking and feeling
_____ None too little social interactions with other
_____ Failure to respond to their names
_____ Prefer to play alone
_____ Difficulty playing social games
_____ Dont imitate the actions of others
_____ Fail to seek comfort or respond to parents displays of anger or affection
_____ Difficulty regulating their emotions.
_____ Others:
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______________________________________________________________________________

COMMUNICATI
_____ON
DelaySKILLS
in speech
_____ Difficult to combine words into a meaningful sentence
_____ Delay in learning to use gestures
_____ Difficulty to Understand
_____ Incoherent Speech
_____ Limited Vocabulary
_____ Repeated the phases over and over
_____ Difficulty sustaining a conversation
_____ Difficulty to understand body language
_____ Tone of voice does not reflect their feeling
_____ Facial expressions, movement, and gesture does not match what they are saying
_____ Responds only when asked a question
_____ Uses AT device, pictures, sign language, electronic word processor, or speech generating
devices to communicate
Others:
______________________________________________________________________________

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Leisure
Hobbies/Ac
tivities

*CHECK ALL THAT APPLY

TABLE
GAMES:

____ Board Games

____ Card Games

____ Crosswords

____ Computer Games

____ Word Search

____ Puzzles

____ Air hockey

____ Table Soccer

____ Chest

____ Others: ___________________________________________________________________

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Arts and
Crafts:
____ Drawing

____ Painting

____ Gardening

____ Coloring

____ Ceramics

____ Pottery

____ Woodwork

____ Sketching

____ Others: ___________________________________________________________________

Sports:
____ Baseball

_____ Bowling

____ Golf

____ Basketball

_____ Football

____ Horseback Riding

____ Swimming

_____ Kickball

____ Hockey

____ Volleyball

_____ Cheerleading

____ Track and Field

____ Soccer

_____ Softball

____ Bowling

____ Other: ___________________________________________________________________

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Do they like sporting events: ( ) Yes ( ) No
If so which sports and which teams:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Other
Interests:
____ Singing

_____ Dancing

_____ Building things

____ Poetry

_____ Drama

_____ Acting

____ Others:
______________________________________________________________________________
______________________________________________________________________________
_____ Reading
If so, which author or books do you like?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____ Music
If so, which musician or type of music do you like?

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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____ Video games
Which video games do you enjoy playing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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Assessment Instrument

Social and
Communica
DATE OF ASSESSMENT: ____________________________________________
tion
RECREATIONAL THERAPIST: _______________________________________
Observation
*Check all that apply
Reaction of Others
_____ Turns towards an individual when name is called
_____ Turns towards an individual that enters a room
_____ Makes little to none eye contact when speaking
_____ Does not listen to others speaking
_____ Does not acknowledge others when entering the room
_____ Rejects being touched
_____ Reacts favorably to being touched

Communicate
_____ Points
out what they need or want
Needs
_____ Makes noises to indicate needing assistance
_____ Raises hand for help
_____ Nonverbally asks for assistance
_____ Verbally asks for assistance
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_____ Repeats same phrases
_____ Limited vocabulary

Interactions with
_____ Returns
a smile
others
_____ Returns a greeting
_____ Responds favorably to a hug or high-five from familiar adult
_____ Responds negatively to a hug or high-five from familiar adult
_____ Responds favorably to a hug or high-five from a peer
_____ Responds negatively to a hug or high-five from a peer
_____ Share objects or toy with others
_____ Maintain eye contact when talking with familiar adults
_____ No eye contact when talking with familiar adults
_____ Maintain eye contact when talking with peers
_____ No eye contact when talking with peers
_____ Repeats the same phrases

Interaction with
objects

_____ Plays with objects

_____ Grasps objects

_____ Reaches for an object when prompted

_____ Reaches for an object without prompting
_____ Displays desire to hold object
_____ Grasps and holds objects

Summary of Assessment:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SIGNATURE: ____________________________ DATE: __________________

Expressi
ve
Finger
Painting

This activity allows the recreational therapist an opportunity to observe the individuals behavior
in a relaxed and safe environment with the use of paint.

MATERIALS:

Paint brushes (if they prefer than using their own hands)
Acrylic Paint
Construction Paper or canvas
Apron (To protect the individuals clothes from getting pain on them)
Napkins (To clean if there is a mess or for clean up time)
Paper plates (To pour the colors into)
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DIRECTIONS:
The participants will be seated at a table in groups of four.
The recreational therapist or activity leader will then give out all the materials needed for
this activity. Such as: paint brushes, paint, construction paper, aprons, and napkins.
The participants will then choose and use any color they would like to paint on their own
canvases or construction paper. (They could share the paint colors with other participants
that will be set in each table.)
After they finish painting, they need to clean their sections.

*Note: This activity could either be a one on one with the therapist or in a
group setting.

V.

Summary and Conclusion

After administering this assessment tool to the participant, the recreational therapist should
have a better understanding of the individuals functional ability and overall barriers that they are
facing. After these findings are done, the recreational therapist would find them a program that
will appropriately fit the needs of the individual. With the list of leisure activities that they enjoy,
this could be used to help implement a program that the individual will enjoy and bring positive
outcomes. This assessment tool will help bring a relationship between the recreational therapist
and the participant in order to move forward with implementing a program for the individual
with autism.

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Assessment Instrument

Reference
What is Autism? (2016). Retrieved October 18, 2016, from https://www.autismspeaks.org/whatautism
Learn the Signs of Autism. (2016). Retrieved October 18, 2016, from
https://www.autismspeaks.org/what-autism/learn-signs
Autism Spectrum Disorder. (2016, October). Retrieved October 19, 2016, from
https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml?
utm_source=rss_readersutm_medium=rssutm_campaign=rss_full
Blaschko, T., & Burlingame, J. (2010). Assessment Tools for Recreational Therapy and Related
Fields (4th Ed.). Ravensdale, WA: Idyll Arbor.
Symptoms. (2016). Retrieved October 24, 2016, from https://www.autismspeaks.org/whatautism/symptoms

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