/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-97086-en.cckm

201606162

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

M-CHAT-Revised and Follow Up Algorithm

M-CHAT-Revised and Follow Up Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton















Modified Checklist for Autism in Toddlers, Revised with Follow-Up
(M-CHAT-R/F)TM











Acknowledgement: We thank Joaquin Fuentes, M.D. for his work in developing the flow chart format
used in this document.

For more information, please see www.mchatscreen.com
or contact Diana Robins at DianaLRobins@gmail.com









⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

Permissions for Use of the M-CHAT-R/FTM
The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F; Robins, Fein, &
Barton, 2009) is a 2-stage parent-report screening tool to assess risk for Autism Spectrum Disorder
(ASD). The M-CHAT-R/F is available for free download for clinical, research, and educational purposes.
Download of the M-CHAT-R/F and related material is authorized from www.mchatscreen.com.

The M-CHAT-R/F is a copyrighted instrument, and use of the M-CHAT-R/F must follow these guidelines:
(1) Reprints/reproductions of the M-CHAT-R must include the copyright at the bottom ( ⁄ 2009
Robins, Fein, & Barton). No modifications can be made to items, instructions, or item order
without permission from the authors.
(2) The M-CHAT-R must be used in its entirety. Evidence indicates that any subsets of items do not
demonstrate adequate psychometric properties.
(3) Parties interested in reproducing the M-CHAT-R/F in print (e.g., a book or journal article) or
electronically for use by others (e.g., as part of digital medical record or other software packages)
must contact Diana Robins to request permission (DianaLRobins@gmail.com).
(4) If you are part of a medical practice, and you want to incorporate the first stage M-CHAT-R
questions into your own practice’s electronic medical record (EMR), you are welcome to do so.
However, if you ever want to distribute your EMR page outside of your practice, please contact
Diana Robins to request a licensing agreement.

Instructions for Use
The M-CHAT-R can be administered and scored as part of a well-child care visit, and also can be used
by specialists or other professionals to assess risk for ASD. The primary goal of the M-CHAT-R is to
maximize sensitivity, meaning to detect as many cases of ASD as possible. Therefore, there is a high
false positive rate, meaning that not all children who score at risk will be diagnosed with ASD. To
address this, we have developed the Follow-Up questions (M-CHAT-R/F). Users should be aware that
even with the Follow-Up, a significant number of the children who screen positive on the M-CHAT-R will
not be diagnosed with ASD; however, these children are at high risk for other developmental disorders or
delays, and therefore, evaluation is warranted for any child who screens positive. The M-CHAT-R can
be scored in less than two minutes. Scoring instructions can be downloaded from
http://www.mchatscreen.com. Associated documents will be available for download as well.

Scoring Algorithm
For all items except 2, 5, and 12, the response “NO” indicates ASD risk; for items 2, 5, and 12, “YES”
indicates ASD risk. The following algorithm maximizes psychometric properties of the M-CHAT-R:
LOW-RISK: Total Score is 0-2; if child is younger than 24 months, screen again after second
birthday. No further action required unless surveillance indicates risk for ASD.
MEDIUM-RISK: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get
additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or
higher, the child has screened positive. Action required: refer child for diagnostic
evaluation and eligibility evaluation for early intervention. If score on Follow-Up is 0-1,
child has screened negative. No further action required unless surveillance indicates risk
for ASD. Child should be rescreened at future well-child visits.
HIGH-RISK: Total Score is 8-20; It is acceptable to bypass the Follow-Up and refer immediately for
diagnostic evaluation and eligibility evaluation for early intervention.


⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton
M-CHAT-RTM
Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your
child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no
for every question. Thank you very much.
1. If you point at something across the room, does your child look at it? Yes No
(FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)
2. Have you ever wondered if your child might be deaf? Yes No
3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink Yes No
from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)
4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground Yes No
equipment, or stairs)
5. Does your child make unusual finger movements near his or her eyes? Yes No
(FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)
6. Does your child point with one finger to ask for something or to get help? Yes No
(FOR EXAMPLE, pointing to a snack or toy that is out of reach)
7. Does your child point with one finger to show you something interesting? Yes No
(FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)
8. Is your child interested in other children? (FOR EXAMPLE, does your child watch Yes No
other children, smile at them, or go to them?)
9. Does your child show you things by bringing them to you or holding them up for you to Yes No
see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed
animal, or a toy truck)
10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she Yes No
look up, talk or babble, or stop what he or she is doing when you call his or her name?)
11. When you smile at your child, does he or she smile back at you? Yes No
12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your Yes No
child scream or cry to noise such as a vacuum cleaner or loud music?)
13. Does your child walk? Yes No
14. Does your child look you in the eye when you are talking to him or her, playing with him Yes No
or her, or dressing him or her?
15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or Yes No
make a funny noise when you do)
16. If you turn your head to look at something, does your child look around to see what you Yes No
are looking at?
17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child Yes No
look at you for praise, or say “look” or “watch me”?)
18. Does your child understand when you tell him or her to do something? Yes No
(FOR EXAMPLE, if you don’t point, can your child understand “put the book
on the chair” or “bring me the blanket”?)
19. If something new happens, does your child look at your face to see how you feel about it? Yes No
(FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will
he or she look at your face?)
20. Does your child like movement activities? Yes No
(FOR EXAMPLE, being swung or bounced on your knee)


⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton
M-CHAT-R Follow-Up (M-CHAT-R/F)TM
Permissions for Use

The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F; Robins, Fein, &
Barton, 2009) is designed to accompany the M-CHAT-R. The M-CHAT-R/F may be downloaded from
www.mchatscreen.com.

The M-CHAT-R/F is a copyrighted instrument, and use of this instrument is limited by the authors and
copyright holders. The M-CHAT-R and M-CHAT-R/F may be used for clinical, research, and educational
purposes. Although we are making the tool available free of charge for these uses, this is copyrighted
material and it is not open source. Anyone interested in using the M-CHAT-R/F in any commercial or
electronic products must contact Diana L. Robins at DianaLRobins@gmail.com to request permission.

Instructions for Use
The M-CHAT-R/F is designed to be used with the M-CHAT-R; the M-CHAT-R is valid for screening
toddlers between 16 and 30 months of age, to assess risk for autism spectrum disorder (ASD). Users
should be aware that even with the Follow-Up, a significant number of the children who fail the M-CHAT-
R will not be diagnosed with ASD; however, these children are at risk for other developmental disorders
or delays, and therefore, follow-up is warranted for any child who screens positive.
Once a parent has completed the M-CHAT-R, score the instrument according to the instructions. If the
child screens positive, select the Follow-Up items based on which items the child failed on the M-CHAT-
R; only those items that were originally failed need to be administered for a complete interview.
Each page of the interview corresponds to one item from the M-CHAT-R. Follow the flowchart format,
asking questions until a PASS or FAIL is scored. Please note that parents may report “maybe” in
response to questions during the interview. When a parent reports “maybe,” ask whether most often the
answer is “yes” or “no” and continue the interview according to that response. In places where there is
room to report an “other” response, the interviewer must use his/her judgment to determine whether it is
a passing response or not.
Score the responses to each item on the M-CHAT-R/F Scoring Sheet (which contains the same items as
the M-CHAT-R, but Yes/No has been replaced by Pass/Fail). The interview is considered to be a screen
positive if the child fails any two items on the Follow-Up. If a child screens positive on the M-CHAT-R/F, it
is strongly recommended that the child is referred for early intervention and diagnostic testing as soon as
possible. Please note that if the healthcare provider or parent has concerns about ASDs, children should
be referred for evaluation regardless of the score on the M-CHAT-R or M-CHAT-R/F.


⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton
M-CHAT-R Follow-UpTM Scoring Sheet
Please note: Yes/No has been replaced with Pass/Fail
1. If you point at something across the room, does your child look at it? Pass Fail
(FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)
2. Have you ever wondered if your child might be deaf? Pass Fail
3. Does your child play pretend or make-believe? Pass Fail
(FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone,
or pretend to feed a doll or stuffed animal)
4. Does your child like climbing on things? Pass Fail
(FOR EXAMPLE, furniture, playground equipment, or stairs)
5. Does your child make unusual finger movements near his or her eyes? Pass Fail
(FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)
6. Does your child point with one finger to ask for something or to get help? Pass Fail
(FOR EXAMPLE, pointing to a snack or toy that is out of reach)
7. Does your child point with one finger to show you something interesting? Pass Fail
(FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)
8. Is your child interested in other children? Pass Fail
(FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)
9. Does your child show you things by bringing them to you or holding them up Pass Fail
for you to see – not to get help, but just to share?
(FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)
10. Does your child respond when you call his or her name? Pass Fail
(FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing
when you call his or her name?)
11. When you smile at your child, does he or she smile back at you? Pass Fail
12. Does your child get upset by everyday noises? Pass Fail
(FOR EXAMPLE, a vacuum cleaner or loud music)
13. Does your child walk? Pass Fail
14. Does your child look you in the eye when you are talking to him or her, playing with him Pass Fail
or her, or dressing him or her?
15. Does your child try to copy what you do? Pass Fail
(FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)
16. If you turn your head to look at something, does your child look around to see what Pass Fail
you are looking at?
17. Does your child try to get you to watch him or her? Pass Fail
(FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”)
18. Does your child understand when you tell him or her to do something? Pass Fail
(FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair”
or “bring me the blanket”)
19. If something new happens, does your child look at your face to see how you feel about it? Pass Fail
(FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or
she look at your face?)
20. Does your child like movement activities? Pass Fail
(FOR EXAMPLE, being swung or bounced on your knee)

Total Score: _______

1. If you point at something across the room, does _____________ look at it?
PASS examples

Looks at object
Points to object
Looks and comments on object
Looks if parent points and says
“look!”
Yes
Please give me an example of how he/she
will respond if you point at something (If
parent does not give a PASS example below,
ask each individually.)
If you point at something, what does
your child typically do?
FAIL examples

Ignores parent
Looks around room randomly
Looks at parent’s finger
No
Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes only to
FAIL
example(s)
Yes to examples borth from
PASS and FAIL
Yes only to
PASS
example(s)
Which one does
he/she do most
often?
Most often is
FAIL example
Most often is
PASS example
PASS FAIL
PASS FAIL
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

2. You reported that you have wondered if you child is deaf. What led you to wonder that?
Does he/she…

often ignore sounds?
often ignore people?

No to both Yes to either
PASS FAIL
Has your child’s hearing been tested?
Yes
What were the results of the hearing test? (choose one):

 Hearing in normal range ☐
 Hearing below normal ☐
 Results inconclusive or not definitive ☐


ALSO ASK FOR
ALL CHILDREN:
No
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

3. Does __________ play pretend or make- believe
Does he/she ever…

Present to drink from a toy cup?
Pretend to eat from a toy spoon or fork?
Pretend to talk on the telephone?
Pretend to feed a doll or stuffed animal with real or
imaginary food?
Push a car as if it is going along a pretend road?
Pretend to be a robot, an airplane, a ballerina, or any
other favorite character?
Put a toy pot on a pretend stove?
Stir imaginary food?
Put an action figure or doll into a car or truck
as if it is the driver or passenger?
Pretend to vacuum the rug, sweep the floor, or the mow lawn?
Other (describe)
_______________________________________________________________________
_______________________________________________________________________
Yes to any No to all
PASS FAIL
Yes No
Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes  No 
Please give me an example of
his/her pretend play. (If parent
does not give a PASS example
below, ask each individually.)
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

4. Does ________ like climbing on things?
Does he/she enjoy climbing on…

Stairs?
Chairs?
Furniture?
Playground equipment?

No to all Yes to any of the
above
FAIL PASS
Yes No
Please give me an example of something
he/she enjoys climbing on. (If parent does not
give a PASS example below, ask each
individually.)
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

5. Does ________ make unusual finger movements near his/her eyes?
Does he/she ever…
(Below are PASS examples)

Look at hands?
Move fingers when
playing peek-a-boo?
Does he/she ever…
(Below are FAIL examples)

Wiggle his/her fingers near his/her eyes?
Hold his/her hands up close to his/her eyes?
Hold his/her hands off to the side of
his/her eyes?
Flap his/her hands near his/her face?
Other (describe)
____________________________________________________
____________________________________________________
Yes to any of
the above
PASS
No to all of the above Yes to any of the above
Does this happen more than
twice a week?
Yes No
FAIL
Please describe these movements (If parent does not give a PASS
example below, ask each individually.)
Yes No
PASS
Yes  No 

Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

6. Does your child point with one finger to ask for something or to get help?
If there is something your child wants that is out of
reach, such as a snack or toy that is out of reach,
how does he/she get it? (If parent does not give a
PASS example below, ask each individually.)
Does he/she…

Reach for the object with his/her whole hand?
Lead you to the object?
Try to get the object for him/herself?
Ask for it using words or sounds?
No to all of the above Yes to any of the above
If you said “Show me”,
would he/she point at it?
Yes No FAIL
PASS
Yes No
PASS
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

7. * If the interviewer just asked #6, begin here: We just talked about pointing to ask for something,
ASK ALL  Does your child point with one finger just to show you something interesting?
Does your child ever want you to see
something interesting such as….

An airplane in the sky?
A truck on the road?
A bug on the ground?
An animal in the yard?
Yes to any
No to all of the
above
How does your child draw your attention
to it? Would he/she point with one finger?
Yes No
Is this to show their interest,
not to get help? No
FAIL
Yes OR both to show interest and to get help
PASS
Yes
Please give me an example something
he’she migh tpoint at to show you. (If
parent does not give a PASS example
below, ask each individually.)
No
FAIL
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

8. Is ____________ interested in other children?
Does your child…

Play with another child?
Talk to another child?
Babble or make vocal noises?
Watch another child?
Smile at another child?
Act shy at first but then smile?
Get excited about another child?
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes
Is he/she interested in children who are
not his/her brother or sister?
When you are at the playground or
supermarket, does your child usually respond
to other children?
No
Yes No
Yes No
FAIL
PASS How does your child respond?
(If parent does not give a PASS
example below, ask each
individually.)
Does he/she respond to other
children more than half of the
time?
Yes No
FAIL PASS
Yes to any of the
above
No to all of
the above
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

9. Does ________ show you things by bringing them to you or holding them up for
you to see? Not just to get help, but to share?
Does your child sometimes bring you…

A picture or toy just to show you?
A drawing he/she has done?
A flower he/she has picked?
A bug he/she has found in the grass?
A few blocks he/she has put together?
Other (describe):
______________________________________________________
______________________________________________________
Yes to any of the above
No to all of
the above
Is this sometimes just to show you,
not to get help?
Yes No
PASS
FAIL
Yes
Please give me an
example of something
he/she might bring to
show you or hold up for
you to see. (If parent does
not give a PASS example
below, ask each
individually.)
No
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

10. Does ___________ respond when you call his/her name?
If he/she is not involved in something fun or
interesting, what does he/she do when you call
his/her name? (If parent does not give a PASS
example below, ask each individually.)
Does he/she…
(below are FAIL responses)
Make no response?
Seem to hear but ignores parent?
Respond only if parent is right in front
of the child’s face?
Respond only if touched?
Yes only to
FAIL
example(s).

Yes to both PASS and FAIL examples
Yes only to
PASS example(s).

Which one does he/she do most
often?
PASS FAIL PASS
response
FAIL
response
Please give me an example of how
he/she responds when you call
his/her name. (If parent does not
give a PASS example below, ask
each individually.)
Yes No
Does he/she…
(below are PASS responses)
Look up?
Talk or babble?
Stop what he/she is doing?
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

11. When you smile at ____________, does he/she smile back at you?
Yes only to
PASS example(s) Yes to both PASS and FAIL examples
Yes only to
FAIL example(s)
Which one does he/she do most
often?
PASS FAIL PASS
response
FAIL
response
What makes _____________ smile? (If parent does not give a
PASS example below, ask each individually.)
Yes No
PASS
Does your child…
(Below are PASS examples)

Smile when you smile?
Smile when you enter the room?
Smile when you return from
being away?
Does he/she ever…
(Below are FAIL examples)

Is your child always smiling?
Does your child smile at a favorite
toy or activity?
Does your child smile randomly
or at nothing in particular?
Yes  No 
Yes  No 

Yes  No 
Yes  No 

Yes  No 

Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

12. Does __________ get upset by everyday noises?
Does your child have a negative reaction to the sound of…

A washing machine?
Babies crying?
Vacuum cleaner?
Hairdryer?
Traffic?
Babies squealing or screeching?
Loud music?
Telephone/ doorbell ringing?
Noisy places such as a
supermarket or restaurant?
Other (describe):
__________________________________________________
__________________________________________________

Yes to two or
more
How does your child react those
noises? (If parent does not give a
PASS example below, ask each
individually.)
Does your child…
(Below are PASS responses)

Calmly cover his/her ears?
Tell you that he/she does not
like the noise?
Does your child…
(Below are FAIL responses)

Scream?
Cry?
Cover his/her ears while upset?
Yes only to PASS
example(s)
Yes to both PASS and FAIL Yes only to FAIL
example(s)
PASS
response
FAIL
response
Which one does he/she do most
often?
FAIL PASS
Yes  No 

Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes No
PASS
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

13. Does __________ walk?
Yes No
Does he/she walk without
holding on to anything?
Yes No FAIL
PASS
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

14. Does _________ look you in the eye when you are talking to him/her, playing
with him/her, or changing him/her?
Does he/she look you in the eye…

When he/she needs something?
When you are playing with him/her?
During feeding?
During diaper changes?
When you are reading him/her a story?
When you are talking to him/her?

Yes to two or
more
Yes only to one No to all
Does your child look you in
the eye every day?
Yes No
On a day when you are together all day, does he/she
look you in the eye at least 5 times?
PASS FAIL Yes No
PASS
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
No Yes
Please give me an example of
when he/she looks you in the
eye. (If parent does not give a
PASS example below, ask each
individually.)
Yes No
PASS
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

15. Does __________ try to copy what you do?
Does your child try to copy you if you…

Stick out your tongue?
Make a funny sound?
Wave good bye?
Clap your hands?
Put your fingers to your lips
to signal “Shhh”?
Blow a kiss?
Other (describe):
_____________________________________________
_____________________________________________
Yes to two or more Yes to one or none
PASS FAIL
No Yes
Please give me an example of
something he/she would try to
copy. (If parent does not give a
PASS example below, ask each
individually.) Yes  No 
Yes  No 
Yes  No 
Yes  No 

Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

16. If you turn your head to look at something, does ________ look around to see what
you are looking at?
What does he/she do when you turn to look at
something? (If parent does not give a PASS
example below, ask each individually.)
Does your child…
(Below are PASS responses)

Look toward the thing you are looking at?
Point toward the thing you are looking at?
Look around to see what you are looking at?

Does you child…
(Below are FAIL responses)

Ignore you?
Look at your face?

Yes only to
PASS
example(s)
Yes to both PASS and FAIL
responses
Yes only to
FAIL
example(s)
Which one does he/she do
most often?
PASS FAIL PASS
response
FAIL
response
No Yes
PASS
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

17. Does __________ try to get you to watch him/her?
Does he/she…

Say “Look!” or “Watch me!”?
Babble or make a noise to get you to watch
what he/ she is doing?
Look at you to get praise or comment?
Keep looking to see if you are looking?
Other (describe):
__________________________________________________________
__________________________________________________________
Yes to any Yes to none
PASS FAIL
Yes  No 

Yes  No 
Yes  No 
Yes  No 
Yes  No 
No Yes
Please give me an example of how he/she
would try to get you to watch him/her. (If parent
does not give a PASS example below, ask each
individually.)
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

18. Does ____________ understand when you tell him/her to do something?
When the situation gives him/her a clue, can
he/she follow a command? For example
when you are dressed to go out and you tell
him/her to get his/her shoes, does he/she
understand?
No Yes
If it is dinnertime and
food is on the table, and
you tell the child to sit
down, will he/she come
sit at the table?
When the situation does not give any clues,
can he/she follow a command? For example…
(ask until you get a yes or use all examples)
(1) If you say, “Show me your shoe” without
pointing, making gestures, or giving hints
(when you are not going out or getting
dressed), does your child show you his/her
shoe? Yes  No 
(2) If you say, “Bring me the blanket” or ask
for another object without pointing, making
gestures, or giving hints, does your child bring
it to you? Yes  No 
(3) If you say, “Put the book on the chair”
without pointing, making gestures, or giving
any other hints , does your child put the book
on the chair? Yes  No 
FAIL
PASS
No Yes
Please give me an example of how
you know he/she understands you.
No Yes
If example
indicates that
child can
understand a
simple
command
without
nonverbal cues
If example does not indicate
that child can understand a
simple command without
nonverbal cues
No to all Yes to any
FAIL
PASS
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

19. If something new happens, does _________ look at your face to see how you feel
about it?
If your child hears a strange or scary
noise, will he/she look at you before
responding?

Yes No
Does your child look at you
when someone new approaches?
PASS
Does your child look at you when he/she is faced
with something unfamiliar or a little scary
PASS FAIL
No Yes
Yes No
Yes No
PASS
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton

20. Does ___________ like movement activities?
When you swing or bounce
him/her, how does he/she react?
(If parent does not give an example
below, ask each individually.)
Does your child…

Laugh or smile?
Talk or babble?
Request more by holding out his/her arms?
Other (describe):
_____________________________________________________
_____________________________________________________
Yes to any specific
examples (or if “other”
is a positive response)
No to all
PASS FAIL
Does he/she enjoy being
bounced or swung?
No Yes
Yes No
PASS
Yes  No 
Yes  No 
Yes  No 
Yes  No 
⁄ 2009 Diana Robins, Deborah Fein, & Marianne Barton