Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction.

• Unusual social initiations (e.g. intrusive touching; licking of others)

• Use of others as tools

• Poor pragmatic/social use of language (e.g. does not clarify if not understood; does not provide background information)

• Failure to respond when name called or when spoken directly to

• Does not initiate conversation

• One-sided conversations/ monologues/ tangential speech

• Doesn’t share

• Lack of showing, bringing, or pointing out objects of interest to other people

• Impairments in joint attention (both initiating and responding)

• Lack of responsive social smile (note: the focus here is on the response to another person’s smile; other aspects of emotional expression should be considered under A2).

• Failure to share enjoyment, excitement, or achievements with others

• Failure to respond to praise

• Does not show pleasure in social interactions

• Failure to offer comfort to others

• Indifference/aversion to physical contact and affection

• Only initiates to get help; limited social initiations

• Failure to engage in simple social games

Ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

Appropriate to developmental level

• Lack of “theory of mind”; inability to take another person’s perspective (CA ≥ 4 years)

• Does not notice another person’s lack of interest in an activity

• lack of response to contextual cues (e.g. social cues from others indicating a change in behavior is implicitly requested)

• Inappropriate expressions of emotion (laughing or smiling out of context) (note: other abnormalities in the use and understanding of emotion should be considered under A2)

• Unaware of social conventions/appropriate social behavior; asks socially inappropriate questions or makes socially inappropriate statements

• Does not notice another’s distress or disinterest

• Does not recognize when not welcome in a play or conversational setting

• Limited recognition of social emotions (does not notice when he or she is being teased; does not notice how his or her behavior impacts others emotionally)

(Note: solitary imaginative play/role playing is NOT captured here)

• Lack of imaginative play with peers, including social role playing (>4 years developmental age)

• Does not try to establish friendships

• Does not have preferred friends

• Lack of cooperative play (over 24 months developmental age); parallel play only

• Unaware of being teased or ridiculed by other children

• Does not play in groups of children

• Does not play with children his/her age or developmental level (only older/younger)

• Has an interest in friendship but lacks understanding of the conventions of social interaction (e.g extremely directive or rigid; overly passive)

• Does not respond to the social approaches of other children

• Lack of interest in peers

• Withdrawn; aloof; in own world

• Does not try to attract the attention of others

• Limited interest in others;

• Unaware or oblivious to children or adults

• Limited interaction with others

• Prefers solitary activities

Example:

• simple motor stereotypes

• echolalia

• repetitive use of objects, or idiosyncratic phrases)

• Pedantic speech or unusually formal language (child speaks like an adult or “little professor”) B1 includes atypical speech, movements, and play

• Echolalia (immediate or delayed); may include repetition of words, phrases, or more extensive songs or dialog

• “Jargon” or gibberish (mature jargoning after developmental age of 24 months)

• Use of “rote” language

• Idiosyncratic or metaphorical language (language that has meaning only to those familiar with the individual’s communication style); neologisms

• Pronoun reversal (for example, “You” for “I”; not just mixing up gender pronouns)

• Refers to self by own name (does not use “I”)

• Preservative language (note: for perseveration on a specific topic, consider B3)

• Repetitive vocalizations such as repetitive guttural sounds, intonational noise‐making, unusual squealing, repetitive humming

• Repetitive hand movements (e.g., clapping, finger flicking, flapping, twisting)

• Stereotyped or complex whole body movements (e.g., foot to foot rocking, dipping, & swaying; spinning)

• Abnormalities of posture (e.g., toe walking; full body posturing)

• Intense body tensing

• Unusual facial grimacing

• Excessive teeth grinding

• Repetitively puts hands over ears (note: if response to sounds, consider B4)

• Perseverative or repetitive action / play / behavior (note: if 2 or more components, then it is a routine and should be considered under B2)

• Repetitive picking (unless clear tactile sensory component, then consider B4)

• Nonfunctional play with objects (waving sticks; dropping items)

• Lines up toys or objects

• Repetitively opens and closes doors

• Repetitively turns lights on and off

Examples:

• motoric rituals

• insistence on same route or food

• repetitive questioning or extreme distress at small changes).

B2 includes rituals and resistance to change

• Routines: specific, unusual multiple‐step sequences of behavior

• Insistence on rigidly following specific routines (note: exclude bedtime routines unless components or level of adherence is atypical)

• Unusual routines

• Repetitive questioning about a particular topic (distinguish from saying the same word or phrase over and over, which goes under B1)

• Verbal rituals ‐ has to say one or more things in a specific way or requires others to say things or answer questions in a specific way

• Compulsions (e.g. insistence on turning in a circle three times before entering a room) (note: repetitive use of objects,, including lining up toys, should be considered under B1)

• Difficulty with transitions (should be out of the range of what is typical for children of that developmental level)

• Overreaction to trivial changes (moving items at the dinner table or driving an alternate route)

• Inability to understand humor

• Inability to understand nonliteral aspects of speech such as irony or implied meaning

• Excessively rigid, inflexible, or rule‐bound in behavior or thought

1. Interests abnormal in intensity or focus

2. Strong attachment to or preoccupation with unusual objects, excessively circumscribed or preservative interests).

• Note: Consider B1 for preservative speech

• Preoccupations; obsessions

• Interests that are abnormal in intensity

• Narrow range of interests

• Focused on the same few objects, topics or activities

• Preoccupation with numbers, letters, symbols

• Being overly perfectionistic

• Interests that are abnormal in focus

• Excessive focus on non-relevant or nonfunctional parts of objects

• Preoccupations (e.g. color; time tables; historical events; etc)

• Attachment to unusual inanimate object (e.g., piece of string or rubber band)

• Having to carry around or hold specific or unusual objects (not common attachment objects such as blankets, stuffed animals, etc.)

• Unusual fears (e.g. afraid of people wearing earrings)

Reactive to sensory input or unusual interest in sensory aspects of environment;

• apparent indifference to pain/heat/cold, adverse response to specific sounds or textures

• excessive smelling or touching of objects, fascination with lights or spinning objects).

• High tolerance for pain

• Poking own eyes

• Preoccupation with texture or touch (includes attraction/aversion to texture)

• Tactile defensiveness; does not like to be touched by certain objects or textures

• Significant aversion to having hair or toenails cut, or teeth brushed

• Unusual visual exploration / activity

• Close visual inspection of objects or self for no clear purpose (for example, holding things at unusual angels) (no vision impairment)

• Looks at objects, people out of corner of eye

• Unusual squinting of eyes

• Extreme interest or fascination with watching movement of other things (e.g., the spinning wheels of toys, the opening and closing of doors, electric fan or other rapidly revolving object)

In all domains of sensory stimuli (sound, smell, taste, vestibular, visual), consider:

• Odd responses to sensory input (e.g. becoming extremely distressed by the atypical sound)

• Atypical and/or persistent focus on sensory input

• Unusual sensory exploration with objects (sound, smell, taste, vestibular)

• Licking

Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.

Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.

• Marked deficits in verbal and nonverbal social communication skills

• Social impairments apparent even with supports in place;

• Limited initiation of social interactions and reduced or abnormal response to social overtures from others.

RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.

Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest.

Severe deficits in verbal and nonverbal social communication skills cause:

• severe impairments in functioning

• very limited initiation of social interactions and minimal response to social overtures from others

Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.

Problems with play/imagination

• Impairments in imaginative/symbolic play

• Lack of functional play skills

• Difficulty distinguishing fantasy from reality
  • Shyness/social anxiety

Language and developmental delays

• Milestone delays/developmental delays

• Speech delays (expressive or receptive)

• Language disorder

• Behavioral difficulties/temper tantrums

• Poor imitation skills (poor SOCIAL imitation skills ARE captured)