ATEC Survey
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A. Information About ATEC User and Project

ATEC User:
Parent Practitioner Message to Practitioners
Researcher Other:
 
First Name Last Name
Name of person entering data (if different from above)
Address1: Address2:
City: State: Zipcode:
Country [if outside U.S.]
Telephone: Fax:
E-mail:
Intervention Being Evaluated

Following is a list of some of the more frequently used interventions. We recommend that you assess
one treatment at a time; otherwise, it will be difficult to determine which treatment was responsible
for any observable changes. Please indicate the intervention you are evaluating:
Biomedical / Non-Drug  
Vit. B6 & Mag. Chelation
DMG Specific Carbohydrate Diet
TMG IVIG
Digestive Enzymes Gluten-free diet
Methyl B12 Casein-free diet
Hyperbaric Oxygen GF/CF diet
Education/Training  
Applied Behavior. Analysis (ABA) Auditory Int. Training (AIT)
Speech therapy Neurofeedback
Sensory Integration Occupational Therapy
Drugs  
Benedryl Prozac
Risperidal Ritalin
Secretin Nystatin
OTHER:
Not Evaluating a Specific Treatment

B. Information Specific to Each ATEC/Person (Research Subject)

Assessment Period
We suggest that at least one baseline ATEC be completed prior to introducing an intervention.
Additional ATECs should be completed every 2 to 4 weeks to assess how well the child is responding
to the treatment.

Which ATEC are you completing today?
Please indicate if you are completing the baseline assessment today or how many weeks (or months)
has it been since you began the intervention.
Baseline (starting)**  
1 week 3 months
2 weeks 4 months
3 weeks 5 months
1 month 6 months
5 weeks 9 months
1 1/2 months 1 year
2 months 1 1/2 years
2 1/2 months Other:
Diagnosis: You may check more than one diagnosis.
Autism Asperger Syndrome
PDD-NOS Landau-Kleffner Syndrome
Fragile X Syndrome Retts Syndrome
Not yet diagnosed Other (please specify)
Autism Treatment Evaluation Checklist (ATEC)
Child Information  
First Name Last Name [or identification code]:
Gender Age:
Male Female Years: Months:
Date of Birth [format: mm/dd/yy]:  
 
Form Completed By: Relationship:

I. Speech/Language/Communication

N = Not true, S = Somewhat true, V = Very true
1. Knows own name N S V
2. Responds to ‘No’ or ‘Stop’ N S V
3. Can follow some commands N S V
4. Can use one word at a time N S V
5. Can use 2 words at a time N S V
6. Can use 3 words at a time N S V
7. Knows 10 or more words N S V
8. Can use sentences with 4 or more words N S V
9. Explains what he/she wants N S V
10. Asks meaningful questions N S V
11. Speech tends to be meaningful/relevant N S V
12. Often uses several successive sentences N S V
13. Carries on fairly good conversation N S V
14. Has normal ability to commmunicate for his/her age N S V

II. Sociability
N = Not true, S = Somewhat true, V = Very true
1. Seems to be in a shell - you cannot reach him/her N S V
2. Ignores other people N S V
3. Pays little or no attention when addressed N S V
4. Uncooperative and resistant N S V
5. No eye contact N S V
6. Prefers to be left alone N S V
7. Shows no affection N S V
8. Fails to greet parents N S V
9. Avoids contact with others N S V
10. Does not imitate N S V
11. Dislikes being held/cuddled N S V
12. Does not share or show N S V
13. Does not wave ‘bye bye’ N S V
14. Disagreeable/not compliant N S V
15. Temper tantrums N S V
16. Lacks friends/companions N S V
17. Rarely smiles N S V
18. Insensitive to other's feelings N S V
19. Indifferent to being liked N S V
20. Indifferent if parent(s) leave N S V

III. Sensory/Cognitive Awareness

N = Not descriptive, S=Somewhat descriptive, V=Very descriptive
1. Responds to own name N S V
2. Responds to praise N S V
3. Looks at people and animals N S V
4. Looks at pictures (and T.V.) N S V
5. Does drawing, coloring, art N S V
6. Plays with toys appropriately N S V
7. Appropriate facial expression N S V
8. Understands stories on T.V. N S V
9. Understands explanations N S V
10. Aware of environment N S V
11. Aware of danger N S V
12. Shows imagination N S V
13. Initiates activities N S V
14. Dresses self N S V
15. Curious, interested N S V
16. Venturesome - explores N S V
17. “Tuned in” - Not spacey N S V
18. Looks where others are looking N S V

IV. Health/Physical/Behavior
N = Not a Problem MI=Minor Problem MO=Moderate Problem S=Serious Problem
1. Bed-wetting N MI MO S
2. Wets pants/diapers N MI MO S
3. Soils pants/diapers N MI MO S
4. Diarrhea N MI MO S
5. Constipation N MI MO S
6. Sleep problems N MI MO S
7. Eats too much/too little N MI MO S
8. Extremely limited diet N MI MO S
9. Hyperactive N MI MO S
10. Lethargic N MI MO S
11. Hits or injures self N MI MO S
12. Hits or injures others N MI MO S
13. Destructive N MI MO S
14. Sound-sensitive N MI MO S
15. Anxious/fearful N MI MO S
16. Unhappy/crying N MI MO S
17. Seizures N MI MO S
18. Obsessive speech N MI MO S
19. Rigid routines N MI MO S
20. Shouts or screams N MI MO S
21. Demands sameness N MI MO S
22. Often agitated N MI MO S
23. Not sensitive to pain N MI MO S
24. “Hooked” or fixated on certain objects/topics N MI MO S
25. Repetitive movements N MI MO S