Participant ID: ______________________________ Date of Birth: _________________________________

Gender: ___________________________________ Date of Evaluation: _______________________

Examiner: _________________________________ Chronological Age: _______________________
ADI-R DSM-5 Algorithm – Phrase Speech (Item 30=0); Ages 4 - 17 years, 11 months
(Convert scores of 3 on the protocol to 2, and treat all scores other than 0–3 as 0)
Social Communication
Ever: Social Verbalization/char (34-Ever) __________
Ever Reciprocal Conversation (35-Ever) __________
Most Abnormal: Pointing to Express Interest (42-MA) __________
Most Abnormal: Nodding (43-MA) __________
Most Abnormal: Head Shaking (44-MA) __________
Most Abnormal: Conventional/Instrumental Gestures (45-MA) __________
Most Abnormal: Attention to Voice (46-MA) __________
Most Abnormal: Spontaneous Initiation of Actions (47-MA) __________
Most Abnormal: Imaginative Play with Peers (49-MA) __________
Most Abnormal: Direct Gaze (50-MA) __________
Most Abnormal: Social Smiling (51-MA) __________
Most Abnormal: Showing and Directing Attention (52-MA) __________
Most Abnormal: Offering to Share (53-MA) __________
Most Abnormal: Seeking to Share Her/His Enjoyment with Others (54-MA) __________
Most Abnormal: Offering Comfort (55-MA) __________
Most Abnormal: Quality of social overtures (56-MA) __________
Most Abnormal: Range of Facial Expressions used to Communicate (57-MA) __________
Most Abnormal: Appropriateness of Social Responses (59-MA) __________
Most Abnormal: Imitative Social Play (61-MA) __________
Most Abnormal: Interest in Children (62-MA) __________
Most Abnormal: Response to Approaches of Other Children (63-MA) __________
Most Abnormal: Group Play with Peers (64-MA) __________

Social Communication Total __________

Restricted & Repetitive Behaviors

Ever: Stereotyped Utterances & Delayed Echolalia (33-Ever) __________
Ever: Verbal Rituals (39-Ever) __________
Ever: Unusual Preoccupations (67-Ever) __________
Ever: Circumscribed Interests (68-Ever) __________
Ever: Repetitive Use of Objects or Interest in Parts of Objects (69-Ever) __________
Ever: Compulsions/Rituals (70-Ever) __________
Ever: Unusual Sensory Interest (71-Ever) __________
Ever: Undue General Sensitivity to Noise (72-Ever) __________
Ever: Anormal, Idiosyncratic, Negative Response to Specific Sensory Stimuli. (73-Ever) __________
Ever: Difficulties with Minor Changes in Routines or Personal Environment (74-Ever) __________
Ever: Hand and Finger Mannerisms (77-Ever) __________
Ever: Other Complex Mannerisms or Stereotyped Body Movements (78-Ever) __________

Restricted & Repetitive Behavior Total __________

Social Communication and Restricted & Repetitive Behavior Total: ____________ (ASD Cut-Off = 28 )
Lampinen, L.A., Zheng, S., Olson, L., Bal, V.H., Thurm, A.E., Esler, A.N., Kanne, S.M., Kim, S.H., Lord, C., Parenteau, C., Nowell, K.P., Roberts, J.E., Takahashi, N. and
Bishop, S.L. (2025), DSM-5 based algorithms for the Autism Diagnostic Interview-Revised for children ages 4–17 years. J Child Psychol
Psychiatr. https://doi.org/10.1111/jcpp.14159
Participant ID: ______________________________ Date of Birth: _________________________________
Gender: ___________________________________ Date of Evaluation: _______________________
Examiner: _________________________________ Chronological Age: _______________________
ADI-R DSM-5 Algorithm – No Phrase Speech (Item 30>0); Ages 4 - 17 years, 11 months
(Convert scores of 3 on the protocol to 2, and treat all scores other than 0–3 as 0)
Social Communication
Most Abnormal: Pointing to Express Interest (42-MA) __________
Most Abnormal: Nodding (43-MA) __________
Most Abnormal: Head Shaking (44-MA) __________
Most Abnormal: Conventional/Instrumental Gestures (45-MA) __________
Most Abnormal: Attention to Voice (46-MA) __________
Most Abnormal: Spontaneous Initiation of Actions (47-MA) __________
Most Abnormal: Imaginative Play with Peers (49-MA) __________
Most Abnormal: Direct Gaze (50-MA) __________
Most Abnormal: Social Smiling (51-MA) __________
Most Abnormal: Showing and Directing Attention (52-MA) __________
Most Abnormal: Offering to Share (53-MA) __________
Most Abnormal: Seeking to Share Her/His Enjoyment with Others (54-MA) __________
Most Abnormal: Offering Comfort (55-MA) __________
Most Abnormal: Quality of social overtures (56-MA) __________
Most Abnormal: Range of Facial Expressions used to Communicate (57-MA) __________
Most Abnormal: Appropriateness of Social Responses (59-MA) __________
Most Abnormal: Imitative Social Play (61-MA) __________
Most Abnormal: Interest in Children (62-MA) __________
Most Abnormal: Response to Approaches of Other Children (63-MA) __________
Most Abnormal: Group Play with Peers (64-MA) __________

Social Communication Total __________

Restricted & Repetitive Behaviors

Ever: Unusual Preoccupations (67-Ever) __________
Ever: Circumscribed Interests (68-Ever) __________
Ever: Repetitive Use of Objects or Interest in Parts of Objects (69-Ever) __________
Ever: Compulsions/Rituals (70-Ever) __________
Ever: Unusual Sensory Interest (71-Ever) __________
Ever: Undue General Sensitivity to Noise (72-Ever) __________
Ever: Anormal, Idiosyncratic, Negative Response to Specific Sensory Stimuli. (73-Ever) __________
Ever: Difficulties with Minor Changes in Routines or Personal Environment (74-Ever) __________
Ever: Hand and Finger Mannerisms (77-Ever) __________
Ever: Other Complex Mannerisms or Stereotyped Body Movements (78-Ever) __________

Restricted & Repetitive Behavior Total __________

Social Communication and Restricted & Repetitive Behavior Total: ____________ (ASD Cut-Off = 34 )

Lampinen, L.A., Zheng, S., Olson, L., Bal, V.H., Thurm, A.E., Esler, A.N., Kanne, S.M., Kim, S.H., Lord, C., Parenteau, C., Nowell, K.P., Roberts, J.E., Takahashi, N. and
Bishop, S.L. (2025), DSM-5 based algorithms for the Autism Diagnostic Interview-Revised for children ages 4–17 years. J Child Psychol
Psychiatr. https://doi.org/10.1111/jcpp.14159