Sense and Self-Regulation Checklist (SSC)

Background:

Comorbid symptoms are common in autism spectrum disorder are associated with increased autism severity. Comorbid symptoms include abnormal sensory responses, sleep disruption, gastrointestinal problems, self-injurious behaviours, aggression, and irritability. It is recommended that comorbid symptoms are identified and treated from the time of autism diagnosis.

The Sense and Self-Regulation SSC was developed following extensive interviews of parents of children with autism about their child’s sensory and self-regulatory responses to ordinary, daily-life situations. It contains six sensory subdomains (touch-pain, auditory, visual, taste-smell, hyperreactive to non-injurious stimuli, and hyporeactive to injurious stimuli). Items are rated never (0), rarely (1), sometimes (2), or often (3). Domain scores are obtained by summing the individual items.

The Sense and Self-Regulation SSC has been shown to be a valid measure of sensory and self-regulatory difficulties for children under 6 years of age. It can be used as a treatment outcome measure for children with autism. It can also be used to identify patterns of sensory and self-regulatory of sensory and self-regulatory difficulties in young children with other disabilities. The SSC caregiver report is suitable for use by caregivers who have an elementary school education and is available in English, Spanish, and Chinese.

Psychometrics:

Acceptable internal consistency and test-retest reliability has been demonstrated (Silva & Schalock, 2012).

Author of Tool:

Silva, L. M. T., & Schalock, M.

Key references:

Primary use / Purpose:

This instrument was designed as a parent/caregiver measure of comorbid symptoms in autism.

Sense and Self-Regulation Checklist

Instructions:

1. Write the date, name of your child, and who is completing the checklist. (It is very important that the same parent/caretaker complete the form each time the form is)
2. Circle the response for each item that most accurately describes your
3. Add all of the numbers
4. Write total into the space

This work is licensed under the Creative Commons, http://creativecommons.org/licenses/by-nc-nd/3.0.

© LMTSilva Nov. 2011. This instrument is protected by copyright; it may not be altered or sold. Permission is granted for duplication free of charge.

Qigong Sensory Training Institute, www.qsti.org

Date:                      Name of child:                                                  Name of person completing checklist:                                                                      

---

Please circle the response for each item that most accurately describes your child.

• Often 3
• Sometimes 2
• Rarely 1
• Never 0

1. TOUCH/PAIN

• Does not cry tears when hurt
• Doesn’t notice if the diaper is wet or dirty
• Face washing is difficult
• Haircuts are difficult
• Refuses to wear a hat
• Prefers to wear a hat
• Cutting fingernails is difficult
• Prefers to wear one or two gloves
• Avoids wearing gloves
• Cutting toenails is difficult
• Will only wear certain footwear (e.g. loose shoes, no socks)
• Prefers to wear the same clothes day after day
• Will only wear certain clothes (e.g. no elastic, not tight, no tags,
• Cries tears when falls, scrapes skin, or gets hurt  (scale is reversed on purpose)
•  Head bangs on a hard surface
• Head bangs on a soft surface

Self-regulation – Orientation/Attention/Self-soothing/Sleep

• Has to be prompted to make eye contact when spoken to
• Seems not to notice when spoken to in a normal voice
• Does not respond to his/her name
• Does not notice or react when tapped on the back
• Does not roll over onto the back when asked
• Stares off into space
• Seems unaware when others are hurt
• Has difficulty calming him/herself when upset
• Gets upset or tantrums when asked to make a transition
• Has difficulty falling asleep at bedtime
• Has difficulty falling back asleep when awakens during the night
• Awakens very early and stays awake
• Has difficulty awakening in morning
• Makes little jokes. (Answer only if your child has language.) (scale is reversed on purpose)

2. VISION

• Looks at objects out of sides of eyes
• Is bothered by certain lights

Self-regulation – Behavior: Irritability, Aggression, Self- injurious

• Tantrums or meltdowns (Tantrums last minutes, and occur times/day)
• Cries easily when frustrated
• Hits or kicks others
• Scratches or pulls other’s hair

Please circle the response for each item that most accurately describes your child.

• Bites others
• Throws things at others
• Pulls own hair (Where on the head?)
• Bites self (Which part of the body e.g. left thumb?)
• Hits self (Which part of the body?)
• Gets aggressive or ‘hyper’ with exposure to certain smells

3. HEARING

• Reacts poorly to certain everyday noises
• Covers ears with certain sounds
• Reacts strongly when others cry loudly or scream
• Is startled by sudden noises

Self-regulation – Toilet Training

• Is dry at night (scale is reversed on purpose)
• Diaper is wet in the morning
• Wears a diaper during the day
• Is toilet trained (scale is reversed on purpose)

4. TASTE/SMELL:

• • Gags with certain smells
• Avoids foods with certain textures
• Tooth brushing is difficult
• Mouths or chews objects

Self-regulation – Digestion

• Will only eat familiar foods
• Does not seem to be interested in food
• Eats very few foods (five to ten items)
• Bowels are loose
• Bowel movements (“poops”) are frequent (more than 3 per day)
• Requires regular use of laxative to avoid constipation
• Bowel movement (“poop”) is hard and dry
• Has a bowel movement every other day
• Has a bowel movement twice a week
• Has a bowel movement once a week
• Bowel movements are often green
  

  ---

  TOTALL: ……………………