A Deaf-Appropriate American Sign Language-Based Autism Spectrum Disorder Clinical Diagnostic Guideline

Running head: DEAF-APPROPRIATE AUTISM DIAGNOSTIC GUIDELINE 1
A Deaf-Appropriate, American Sign Language-Based Autism Spectrum Disorder Clinical
Diagnostic Guideline
Ryanne K. Reddick and Kiersten B. Washburn
Central Michigan University

DEAF-APPROPRIATE AUTISM DIAGNOSTIC GUIDELINE 2
Table of Contents
Abstract 4
Introduction 5
Disclaimer 6
Literature Review 7
Autism Diagnosis and Educational Placement 7
Etiologies 8
Diagnosing ASD in Deaf Individuals 9
Echolalia 9
Language Behaviors 12
Theory of Mind 13
Cultural and Linguistic Differences 15
Methodology 17
Discussion 22
The Importance of Interpreters 22
Sign System Variations 23
American Sign Language 23
Manually Coded English 24
Fingerspelling and the Rochester Method 24
Signed Exact English 25
Pidgin Signed English 25
The Importance of Sign System Variations 26
A Very Brief Introduction to Deaf Culture 26
The Importance of Deaf Culture Awareness 30
Environmental Testing Considerations 31
References 33
Appendix 39
Appendix A - Glossary 39
Appendix B - Visual Appendix 46
Appendix C - Adaptation Categories 48
Communication and Lingual 48
Sensory and Medical 48
Cultural 48
Appendix D - Author Biographies 49
Abstract
Autism spectrum disorder (ASD) and deafness are regularly occurring medical diagnoses.
However, they are rarely academically or scientifically considered together, with very little
current understanding of how to accommodate an autism diagnostic exam for a native signer or a
person with a profound hearing loss (Mood & Shield, 2014). With the knowledge from an
assembled panel of experts who are all highly informed in the realm of ASD or Deaf cultural
norms, we created a guideline and tool for navigating a diagnostic exam, the Autism Diagnostic
Observation Schedule 2 (ADOS-2), for a Deaf or native signing child (see Appendix A). The
guideline combines relevant literature on the topic with important information regarding Deaf
culture, interpreters, sign system variations, and environmental testing considerations to prepare
the clinician for working with a Deaf or native signing child. The tool contains modifications that
were determined necessary for cultural, sensorial, or linguistic reasons and were approved by our
panel of experts as both being Deaf-appropriate and meeting the original intents of the ADOS-2
activities. Using the tool and guideline in tandem with the ADOS-2 can provide the best and
most accurate autism examinations and diagnoses for the Deaf and native signing population.
Keywords: d/Deaf, autism spectrum disorder (ASD), American Sign Language (ASL)
Introduction
Autism and deafness are two commonly occurring medical diagnoses that can present
comorbidly in an individual. We define autism spectrum disorder (ASD) as encompassing a
broad variety of neurodevelopmental variances that contribute to challenges in communication
and human interaction (What Is Autism?, n.d.). These challenges are accompanied by repetitive
and restrictive behavioral patterns, which may include abnormal fixations and limited interests
and may include difficulties with acquiring social skills and delays in developing both verbal and
nonverbal communication (What Is Autism?, n.d.). The spectrum aspect refers to the wide range
of problems posed by the disorder, as the severity of difficulties can vary immensely from person
to person. There are two variances of the word d/Deaf, which have unique connotations. The
ith a lowercase d refers to the audiological diagnosis of a profound hearing loss

term deaf w
(Community and Culture, 2016; see Appendix A). Deaf with a capital D refers to the cultural and
linguistic community aspects of being deaf, which includes, in the United States, the use of
American Sign Language (ASL; see Appendix A; Berke, 2019). ASD and deafness are separate
conditions, but there exists a population that has both autism and profound hearing loss.
ASD is more prevalent among those who are deaf compared to their hearing counterparts,
however, there is no validated test to use for assessing potential ASD diagnoses in deaf or native
signing individuals (Szymanski, Brice, Lam, & Hotto, 2012; Shield, Cooley, & Meier, 2017).
Diagnosing materials for ASD such as the Autism Diagnostic Observation Schedule 2 (ADOS-2)
directly warn against being used for individuals with hearing loss (Mood & Shield, 2014).
Despite this, the ADOS-2 currently serves as clinicians go-to testing material even when
observing a d/Deaf individual (Meinzen-Derr, Wiley, Bishop, Manning-Courtney, Choo, &

Murray, 2014; Szarkowski, Mood, Shield, Wiley, & Yoshinaga-ltano, 2014). Additionally, there
is a limited population of professionals that have education or training in both Deafness and ASD
(Mood & Shield, 2014). To allow for the ADOS-2 to be used as an effective clinical tool among
the Deaf and native signing population, there must be comprehensive adaptations that are
compatible with both ASL and Deaf cultural norms, though such an adaptation will make the
standardized scoring aspect of the original ADOS-2 invalid. Clinicians will be able to use these
adaptations as a guide alongside a certified ASL interpreter to aid in providing a more accurate
ASD diagnostic examination for a Deaf or native signing client.
Disclaimer
This document and the following ADOS-2 module modifications are not a formalized,
clinically-approved autism diagnostic test. Scoring as it exists in the unadapted ADOS-2 does not
apply to our tool. As such, we emphasize that this is just that: a tool. Our work is intended to be
used to aid administrators in making clinical judgments regarding the diagnosis of autism in Deaf
and native signing children. We understand that, in following our modifications and foregoing
the scoring and standardization of the ADOS-2 as originally created, the test is no longer
technically clinically valid. However, we argue that using the ADOS-2 as-is for testing Deaf and
native signing children, as well as the lack of an appropriate test as a whole, leads to invalid
results, despite however clinical they may be. We would thus prefer for the results to be accurate
and non-scorable than inaccurate but quantifiable. Unless the clinician is certifiably fluent in
American Sign Language, a certified interpreter must be present to aid in administering the test.
We also recommend that all modules be administered by observing and using manual signs in
place of vocalizations for all test takers using a sign system as their primary language.
Literature Review
Autism Diagnosis and Educational Placement
The literature and research focused on autism spectrum disorder (ASD) and d/Deafness is
severely lacking. The research that exists has found generalities that have been observed in Deaf
children with autism, as well as a great need for further research and better testing tools for
properly diagnosing autism in Deaf populations. ASD among the Deaf is typically diagnosed at a
later time compared to the hearing population (Mood & Shield, 2014; Meinzen-Derr et al.,
2014). Despite the diagnosis occurring later, Deaf children are more likely to receive an ASD
diagnosis than their hearing counterparts. In the United States, one in every 59 Deaf children is
diagnosed with ASD, whereas the rate for diagnosing in hearing children is one in every 68
children (Shield et al., 2017).1 The more profound that a hearing loss is, the more likely the child
will be diagnosed with ASD (Szymanski et al., 2012). However, deaf or hard of hearing children
with ASD are less likely to be comorbidly diagnosed with an intellectual disability than are
hearing children with ASD (Szymanski et al., 2012). This may be due to inexperienced clinicians
overgeneralizing typical Deaf behaviors rather than a tangible difference in brain function among
the two groups (Szymanski et al., 2012). Interestingly, Deaf children with ASD are less likely to
be mainstreamed into hearing-centered public education facilities than are their neurotypical
Deaf peers (Szymanski et al., 2012; see Appendix A). This suggests a perceivable need from the
viewpoint of teachers and caregivers to provide access to signed language to Deaf children with
ASD. Compared to neurotypical Deaf children, the primary communication modality at school
1
It is important to note that the data has been updated more recently for the general population,
but no new numbers have emerged for the Deaf population with ASD. To properly compare the
two populations, the 2017 numbers are used here.
for Deaf children with ASD is 3.6% more likely to be sign-only and 7.7% more likely to be a
combination of speech and sign, a model known as total communication (Szymanski et al.,
2012).
Etiologies
As for the causes of deafness and autism, children with autism are more likely than their
neurotypical deaf peers to have their hearing loss contributed to issues during pregnancy, such as
fever, meningitis, and Cytomegalovirus, or syndromic etiologies such as CHARGE syndrome,
Usher syndrome, and Waardenburg syndrome, rather than to hereditary genetics (Szymanski et
al., 2012; Meinzen-Derr et al., 2014). These same complications could also potentially contribute
to autism (Szarkowski et al., 2014). As suggested by Szymanski (2012) this suggests that autism
and hearing loss are based on “neurological risk factors” (p. 2034) instead of a causal sensory
impairment associated with autism, or the assumption that the sensory difficulties regularly
experienced by people with autism cause hearing loss. The limited research available is in
agreement on these occurrences.
Diagnosing ASD in Deaf Individuals
ASD is more difficult to accurately diagnose among those that are Deaf. This may be due
to the lack of knowledge and research surrounding the topic, the possible overlap of symptoms
such as language delay and difficulty with Theory of Mind, or the lack of a testing material
verified for use among this population (see Appendix A). The Autism Diagnostic Observation
Schedule 2 (ADOS-2) is the most commonly used diagnostic tool in modern autism evaluations,
but the test specifically warns against being used for testing those with significant hearing losses
(Meinzen-Derr et al., 2014; Szarkowski et al., 2014). However, there are several similarities in
behavior and language among Deaf children and children with autism that may make it easier to
recognize autism in Deaf children who have yet to be diagnosed (Shield, 2014). Similarities that
occur among both speaking and signing children with ASD include echolalia, using neologisms,
and avoiding pronoun usage (Shield, 2014; see Appendix A). Common occurrences among Deaf
children with ASD that differ from the hearing population with ASD include facial grammar
usage and reversing pronouns and palm orientations while signing (Shield, 2014; see Appendix
B). These occurrences are so common that they can be significant and reliable indicators of
autism in Deaf and native signing children (Shield, 2014). A closer examination of these
occurrences can be useful indicators of autism for clinicians testing Deaf and native signing
children.
Echolalia
Echolalia refers to the repetition of words, sounds, noises, or phrases, and it commonly
occurs in children with ASD (Rudy, n.d.). Approximately 75% of verbal children with ASD are
echolalic, and 100% of those children are echolalic between 37 and 54 months of age (Shield et
al., 2017). In addition to its use as a comprehensive language, ASL is commonly used in clinical
practice as an augmentative or alternative source of communication (Shield et al., 2017).
Children with ASD who are native signers (meaning they are born into Deaf families and ASL is
their first language) still exhibit similar language patterns to verbal, hearing children with ASD,
such as using names more often than pronouns (Shield, 2014). Some children who should be
fluent native signers produce few or no signs, which is akin to nonverbal or minimally verbal
hearing children with ASD (Shield et al., 2017). When they do sign, echolalia is very often
present.
To explore the echolalia connection between verbal and signing children with ASD,
Shield, Cooley, and Meier (2017) conducted research on the topic with three goals: (a) determine
if and how often echolalia occurs in signing children; (b) gain information on the link between
overall language skills and echolalia; and, (c) see what sign echoes physically look like and if the
modality is similar to spoken echoes. Before delving into the results, they defined ‘signing
echolalia.’ A pure echo was signed with the exact meaning, though often with directional
mirroring, whereas a partial echo was signed if the directionality was maintained, thus changing
the meaning. For example, if a person signs I give you (give is a directional sign that starts at the
giver and moves toward the receiver) to the child, the child produces a pure echo if he or she
signs back I give you, thus changing the direction but retaining the exact meaning (Shield and
Meier, 2012). Shield et al. (2017) explain that the child produces a partial echo if he or she signs
back you give me (p. 1624), thus retaining the direction as it was originally performed but
changing the exact meaning (see Appendices A & B).
The children Shield et al. (2017) studied were diagnosed with ASD using the Autism
Diagnostic Observation Schedule-Second Edition, or the ADOS-2, administered in ASL. Seven
of the 17 Deaf children with ASD produced signed echolalia and at the same rate as they
produced spontaneous signs (Shield et al., 2017). Shield et al. (2017) note that those echolalic
children “had significantly lower receptive language skills” (p. 1628) compared to their
non-echolalic peers. The findings from Shield et al. (2017) suggest that echolalia is not related to
age, ASD severity, or intelligence but is instead an inherent aspect of communication in people
with ASD, in either spoken or signed language modalities, that occurs when receptive language
abilities are low (Shield et al., 2017). Furthermore, partial or mitigated signed echoes do not
suggest an advancement in language comprehension, as is assumed for spoken mitigated echoes
(Shield et al., 2017; see Appendix A). Verbally mitigated echolalia which occurs, for example,
when pronouns are modified correctly, is often viewed as a progressive step towards producing
creative speech (Shield et al., 2017). On the contrary, signed mitigated echolalia involves
changes in movement and direction. In the study, those changes often resulted in echoes without
clear formation or a clear object or subject (Shield et al., 2017). As such, signed mitigated echoes
seem to suggest imitation more than comprehension, thus differentiating the effectiveness of
mitigated echoes between signed and spoken languages (Shield et al., 2017).
Another noticeable difference appeared between echolalic children who sign and those
who speak: the signing children overlapped their echoes temporally (Shield et al., 2017). This is
not something that is done in speaking children, likely due to the modality difference (Shield et
al., 2017). Manually repeating a phrase while someone is signing does not hinder communication
as it would if a child were to verbally repeat words while someone is speaking (Shield et al.,
2017). Echolalia proves to be a very common occurrence in children with ASD, regardless of if
the children communicate through verbal or signed language, and thus can be a useful indicator
of autism in the Deaf and native signing population (Shield et al., 2017).
Language Behaviors
Other language behaviors common in Deaf and signing children with autism include
signing with inaccurate palm reversals, not signing inaccurate pronoun reversals, using incorrect
facial grammar, using neologisms, and avoiding pronouns in favor of names (see Appendix A).
Shield (2014) found that 64.3% of Deaf children with ASD fingerspell or use name signs in
places where typically developing (TD) Deaf children use pronoun signs. According to a survey
of parents of Deaf children with ASD, the use of neologisms, or invented signs or phrases, are
common in 55% of their children, and 65% of their children sign odd phrases (Shield, 2014).
Pronoun reversals are common in 13.15% of spoken pronouns of hearing children with ASD but
are very rarely observed in Deaf children with ASD (Shield, 2014). Signing children with ASD
only reverse 0.51% of pronouns, and those reversals only occur in echolalic signs (Shield, 2014).
Palm reversals, where a sign is produced with the palm of the hand facing opposite from the
normal sign position, is common in young native signing children with ASD, whereas TD Deaf
children do not tend to display palm reversals (Shield and Meier, 2012). Seventy-five percent of
Deaf children with ASD tend to reverse palm orientation while fingerspelling, which can make it
more difficult to communicate their words to other people, as the correct fingerspelled alphabet
faces towards the person being signed to (Shield and Meier, 2012). However, research suggests
that children grow out of palm reversal errors, so this may only be indicative of autism in young
Deaf children (Shield, 2014). Deaf children also utilize very different facial expressions than do
hearing children, as the face is used to display emotion and grammar as spoken language
intonations and inflections do. Deaf children who do not properly utilize facial grammar may be
displaying a manifestation of autism communication difficulties (Szarkowski et al., 2014). Based
on the literature, it is apparent that understanding common language and behavioral patterns for
Deaf children with autism can be important indicators in autism diagnostic evaluations for Deaf
and signing children.
Theory of Mind
Theory of Mind delays may make it more difficult to properly diagnose autism in Deaf
populations (Mood & Shield, 2014). Theory of Mind is the developmental concept that other
people have different thoughts, perspectives, experiences, and plans compared to everybody else
(Mood & Shield, 2014). When discussing Theory of Mind in people with autism, the focus is
more on how people with autism often lack Theory of Mind, thus contributing to their difficulties
in understanding other people’s emotions, attitudes, and beliefs (Edelson, n.d.). Theory of Mind
delays are therefore common in people with ASD, but similar developmental delays are
mimicked in late-signing Deaf children (Shield, Pyers, Martin, & Tager-Flusberg, 2016).
When given standard Theory of Mind tests, 80% of high-functioning people with autism
fail. Similarly, 90% of Deaf children (none of whom tested had ASD) with hearing parents show
delays in Theory of Mind development (Peterson, Wellman, & Liu, 2005). However, there is
evidence to suggest that a delay in Theory of Mind among the deaf may be due to their form of
communication. Native signers do significantly better on Theory of Mind tests than do late
signers or oral children who are deaf; some native signers even master Theory of Mind false
belief concepts sooner than do typically developing (TD) hearing children (Peterson et al., 2005).
TD hearing children and Deaf native signers usually pass Theory of Mind tests around five or six
years of age, but late-signing deaf children and children with high-functioning autism still fail
the test between eight and ten years of age (Peterson, Wellman, & Liu, 2005). However, late
signers develop Theory of Mind in the same sequence as TD hearing children and native signers
do, just at a later age (Peterson, Wellman, & Liu, 2005). Children with ASD develop Theory of
Mind through an abnormal sequence: these children consistently understand hidden emotion
tasks before developing false belief concepts (Peterson et al., 2005). TD hearing and Deaf
children develop those in the reverse order (Peterson et al., 2005).

The reasons for Theory of Mind delays regarding joint attention are different for children
with autism and Deaf children (Brenman et al., 2017). Lack of joint attention is usually followed
by slowed language development and delayed Theory of Mind progress. For children with ASD,
lack of joint attention originates in the child not reciprocating eye gaze at a comparable rate to
TD children (Szarkowski et al., 2014). In Deaf children, lack of joint attention arises from
hearing parents’ limited use of extended joint attention communication, something that Deaf
parents are much more likely to utilize when interacting with their children (Shield et al., 2016).
The Theory of Mind delays in late signers without ASD can masquerade as autism because, for
several years, those delays mirror the delays in hearing children with ASD (Brenman et al.,
2017). This may be contributing to incorrect diagnoses of ASD in Deaf children who were born
to hearing parents and as such did not acquire sign language as their first language, because
language development is strongly related to Theory of Mind development (Brenman et al., 2017;
Shield et al., 2016). Thus, there remains a need for more comprehensive ASD testing for Deaf
children, so Theory of Mind delays in Deaf children are not automatically viewed as being
indicative of autism.
Cultural and Linguistic Differences
In addition to Theory of Mind delays, the cultural and linguistic differences between the
oral hearing world and the signing Deaf world pose difficulties for properly assessing autism in
people with profound hearing losses (Brenman, Hiddinga, & Wright, 2017). About 8% of
children with ASD have a mild to moderate hearing loss, which is higher than the rate in TD
children (Brenman et al., 2017). The standard diagnostic test and model, the ADOS and the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, respectively, criteria are
based primarily on spoken language deficits, but neurotypical Deaf children usually have
delayed speech (Szymanski et al., 2012). These assessments were designed for hearing
populations and cannot simply be translated into sign language to properly diagnose Deaf people.
As such, there are tasks examined in the ADOS-2 that would need to be heavily modified to test
a Deaf child. One task looks at how children respond to their names. A Deaf child will very
likely not respond to their name if spoken, so a comprehensive ASD test for Deaf children
should instead assess how they respond to their name sign produced first in their peripheral
vision followed by attention-getting based on Deaf norms, such as tapping, flickering the lights,
stomping, or waving (Mood & Shield, 2014). An additional modification would be changing the
structure of the testing of joint attention by giving signed directions that replicate the pointing
gesture used by hearing individuals (Mood & Shield, 2014). This is done by, first, using the sign
for SEE with a head turn and no directional element; second, using the sign for SEE and a
non-directional THAT with a head turn; then, using the sign SEE and a directional THAT with a
head turn (Mood & Shield, 2014). All these changes in the way an assessment should be given to
a Deaf or native signer pose some necessary elements to bear in mind while reviewing an
assessment. First, due to the rarity of speech among the Deaf population, facial expression must
be interpreted as intonation in signing (Mood & Shield, 2014). This could include the manner of
speed, crispness of signs, location and other variables (Mood & Shield, 2014). Second, facial
exaggerations common in Deaf communication should be taken into consideration (Mood &
Shield, 2014). The ADOS is not designed to assess Deaf people (Meinzen-Derr, et al., 2014;
Szarkowski et al., 2014). However, it can be a scaffold on which to model a comprehensive ASD
test for Deaf children, so long as the clear objective is to look for hints of autism in Deaf people.
Autism is prevalent across all populations (What Is Autism?, n.d.). Deaf people are more
likely to be diagnosed with ASD than are hearing people, yet little research has been conducted
on the population of Deaf people with autism, showing a need for further studies. These studies
could: dive deeper into the relationship of echolalia in verbal and signing children; clearly define
the differences in Theory of Mind delays between late signers and hearing children with ASD;
call for recognition that standard diagnostic materials are not adequate for assessing Deaf
children; and, propose a new diagnostic test designed specifically for Deaf and signing people.
Much more literature and research should be completed or conducted, but there does exist a solid
foundation upon which to model an autism diagnostic assessment suitable for Deaf people. This
is where we have stepped in, working closely with a team of professionals and experts, to create
a necessary guideline for testing Deaf individuals for autism until an approved diagnostic model
comes to fruition.
Methodology
The current literature regarding autism spectrum disorder (ASD) prevalence among
people with profound hearing loss unanimously agrees that the Deaf population is more likely to
be diagnosed with ASD compared to the general hearing population (Szymanski, Brice, Lam, &
Hotto, 2012; Shield, Cooley, & Meier, 2017). However, the go-to autism diagnostic exam, the
Autism Diagnostic Observation Schedule 2 (ADOS-2), was designed to be used only with people
who can hear within the typical decibel range. It was not intended to be used for d/Deaf or native
signing people (Mood & Shield, 2014). As such, we sought to fill in the gap by proposing a
series of adaptations for the ADOS-2 to transform it into a Deaf-appropriate clinical diagnostic
tool. Our tool contains suggested adaptations of the activities in Modules 1, 2 and 3 with three
potential modification categories in mind: communication and lingual, sensory and medical, and
cultural (see Appendix C). By working with a panel of experts who are all highly informed in the
realm of ASD or Deaf culture norms, our goal was to create a guideline for testing Deaf or native
signing children for autism using the ADOS-2.
Our panel of experts included parents of children who are Deaf or have autism, educators,
psychologists, and Deaf culture experts. While the identities of our eight panel members will
remain anonymous, we have included their credentials and applicable information to prove their
credibility and breadth of knowledge.
● A licensed psychologist and Board Certified Behavior Analyst with a Doctor of
Philosophy in School Psychology.
● A college psychology professor, State of Michigan Licensed Psychologist, and Nationally
Certified School Psychologist with a Doctor of Philosophy in School Psychology from
Central Michigan University.
● A teacher consultant for Deaf and hard of hearing students, college practicum
student-teacher field placement supervisor, and adjunct college instructor in special
education with an undergraduate degree in Deaf Education and a graduate degree in K-12
Educational Administration, both from Michigan State University, and the mother of a
14-year-old child with autism.
● An American Sign Language college professor with a Bachelor of Science in Early
Childhood Education with a concentration in Human Development and Family Studies
from the University of Vermont and a Master of Science in Deaf Education from
McDaniel College.
● An American Sign Language college professor with a Bachelor of Science from Central
Michigan University who is the brother of a Deaf man and the father of a Deaf child and
a child with autism.
● A State of Michigan Qualified American Sign Language Interpreter at Level 2 (BEI
Advanced) and Nationally Certified American Sign Language Interpreter (NIC) by the
Registry of Interpreters for the Deaf (RID) with a Master of Arts in Counseling.
● A certified Michigan and National School Psychologist and Michigan School
Administrator with a Bachelor of Arts in Deaf Education from Michigan State University
and a Master of Arts in Developmental Psychology with a Certificate of Advanced
Studies in Deafness from Gallaudet University.
● An educator of the Deaf with experience as a classroom teacher, teacher consultant, and
state consultant who serves as president of the Board of CEC Special Interest Group,
Division for Communication, Language, and Deaf/Hard of Hearing (DCD), and the
grandmother of two blind granddaughters with autism and a grandson with a severe to
profound bilateral hearing loss.
To build our guideline and suggest modifications, we combined input from our experts,
our knowledge of Deaf culture, and current literature explanations of the difficulties that arise
from testing a person who is deaf using a hearing-based exam and the general behaviors that are
often present in Deaf people with ASD. Before delving into the modifications, we first
determined the intent of each activity and confirmed those intents through surveys by gaining
full (100%) agreeance on each one by our two expert ASD psychologists. We used a scale of one
to four, with a score of one representing “Strongly Disagree” and four representing “Strongly
Agree.” We altered the wording of the intents until they all received full agreeance.
We then created surveys of our proposed modifications to be approved by our Deaf
experts on our panel. The three surveys were separated by module, and each survey included a
question for every activity in that module. Each question contained the intent of the activity as
approved by our ASD psychologists, a description of the original activity procedure, and our
reason for proposing a modification, if applicable (see Appendix C). We then described our
proposed modification and, using a 5-point Likert scale, asked if the suggested adaptations were
appropriate for a Deaf child while still seeming to meet the intent of the original assessment. For
questions that included modifications, we asked “What do you believe to be the effectiveness of
this modification?” and our ranking and scoring were as follows: not at all effective (scored as
-2), slightly effective (scored as -1), somewhat effective (scored as 0), very effective (scored as
1), and extremely effective (scored as 2). For questions that had no suggested modifications, we
asked “To what extent do you agree that no modification is needed?” and our ranking and
scoring were as follows: not at all (scored as -2), slightly (scored as -1), somewhat (scored as 0),
very much (scored as 1), and extremely (scored as 2). Each question was followed by “If you
selected anything other than "Extremely Effective" why do you believe that the modification is
not effective? Do you have any additional questions or feedback?” and included a space for
typed feedback. We revised our modifications until at least 80% agreeance was obtained for each
activity.
Once we achieved agreeance from our Deaf experts, we created a survey for our ASD
psychologists that included all of the activities throughout the three modules. Each question
included the name of the activity, the modules the activities were in, and our reason for
proposing a modification, if applicable (see Appendix C). We then described our proposed
modification and, using the same 5-point Likert scale, asked if the suggested adaptations still
seemed to meet the intent of the original assessment. We used the same scoring and wording as
the surveys for the Deaf experts and included the same feedback question and space. We revised
our modifications until 100% agreeance was obtained for each activity.
For the few activities that needed further revision to reach agreeance from the ASD
psychologists, we sent a shortened version of that same survey back to our Deaf experts until at
least 80% agreeance was reached by those experts. At this point, every modification had reached
full agreeance from our entire panel of experts that our modified modules were acceptable for
both clinicians and Deaf and native-signing children, and our surveys were finished.
We are highly pleased with our finished product, but we recognize that there is much
more work to be done. First, we left open the specifics of training an interpreter to help
administer this modified test. Future research could detail how such training would look and
where it would take place; where the time and funding would come from to ensure sufficient
training; and, how to determine if an interpreter is properly-versed in the material before helping
with a diagnostic exam. Additionally, we did not use our adaptations for a trial of a clinical
autism evaluation. Ideally, future studies would do so to see how successful the modifications
seem to be in an actual diagnostic setting. We do feel confident that the adaptations will be
effective, as we did not suggest any modifications without at least 80% agreeance from our panel
of experts. Nevertheless, it would be beneficial to this field of research to examine the validity of
our tool by conducting such a study. Finally, in the future, our tool would ideally become
quantitatively scorable. The original ADOS-2 scoring became inapplicable as soon as an
adaptation was suggested. As such, we proposed that our tool be used as just that: a tool for
navigating a diagnostic exam for a Deaf or native signing child. The results of the tool will be
taken into consideration qualitatively when discussing a potential autism diagnosis, but having
an adapted scoring rubric for this tool could make the results clearer and more consistent.
Given that this is the first-known extensive ADOS-2 modification tool designed for the
Deaf and native signing population, we are very satisfied with our results. Every potential
adaptation was approved by our panel of experts who have immense knowledge in Deafness,
ASL, or autism, or some combination of those three. We synthesized empirical evidence from a
variety of resources as well as our own knowledge of Deaf culture to guide our direction with
this project, and the results uphold our original goal: we have created a comprehensive
Deaf-appropriate clinical autism diagnostic guideline and tool.
Discussion
The Importance of Interpreters
Ideally, any clinician testing a Deaf child or a child whose first language is ASL would
be fluent in ASL and highly familiar with, if not a part of, Deaf culture and its norms. More
reasonably interpreters will be needed to properly administer the modified ADOS-2 to this
population. Interpreters involved in these evaluations should be comfortable with assisting in its
administration. It is recommended that the clinician and the interpreter meet before conducting
an evaluation to be sure the interpreter has time to go over the material and understand their role:
a cultural and linguistic bridge between the Deaf or native signing child and the hearing
clinician. As an interpreter becomes more familiar with the material, likely after participating in
assessments for numerous children, they can forego meeting with the clinician before each test.
Interpreters must hold appropriate credentials. Check your state policies for guidance. They
should have no prior relationship with the child being tested to prevent relational support bias
(Kirkpatrick & Teijlingen, 2009).
The ADOS-2 was designed for hearing populations and cannot simply be translated into a
signed language to properly determine autism in the Deaf and native signing population.
Translating alone is not enough because it ignores the cultural differences between the Deaf and
hearing populations. For a short-term solution to avoid these assessment issues, the use of ASL
interpreters who have a strong understanding of Deaf culture will help bridge the linguistic and
cultural gaps between hearing clinicians and Deaf children (Brenman et al., 2017). The long-term
solution is to develop a test like the ADOS for Deaf and signing people, as the current ADOS
test becomes technically invalid if it is adjusted to meet the needs of a Deaf child (Brenman et
al., 2017). Until then, interpreters will continue to play an important role in bridging the gaps that
result in using the ADOS. For that reason, the multidisciplinary team should include the
interpreter, as their group discussion and opinion post-assessment must be used in place of any
formal results of the test, which can no longer be scored and standardized (Brenman et al., 2017).
Even with a proper diagnostic tool, someone familiar with ASL and Deaf culture will be needed
to accurately assess a Deaf or native signing person for autism.
Sign System Variations
American Sign Language
American Sign Language is a rule-governed, complete language that is visually and gesturally
focused (Paul, 2009). ASL has finite rules for proper sign formation, execution, and sequencing.
As with any other language, these rules must be acquired by a user of the language to accurately
convey thoughts and ideas (Paul, 2009). However, there are several variations of ASL that do not
inherently follow these rules; these variations constitute an array of signed forms deemed manual
communication (see Appendix A). These different sign systems are otherwise known as
manually coded English (MCE), and they include such methods as fingerspelling, the Rochester
Method, signed exact English (SEE), pidgin signed English (PSE), and more.
Manually Coded English
Manually coded English (MCE) is synonymous with simultaneous communication, or
simcom. In this form of communication, the signer is expected to use spoken English as they
produce manual signs, thus communicating in two different modes simultaneously. The purpose
of MCE is to represent English structure through signing without learning the proper full
language of ASL (Paul, 2009). Deaf children are expected to manually learn the rules of English
as a hearing child would verbally learn the rules (Paul, 2009). The emphasis leans toward
English more so than signed communication.
Fingerspelling and the Rochester Method
In ASL, there are 26 specific signs that symbolize each of the English alphabet’s 26
letters. When a word is spelled out manually, this is called fingerspelling; this term also refers to
manual usage of the English number system (Paul, 2009). The Rochester method is a sign system
where the user must fingerspell and speak simultaneously (Paul, 2009). This method requires a
strong proficiency in English language skills that most children, deaf or hearing, do not possess
(Paul, 2009). As such, this can be a very difficult and ineffective sign system to learn and utilize
regularly, though it can be useful for learning specific English morphemes (Paul, 2009).
Signed Exact English
Signed Exact English (SEE) is a system that expects English to be signed exactly as it is
spoken, and each SEE sign is specific to one English word only (Paul, 2009). Some English
words are spelled the same but have entirely different meanings, such as the word run. To run
from something is completely different than finding a run in one’s sweater (Paul, 2009).
However, in SEE, these two usages of the word run would be associated with the same sign
because a word that meets at least two criteria of sound, meaning, or spelling is given one
specific sign (Bornstein, 1990). Generally, all affixes are signed in this form of communication,
though a user may exclude an affix in the middle of multiple-affix words. For example, there are
specific signs for suffixes such as -s or -ly, but a word like examination, with multiple affixes,
would be signed EXAM-tion, without the middle affix -ine (Paul, 2009). In addition to standard
English affixes, SEE uses markers to represent different tenses, thus differentiating a signed base
word from its past, present, and future English forms (Paul, 2009). SEE utilizes true ASL
vocabulary where it can, but only where the ASL word translates to a sole word in English, such
as with baseball or can’t (Paul, 2009). While this sign system is the most widely used MCE, it is
not a true language like ASL (Paul, 2009.)
Pidgin Signed English
Pidgin Signed English (PSE) is a form of MCE where there are signs for English words
but no accompanying grammatical features (Lynas, 1994). There may be present a few contrived
markers such as for the suffixes -ing or -ed, but generally, these are not utilized. PSE tends to
follow English word order but encompasses a wide array of ASL-like variations. Pidgin Signed
English is not American Sign Language, nor is it a manual form of English. Instead, it represents
the spectrum between the two languages (Bornstein, 1990). For example, a Deaf person may use
PSE when trying to sign with a hearing person who does not know ASL, or a hearing person may
use a variation of PSE when learning ASL (Paul, 2009). Since few people learn ASL well, most
deaf and hearing people use a form of PSE (Bornstein, 1990). PSE may also be considered the
middle ground in the continuum from MCE to pure ASL (Bornstein, 1990). As such, it is not
considered a complete language.
The Importance of Sign System Variations
It is important for both interpreters and clinicians to be aware of the various sign systems.
A Deaf child is considered one who utilizes true ASL, but any signing deaf child may gravitate
toward any variation of MCE (Bornstein, 1990). When examining a signing child for autism, his
or her language abilities should be assessed within the parameters of his or her preferred sign
system. For example, a child who communicates via Signed Exact English should be assessed for
his or her usage of SEE rather than his or her lack of proper ASL usage. Whichever method of
manual communication a child most often utilizes should be the system used to assess that
child’s language ability (Lynas, 1994). This will be important for choosing the most accurate
module with which to assess a child. During the assessment, the interpreter should also adapt to
the child’s preferred sign system to facilitate comfortable and appropriate communication for the
child (Leigh & Andrews, 2017).
A Very Brief Introduction to Deaf Culture
Culture is defined as a system that includes beliefs, behaviors, customs, and values that
are transferred generationally by a society (What Is Cultural Competence?, n.d.). American Deaf
culture is no different. American Deaf culture is a social society based linguistically around
American Sign Language (ASL) (American Deaf Culture, n.d.). ASL is the glue of the culture
where values, history, and literature reside (American Deaf Culture, n.d.). Deaf is the title that
individuals take on as they become a part of, and identify with, the culture. The identity of the
Deaf holds great importance among the community (American Deaf Culture, n.d.). Clinicians
need to be culturally competent about this group, as there are many differences in values and
customs that may affect clinical actions and judgments.
One important difference in Deaf culture involves strategies for gaining attention, and the
methods used to do so are called attention getters (Vicars, n.d.-c). Attention getters are
culturally appropriate ways of getting the attention of a Deaf individual include waving, tapping
his/her shoulder, lightly slapping a shared table, stomping your feet, flashing the lights in the
room, or asking a person closer to the Deaf individual to you get his/her attention (Vicars, n.d.-c;
see Appendices A and B). You may also gain an individual's attention through the assistance of
another person in their vicinity. Attention getters are an important part of Deaf culture given that
typical American hearing forms, such as calling an individual's name, would not be effective.
ASL is the focal point of Deaf culture as a whole, and as such, ASL Grammar is a
principal part of the language (Vicars, n.d-b). ASL grammar consists of two main parts: sentence
structure and physical identifiers (Vicars, n.d-b). ASL syntax is formed in the order of setting,
object/subject, verb (Vicars, n.d-a). As it is a visual language it is important that the conversation
partner first set up the scene before noting the objects and actions that take place within. For
example, a hearing individual may say “I went to the store today,” while an ASL user would use
“TODAY STORE GO-TO FINISH”. In addition to the change in sentence structure, physical
identifiers and movements are an integral part of the language as a whole. Facial expressions are
one form of physical identifiers. One important feature of facial expressions in ASL grammar is
how one uses their eyebrows. Eyebrows are an essential part of asking questions. Raising one's
eyebrows is usually an indicator of a yes/no question while furrowing the brows indicates that a
more involved answer is needed (Vicars, n.d-b; see Appendix B). In addition to eyebrows,
pointing is an essential part of this visual language (Vicars, n.d-a). Pointing often indicates a
reference to what an individual is talking about, and unlike hearing culture is not considered rude
but rather necessary and encouraged (Brenman et al., 2017).
In addition to the grammar differences noted above, when communicating with an ASL
user it is important to understand how directionality can be important. When an individual signs,
it is always from their perspective even when giving directions or describing an object (Fischer
& Gough, 1978). A conversation partner must remember to flip to the signer’s perspective to
fully understand the information. Beyond paying attention to perspective, it is important to note
that signs themselves can be directional. Signs such as GIVE, INFORM, and TELL can all be
directed towards a destination (Fischer & Gough, 1978). For example, with one motion one can
say she told him and by simply reversing the motion, the meaning changes to he told her. For this
reason, it should be of utmost importance to note the directionality of signs when having a
conversation.
One part of Deaf culture that differs significantly from typical hearing culture is
bluntness (Brenman et al., 2017). Individuals within the Deaf community value directness and
accuracy rather than sugar coating or tiptoeing around an issue (Brenman et al., 2017). One way
the Deaf community may be considered blunt often occurs when they are describing someone or
something. Because this community and their language are very visual, they describe things
simply how they are (Joseph, 1993). It is not seen as rude to use physical descriptors such as
weight, nationality, height, or distinctive facial features (such as referencing a person’s large
nose) (Joseph, 1993). In a similar fashion, if one does not like or agree with something, it is
appreciated if and expected that the individual is upfront and truthful (Joseph, 1993).
An important part of an individual's introduction to Deaf Culture is name signs (Callis,
2017; see Appendix A). Name signs, similar to spoken names, are an identifier for individuals
within the community (Callis, 2017). They can come in many forms but will often represent an
initial of the individual’s name (Callis, 2017). The placement and movement are extremely
important for name signs. Placement and movement can represent a family name sign or a
distinctive trait (physical or personality-wise) that is associated with the individual (Callis,
2017). For example, a person named Kelli with curly black hair may have a name sign in the
handshape K starting at the front of the head and moving backward in a circular motion to
represent her hair. Signed name signs are equally as legitimate as the spoken form of a person’s
name when it comes to an individual’s identity and identification.
Storytelling is an important part of ASL literacy (Cook, 2011; see Appendix A).
Storytelling in ASL is similar in structure to how those of the hearing world tell stories. In both
English and ASL storytelling, there are characters, a setting, rising events, a climax, and a
resolution. The main difference between ASL and oral storytelling is simply how the information
is presented (Cook, 2011; Rayman, 1999). While a hearing individual may change voices when a
new character is introduced, someone telling a story in ASL would shift their spatial position to
face a slightly different direction or shift their eye gaze and facial expression (Rayman, 1999).
Whenever they return to that character’s perspective, the storyteller will return to that same
position. This concept is referred to as role shifting (see Appendix B; Cook, 2011; Rayman,
1999). Additionally, Deaf Storytelling relies heavily on the use of classifiers (see Appendix A) to
effectively relay information (Rayman, 1999). Classifiers are a grammatical feature of ASL, and
they constitute specific handshapes that are used for a general purpose, such as denoting shape,
arrangement, size, and the animation or stationary position of an object or person (Paul, 2009;
Rayman, 1999). Like ASL as a whole, Deaf storytelling is focused on the overall comprehension
of concepts and details (Cook, 2011). For examples of Deaf Storytelling, one may look up
traditional narratives such as “The Lumberjack Story” or “The Gum Story”.
The Importance of Deaf Culture Awareness
It is important to note these cultural and linguistic norms due to how they contrast with
typical hearing American norms. For example, if a Deaf child being tested shows the directness
of pointing or tapping someone that is typical of Deaf communication, a hearing professional
may interpret such behaviors as indicative of social insensitivity, thus suggesting a link to
autism. But rather than being socially insensitive, the child may be displaying social behaviors
typically associated with his or her culture (Brenman et al., 2017). Awareness of cultural
differences is a crucial part of cultural competence. Awareness allows clinicians to make
accurate judgments on the basis of diagnosis or the need to provide services. Understanding
cultural differences when working with a Deaf client is critical because information regarding
this cultural group is not common knowledge.
Environmental Testing Considerations
When testing individuals who are Deaf, it is important to recognize that specific testing
environmental considerations may be necessary. The interpreter or the participant's parents or

caregivers may have some environmental adaptation suggestions specific to a particular client or
child, and these should be taken into consideration by the clinician and used to help ensure
accessibility. Some general considerations that researchers recommend implementing when
testing any Deaf or native signing child are as follows:
● Non-Reflective Surfaces It is important to limit surfaces on which reflections may be
seen, to limit distractions and encourage communication. Reflective surfaces can serve as
distractions and increase eye fatigue (Hartke, 2018). This applies to not only the table and
chairs, but to the floor, ceiling, and walls as well.
● Proper Clothing Wearing clothing of a solid color that contrasts with one’s skin tone
allows for ASL to be understood most effectively (Clothing to Contrast Skin Tone,
2017). Avoid clothing with patterns or images or that are similar in color to your hands,
as these can be distracting and will require more visual effort on behalf of the recipient.
Additionally, avoid wearing any flashy or reflective jewelry or accessories, as they can
distract from the hands (Clothing to Contrast Skin Tone, 2017). Even if you are not
signing directly with the participant, being conscious of the visibility of your hand against
your clothing is important because a Deaf child may still look at your gestures or be
distracted by unnecessary accessories.
● Sufficient Lighting Lighting is important as it allows the conversation partners to have a
clear view of the conversation. It is important in this case to not use overstimulating light
such as fluorescents, as these lights can sometimes be over-stimulating for people with
autism (Sensory Differences, 2016). Natural light is the best option, though one should
try to avoid proximity to windows in such a way that shadows are not cast on any of the
signers’ hands or faces.
● Appropriate Table Height It is important to limit any obstructions to the conversation,
such as ensuring tables are not blocking people’s hands. If the conversation partner is not
able to see what is happening, they will not be able to communicate effectively. As such,
table heights must be low enough in comparison to the chairs so everyone’s hands can be
clearly visible. If the table is too tall, the signer’s arms and hands will have to be raised to
accommodate that height, which can affect the presentation of the conversation. Signs
generally take place in front of the singer’s torso or around their head, so the arms and
hands need to be clearly visible across the table (Hartke, 2018). Additionally, the chairs
should be spaced out enough for a free-flowing ASL conversation to occur. ASL can
require a lot of space, especially if the signer is expressive and engaged (Hartke, 2018).
There must be sufficient spacing for both the child being assessed and the interpreter to
communicate freely.
● More Frequent Breaks Completing any sort of test in ASL is generally tiring due to the
increased visual concentration required by Deaf people. This is known as concentration
fatigue (Hartke, 2018). This can be exhausting for everyone involved: the clinician, the
interpreter, and the participant being tested. Interpreters often need breaks every 20 to 30
minutes due to the immense concentration and physical demands of interpreting (How to
Use an Interpreter, n.d.; Working with Interpreters, n.d.; Leigh & Andrews, 2017). An
increase in breaks will provide a much needed sensorial recess for everyone (Hartke,
2018).
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Appendix
Appendix A - Glossary
Term Meaning
Autism Diagnostic The most commonly used diagnostic tool in modern autism
Observation Schedule 2 evaluations (Mood & Shield, 2014)
(ADOS-2)
American Sign Language The linguistic mode of communication for the Deaf community
(ASL) in the United States with its own grammar, syntax, pragmatics,
and vocabulary distinct from English (Paul, 2009, p. 220-221)
Autism Spectrum Disorder A broad variety of neurodevelopmental variances that contribute

(ASD) to challenges in communication and human interaction (What Is
Autism?, n.d.)
Attention getters Culturally appropriate ways of getting the attention of a Deaf

individual, such as waving, tapping his/her shoulder, lightly
slapping a shared table, stomping your feet, flashing the lights in
the room, or asking a person closer to the Deaf individual to help
you get his/her attention (Vicars, n.d.-c)
Classifiers A grammatical feature of ASL that constitutes specific

handshapes that are used for a general purpose, such as denoting
shape, arrangement, size, and the animation or stationary position
of an object or person (Paul, 2009, p. 229, 231-232)
deaf Spelling used for the audiological diagnosis of a profound

hearing loss (Community and Culture, 2016)
Deaf Spelling used for the cultural and linguistic community aspects of
being deaf, which includes, in the United States, the use of
American Sign Language (Berke, 2019)
Echolalia The repetition of words, sounds, noises, or phrases (Rudy, n.d.)
● Mitigated signed A signed echo that involves changes in movement and direction
echolalia which often result in echoes without clear formation or a clear
object or subject; an indication of imitation more than
comprehension (Shield et al., 2017)
● Partial signed A signed echo that maintains the directionality of the original
echolalia phrase, thus changing the meaning of the sign from its original
intent (Shield and Meier, 2012)
● Pure signed A signed echo that maintains the exact meaning of the original
echolalia phrase, generally by mirroring the original directionality (Shield
and Meier, 2012)
Manual communication Signed or manually-coded gestures utilized as a form of

communication which varies from the official language rules of
ASL (Paul, 2009)
Name sign A signed identifier of a person, typically given to and by an

individual who is involved in the Deaf community (Callis, 2017)
Neologism An invented or made-up sign or phrase, or a family-specific home

sign that is not a true ASL sign (Shield, 2014)
Neurotypical Refers to the population without Autism Spectrum Disorder or

other neurologically atypical diagnoses (Rudy, L. J., 2019)
Palm reversal Occurs when a sign is produced with the palm of the hand facing
opposite from the normal sign position (Shield, 2014)
Storytelling in ASL A visually represented story that utilizes role shifting, classifiers,
facial grammar and more to successfully convey concepts and
details, including characters, a setting, rising events, a climax,
and a resolution (Rayman, 1999, p. 65; Cook, 2011, p. 37)
Theory of Mind The developmental concept that other people have different
thoughts, perspectives, experiences, and plans compared to
everybody else (Mood & Shield, 2014)
Typically developing (TD) Refers to the population without any developmental delays or
diagnoses that may interfere with standard projections of child
development
Appendix B - Visual Appendix
Title Image Description
Deaf Applause A positive facial

expression combined
with hands waving
back and forth
I GIVE YOU (Standard) The sign GIVE

moving from the
signer to the receiver
to accurately say I
GIVE YOU
I GIVE YOU (Echolalic) The sign GIVE

moving from the
receiver to the signer
to say YOU GIVE ME
as an inaccurate
partially signed echo
Palm Orientation (Tuesday) A T handshape with

the palm facing the
signer
Palm Orientation (Bathroom) A T handshape with

the palm facing the
receiver
Role Shifting (Storytelling) A shift in body

position to represent
two different
characters or
perspectives; a role
shift may not be this
exaggerated and may
instead be represented
by a slight shift in eye
gaze or facial
direction or
expression
Tapping (Attention Getter) A

culturally-appropriate
attention getter that
involves tapping the
receiver lightly on the
shoulder or arm
THAT (Standard) The sign LOOK

followed by the sign
THAT that is fully
oriented toward the
desired object with an
extended arm
movement,
accompanied by an
eye gaze in the same
direction
THAT (Nondirectional) The sign LOOK

followed by the sign
THAT that is slightly
oriented toward the
desired object without
an extended arm
movement,
accompanied by an
eye gaze in the same
direction
Waving (Attention Getter) A

culturally-appropriate
attention getter that
involves noticeably
waving the hand up
and down to catch the
attention of the
receiver
WH- Questions Facial The sign HOW

Grammar accompanied by
furrowed brows to
indicate that further
information is being
requested
Yes/No Questions Facial The sign WELL

Grammar accompanied by
raised brows to
indicate that a yes or
no answer is being
requested
Appendix C - Adaptation Categories
Communication and Lingual
Communication/Lingual adaptations encompass modifying the testing material from
standard verbal English to grammatically and manually correct American Sign Language (ASL).
Simply translating the test from English to ASL is not advised nor entirely accurate, as each
language has its own grammar, syntax, pragmatics, and vocabulary and is not directly reflective
of the other (Shield, Cooley, & Meier, 2017). Translating the English test in ASL also
technically invalidates the test and its results (Shield, Cooley, & Meier, 2017; Brenman,
Hiddinga, & Wright, 2017; Mood & Shield, 2014). Nevertheless, administering the test in the
child’s native language will provide a much more comprehensive picture of the child’s
development if it is used as a clinical tool rather than a test.
Sensory and Medical
Sensory/medical adaptations involve situations where the participant would not be able to
fully complete the task, or the task would be unfair to the participant due to their hearing loss.
Situations may include, but are not limited to, spoken instruction, vocalizations, and materials
that make sound.
Cultural
Cultural adaptations are used when a difference in cultural norms may result in an
incorrect understanding of the task or results. Deaf culture is a full and complete culture that has
its own customs, heritage, artforms, and niceties. Mere translation of the ADOS-2 from English
to ASL does not account for the cultural differences that contribute to differences in
psychopathology among various populations (Brenman et al., 2017). In other words, diagnosing
autism in Deaf children through a lens explicitly built for the oral, hearing world ignores the
linguistic and cultural norms of the signing, Deaf world (Mood & Shield, 2014). Professionals
must understand that there are norms that are unique to the Deaf community that are not standard
in the hearing community. Hearing clinicians may overgeneralize habits in Deaf children,
assuming some behaviors to simply be associated with their hearing loss rather than noticing
when a characteristic is abnormal for a Deaf child to exhibit (Brenman et al., 2017).
Appendix D - Author Biographies
Project Leads
Ryanne Reddick is a senior Centralis Honors student at Central Michigan University
(CMU) who is majoring in Social Science and minoring in American Sign Language (ASL).
During her junior year at CMU, Ryanne took a seminar class about autism and volunteered at the
Central Autism Treatment Center, which focuses on Applied Behavior Analysis techniques when
working with children of all ages who have autism. This capstone project grew from a research
paper for that seminar class, where she discovered a lack of resources for the Deaf and
native-signing population with autism. Ryanne was actively involved in a variety of volunteer
and work opportunities throughout her CMU career, but the most applicable to this project was
her time as a member of the Executive Board of the American Sign Language Society where she
served as the Public Relations and Volunteer chair her junior year and as the President her senior
year. Upon graduating from CMU in May 2020 with her Bachelor of Science, Ryanne plans to
attend a community college interpreting program and become a certified ASL interpreter.
Kiersten Washburn is a third-year Centralis Honors student at Central Michigan
University (CMU) who is pursuing a Bachelor of Applied Arts in Communication Sciences and
Disorders with a minor in American Sign Language (ASL). Kiersten’s experiences within special
education settings, the Deaf community, and college classes, as well as learning under speech
language pathologists combined with combined with personal interactions instilled passion for
both the Deaf population and for individuals who have autism. During her time at CMU Kiersten
was on the Executive Board of the American Sign Language Society serving as Social Chair,
followed by Vice President. After graduating from CMU in May 2021, Kiersten will attend
graduate school to obtain a Masters in Speech-Language Pathology.
Advisor
Beth Kennedy currently works as the Director of DeafBlind Central: Michigan’s Training
& Resource Project and as the Director and instructor for the online DeafBlind Intervener
Training Program that she developed for Central Michigan University (CMU). Beth has worked
in the field of deafblindness for over 28 years, also having held positions at Perkins School for
the Blind, and the Florida DeafBlind project. She earned her Bachelor’s Degree in Psychology
from the University of Massachusetts and her Master’s in Special Education, with a
specialization in deafblindness, from Boston College. Beth completed the Interpreter Training
Program at Lansing Community College (LCC) and held an interpreting credential for nine
years. She taught American Sign Language (ASL), Deaf culture, and interpreting classes at LCC
and ASL classes at CMU for a total of thirteen years. Beth is currently a doctoral candidate in the
Educational Leadership Ph.D. Program at Central Michigan University.

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Running head: DEAF-APPROPRIATE AUTISM DIAGNOSTIC GUIDELINE 1

A Deaf-Appropriate, American Sign Language-Based Autism Spectrum Disorder Clinical

Ryanne K. Reddick and Kiersten B. Washburn

Central Michigan University

comorbidly in an individual. We define autism spectrum disorder (ASD) as encompassing a

broad variety of neurodevelopmental variances that contribute to challenges in communication

​ ith a lowercase ​d ​refers to the audiological diagnosis of a profound hearing loss

observing a d/Deaf individual (Meinzen-Derr, Wiley, Bishop, Manning-Courtney, Choo, &

ASD diagnostic examination for a Deaf or native signing client.

Autism Diagnosis and Educational Placement

fever, meningitis, and Cytomegalovirus, or syndromic etiologies such as CHARGE syndrome,

agreement on these occurrences.

Diagnosing ASD in Deaf Individuals

practice as an augmentative or alternative source of communication (Shield et al., 2017).

changing the exact meaning (see Appendices A & B).

Diagnostic Observation Schedule-Second Edition, or the ADOS-2, administered in ASL. Seven

suggest an advancement in language comprehension, as is assumed for spoken mitigated echoes

displaying a manifestation of autism communication difficulties (Szarkowski et al., 2014). Based

and signing children.

children develop those in the reverse order (Peterson et al., 2005).

Cultural and Linguistic Differences

signing children for autism using the ADOS-2.

credibility and breadth of knowledge.

● A licensed psychologist and Board Certified Behavior Analyst with a Doctor of

Philosophy in School Psychology.

● A college psychology professor, State of Michigan Licensed Psychologist, and Nationally

Certified School Psychologist with a Doctor of Philosophy in School Psychology from

Central Michigan University.

student-teacher field placement supervisor, and adjunct college instructor in special

14-year-old child with autism.

● An American Sign Language college professor with a Bachelor of Science in Early

Childhood Education with a concentration in Human Development and Family Studies

a child with autism.

● A State of Michigan Qualified American Sign Language Interpreter at Level 2 (BEI

● A certified Michigan and National School Psychologist and Michigan School

and a Master of Arts in Developmental Psychology with a Certificate of Advanced

Studies in Deafness from Gallaudet University.

profound bilateral hearing loss.

We then created surveys of our proposed modifications to be approved by our Deaf

quantitatively scorable. The original ADOS-2 scoring became inapplicable as soon as an

Deaf-appropriate clinical autism diagnostic guideline and tool.

The Importance of Interpreters

(Kirkpatrick & Teijlingen, 2009).

to accurately assess a Deaf or native signing person for autism.

Sign System Variations

American Sign Language

Manually Coded English

Manually coded English (MCE) is synonymous with simultaneous communication, or

English more so than signed communication.

Fingerspelling and the Rochester Method

Signed Exact English

not a true language like ASL (Paul, 2009.)

Pidgin Signed English

considered a complete language.

The Importance of Sign System Variations

child (Leigh & Andrews, 2017).

A Very Brief Introduction to Deaf Culture

customs that may affect clinical actions and judgments.

but rather necessary and encouraged (Brenman et al., 2017).

An important part of an individual's introduction to Deaf Culture is name signs (Callis,

name when it comes to an individual’s identity and identification.

traditional narratives such as “The Lumberjack Story” or “The Gum Story”.

The Importance of Deaf Culture Awareness

ith a lowercase d refers to the audiological diagnosis of a profound hearing loss

● Non-Reflective Surfaces It is important to limit surfaces on which reflections may be

● Sufficient Lighting Lighting is important as it allows the conversation partners to have a

● Appropriate Table Height It is important to limit any obstructions to the conversation,

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comprehending emotional facial expressions in British sign language? Journal of Autism

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Winston (Ed.), Storytelling and Conversation: Discourse in Deaf Communities (pp.

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spectrum disorders. Journal of Autism and Developmental Disorders, 42(10), 2027-2037.

Vicars, B. (n.d.-c). Attention Getting Techniques. Retrieved December 2, 2019, from

I GIVE YOU (Standard) The sign GIVE

I GIVE YOU (Echolalic) The sign GIVE

Palm Orientation (Tuesday) A T handshape with

Palm Orientation (Bathroom) A T handshape with

THAT (Standard) The sign LOOK

THAT (Nondirectional) The sign LOOK