MILLER DIAGNOSTIC SURVEY
FOR CHILDREN WITH DEVELOPMENTAL ISSUES

Language and Cognitive Development Center
154 Wells Avenue - Suite 5
Newton, MA 02459
Phone: (617) 964-0045
Fax: (617) 219-8699

Date of Response to MDS:
Child's Name:
Date of Birth:
Sex: Male    Female
Child's Diagnosis:
Made by Whom:
Their Address:

Which of the following does your child regularly attend: (Choose one or more):
Private School Public School Clinic Private Speech Private OT Other

Please indicate the name and location of your child's school or clinic:

What is the primary approach used with your child? (Choose only one):
Applied Behavior Analysis  Greenspan  Miller Method  Option  TEACCH  Other

If you choose Other, please explain


Person Answering Questions:

Full Name:
Relation to Child:
E-Mail Address:
Address line 1:
Address line 2:
City:
State or Province:
Country:
Postal Code:
Phone Number:
Fax Number:

Does your child have a seizure disorder?
Yes No Don't Know

If Yes, what is the nature of this disorder?

Is the seizure disorder
Completely Controlled Partially Controlled Not Controlled

What medications, if any, does your child take?

How often must he/she take them?

Chromosomal Anomalies: Does he/she have a chromosome anomaly such as Fragile x?

Sensory Issues: Are there any visual or hearing issues? If so, please explain.

Other Medical Issues: Is there any other medical or genetic issue that may affect your child's functioning? If so, please explain:

Sensory Reactivity

  1. Does your child respond to tickles with giggles and expressions of delight?

    2. Never Rarely Sometimes Often Always

  2. When you engage in rough physical play with the child (tossing him/her in the air, rolling him/her around, upside down, etc.) does the child laugh and, when you stop, seem to want more?

    3. Never Rarely Sometimes Often Always

  3. If you make a loud noise (dropping a metal pot) in back of the child does he/she startle and turn toward the sound?

    4. Never Rarely Sometimes Often Always

  4. When the child has a nasty fall, touches something hot or is hit by someone, does he/she cry?

    5. Never Rarely Sometimes Often Always

  5. Does he/she locate and touch the injured part?

    6. Never Rarely Sometimes Often Always

    Body Organization

    Gross Motor

  6. Does the child seek out things to climb (monkey bars, trees, etc.) as if "the higher the better?

    Never Rarely Sometimes Often Always

  7. When climbing over a fence the child knows which leg to bring over first.

    8. Never Rarely Sometimes Often Always

  8. While walking with caregiver the child avoids stumbling over obstacles in his/her path.

    9. Never Rarely Sometimes Often Always

  9. Does the child use the toilet to urinate or defecate?

    10. Never Rarely Sometimes Often Always

  10. Does the child ride a tricycle (or bicycle) without support?

    11. Never Rarely Sometimes Often Always

  11. Does the child ride his/her tricycle (or bicycle) from one place to another even when it means steering around an obstacle to get there?

    12. Never Rarely Sometimes Often Always

  12. Does the child find his/her way from one place in the house (or apartment) to another (from bathroom to bedroom, from kitchen to bedroom, from downstairs to upstairs)?

    13. Never Rarely Sometimes Often Always

  13. When the child is about 50 yards from his/her home (with the home still visible) can the child find his/her way back to it?

    14. Never Rarely Sometimes Often Always

  14. When the child is about 50 yards from his/her home (with the home no longer visible) can he/she find his way home?

    15. Never Rarely Sometimes Often Always

    Fine Motor

  15. Can the child pick up small objects with pincer grasp (thumb and index finger)?

    16. Never Rarely Sometimes Often Always

  16. Does the child pull and turn a knob to open a door?

    17. Never Rarely Sometimes Often Always

  17. The child opens a jar with a top requiring two turns of the lid.

    18. Never Rarely Sometimes Often Always

  18. When the child performs a task (stacking blocks, hanging up a coat, putting toys away) his eyes focus on what his hands are doing.

    19. Never Rarely Sometimes Often Always

  19. Does the child stack blocks one on top of the other (at least 3 or 4 blocks)?

    20. Never Rarely Sometimes Often Always

  20. If the child stacks, does he/she attend to how well they are balanced while stacking?

    21. Never Rarely Sometimes Often Always

  21. Does the child hang his clothing on a hook in such a way that it stays?

    22. Never Rarely Sometimes Often Always

    Problem Solving and Tool Use

  22. Visiting a new setting with toys and devices to climb, the child soon begins to explore the various possibilities.

    23. Never Rarely Sometimes Often Always

  23. If you placed three chairs on the ground in different positions (one on its side, another on its back and a third with its back up) and you asked the child to right (or fix) the chairs, could he/she do it?

    24. Never Rarely Sometimes Often Always

  24. Would the child place his/her hands in the proper position to gain the leverage required to right each chair?

    25. Never Rarely Sometimes Often Always

  25. The child opens a slide bolt or other door fastener to open a closet or screen door.

    26. Never Rarely Sometimes Often Always

  26. If the child wishes to get an out-of-reach object on a shelf -- and there is a stool near the shelf -- the child climbs up on the stool to get that object.

    27. Never Rarely Sometimes Often Always

  27. If the stool (or chair) is on the opposite side of the room, the child looks around to find it, brings it to the shelf, climbs up and gets the object.

    28. Never Rarely Sometimes Often Always

  28. If the stool is in an adjacent room (out of sight), the child spontaneously finds it and bring it to the shelf to get the out of reach object.

    29. Never Rarely Sometimes Often Always

  29. The child cannot solve a problem at first but does so after seeing you model the solution.

    30. Never Rarely Sometimes Often Always

  30. Does the child pull a string attached to a toy either to bring it closer or to pull it along?

    31. Never Rarely Sometimes Often Always

  31. Does the child use a stick or other object to knock over a stack of blocks or other stacked items?

    32. Never Rarely Sometimes Often Always

  32. Does the child use a stick to get an object out of reach (ball or toy car) under the couch or behind something?

    33. Never Rarely Sometimes Often Always

    Social Contact

    Aberrant Social Contact

  33. The child avoids making direct eye contact with you.

    34. Never Rarely Sometimes Often Always

  34. The child is more interested in objects than people.

    35. Never Rarely Sometimes Often Always

  35. The child walks over people in his/her way as if they were objects.

    36. Never Rarely Sometimes Often Always

  36. If a stranger walks up to your child and holds out his/her hand, your child takes that hand and walks off with the stranger?

    37. Never Rarely Sometimes Often Always

  37. When you (the caregiver) follow the child through a swinging door, the child neglects to hold the door so that it doesn't hit you in the face.

    38. Never Rarely Sometimes Often Always

    Adaptive Social Contact

  38. When 3 or 4 adults are sitting in a living room your child consistently tries to be closer to his/her mother or caregiver than to the others.

    39. Never Rarely Sometimes Often Always

  39. When the child's caregiver leaves him/her with unfamiliar baby sitters the child becomes very upset and tries to stay with the caregiver.

    40. Never Rarely Sometimes Often Always

  40. When the child is hurt he comes to you, his caregiver to make it better.

    41. Never Rarely Sometimes Often Always

  41. The child plays successfully with children his/her own age.

    42. Never Rarely Sometimes Often Always

  42. When the child ventures into new space he/she periodically returns to mother or caregiver for refueling before venturing out again.

    43. Never Rarely Sometimes Often Always

  43. The child wants to be close to and spend time with one particular child rather than others.

    Never Rarely Sometimes Often Always

  44. The child plays "peek-a-boo" with his/her mother or caregiver (hiding and then suddenly reappearing).

    45. Never Rarely Sometimes Often Always

  45. The child looks over his/her shoulder at you with glee and excitement when you come after him/her saying, "I'm going to get you!" or something similar.

    46. Never Rarely Sometimes Often Always

  46. The child plays a game of catch or ball-rolling with another in which one first receives the ball and then returns it.

    47. Never Rarely Sometimes Often Always

  47. The child plays a bowling game (or something like it) in which one child bowls and knocks down pins while the other child sets them up until, after a time, they switch positions.

    48. Never Rarely Sometimes Often Always

  48. The child waits for someone to "take their turn" before he/she takes his/her turn.

    49. Never Rarely Sometimes Often Always

  49. The child shows by his/her behavior that he/she understands that some things are "mine" and that others are "yours."

    50. Never Rarely Sometimes Often Always

  50. When you play a game with the child to see who can be first to get a desired object under a cup, the child strives to pick up the cup rapidly in order to be first.

    51. Never Rarely Sometimes Often Always

    Communication

    Receptive

  51. When you ask the child to show you either his/her mouth, nose, eyes, ears or hair, he/she does so.

    52. Never Rarely Sometimes Often Always

  52. When you ask the child to point to your mouth, nose, eyes, ears or hair he/she does so.

    53. Never Rarely Sometimes Often Always

  53. When you ask the child to point to any of these parts on a large picture, he/she does so.

    54. Never Rarely Sometimes Often Always

  54. If there is an object in front of the child (a block or toy) and you hold out your hand and firmly tap your palm as you say, "Give!" the child gives you that object.

    55. Never Rarely Sometimes Often Always

  55. If you ask the child by word and gesture (pointing) to bring a familiar object (located 6-7 feet away) the child does so.

    56. Never Rarely Sometimes Often Always

  56. When asked by word and gesture to bring a familiar object from another room the child does so.

    57. Never Rarely Sometimes Often Always

  57. Asked to get a familiar object from another room when that object is in an unfamiliar location as in "Bring the shoe on the table in the dining room" the child does so.

    58. Never Rarely Sometimes Often Always

  58. When the child is asked in a single sentence to bring two different things from another room, the child does so.

    59. Never Rarely Sometimes Often Always

  59. When you call the child to come to you the child comes.

    60. Never Rarely Sometimes Often Always

  60. When the child is doing something unacceptable and you firmly tell him/her to stop, the child stops.

    61. Never Rarely Sometimes Often Always

    Non Verbal Communication

  61. The child makes "call sounds" to get your attention.

    62. Never Rarely Sometimes Often Always

  62. The child babbles or jargons (which sounds as if he/she is saying something).

    63. Never Rarely Sometimes Often Always

  63. The child signals with gesture or sound when he/she is hungry or needs to go to the toilet.

    64. Never Rarely Sometimes Often Always

  64. When the child wants something he/she expresses this by pulling you by the hand toward the desired object.

    65. Never Rarely Sometimes Often Always

  65. The child points or uses other gestures to indicate what he/she wants.

    Never Rarely Sometimes Often Always

  66. When the child points or gestures to indicate a desired object, he/she looks at the object or event first and then at you.

    67. Never Rarely Sometimes Often Always

    Aberrant Verbal Communication

  67. The child echoes words used by another.

    68. Never Rarely Sometimes Often Always

  68. The child utters words but does not direct them to a person.

    69. Never Rarely Sometimes Often Always

  69. The child confuses the terms "I" and "you" and may refer to himself as "you."

    70. Never Rarely Sometimes Often Always

    Adaptive Verbal Communication

  70. The child uses single words to indicate his/her needs.

    71. Never Rarely Sometimes Often Always

  71. After you supply the first few words of a song or story, the child completes it.

    72. Never Rarely Sometimes Often Always

  72. The child uses multi-word sentences to communicate his/her wishes.

    73. Never Rarely Sometimes Often Always

  73. The child looks at you while using his/her words and waits for a reply.

    74. Never Rarely Sometimes Often Always

  74. The child varies his/her sentences by changing subjects and verbs appropriately as needed.

    75. Never Rarely Sometimes Often Always

  75. The child tells you about things that happened in school or elsewhere.

    76. Never Rarely Sometimes Often Always

  76. The child tells you about things that happened in the past or that he/she expects will happen in the future.

    77. Never Rarely Sometimes Often Always

    Symbolic Functioning

  77. Does the child match pictures to objects?

    78. Never Rarely Sometimes Often Always

  78. If so, does he understand that it is possible to point to a picture to express his wish for that object?

    79. Never Rarely Sometimes Often Always

  79. Does the child scribble on paper?.

    80. Never Rarely Sometimes Often Always

  80. Does the child complete a drawing of a face if the teacher or caregiver draws a circle with some of the facial parts put in?

    81. Never Rarely Sometimes Often Always

  81. Does the child draw objects or people?

    82. Never Rarely Sometimes Often Always

  82. The child varies his/her drawings to reflect different things, people or events that have impressed him/her during the week.

    83. Never Rarely Sometimes Often Always

  83. The child plays "make believe" with toys such as "driving" a toy car while making motor sounds or feeding a baby doll with a bottle.

    Never Rarely Sometimes Often Always

  84. The child's "make believe" play varies to reflect his/her changing interests and experiences?

    85. Never Rarely Sometimes Often Always

  85. Does the child count from one to five or from one to ten?

    86. Never Rarely Sometimes Often Always

  86. When asked does the child give you 3, 5, 7 of a particular set of objects?

    87. Never Rarely Sometimes Often Always

  87. Does the child add and subtract numbers?

    88. Never Rarely Sometimes Often Always

  88. Does the child apply his/her knowledge of numbers in counting change from a purchase?

    89. Never Rarely Sometimes Often Always

  89. Does the child sight-read single words (STOP, GO, DANGER, HOT) and know what they mean?

    90. Never Rarely Sometimes Often Always

  90. Can the child sight-read sentences and show understanding of what he/she has read?

    91. Never Rarely Sometimes Often Always

  91. Does the child derive meaning from sounding out unfamiliar words?

    92. Never Rarely Sometimes Often Always

  92. Can the child write a letter to a friend or relative with only modest help?

    93. Never Rarely Sometimes Often Always

    Aberrant Behavior

  93. The child "twiddles" or spins certain objects that he/she comes across.

    94. Never Rarely Sometimes Often Always

  94. The child rocks, arm-flaps or walks on toes.

    95. Never Rarely Sometimes Often Always

  95. When distressed the child hits self, bites hands, bangs his/her head.

    96. Never Rarely Sometimes Often Always

  96. In a new setting the child will either repetitively run in circles or run from one wall of the room to the other.

    97. Never Rarely Sometimes Often Always

    System Functioning

  97. The child is so drawn toward any new sound or visual change (something moving) that he/she needs to move toward it.

    98. Never Rarely Sometimes Often Always

  98. If while stacking blocks, the stack falls down, the child needs to restore it.

    99. Never Rarely Sometimes Often Always

  99. When the child goes down a slide he/she seems to "forget" where the ladder is so he/she can climb up and slide down again.

    100. Never Rarely Sometimes Often Always

  100. The child has difficulty putting puzzle pieces in a puzzle or pegs in their holes because he/she looks elsewhere while hands fumble to find where the object belongs.

    101. Never Rarely Sometimes Often Always

  101. When the child has an object in his/her hand and someone takes it, the child is distressed.

    102. Never Rarely Sometimes Often Always

  102. Given a similar but not identical object (perhaps a green balloon instead of the red one taken) the child rejects it.

    Never Rarely Sometimes Often Always

  103. The child lines up blocks, animals, cars, etc. and resists anyone altering his/her arrays.

    104. Never Rarely Sometimes Often Always

  104. The child does one or more of the following: Opens and closes doors, flicks light switches on and off, flushes the toilet, turns water faucet on and off.

    105. Never Rarely Sometimes Often Always

  105. The child becomes upset if the usual seating arrangement around the table is altered or if you change the usual route to school or to the store.

    106. Never Rarely Sometimes Often Always

  106. In a setting with toys and climbing devices, the child will wander from one toy or climbing device from another but Never gets involved with any of them.

    107. Never Rarely Sometimes Often Always

  107. The child tantrums when required to shift from one thing to another.

    108. Never Rarely Sometimes Often Always