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ADOS-2: Training for Clinicians

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Marie Velasco

on 26 January 2016

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Transcript of ADOS-2: Training for Clinicians

ADOS - 2
Accurately diagnosing ASD is challenging
No biological test for ASD exists
Variability in behaviors across different children with ASD
Variability in behaviors within the same child with ASD across different contexts and across time/development
Symptom overlap between ASD and other developmental disorders (e..g., ID, language disorders, ADHD, anxiety, etc.)
Goals of this training
Introduction to ADOS-2, including theoretical underpinnings related to autism spectrum disorders (ASD)
Demonstration of ADOS-2 to illustrate administration and coding
Introduction to coding conventions
Information necessary for further use
What is Autism?
Developmental disorder
Affects communication, reciprocal social interactions, play, interests, and behavior
Presentation often varies with age and development
Symptoms present prior to 3 years of age
One in a spectrum of Pervasive Development Disorders
ADOS-2 response to diagnostic challenges
Challenge: Variability in defining ASD symptoms and behaviors
Because the DSM is just a guide, there can be variability in how people interpret the diagnostic criteria of ASD

Solution: The ADOS-2 provides operationalized, standardized criteria for defining behaviors associated with ASD
ADOS-2 is standardized by:
Behavior of the examiner
How the individuals behavior are quantified
Training of examiner
Autism is one of a spectrum of disorders
We know more about the "core" of autism than about its edges
BEFORE the administration
BEFORE the administration (cont.)
Select what you think is the correct module, but have alternate protocol and materials ready in case you need to switch modules

Know how to administer activities without the manual
Read the manual carefully and practice, practice, practice!
Training for Clinicians
The ADOS-2
Provides a context for a semi-structured standardized observation of behaviors associated with ASD:
Communication (verbal and nonverbal)
Social interaction
Play use of materials
Restricted and repetitive behaviors and interest
To provide an opportunity to observe behaviors associated with ASD and to construct a profile of strengths and difficulties that may be useful in intervention planning
To standardize observation across different children, and different sites
What we observe is affected y the context we create
Issues the ADOS-2 addresses
Changes with age and development
Module system (different "presses" and codes by age/language level)
Operationalizing specific abnormalities rather than relying on overall general impressions
Diagnostic overlap: unusual development (deviance) vs. delay
Behaviors are defined as unusual based on their presence, absence, frequency, intensity, duration, context, etc.
ADOS-2 as a clinical instrument
The ADOS-2 helps a clinician create a "social world" in which ASD-related behaviors can be observed
Structured and unstructured activities are used to elicit behavior/observation

Guidelines for "hierarchy" of examiner's behavior are included

Ultimately, the quality of the information derived from the ADOS-2 is dependent on examiner's experience and sensitivity (to act and to not act)
ADOS-2 design
For individuals aged 12 months to adulthood
For individuals with a minimum nonverbal mental age of 12 months (for Toddler Module) or 15-18 months (all other modules)
For individuals without significant sensory impairments (e.g., blindness, deafness) or motor impairment
To be used as just one source of information - the ADOS-2 on its own is not sufficient for a diagnosis

ADOS-2 design (cont.)
Takes approx. 40-60 minutes to administer (additional time needed to code)
Observations are obtained from standardized social "presses"
Individual behaviors are coded and an algorithm is used to determine diagnostic classification
The ADOS-2 is based on diagnostic criteria for ASD
Appropriate use of the ADOS-2 relies on an understanding of:
Symptoms and behaviors characteristic of ASD across development
Differential diagnostic of ASD vs. typical development vs. non-ASD development
Typical development
ADOS-2 users should have substantial clinical experience working with children and adults with and without ASD

ASD can be diagnosed reliably in children as young as 2 years of age up through adulthood by experienced clinicians or researchers using standardized instruments
ASD statistics
Found in all cultures and economic groups
Symptoms present before the age of 3, but a diagnosis often later
Some difficulties may not become apparent until child moves into environments where social-communication expectations increase
Children from certain cultural and economic groups may be particularly likely to be "missed" by professionals
Steady increase in prevalence over the years
ASD prevalence
Increase in prevalence due to truly rising rates?
Better identification? Misclassification?
Rising ASD prevalence*
Older studies focused on more narrowly defined "autism"
More recent studies look at combined PDD

27 studies published since 2000, from 8 countries
Prevalence ranged from 30.0/10,000 to 181.1/10,000
(median 62.0/10,000)

Recent surveys suggest that 70/10,000 can be used as current estimate of all PDDs (1 in 143)
*See Fombonne, Quirke, and Hagen (2011)
Changes in epidemiology: ASD and other conditions
Historically, 70% - 85% of autism cases were associated with the intellectual disability, but this is no longer the case
14 recent population-based studies reported IQ data: Across samples 30% had IQ in the average range

75% - 90% of children with ASD acquire some functional language (compared to earlier estimate of 50%)

Male to female ratio range = 2.7:1 to 15.7:1 (median 4.9:1)

Regression estimates range from 12.5% to 38.6% (median 23%)
ASDs are characterized by tremendous heterogeneity
Although ASDs are defined by a particular patterns of behavior, these behaviors are very diverse
ASD defies generalization
Measured Intelligence
Severely Impaired ............................................................................... Gifted

Social Interaction
Aloof .......................................... Passive ............................. Active but odd

Nonverbal .......................................................................................... Verbal

Intense .................................................................................................. Mild

Sensory-seeking ............................................................ Sensory aversions

Uncoordinated .......................................................................... Coordinated
ASD is a developmental disorder
Symptoms and behaviors change with development
Development is affected by having ASD
Both positive (abnormal) and negative (the absence of normal)behaviors are required to make a diagnosis of ASD
Age developmental level, expressive language level, culture, and context (e.g., different settings or social circumstances) can significantly affect how behaviors manifest
Response to diagnostic challenges
Challenge: Developmental changes in autism
Expressive language level is an ability that affects almost every aspect of social interaction and play

Solution: Module System
Minimizes the effect of language level/age (five modules)
Diagnostic assessment
A strength of the ADOS-2 is its ability to address these diagnostic challenges and serve as a valuable tool in the overall assessments of ASD
One source of information for determining whether a diagnosis of ASD is appropriate

Accurate diagnosis is dependent on comprehensive assessment by trained clinicians
Examiners should have experience working with typically developing individuals, individuals with ASD, and those with other developmental disabilities

ADOS and ADOS-2 based on DSM criteria for ASD
Original ADOS was based on DSM-IV criteria for autism
Revisions to the DSM definition of ASD in 2013
Despite some changes to the ASD category, general diagnostic constructs (the symptoms and behaviors that define ASD) remain largely the same in DSM-5
Revised algorithms n ADOS-2 reflect changes in DSM-5 symptom organization

DSM-IV Criteria
DSM-IV Criteria
Multiple ASD category (autism, Asperger's, PDD-NOS, etc.)
Autism criteria - three core symptom domains:
A: Qualitative Abnormalities in Reciprocal Social Interaction
B: Qualitative Abnormalities in Communication
C: Restrictive, Repetitive, and Stereotyped Patterns of Behavior
Abnormality of Development at or before 36 months
DSM-IV: Social Criteria
Qualitative impairment in social interaction
A. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
B. Failure to develop peer relationships appropriate to developmental level
C. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by lack of showing, bringing, or pointing out objects of interests)
D. Lack of social or emotional reciprocity
DSM-IV: Communication Criteria
Qualitative impairment in Communication
A. Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mine)
B. In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
C. Stereotyped and repetitive use of language or idiosyncratic language
D. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
DSM: IV: Behaviors/Interests Criteria
Restricted, repetitive and stereotyped patterns of behavior, interests, and activities
A. Encompassing preoccupation with one or more stereotyped and restricted patterns of interests that is abnormal either in intensity or focus
B. Apparently inflexible adherence to specific, nonfunctional routines or rituals
C. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
D. Persistent preoccupation with parts of objects
Changes to DSM-5 criteria for ASD
Two core symptom domains instead of three:
(1) Deficits in social communication and social interaction
(2) Restricted, repetitive patterns of behavior, interests, or activities

Movement of some symptoms
e.g., stereotyped speech moved from Communication to Restricted, Repetitive Behaviors

Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

Symptoms together limit and impair everyday functioning
Proposed changes to DSM-5 criteria for ASD (cont.)
A single ASD category (w/ levels of severity)

Requires evidence of both social-communication impairments and repetitive behaviors
Repetitive behaviors can be "by history"
Symptoms to include sensory interests/aversions

ASD may be diagnosed with other disorders such as ADHD or language impairments
Changes from the ADOS to the ADOS-2
The research informing DSM-5 change has also informed the recent revisions of the ADOS:
Revised algorithms for Modules 1-3 (two domains; repetitive behavior now included in calculation)

ADOS-2 introduces

Toddler Module (ages 12-30 months)
A "Comparison Score" for Modules 1-3 which converts ADOS-2 Overall Total scores to a 10-point severity metric
Clarification of item scoring
Some 2-point codes have been expanded to 3-point codes, and each module ha at least one new code

For Modules T-1, Item A1 (Overall Level of Non-Echoed Spoken Language) is now differentiated from all other items with a 0-4 coding scheme. Codes on A1 are used to select an appropriate algorithm for Modules T-1. A1 is the only item that does not adhere to the ADOS-2 coding conventions.

The ADOS-2 also includes a revised manual
Improved details of administration guidelines
Further clarification of codes
Includes Toddler Module
ADOS-2 General Administration Guidelines
Guidelines for selecting an ADOS-2 module
Selecting a Module: Toddler Module
Nonverbal to primarily single words and occasional phrases
If flexible three-unit phrases -> Module 2
Regardless of age

Between 12 and 30 months
If 31 months or older -> Module 1

Only valid for children who are able to walk independently AND who have a nonverbal mental age of at least 12 months
Selecting a Module: Module 1
Nonverbal to primarily single words and occasional phrases
If flexible three-unit phrases -> Module 2
Regardless of age

31 months and older
If 30 months or younger -> Toddler Module is recommended
Minor modifications may be useful for older children and adolescents (or use of the ADOS-2 may not be appropriate in these cases)

Selecting a Module: Module 2
Flexible phrase speech, but not regular use of complex sentences
Phrase speech: regular, spontaneous, non-echoed utterances of at least three words, usually including a verb
Typical expressive language between 24 and 48 months

Minor modifications may be useful for older children or adolescents (or use of the ADOS-2 may not be
Selecting a module: Module 3
Regular use of complex sentences
Expressive language skills of a typical 4-year old
Produces a range of sentences types and grammatical forms
Provides information beyond immediate context
Uses logical connections such as but and because

Appropriate for children and most younger adolescents
And sometimes for older adolescents and adults, depending on developmental level and interest in toys
Selecting a module: Module 4
Regular use of complex sentences
Expressive language skills of a typical 4-year-old
Produces a range of sentence types and grammatical forms
Provides information beyond immediate context
Uses logical connections such as but and because

Appropriate for most older adolescents and adults

Revised algorithms and Comparison Scores not yet available for Module 4

Prepare room and materials before participant arrives

Arrange the environment
Choose appropriately sized table and chairs
Set the tasks out but not on the table you are working at; hide them (e.g., cover them with a blanket)

Proper materials
Make sure your equipment works (e.g., bubble toy, remote car or bunny, balloons)
Have a stash of extras, including batteries
Have a proper snack materials (e.g., ask about food restrictions or allergies)
DURING the administration
Set up a "social world" rather than a "test" or just an observation of the child playing

Take a language sample at the beginning of the administration to confirm you are using the correct module before proceeding too far

If you switch modules, exclude behaviors observed during tasks that are exclusive to the "incorrect" module when coding

You CAN administer tasks in any order

TAKE NOTES! Develop a shorthand that works for you.
See ADOS-2 Manual p.16 for tips
DURING the administration (cont.)
Behavior and response of child in part depends on examiner's sensitivity to respond
Knowing when to act and when not to act

Be flexible - with the materials, with the space, with yourself and your behavior

Move from less structure to more structure

Keep pace with the child

Try to match affect and activity level of child
There should only be one examiner
Observer can be a great help uncovering the bunny, cleaning up materials, handling things to the examiner, etc.
Codes should be assigned only with regard to behavior directed to the examiner (and/or parent/caregiver as specified) and NOT the observer
Examiner needs to take notes for him or herself
Observer can also take notes for consulting and consensus coding purposes, but the examiner's codes should be based on his or her own observations and notes during the administration

For Modules T-2, make sure that a parent or familiar caregiver is present. Involve this person in the administration as specified in the manual.
AFTER the administration
Assign ADOS-2 codes immediately following the assessment
Codes should ALWAYS be assigned based on live (not recorded) administration
Importantly, psychometric data are based on information from live coding
Video recordings can be used for detailed study, assessment of reliability, etc.

Use information from the ADOS-2 in combination with all other information from the diagnostic assessment
Remember that the ADOS-2 classification will not always match the overall clinical diagnosis for every child
ADOS-2 Administration Modules 3 and 4
Module 3-4 activities (Fluent Speech)
Construction Task
Make-Believe Play
Joint Interactive Play
Demonstration Task
Description of a Picture
Telling a Story From a Book
Conversation and Reporting
Module 3 Administration Construction Task
Observation - how child indicates a need for more pieces, how s/he does so - eye contact, gesture, vocalization, reaching over examiner's arm

Place some of the block pieces out of reach of the child "Show me how you would put these blocks together - when you need more let me know"

Ensure the remaining blocks are within the child's view but at the other side of the examiner's arm

When the child has assembled the blocks s/he has the examiner should move slightly away and wait for the child to ask for the remaining blocks

If the child does nothing, the examiner should look deliberately at him/her

If there is no response in 3 seconds, the examiner should say, "Are you doing OKAY?" or "How are you doing?". Only then should the examiner ask "Do you need more blocks?"

At the end of the task, the examiner begins to clear away the blocks while saying "Time to clear up" - Watch to see if the child helps to put away the remaining blocks

Module 3: Administration Make-Believe Play
Observation - extent to which the child produces imaginative or creative use of miniature objects, in particular how s/he uses the dolls as animate beings interacting with each other

Present the figures "This is a family, with a mother and father, a little boy/girl and a baby. Here are some of their things. Could you play with these now for a while?"

If child does nothing, examiner can pick up some of the toys and make limited but creative use of them to demonstrate some make believe use of the objects "What are you going to do with yours?"

Examiner should show interest without telling the child what to do, it can be helpful to to talk about what s/he is doing "Who is this?"

Important to distinguish the child's own creative actions from merely copying the examiner's prompts
Module 3: Joint Interactive Play
Observation- reciprocity shown by the child in joint play with examiner - how the child, not the examiner develops the interaction and provides novel initiatives that go beyond responses to the examiner's overtures

When the child has had sufficient time to initiate make believe play, the examiner asks "Can I play too?"

Examiner may pick up a doll and have it give something to the child's doll

If the child responds, the examiner responds in return

It can be helpful to say, "Who do you want to be? I'll be the daddy"

Imitate what the child does "Oh, can I do that too?"

Enter into the spirit of the play and shoe appropriate enthusiasm and pleasure
General issues relating to Modules 3 and 4
Modules design for children, adolescents and adults with fluent speech

Module 3 is age appropriate for children and thus includes many play items

Module 4 is aimed at older adolescents/adults and is more conversation based
Modules 3-4 administration
Don't let it be too easy (don't be too nice or too structured)

Keep at it - don't rush

Make sure that there is some time when it's fun as well

Parent/caregiver not in the room

Preferably sit at a 90-degree angle; large enough
Module 3 - Administration
Telling a Story From a Book
Observation - spontaneous language sample and how the child conveys continuity in a story

Present the story book "Have a look at this book. It tells a story. See it starts out with..." and describe the first picture

Give the book to the child and prompt as necessary

Give no more than specific prompts to get started
"I wonder what happens next?"

Probe to emotions of characters in the book

Expect greater description and development of story
Observation - use of gesture and its coordination with speech, response to humour, insight and narrative ability, comments bout affect, additional language sample.

Participant told that s/he will be shown some cartoons and will have to retell the story without looking at the pictures.

Examiner can introduce the cartoon in general terms, can clarify if the participants seems confused.

Give the cartoon book to the participant and allow time to look through until s/he is ready to retell the story.

Ask the participant to push back her/his chair, stand up and retell the story.
Conversation and Reporting
Observation - how the participant builds on the examiner's comments and participates in to and from conversation. How s/he reports routine and non routine events. Description of relationships and emotions, use of gaze, facial expression, intonation and gesture.

Avoid Q&A Style

Conversations cannot be centered on "special interests" of the participant

Use judgment about what to put participant at ease and invite conversation

At some point, the examiner should stop maintaining the conversation & remain silent to see if the participant can take the initiative.
Observation - to identify events or objects that elicit different emotions in the participant and how s/he describes these emotions

Questions may be presented in any order

Often helpful to either begin or end on a positive note - "what makes you feel happy"
Demonstration Task
Observation - how the child represents familiar action in gesture and/or words

"I want you to play a pretend game with me" and set the imaginary scene with gestures

"This is the pretend washbasin and this is the pretend toothbrush and pretend toothpaste" - gestures should be slow and without extraneous movement

"Now I want you to teach me how you brush your teeth. Can you show me and tell me. Start right in the beginning. You've come into the bathroom. What do you do know?"

If the child does not understand, repeat the instruction

A demonstration of another scene can be given of a different event - driving a car

If the child gestures without words, say "That's good, now tell me, it's OK to talk as well as show me"

If this proves impossible for the child, real items (soap, flannel and towel can be used) in another scene
Module 2 - Description of a Picture
Observation - generation of spontaneous language sample and what captures the child's interest

Present the picture to the child, Let's look at this picture ow Can you tell me about it? What's happening in the picture?"

Prompt can be repeated in different words

Encourage the child to talk in at any level and respond enthusiastically, no further information about the picture is given

If the child does not respond after general prompts or questions or produces only labels - the examiner should model a complex sentence and repeat as necessary

Specific questions may be used. "What/who/where"

If the child is not interested in the first picture, the examiner asks a question which requires a pointing response "Do you see the kite in the picture?"
Observation - how the participant occupies her/himself during free time, her/his response to withdrawal of examiner's attention, any initiation of unstructured conversation with examiner

Present materials - puzzles, paper, markers, radio, newspaper and magazine - "Let's take a break"

Examiner moves position so that s/he is away from the table, work on notes for at least 2 minutes, if the participant initiates interaction, the examiner should respond positively but indicate that s/he has a paperwork to finish

After a few seconds, the examiner should look at the participant to take the lead in any conversation
Friendship and Marriage
Observation - the participant's understanding of the concepts of friendship and marriage, not if s/he has friends, and her/his own role in these relationships

Questions can be asked in any order
Observation - the understanding of the participant of the concept of loneliness and how this pertains to her/him

Examiner can comment about her/his own feelings, if the participant has difficulties
Creating a Story
Observation - the participant's creative use of objects to tell a novel story

Examiner tells participant "Now we are going to make up a story using these objects"

Items should be used in ways that they were not intended - a disc can be used as a person or thing

One object should be used as the agent in the story

The participant then chooses five items and makes up her/his own story
Social Difficulties and Annoyances
Observation - participant's perception of social difficulties, insight into them and if s/he has made any attempt to modify her/his behaviour to fit in with others

Questions can be asked in any order

Participants understanding of appropriateness and implications of her/his feelings are noted
Module 3:
Administration Break
Socioemotional questions: Emotions
Socioemotional questions: Social Difficulties and Annoyance
Socioemotional questions: Friends, Relationships, and Marriage
Socioemotional questions: Loneliness
Creating a Story
Current Work or School
Observation - evaluate how participant describe current situation, level of insight into everyday situations and understanding about what will happen in the future and on role in determining this

Obtain general information about employment or school

If person has had to leave a job and why?

Does the person has realistic understanding of employment prospects for the future?

What school experience is like and why what is their understanding about training required for future employment

Daily Living
Observation - provides factual information about financial responsibility, where s/he is living and how this is arrange and the extent to which the participant is realistic about independence

Questions can be asked in any order

If information has already been obtained about insight and responsibility, some parts can be omitted
Plans and Hopes
Observations - provides a positive end to the interaction and gives the participant an opportunity to describe goals and aspirations s/he may have

Examiner responds to what the participant says and can give some personal information if necessary to encourage the participant
Independent Coding of ADOS-2
Module 3 0r 4
Module 4 activities (Fluent Speech)
Construction Task*

Telling a Story from a Book

Description of a Picture*

Conversation and Reporting

Socioemotionl Questions: Social Difficulties and Annoyance

Socioemotional Questions: Emotions

Module 4: Administration
Socioemotional questions: Current work or School

Daily Living

Plans and Hopes
How well does ADOS-2 work?
Will people with overall clinical diagnoses of
ASD vs non-ASD end up in the right jars?
Plans and Hopes
Observations - provides a positive en to the interaction and gives the participant an opportunity to describe goals and aspirations s/he may have

Examiner responds to what the participant says and can give some personal information if necessary to encourage the participant
ADOS-2 algorithms (Gotham et al., 2007)
Previous ADOS validity studies were based on small samples

Updated validity study included:
n = 912 cases with autism
n = 439 cases with non-autism ASD
n = 279 cases with non-spectrum disorders (including non-specific ID, language disorders, ODD, ADD,
Chocolate Chip Chocolate Chip
Chocolate Chip Cookie Classification Test:
6 out of 10 chocolate chip cookies (correctly) put in a chocolate chip jar.
2 out of 10 Oreos (incorrectly) put in a chocolate chip jar.
ADOS-2 Comparison Score for Modules 1-3

• To indicate level of autism-related symptomatology, as observed during the ADOS-2, as compared with children who have ASD and are of same chronological age and language level.

• To help interpret an individual’s changes over time (i.e., across age and modules)

What comparison score is NOT…

• Does NOT represent the child’s ASD symptoms or overall functioning relative to a typically developing reference group

 It is in reference to children with ASD of the same age and language level

• It is NOT based on population or epidemiological sample
 It is derived from a large clinical/research sample

• Does NOT measure daily functioning or adaptive behavior
 It measures ASD-specific symptoms in relation to children of same age and language level in the context of the ADOS-2

Autism Symptomatology vs. Level of Functioning
Comparison Score quantifies ASD symptoms only (and in ADOS-2 context only)

Language-based module choice, IQ scores, and adaptive behavior scores tell you more about an individual's overall level of functioning than do Comparison Scores
**Important caveats about the sensitivities e and specifications of the ADOS-2**
• The ADOS-2 sensitivity and specificity are based on data from examiners who are research reliable.
• Sensitivity and specificity of the ADOS-2 is likely to be lower when used by examiners who are not research reliable
• All examiners (research reliable or not) must take care to interpret the ADOS-2 results in the context of all other information
 Examiners should also consider differences between their clinical population and the validation samples in terms of medical complexity, cultural diversity, behavioral issues etc.

Important elements of an ASD diagnostic assessment
Interview with parents/caregivers
Developmental history
Pervasiveness of Behaviors
History of restricted and repetitive behaviors

Child Assessment
Direct observation of current ASD-related symptoms and behaviors (e.g., ADOS-2)
IQ and language testing

Medical Assessment and hearing screening

Observation in and/or reports about behavior in relevant environments
At home, school, daycare

Examples of measures used in diagnostic evaluations for ASD
Autism measures



Utility of the ADOS-2 in clinical assessment
Provides framework for identifying particular areas of social and communication difficulty

If the child has difficulty with specific activities during the ADOS-2, what are the implications for everyday functioning (including peer and group interactions)?

Individual tasks and item scores do not always translate to a specific teaching objective
Program planning
Modules 1 and 2
Breaking down social and communication behaviors

Use of different modes of communication
Vocalizations, words, eye contact, facial expressions, gestures
A useful tool but not the only tool
ADOS-2 will not provide you with every answer you seek

Additional components will be necessary to answer various clinical an research questions relevant to ASD, such as:
Developmental/Cognitive testing
Measures of Comorbid Symptoms
Medical History
Developmental History
School Functioning

A useful tool but not the only tool (cont.)
The ADOS-2 is not necessarily appropriate for every person, clinical situation, or study
Toddler Module requires nonverbal mental age of at least 12 months; Module 1-3 require nonverbal mental age of at least 15-18 months
Not validated for people with blindness or deafness or for people who cannot walk independently
Not always appropriate for older children/adults with with very limited language
Not always appropriate for peopl with selective mutism, extreme anxiety, severe behavioral issues, severe developmental delay, or cultural/linguistic differences
Must be administered by the examiner in the individual's dominate language (use of translators during the ADOS-2 is not appropriate)

Module 4
Demonstration Task



Daily Living*

Socioemotional questions: Friends, Relationships, and Marriage

Socioemotional questions Loneliness

Plans and Hopes

Creating a Story
*Denotes optional
Sensitivity and Specificity: Modules 1-3
Sensitivity and Specificity: Module 4
Toddler Module
ADOS-2 Comparison Score: Module 3
(Fluent Speech)
IQ and Adaptive measures

Vineland-II, ABAS-II, or SIB-R

Language Measures


Other Symptoms

ADOS-2 RRB Summary - young child
ADOS-2 RRB Summary - adolescent
Where to go from here?
Preparation and further training for clinical/school use:
Read manual and protocols carefully
Practice extensively with a variety of individuals
"Shadow" a seasoned ADOS-2 examiner

Receive further training
ADOS-2 Research training
WPS DVD training
FAQs and Bulletin Board

ADOS-2 should be used only by people who frequently assess individuals with ASD
Incorporating ADOS-2 results into evaluation reports
Provide description of ADOS-2 (why administered, which module, types of activities)

Report diagnostically relevant behaviors observed during the ADOS-2 (social-communication and repetitive behaviors)
ADOS-2 Social Affect Summary - young child
Social overtures and responses
Overtures to request vs. to initiate social interaction

Play and use of materials
Imaginative play vs. repetitive play
Modules 3 and 4

Teachers have found observing the ADOS-2 quite useful in programming; this is often less the case for parents

Not worthwhile to teach answers to specific emotions or relationship questions

Gain sense of level of support needed to have effective communication
ADOS-2 Social Affect Summary - young adult
Value of assessment = more than just a diagnosis
Accurate diagnosis is needed to access appropriate intervention services

Assessment is needed to:
Establish developmental language levels
Determine patterns of strengths and weaknesses
Develop individualized behavioral and educational intervention programs
Educate parents and teachers
ADOS-2 is a semi-structured standardized assessment that creates contexts in which to observe ASD-related symptoms and behaviors

Sensitivity and specificity of classifications are good but not 100%
As with all assessment measures, some children will be incorrectly classified based on the ADOS-2

ADOS-2 is one part of a comprehensive evaluation
Scores yield a classification, NOT a diagnosis
Your ADOS-2 reliability
The ADOS-2 creates a social situation where the examiner's behavior matters. It is important to keep reliable with other people using it:

- Practice with a range of individuals (ASDs, other disabilities/disorders, typically developing); create a team to independently score and compare administration and scoring

- More stringent reliability; must go through complete research training and establish reliability with approved ADOS-2 training group; monitor drift
Common ADOS-2 errors:
Not reading the manual carefully; just relying on the protocol in carrying out each task

Not getting enough practice

Poor practicing
-Talking too long enough

Non-standard administration
-Giving the wrong module
-Using non-standardized materials
-Skipping questions or tasks you don't think apply
Administration (cont.)
Errors in prompting
-Too much or too little
-Not following the specified hierarchy

Not taking notes; relying on observer to take notes and/or score

Not scoring immediately after the administration

No caregiver present for Modules T-2
Coding everything as 2, because the child is "clearly autistic"

Undercoding, because the child is doing well "for someone with autism"

Neglecting to
read each code and description carefully
to operationalized behaviors

Not converting 3 to 2 (or 8 to 0) on the algorithm
Use and Interpretation
Using the results of the ADOS-2 in isolation to determine diagnosis or eligibility

Not communicating to parents and other professionals than an ADOS-2 Classification is not the same thing as a diagnosis

Reporting raw scores in the report
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