Aims of ADOS-2 and ADI-R

Gather standardised information on autism ‘triad’

• social behavior
ADOS-2 Administration and Coding
• vocalizations/speech, gesture, non-verbal language

• play/interests/creativity

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Diagnostic Criteria – DSM / ICD Diagnostic Criteria – DSM / ICD

Impairments in communication
Qualitative Impairment in social interaction
• eye-gaze,
• spoken language / gesture
• facial expression,
• body postures,
• Initiating / maintaining conversation
• gestures to regulate social interaction
• seeking to share enjoyment, interests or • stereotyped repetitive idiosyncratic language
achievements
• social or emotional reciprocity
• make-believe or social imitative play

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 Diagnostic Criteria – DSM / ICD DSM-5 Autism Spectrum Disorder

Restricted, repetitive /stereotyped behaviour Must meet criteria A, B, C, and D:

• encompassing preoccupations, • A Persistent deficits in social communication and
social interaction across contexts
• stereotyped and restricted patterns of interest; • B Restricted, repetitive patterns of behaviour,
interests, or activities
• abnormal in intensity or focus
• C Symptoms must be present in early childhood -
• inflexible adherence to routines/rituals – but may not become fully manifest until social demands
exceed limited capacities
• stereotyped and repetitive motor mannerisms
• D Symptoms together limit and impair everyday
• persistent preoccupation with parts of objects functioning.
• E – Not better explained by LD

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Social Communication Disorder Diagnostic Guidelines DSM – IV / ICD-10

• Persistent difficulties in pragmatics or social uses of Autistic Disorder / Childhood Autism

verbal /nonverbal communication – difficulties in all three areas age of onset < 36m
• affects development of social reciprocity and social
relationships Asperger’s Disorder / Syndrome
• Persistent difficulties in acquisition /use of spoken / – social interaction deficit,
written / other language modalities for narrative and
discourse – restricted, repetitive behaviours.
• Rule out ASD – no language delay and average cognitive skills
– Particularly in respect of restrictive repetitive
PDD-NOS / Atypical Autism
behaviours
• Onset in early childhood – when demands exceed – social impairment
capacity
– language difficulties or repetitive behaviours,
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 ADOS-2 Modules One to Four – Language and
ADOS-2 and ADI-R Developmental Levels

Expressive Language Level

Informant interview (ADI-R) ADOS-2 Module
Minimum Maximum
• developmental history / events at onset Toddler (12-30 m)
No Speech Simple Phrases
• pervasiveness and context One (> 30m)
Flexible Three Verbally Fluent*
• phenotypic description Two
Word Phrases* (younger child < 6yrs)

Direct observation (ADOS-2) Verbally Fluent

Three (older child / younger ---------
• context to observe current behaviors adolescent < 16yrs)

Verbally Fluent
• include parents for young children Four ---------
(older adolescent/ adult)

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CODING Coding Conventions

0 Behavior of type specified is not present - not necessarily normal

Five Domains in Coding Section 1 Behavior of type specified is present, but not sufficiently severe,
frequent or marked for code of 2
• Language and Communication
2 Behavior of type specified definitely present and meets specific
mandatory criteria
• Reciprocal Social Interaction
3 Behavior present to a degree that interferes with functioning or
• Play / Imagination / Creativity ordinary life

• Stereotyped Behaviours / Restricted Interests 7 Definite abnormality in general area of coding, but not of type
specified

• Other Abnormal Behaviours 8 Not applicable

9 Not known

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 Administration: Features of ADOS-2 ADOS-2 Toddler Module Activities

• creates a “social world” in which behaviors related to • Free Play – including Free Play Ball
the autism spectrum can be observed if they occur • Blocking Toy Play
• Response to Name
• Bubble Play – including Teasing Toy Play
• Prompts or created opportunities for these behaviours
• Anticipation of Routine with Objects – including Unable Toy Play
• Response to Joint Attention
• Essentially, increasing likelihood of their occurrence • Responsive Social Smile
during observation • Anticipation of Social Routine
• Functional and Symbolic Imitation
• Structured hierarchy / some flexibility • Bath Time – including Bath Time Ignore
• Snack

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ADOS-2 Module One Activities ADOS-2 Module Two Activities

• Free Play
• Response to Name
• Demonstration Task
• Response to Joint Attention • Construction Task
• Description of Picture
• Bubble Play • Response to Name
• Telling a Story from a Book
• Anticipation of Routine with Objects • Make Believe Play
• Free Play
• Responsive Social Smile • Joint Interactive Play
• Birthday Party
• Anticipation of Social Routine • Conversation
• Snack
• Functional and Symbolic Imitation • Response to Joint
• Anticipation of Routine with
• Birthday Party Attention
objects
• Snack • Bubble Play

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 ADOS-2 Module Three Activities ADOS-2 Module Four Activities

• Construction Task* • Demonstration Task

• Construction Task • Conversation and Reporting
• Telling a Story from a Book • Cartoons*
• Make Believe Play • Emotions
• Description of Picture* • Break
• Joint Interactive Play • Social Difficulties and
• Conversation and Reporting • Daily Living*
• Demonstration Task Annoyance
• Current Work or School* • Friends and Marriage
• Description of Picture • Break
• Social Difficulties and • Loneliness
• Telling a Story from a • Friends and Marriage Annoyance • Plans and Hopes
Book • Loneliness • Emotions • Creating a Story
• Cartoons • Creating a Story

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Additional Notes on Administration Coding and Classification: Diagnostic Challenges

• Read the information with items

• Overlap in ASD / developmental delay / PD / psychiatric
conditions
• Order is flexible
• Inter-personal variability in presentation
• Be prepared for opportunistic
• Intra-personal (developmental) variability
administrations (clinical)
• Broad criteria
• Be aware of ability related items and codings
• Variable interpretations of behaviours of interest

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 Addressing the Diagnostic Challenges Diagnostic Algorithm

For selected items: algorithms for diagnosis

• Overlap • Algorithm for classification • ADI-R: Autism (incl. Atypical Autism, and PDD-NOS) vs. Non-Autism
• ADOS-2: Autism vs. ASD/Atypical / PDD-NOS vs. Non-Autism
• Inter-personal variability • Modular assessment
Not specific to Asperger’s Syndromes: insufficient information
• Intra-personal
• Structured activities For items scored

• Broad criteria 0 Remains as 0

• Operationalised descriptions 1 Remains as 1
• Variable interpretations 2 Remains as 2
of behaviours of interest 3 Becomes 2
• Standardisation / Training
7 Becomes 0
8 Becomes 0
9 Becomes 0
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ADOS-2 Scoring and Classification ADOS-2 Scoring and Classification

Module 1 The algorithm process in Modules 1, 2, 3 and 4

leads to an ADOS-2 classification of autism,
Code Assigned Algorithm Score
autism spectrum or non-spectrum.
0 Unchanged as: 0
Module 2
When the item codes are
1 Unchanged as: 1*
transferred to page 23 of The process also generates a comparison score
2 Unchanged as: 2
the Protocol Booklet, they 3 Converts to: 2 Module 3 indicating one of four levels of autism spectrum-
are converted to algorithm 7 related symptoms: high, moderate, low, minimal-
Converts to: 0
8 to-no-evidence.
scores as shown. 9 Module 4
* there is one exception to this in the Toddler Module

The algorithm process for the Toddler Module

Module T leads to an ADOS-2 Range of Concern.

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 Exercise Scores Exercise Scores: Module Four

Toddler Module Four

– Oliver: SA 13 RRB 4 Total 17 Moderate-to-Severe – Kevin: Comm 2 RSI 4 Total 10 Non-ASD
Module One – Cindy: Comm 3 RSI 7 Total 10 Autism
– Darren: SA 15 RRB 3 Total 18 Autism CS: 8 High – Ahmed: Comm 2 RSI 5 Total 7 ASD
Module Two
– Penny: SA 5 RRB 2 Total 7 Non-ASD CS: 3 Low Remember M4 uses only:
Module Three Communication Total
RSI Total
– Sarah: SA 8 RRB 6 Total 14 Autism CS: 8 High
Communication + RSI Totals
– Brian: SA 4 RRB 3 Total 7 ASD CS: 4 Low
Must meet criterion on all three
– Bruce: SA 4 RRB 2 Total 6 Non-ASD CS: 3 Low

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Diagnosis and Classification - ADOS-2 Cut-Offs Calculating Consensus

• Cut-offs are module specific

• Code all Items 0 – 3, 7, 8 or 9
• For Modules 1 to 4 three scores
• Establish consensus score for each item
– M1 to M3 : SA (comm. + RSI), RRB and Overall Total
• Compare your score to consensus for:
– M4 : Communication, RSI and Total (Comm+RSI)
– Total Item Set
• For Modules 1 to 3 only one cut-off score – Overall Total – Algorithm Item Set
• For Module Four 3 cut-offs Communication RSI and Total • Calculate agreement proportion
– Denominator excludes consensus scores > 3
• Comparison Score allows comparisons
– Numerator is the number of agreements
– Between same child on different modules
– 3 vs. 2 (and vice versa) count as agreements
– Between different children
• Multiply by 100 for consensus percentage

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 Item Sets by Module Coding Items

• Toddler Module • Summary vs. Specific

– Gathered throughout the session as a whole
– total item set = 41; algorithm item set = 14
– Social Overtures and Responses, Rapport, Conversation, Reciprocal
• Module One Social Communication
– total item set = 34; algorithm item set = 14 – Specific – early modules – RJA, RSS
• Majority vs. Best
• Module Two
– Take the majority of examples – not just the best (or vv).
– total item set = 29; algorithm item set = 14 – Conversation vs. Reporting of Events
• Module Three • High Incidence vs. Low Incidence
– total item set = 29; algorithm item set = 14 – Several means 3; frequent, take base estimate or proportion

• Module Four • Same title different content

– Early Modules: Pointing, Gestures
– total item set = 32; algorithm item set = 16

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Coding Items Social Overtures and Social Responses

• Directed to Examiner or Other • Social Overture

– Early modules: MT to M2 need another person – Behaviour initiated/maintained by examinee directed at examiner with
– Any others (student, assistant, not considered in coding purpose of communicating social intent
– Eye-contact, facial expression, touching, addressing verbally
• Functional vs Imaginative Play – Subtle (checking in with eye-contact); overt (its your turn now)
– Poor quality (hold hand out for pieces); good quality (ask with ec /
– Functional includes using objects directly as intended; representational
smile)
play and constructional play
– Symbolic involves symbolic use of objects and pretense; using figures • Social Response
as agents of action; in Creating a Story using the lace as spaghetti – As above but in response to a direct approach (subtle or otherwise) by
examiner
• Initiation of Joint Attention • Differences for Coding
– 3 point gaze shift; not holding; for interest – Don’t code ABSENCE of Social Overtures as unusual in the quality
items. A social overture cannot be expected
– Do code absence of Social Response. A response can be expected

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 Functional Play
Symbolic Play

Functional Imaginative / Symbolic

– Use of toys / objects in way intended – Use of toys / objects in ways not obviously intended
– Catch / stacking blocks/reading a book / racing toy cars / – Yarn as spaghetti / measuring cup as bath-tub
talking into a toy telephone – Can be same toys as functional but INTENT is different
– Representational/ miniatures: Toy telephones, toy cars, – Anything that involves a figure or doll in an action
vehicle (dump truck), utensils, doll furniture, purse, tools, – Giving ‘play-doh’ to doll as cake or cup to doll as ‘drink
key ring, pretend food, toy rocket and teapot
– Cause Effect : require action: Jack-in-a-Box, balls, pop-ups
Scoring
– Construction: primary purpose is stacking or building – ‘Little’ spontaneous – judge according to age expectations
– Always repetitive would be 2
Scoring
– No use of figures or doll excludes 0
– Driving the truck around, (vs. rolling it slightly), phone to
ear (vs. pushing a button). – One use of doll and nothing else 2 (early Mods)
– One use of object in Creating a Story – convention = 1
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Coding: Pointing Toddler and Module 1 Coding: Module 2

0= A distal point with an index finger and co-ordinated gaze or 0 = Interest: Index Finger: Distal: Co-ordinated Gaze (x2)
vocalisation for Request or Interest (x2) 1 = any of the following:
1= Less flexible or frequent – Express Interest no co-ordinated gaze
– Distal with absence of any others – Express Interest with gaze but no index finger
– No index finger but presence of all others – Express Interest, with gaze and index but not distal
– Points only to self or other person – Not to express interest (i.e. request) but co-ordinated gaze
– Touching with co-ordinated gaze / vocalisation – Points only to self or other person
– All other aspects correct but one time only 2 = Request only without Co-ordinated Gaze
2 = Proximal only without co-ordinated gaze or vocalisation 3 = No pointing
3 = No pointing

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 Coding Descriptive and Other Gestures (M2 – M4) Special Groups

• 0 = three or more descriptive, more than one of • Learning Disability / Limited Speech
them outside Demo Task – M1 and M2 age-inappropriate materials
– Standardised on children
• 1 as follows:
– Inappropriate assumptions re communicative intent
– three descriptive gestures but all in one task,
– Adapted ADOS
– two descriptive gestures anywhere
– at least descriptive, with three or more other gestures
• Forensic / Secure Environments
• 2 = one descriptive, with two other gestures – M3 and M4
• 3 = only one gesture of any kind – Security issues / kit / questions
• Local Issues

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Some FAQs Some FAQs (cont.)

• Use with deaf children: not standardised

• Age Range: from 12m to adulthood
– Use as clinical tool, materials often relevant for informal/qualitative use
– NV developmental age >=12m, walk independently
• Repeat Administrations
• Ability: from 12m to adulthood
• Slight practice effects on scored responses
• Caution re Module One with pre-verbal adults
• Repetitive behaviours score higher
• Berument, Starr, Pickles, Tomlins, Papanikolauou, Lord et al. (2005).
• Social behaviours score lower
Pre-linguistic autism diagnostic observation schedule adapted for older
individuals with severe to profound mental retardation: A pilot study. Journal of • 2-3 months apart, minimal effect on overall score or classifications
Autism and Developmental Disorders, 35(6), 821-829. • Parents teach
• list of recommended materials for adults and adolescents • Administer at home or in clinic
who need a Module 1 or 2, available from WPS – Either. Clinic / research centre preferable
– Clear instructions prior to home visit: space; bubbles; no sibs; no noise
– Children with ASD usually respond better to greater structure

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 Single Administration Discussion points

• ADOS / ADOS-2 standardised for single admin • Early Diagnosis (DD from Attachment issues, SLI, ADD)
• Differential Diagnosis / Attachment / SLI / PD
• Training / practice include an observer
• English as second language
• Observer doesn’t code • Special groups: Forensic populations, Non-verbal adults
• Consensus meetings for calibration • Women / girls with ASD
• Dual admin non-standardised • Impact of LD / other conditions (e.g. DS) on Validity
• Comorbidity or not
– lower default score
• Prevalence
– interferes with social engagement
• Evaluating Treatment Outcomes: Single Case vs. RCTs
– observe more / affects standardisation stats
• Embedding into practice – not dual admin
• Report Writing

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ADOS-1 to ADOS-2 ADOS-1 to ADOS-2

• Administration is essentially identical • Age Range extended downwards to 12m

• Toddler Module introduced • Cut-offs are still module specific

• TM has two algorithms • For M1 – M4 there are three summary scores

– All Younger (12- 20m) + Older with Few Words (3 or 4 on A1 - <5 words) – M1 to M3 : SA (comm. + RSI), RRB and Overall Total

– Older with some words (21m or older) – M4 : Communication, RSI and Total (Comm+RSI)

• M1 and M2 have two algorithms • For Modules 1 to 3 only one is compared to a cut-off
– M1: Language: few or No Words vs Some Words • Overall Total
– M2: Age: Younger than 5 vs 5 or older
• For Module Four 3 cut-offs Communication RSI and Total
• Modules 3 and 4 have one algorithm
• Comparison Score allows comparisons
– Between same child on different modules

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 Post Course- Administration Reliability Supplementary Slides: Activities and Codes: M4

• Telling a Story from a Book

• Must reach reliability for research administration – As M2 plus: B6: Comments on Others Emotions, C1 Creativity
• Return coded and taped administrations as required
• Conversation /Reporting
• On the full item set and on algorithm items
– As M2 plus: A7: Reporting an Event, B5: Communication Own Affect
• Code appropriately B5; Others Emotions B6, Insight B7; Summary Items B9-B13
• 2/3 = 2; anything above 3 becomes 0
• Current Work or School
• Compare your code to trainers
• 80% agreement for ADOS-2; 90% for ADI-R – As Conversation /Reporting plus Responsibility B8
• Social Difficulties and Annoyance
– As Conversation /Reporting plus Insight B7, Responsibility B8

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Supplementary Slides: Activities and Codes: M2 Supplementary Slides : Activities and Codes: M2

• Construction Task • Conversation

– Initial language: A1-A4; Pointing: A6; Desc Gest. :A7 Eye-Contact: – Language: A1-A5; Gesture: A7, Eye-Contact: B1; Facial Expression:
B1; Facial Expression: B2; Summary B8-B12; Creativity: C2; D1-D4 B2; Summary B8-B12; Repetitive Interests: D4
• Response to Name:
• Response to Joint Attention
– B4
– Own Code: B7
• Make Believe Play
– Initial language: A1-A4; Pointing: A6; Desc Gest. :A7 Eye-Contact: • Demonstration Task
B1; Facial Expression: B2; Showing B4: Response to Name; B5: – Descriptive Gestures: A7
Showing; B6 Initiation Joint Attention; Summary B8-B12; Creativity:
C2; D1-D4 • Description of a Picture
• Joint Interactive Play – Language: A1-A5; Eye-Contact: B1; Facial Expression: B2;
– As Make Believe – plus B3: Shared Enjoyment Summary B8-B12; Repetitive Interests: D4

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 Supplementary Slides : Activities and Codes: M2 Supplementary Slides : Activities and Codes: M2

• Telling Story from Book

– Language: A1-A5; Gesture: A7; Eye-Contact: B1; Facial Expression: • Snack
B2; Summary B8-B12; Repetitive Interests: D4 – A6: Pointing, Summary: B8-B12
• Free Play • Anticipation Routine with Objects
– Language: A1-A5; Gesture: A7; Eye-Contact: B1; Facial Expression: – Gesture: A7; Eye-Contact: B1; Facial Expression: B3: Shared
B3: Shared Enjoyment, B5: Showing; B6: Initiation JA, B2; Enjoyment, B5: Showing; B6: Initiation JA, B2; Summary B8-B12
Summary B8-B12; Functional Play: C1, Creative/Imaginative Play:
C2; Repetitive Interests: D4
• Bubble Play
• Birthday Party – Gesture: A7; Eye-Contact: B1; Facial Expression: B3: Shared
– Shared Enjoyment: B5; Showing: B6; Functional Play: C1, Creative / Enjoyment, B5: Showing; B6: Initiation JA, B2; Summary B8-B12
Imaginative Play: C2 C1: Functional Play

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Supplementary Slides: Activities and Codes: M4 Supplementary Slides: Activities and Codes: M4

• Break
– Summary Items B9-B13 particularly B9 – B12
• Emotions
• Daily Living
– As Conversation/Reporting plus B5: Communication Own
Affect, B6: Comments on Others Emotions – As Conversation and Reporting plus Responsibility- B8
• Demonstration Task • Friends, Relationships and Marriage
– Descriptive Gestures A9, Emphatic Emotional Gestures A10, – As Conversation and Reporting particularly B5 – B8
Reporting an Event A7, Summary Items B9-B13
• Loneliness
• Cartoons
– As Conversation and Reporting particularly Emotions in Others B6
– Descriptive Gestures A9, Emphatic Emotional Gestures A10,
Summary Items B9 – B13 • Plans and Hopes
– As Conversation and Reporting plus Responsibility B8
• Creating a Story – C1
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 Research Slides:
Einstein and Measurement
What, Why and How Many?

Not everything that It seemed to me that

is important can be you have to know
measured and not the ‘what’ before
everything that can deciding on the
be measured is ‘why’
important’ Leo Kanner in ‘Infantile Autism’:
Rimland, 1962
Albert Einstein
And before deciding
on the ‘how
many’….?

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Classification for Research PKU …and how the RCT would have missed it

Prevalence – of? Phenylketoneuria

• Case-description – what are we counting • Genetic – autosomal recessive disorder
Causality – of? • Mutation in gene for phenylalanine hydroxilase
• Case-description – x caused what? (PAH) – metabolises phenylalanine to tyrosine
• Mutation renders PAH non-functional
Treatment evaluation
• Phenylalanine (Phe) appears in urine
• What aspect of presentation are we treating
• Non-metabolised Phe is toxic
• How are we measuring outcome
• Testable
• What constitutes a change – statistical or clinical
• Untreated severe MR + Autistic traits
• How are we defining treatment success
• Treated – normal development
• Treatment – strict Phe restricted diet
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 Prevalence of Autism Spectrum Conditions: UK school-based
population study
PKU …and how the RCT would have missed it

Baron-Cohen et al. British Journal of Psychiatry (2009) 194 -

Phenylketoneuria
• Recognised clinically Representative Sample Selection
- all schools within Cambs, including mainstream and special schools in both
• Testable by neonatal heel-prick private and state sectors
Screening
• Phe exclusion diet – otherwise autism
- well validated peer-reviewed screening questionnaire
Dietary exclusion alone - published psychometric properties:
- good test-retest reliability,
• All newborns or randomly selected group - specificity ( 97%) sensitivity (100%) vs. ADOS-2 and ADI-R
• Half given exclusion diet; half normal diet - well documented cut-off (>15), plus random 33% borderline (12-14)
Case Definition
• Autism as outcome - clearly stated and Based on standardised interview – ADI-R
- direct observation
• Several in both groups with autism - 2 fewer in (a) - clinical judgment / consensus diagnosis
• Difference in effect size – minimal; p value 0.7
• Treatment doesn’t work – carry on with the Phe
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The ScanBrit randomised, controlled, single-blind study of a

gluten- and casein-free dietary intervention for children with The ScanBrit study (cont.)
autism spectrum disorders

Whitely et al. (2010) Nutritional Neuroscience 13(2): 87-100

Stage One
– Tested at baseline 8 and 12 months
Sample and Design – Data on 26 diet and 29 controls available for analysis
– Two-stage 24 month RCT – Significant improvement to mean diet group scores on sub-domains of ADOS-
– adaptive catch-up with interim analysis 2, GARS and ADHD-IV
– 72 Danish children aged 4 – 10 yrs 11 months Stage Two
– Assigned to diet (A) or non-diet (B) – 18 Group A continued; 17 Group B re-assigned
– Inter- and intra-group comparisons
Measures – Some evidence of sustained clinical group improvements
– ADOS-2 and Gilliam Autism Rating Scale - core autism behaviours – Plateau effect of treatment
– Vineland Adaptive Behaviour Scale - developmental level
– Attention Deficit Hyperactivity Disorder-IV Scale – inattention and hyperactivity Conclusion
– Dietary intervention may possibly affect developmental outcome for ASD
children
– Caution in absence of placebo control

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 Improved diagnostic validity of the ADOS-2 revised algorithms: a
A Replication of the ADOS-2 Revised Algorithms
replication study in an independent sample

Gotham et al. (2008) J American Academy Child and Adolescent Psychiatry

47(6): 642–651.
Oosterling et al. J Autism Developmental Disorders (2010) 40(6) 689 - 703
Objective
Aims and Sample - Replicate original factor structure and predictive validity using revised ADOS-2
– Replicate predictive validity, factor structure, and correlations with age, VIQ, NVIQ algorithms in an independent dataset (N = 1,282).
– ADOS-2 revised algorithms for Modules 1 and 2
– Dutch children (n=532)
Method
- Algorithm revisions applied to 18 m to 16yr age-range
- 11 North American CPEA & AART sites
Results and Conclusions
– Improvements in diagnostic validity most apparent for autism Results
– Support the use of revised algorithms - Sensitivities and specificities >= old algorithms
– Use of similar items across developmental cells - Except for young children with phrased-speech and PDD-NOS.
– Easier to compare scores between and within individuals
Conclusions
- revised algorithms increase comparability between modules and
- improve the predictive validity of the ADOS-2 for autism

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Diagnosing Autism Spectrum Disorders in Adults: Use of ADOS-2 Module 4

Bastiaansen, et al. (2010) Journal of Autism and Developmental

Disorders (online DOI 10.1007/s10803-010-1157-x)

Aims and Sample

- to evaluate reliability and predictive validity of ADOS-2 M4
- high-functioning adult ASD males
- schizophrenia, psychopathy, typical development.

Results and Conclusions

- ADOS-2 M4 demonstrated reliability and predictive validity
- discriminated ASD from psychopathy and typical development,
- less specific re schizophrenia
- latter groups differed on some core items
- explorative analyses indicate that a revision as per Gotham et al. 2007
(JADD 37: 613–627, 2007) potentially beneficial

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