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Clinical ADOS Training - Goals of this training What this training

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Clinical ADOS Training - Goals of this training What this training Powered By Docstoc
					Autism Diagnostic
Observation Schedule (ADOS)

A Standardized Instrument for the
Diagnosis of Individuals with Autism

Clinical Workshop with Catherine Lord, Ph.D.
     3-
July 3-4, 2009
2009 SA ACAPAP




Goals of this training
Introduction to the ADOS, including
theoretical underpinnings related to
Autism Spectrum Disorders (ASD)
Demonstration of the ADOS
Introduction to coding conventions
Information necessary for further training
in clinical and research use




What this training is not:
 Equivalent to full preparation for
 clinical use
 A replacement for reading the manual!

 More training, experience, and practice
 will be needed before you can use the
 ADOS reliably to make diagnosis and
 eligibility decisions.
What is Autism?
  Developmental Disorder
  – Affects communication, reciprocal social
    interactions and play, interests, and behavior
  Symptoms are present prior to 3 years of
  age
  Lifelong
  Changes with age and development
  One in a spectrum of Pervasive
  Developmental Disorders




 Autism Statistics
                  2-
   Estimates of 2-6+ in 1,000 children for
   spectrum (4-5 in 10,000 for autism)
              (4-
   Truly rising rates or better identification?
   Present before the age of 3, but diagnosis
   often later
   Found in all cultures and economic groups
   Four times more common in boys
   Many children test as also having an
   intellectual impairment (approximately 50%)




ASD Defies Generalization
Measured Intelligence
Severely Impaired-------------------------------------Gifted

Social Interaction
Aloof-------------------Passive---------------Active but odd

Communication
Nonverbal----------------------------------------------Verbal

Behaviors
Intense---------------------------------------------------Mild

Sensory
Hyposensitive--------------------------------Hypersensitive

Motor
Uncoordinated-----------------------------------Coordinated
      Autism Spectrum Disorders
      (ASD)
        Autism
        PDD-
        PDD-NOS / Atypical
        Autism
        Asperger’
        Asperger’s Disorder
        Childhood Disintegrative
        Disorder
        Rett’
        Rett’s Syndrome




      The ADOS is based on the
      DSM-       ICD-
      DSM-IV/ ICD-10
      Criteria for Autistic Disorder
        Qualitative abnormalities in Reciprocal Social
        Interaction
        Qualitative abnormalities in Communication
        Restricted, Repetitive and Stereotyped
        patterns of behavior
        Abnormal or impaired development at or
        prior to age 3




     DSM-IV/ICD-10
     Social Criteria
A.    Qualitative impairment in social interaction as
      manifested by at least two of the following:
     1. Marked impairment in the use of multiple nonverbal
                           eye- to-
        behaviors such as eye-to-eye gaze, facial
        expression, body postures, and gestures to regulate
        social interaction
     2. Failure to develop peer relationships appropriate to
        developmental level
     3. Marked impairment in seeking to share own
        pleasure with others
                 social-
     4. Lack of social-emotional reciprocity
      DSM-IV/ICD-10
      Communication Criteria
B.    Qualitative impairments in communication as
      manifested by at least one of the following:
     1. 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 mime)
     2. Marked impairment in the ability to initiate or
        sustain a conversation with others despite adequate
        speech
     3. Stereotyped and repetitive use of language or
        idiosyncratic language
                                       make-
     4. Lack of varied spontaneous make-believe play or
        social imitative play appropriate to developmental
        level
      DSM- IV/ICD-
      DSM-IV/ICD-10
      Behaviors/Interests Criteria
C.    Restricted, repetitive and stereotyped
      patterns of behavior as manifested by at
      least one of the following:
     1. Encompassing preoccupation with one or more
        stereotyped and restricted patterns of interest
        abnormal in either intensity or focus
     2. An apparently compulsive adherence to
        specific nonfunctional routines or rituals
     3. Stereotyped and repetitive motor mannerisms
        (e.g., hand or finger flapping or twisting or
        complex whole body movements)
     4. Persistent preoccupation with parts of objects
DSM- IV/ICD-
DSM-IV/ICD-10
Criteria for Autistic Disorder
 Abnormal or impaired development prior to
 age 3 manifested by delays or abnormal
 functioning in at least one of the following
 areas: (1) social interaction, (2) language as
 used in social communication, or (3)
 symbolic or imaginative play.
                                Rett’
 Not better accounted for by Rett’s
 Syndrome or Childhood Disintegrative
 Disorder.
 Autism as a spectrum of
 disorders

We know more about
     core”
the “core” of autism      Childhood                Asperger’s
than about its edges.   Disintegrative
                           Disorder
                                          Autism    Disorder




                                         PDD-NOS




Discriminating ASD from other
disorders is easiest for school age
children with some language, who
are not fluent speakers. As we move
up and down the age span, and up
and down levels of mental
retardation and language delay,
discriminations become more
difficult.




The Autism Spectrum

                Social Interaction

                Communication

     Restricted, Repetitive, Stereotyped
     Patterns of Behavior, Interests and
                  Activities
Autistic Spectrum
Disorders
 Asperger’
 Asperger’s Disorder
 – Social deficits like autism
 – Circumscribed interests and sometimes
   other repetitive behaviors like autism
 – By exclusion
      Not autism
          language-
      Not language-delayed
      Not mentally handicapped




Autistic Spectrum
Disorders
          Autism/PDD-
 Atypical Autism/PDD-NOS
 – Must have social deficits like autism
 – Must have either or both communication
   or repetitive behaviors like autism
 – By exclusion
      May not have communication deficits
      or not have restricted, repetitive
      behaviors
      May have late onset




Autistic Spectrum
Disorders
 Childhood Disintegrative Disorder
 – Features are much like autism (3
   domains) but differs in onset
 – Very rare
 – Must have normal development to 2
   years
 – Must lose receptive language and social
   skills
 – May lose motor and adaptive skills
Autism as a heterogeneous
disorder
                           Although defined
                           by behavior,
                           these
                           characteristic
                           behaviors are
                           very diverse.




Autism as a developmental
disorder




 What is manifested as autism changes
 with development
 Development is affected by having autism




 Both positive (abnormal) behaviors, and negative
 (the absence of normal) behaviors are required
 to make a diagnosis of ASD.




 Developmental level and context (in what kinds
 of circumstances does the child or adult function?)
 can both have significant effects on diagnostic
 judgments.
Changes in Demographics
of ASD
                 70-
  Historically, 70-85% of cases of autism are
  associated with mental retardation, but this
  statistic is in question.
  Similarly, the statistic that half of all children
  with autism will not speak is often cited, but
                                    75-
  recent estimates suggest that 75-90% of
  children with ASD have some functional
  language.
  Increase in prevalence.




Autism Spectrum Disorders (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.




Reasons for Accurate
Diagnosis
  Access appropriate intervention
  services
  Establish developmental levels
  Determine patterns of strengths and
  weaknesses
  Educate parents and teachers
  Develop individualized behavioral and
  education intervention programs
ADOS
                         semi-
Provides a context for a semi-structured
standardized assessment of
– Social Interaction
– Communication (verbal and nonverbal)
– Play or imaginative use of materials




Issues the ADOS
Addresses
 Changes with age and development
 Unusual development (deviance) vs.
 delay
 – Behaviors as unusual because of their
   presence, absence, frequency, intensity,
   duration, context, etc.
 Distinguishing problems in social
 reciprocity from social anxiety or
 noncompliance




ADOS is meant for…
 Children without significant hearing loss
 Children who are mobile (use of space is
 important)
 Algorithms successfully identify children
 with ASD who have a nonverbal mental
 age of at least 15 months (Module 1
 tasks can be given to younger children
 but algorithms are not meaningful)
ADOS Behaviors Targeted
 ASD behaviors across developmental levels
 Spontaneous communication and language
                 person’
 A snapshot of a person’s behaviors in a
 prearranged context
 ADOS is not a cognitive assessment
 ADOS is one source – not sufficient for a
 diagnosis alone




ADOS Response to
Diagnostic Problems
 Diagnostic Problem: Overlap between
 developmental delays and autism

 Solution: Specificity of Abnormalities
 – Detailed descriptions of actual behaviors
 – Operationalized criteria
 – Focus on key situations
 – Training of investigators




ADOS Response to
Diagnostic Problems
Diagnostic Problem: Variability in how
people interpret the definitions of
autism spectrum disorders

Solution: Standardization
 – Of procedures
 – Of rating scales
 – Of age focus
 – Of summarization
ADOS is standardized by:
Tasks and activities
Materials
Behavior of the examiner
Behaviors to be observed
            individual’
How the individual’s behaviors are quantified
How the diagnosis is achieved
Training of examiner
Standards for achieving and maintaining
reliability




ADOS Response to
Diagnostic Problems
Diagnostic Problem: Validation

Solution: Using alternative approaches
   ADI-
 – ADI-R
 – SCQ
 – CARS




ADOS Response to
Diagnostic Problems
 Diagnostic Problem: 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
                             world”
 The ADOS creates a “social world”
 in which behaviors related to the
 autism spectrum can be observed.




ADOS as a Clinical
Instrument
Structured and unstructured activities.

                hierarchy”
Guidelines for “hierarchy” of
examiner’
examiner’s behavior.

                examiner’
Dependent on examiner’s experience
and sensitivity (to act and not to act).




General Strategy
 Make notes during administration
 (include a language sample).
 Complete all coding immediately
 after.
 Video available for detailed study.
Guidelines for Selecting
a Module
 Module             Expressive Language Level
                   Minimum                Maximum
    1             No speech            Simple phrases


    2        Three-word phrases/       Verbally fluent
             not yet verbally fluent


    3           Verbally fluent        Toys not helpful
                (Child/younger
                  adolescent)
    4           Verbally fluent
              (Adolescent/adult)




Selecting a Module
         1: Non-
 Module 1: Non-verbal to primarily
 single words and occasional
 phrases.
 phrases.
   – Developmental age typically between
     18 and 36 months
   – Walking independently




Selecting a Module (cont.)
         2:              speech,
Module 2: Some phrase speech,
but not verbally fluent.
  – Phrase speech: regular,
                  non-          3-
    spontaneous, non-echoed, 3-word
    utterances, usually including a verb
  – Expressive language level typically
    between 30 and 48 months
Selecting a Module (cont.)
Modules 3 and 4:
     Verbally fluent: Expressive language
                         4- year-
     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
      though




Selecting a Module (cont.)
             3:
     Module 3: Verbally fluent children and
     younger adolescents
       – Participants who might enjoy playing with toys and
                                              12-
         action figures usually up to between 12-16 years of
         age)

            4:
     Module 4: Verbally fluent adolescents and
     adults
       – Not interested in play materials
       – Life situation is better reflected by the questions




 ADOS Module 3 Activities
 Fluent Speech
 Child/Adolescent

1.   Construction Task        9. Socioemotional questions:
2.   Make Believe Play            Emotions
3.   Joint Interactive Play   10. Socioemotional questions:
4.   Demonstration Task           Social Difficulties/Annoyance
5.   Description of a         11. Break
     Picture                  12. Socioemotional questions:
6.   Telling a Story from a       Friends & Marriage
     Book                     13. Socioemotional questions:
7.   Cartoons                     Loneliness
8.   Conversation &           14. Creating a Story
     Reporting
Administration Module 3
(1) Construction Task
   Purpose:               warm-
 – Purpose: Serves as warm-up activity and chance to observe
   interactive style during structured task. Also whether and how the
   child asks for help.
   Materials:
 – Materials: Block puzzle and printed design to be duplicated.
   Instructions:
 – Instructions:
       Child is asked to assemble interlocking blocks to construct the design
                                                                opportunity
       shown on the printed form. Purpose is solely to create opportunity for child
                                                         visual-
       to ask for help, not to measure his/her motor or visual-spatial skills.
                                                           you’
       Offer a couple blocks and prompt “Show me how you’d put these blocks
                                  picture.”                                 blocks,”
       together to look like this picture.” “Let me know if you need more blocks,”
       while remaining blocks should be kept on table and within site, but outside
          child’                              examiner’
       of child’s reach and on other side of examiner’s arm. Additional prompts:
                             blocks?”                                  more.”
       “Do you need more blocks?” or “Just let me know if you need more.”
 – Focus of Observation: Whether child indicates need for more pieces,
   and how he/she attempts to do so.




Administration Module 3
     Make-
 (2) Make-Believe Play
 – Purpose: Observe creative or imaginative play with objects in an
                                                    child’
   unstructured task with materials appropriate to child’s interest.
 – Materials: Contents of Bag 3 – two male action figures and a female
                            prop”
   action figure, with one “prop” for each, toy dinosaur, hairbrush and two
                                                                  props.
   small tools. Also items from Bag 2 which includes additional props.
 – Instructions:
        Materials are laid out and child is told “Here are three characters for you to
                                                                          while?”
        use to make up a story. Could you play with these now for a while?”
        Introduce action figures with appropriate descriptions.
        If child does nothing or cannot get started, okay to demonstrate some
                                                                         out.
        limited but creative use of items describing events as carried out. Then
                                                       yours?”
        follow with “What are you doing to do with yours?” while gesturing.
        Throughout should comment, show interest and encourage child without  without
                                            What’              now?”
        telling him/her what to do e.g., “What’s happening now?” However, it is
                                child’
        critical to distinguish child’s own creative use of materials from response to
        examiner’                                  examiner’
        examiner’s specific prompts or copying examiner’s actions.
 – Focus of Observation: Extent to which child produces sequences of
   actions that involve using materials beyond their most obvious
                                                                  they
   intention, particularly how child casts the dolls and pretends they are
   interacting with each other.




Administration Module 3
 (3) Joint Interactive Play
  – Purpose: Assess degree and quality of coordination of behavior
     and affect with examiner in joint interactive play.
                                 Make-           Play.”
  – Materials: Materials from “Make-Believe Play.”
  – Instructions:
                                          make-
        After sufficient time to initiate make-believe play, examiner
                                                  too?”          I’
        redefines activity by saying “Can I play too?” or “Now, I’d like to
                      may?”
        join you if I may?” and immediately proceeds to manipulate objects
        to produce a press for joint interactive play.
        Examiner should use his/her imagination to think of appropriate
        ways of producing interactive play, and should add complexities as
        appropriate.
                                                                        affect.
        Important examiner enter into spirit of play and show ample affect.
              Observation:
 – Focus of Observation: Reciprocity shown by the child in
   interactive play. Goal is for the child (not the examiner) to
   develop the interaction and to provide a novel initiative that
                                            examiner’
   goes beyond a direct response to the examiner’s overtures.
Administration Module 3
 (4) Demonstration Task
  – Purpose: Assess ability to communicate about familiar series of actions
    using gestures with accompanying language to report on familiar event.
  – Materials: Hand towel and soap.
  – Instructions:
        Tooth-                                                            me.” Let’
        Tooth-brushing. “Now I want you to play a pretend game with me.” “Let’s
                            sink… ..”
        pretend this is the sink…..” “Now I want you to teach me how you brush
                                                                          You’
        your teeth. Show me and tell me. Start right at the beginning. You’ve just
        come into the bathroom. Now what do you do?”do?”
                                                                         entirely
        If child does not understand the task you may demonstrate an entirely
        different event e.g. driving a car.
        Hand-              face-                     doesn’
        Hand-washing or face-washing. If child still doesn’t understand task, or fails
                                                                real’
        to coordinate gestures, reset scene with props, actual ‘real’ soap and towel
        this time.
               Observation:
  – Focus of Observation: Determine how child represents familiar
    actions in gesture, particularly through use of his/her body to represent
                                                                   report
    an object, or in miming the use of a pretend object. Also, a report of a
    familiar event.




Administration Module 3
 (5) Description of a Picture
  – Purpose: Generate sample of language and/or other communicative
    behaviors.
  – Materials: American montage scene and resort scene.
  – Instructions:
                  Let’
        Prompt “Let’s look at this picture now. Can you tell me about it? What is
                            picture?”
        happening in this picture?”
                                                                      beginning,
        Examiner should be enthusiastic and interested, but at the beginning, should
                                                                 encourage
        not offer substantive information about the picture (to encourage language).
                                                       doesn’
        If after general prompts and questions, child doesn’t respond, fails to
        provide more than isolated specific labels of objects or people, or only
        mentions one statement beyond labeling, examiner should model a complex
        sentence.
                                                                     friends,
        If child relates picture to his/her own experiences (family, friends, activities),
                                                                conversation.
        this should be encouraged as opportunity to generate conversation.
                                                    What’ this?”           this?”
        If necessary, then ask specific questions “What’s this?” “Who is this?” “What
               doing?”                       here?”
        is he doing?” “What is happening here?”
        May then repeat with second picture as necessary.
                                                       child’
  – Focus of Observation: Goal is to obtain example of child’s spontaneous
                                                                     his/her
    language and communication, as well as sense of what captures his/her
    interest.




Administration Module 3
 (6) Telling a Story From a Book
  – Purpose: Assess ability to follow and comment on sequential story in a
    picture book and to generate spoken language.
  – Materials: Either of the two picture books may be used.
  – Instructions:
                                                                             it
        Prompt “Have a look at this book. It tells a story in pictures. See, it starts
             with…
        out with… (describe the first picture in the book). Can you tell me the story
                                            I’         turn.”
        as we go along? You go first, then I’ll take a turn.” Should offer no more
        than two specific prompts to get him/her started e.g., “I wonder what
                  next.”
        happens next.”
        After child describes books for few minutes, say, “That was great. Now I’d I’
                       turn.”
        like to take a turn.”
        Stay within spirit of story.
        Note facial expressions demonstrated.
              Observation:
  – Focus of Observation: Goal, like preceding, is to obtain spontaneous
    language and communication, and a sense of what captures his/her
                   child’
    interest. Also child’s ability to convey continuity in a story.
Administration Module 3
(7) Cartoons
 – Purpose: Observe way child narrates story, uses gesture to enact
   events, and integrates gesture with gaze and language.
 – Materials: Series A cartoons (story involving fisherman, cat and
   pelican) and Series B cartoons (story about two monkeys and some
   coconuts).
 – Instructions:
                                                                      narrated
       Participant is told that, unlike previous task in which he/she narrated story
       while looking at pictures, he/she will now be shown a very brief story in
                                                                    pictures.
       cartoons and then asked to retell it without looking at the pictures.
       Participant should then be asked to push his/her chair back from the table,
       stand up, and tell the story. Particularly important he/she is away from table
                                                                    gesture
       and has nothing in his/her hands so that he/she is able to gesture freely.
       May ask the child to tell the story to the parent or caregiver.
 – Focus of Observation: Use of gesture, and its coordination with
                                                                    additional
   speech; further observe his/her response to humor; taking an additional
   language sample; obtaining sense of his/her degree of insight andand
   flexibility in adapting a narrative to the audience; and noting any
   comments on affect or relationships.




Administration Module 3
(8) Conversation and Reporting
                                                                   back- and-
 – Purpose: Assess ability to carry out minimal conversation with back-and-forth
   interchange and to describe events or situations for which there are no current
                                                                 and participant’
   visual cues. Also opportunity for additional language sample, and participant’s
                        non-
   ability to recount a non-routine event is evaluated.
 – Materials: None.
 – Instructions:
                                                                              sufficient
        To carry out conversational interchange, examiner must provide sufficient leads,
        guides, and prompts on a topic.
                                                                      participant’
        Conversations cannot be centered exclusively around the participant’s strongest
        interests (e.g., power tools), however, but should include some discussion of age-age-
                                                                      sports)
        appropriate topics of interests (e.g., music, pets, outings, sports) that are not
        stereotyped or circumscribed.
                       question- and-
        Should avoid question-and-answer style, instead deliberate effort to use conversational
        approach – examiner must show interest and involvement and respond with
                      hand- over”                                to- and-
        appropriate “hand-over” prompts to provide press for to-and-for interchange.
                                                                             point
        To emphasize reciprocal nature of task, examiner should make point of including brief
        statements about his/her own interests, activities, or feelings, and then wait to see if
        the participant can build upon or follow up on such comments.
                                                                      non-
        Participant should also be given opportunity to describe a non-routine event (e.g.,
                                                                            introduce
        vacation or celebration). Specific questions may be needed to introduce a topic.
                                                               examiner’
 – Focus of Observation: Extent to which child builds on the examiner’s
                                                          back- and-
   statements, and makes leading statements to facilitate back-and-forth
   conversation.




Administration Module 3
(9) Emotions
 – Purpose: Examiner should probe until participant has given
   detailed descriptions of two emotions, the contexts in which
   they arise, and what his/her experience of these emotions is
   like.
 – Materials: None.
 – Instructions:
                           matter-of-
        Ask questions in a matter-of-fact manner.
        Generally speaking, questions work best in order written.
        If uncomfortable ending segment on negative note, examiner may
                                                                peaceful.
        want to follow up with questions about being relaxed or peaceful.
                             Two-
 – Focus of Observation: Two-fold: (a) identify what events elicit
   different emotions (and particularly whether they are social or
   not), and (b) to observe how he/she describes his/her emotions.
Administration Module 3
(10) Social Difficulties and Annoyance
 – Purpose: Assess insight into personal social difficulties, and
   sense of responsibility for his/her own actions.
 – Materials: None.
 – Instructions:
                          matter-of-
       Ask questions in a matter-of-fact manner.
       Generally speaking, questions work best in order written.
 – Focus of Observation: Participants perception of social
   difficulties, his/her insight into the nature of these problems and
   whether he/she has made any attempt to change his/her own
                                                              Attention
   behavior in order to fit in with others more smoothly. Attention
                        participant’
   should be paid to participant’s understanding of appropriateness
   and implications of his/her feelings.




Administration Module 3
(11) Break
              Two-
 – Purpose: Two-fold: (a) give participant a break from demands of
   assessment, and (b) observe his/her behavior in less structured
   circumstances. May be at any time during schedule, and multiple
   breaks may be taken if necessary.
 – Materials: Shape puzzle, drawing paper, markers, pin art, spin top
                                                                   select
   pen, small radio, current copies of newspaper and magazine and select
                                  Play.”
   materials from “Make Believe Play.”
 – Instructions:
                  Let’        break.”
       Prompt “Let’s take a break.” Point out specific materials and express hope
       that participant can find something of interest among them. Then move
       chair back and away, disengaging from participant.
                                                                        offered,
       Once participant is settled and everything possible has been offered,
                                                                          participant
       examiner should work on his/her notes for several minutes. If participant
       initiates, respond briefly.
                                                                 interaction.
       Goal is to create occasion for participant to initiate an interaction.
 – Focus of Observation: Multiple foci: (a) how the participant occupies
                                                               examiner
   him/herself during free time, (b) how he/she responds to examiner’s
   withdrawal from interaction, (c) if and how he/she initiates and
                                                                 examiner.
   participates in unstructured conversation or interaction with examiner.




Administration Module 3
(12) Friends and Marriage
 – Purpose: Goal of questions is to obtain detailed description of one or
                                                               friendships,
   more complex relationships participant would describe as friendships,
   and more general description of his/her understanding of concept of
                                                                   long-
   friendship and the idea of establishing a family or building a long-term
   relationship as a couple.
 – Materials: None.
 – Instructions:
                          matter- of-
       Ask questions in a matter-of-fact manner.
       Generally speaking, questions work best in order written.
 – Focus of Observation: Focus is not on whether or not participant has
   friends, but on how he/she understands the concept of friendship
                                                                   how
   and/or marriage and the nature of these relationships, and on how
                                                             Marriage
   he/she perceives his/her own role in these relationships. Marriage
                           participant’
   questions also focus on participant’s understanding of why a person
                              long-
   might want to be a part of long-term relationship, and on his/her
                                                        relationship.
   understanding of his/her own possible role in such a relationship.
Administration Module 3
  (13) Loneliness
   – Purpose: Provide another opportunity to assess
     participant’
     participant’s insight into his/her social situation, and the
     ability to describe his/her emotional reaction to it.
   – Materials: None.
   – Instructions:
                             matter- of-
         Ask questions in a matter-of-fact manner.
         Generally speaking, questions work best in order
         written.
   – Focus of Observation: These questions address whether
     the participant understands the concept of loneliness, and
     how he/she feels it pertains to him/her.




Administration Module 3
 (14) Creating a Story
                                       play-
  – Purpose: Observe creativity in a play-like situation that is appropriate
    for older children, adolescents and adults.
  – Materials: Six items with a definite purpose and six items with no clear
    purpose.
  – Instructions:
        Prompt “Now you and I are going to make up stories using some of these
        objects.” Participant’
        objects.” Participant’s task is to use five items to make up a story, newscast,
        or commercial.
        Examiner should first model task choosing five items and making up a simple
        narrative, primarily using items in ways for which they are not intended (e.g.,
                                            Examiner’
        using a toy parasol as a basket). Examiner’s story should be simple enough
        so as not to inhibit participant.
                                             actor”
        One object should be used as the “actor” in the story (e.g., Mr. Flame woke
                morning,”
        up one morning,” using a candlestick).
        Examiner should not replace their chosen five items, but rather instruct the
        participant to choose from the remaining seven items.
                              Participant’
  – Focus of Observation: Participant’s creative use of objects in telling a
    novel story or creating a newscast or commercial.




ADOS Module 4 Activities
Fluent Speech
Adolescent/Adult
1. Construction Task*                       8.  Demonstration Task
2. Telling a Story from a                   9.  Cartoons*
   Book                                     10. Break
3. Description of a Picture*                11. Daily Living*
4. Conversation &                           12. Socioemotional
   Reporting                                    questions: Friends &
5. Socioemotional                               Marriage
   questions: Current Work
   or School*                               13. Socioemotional
                                                questions: Loneliness
6. Socioemotional
   questions: Social                        14. Plans & Hopes
   Difficulties & Annoyance                 15. Creating a Story
7. Socioemotional
   questions: Emotions                        *denotes optional
Administration Module 4
(1) Construction Task
                          warm-
 – Purpose: Serves as warm-up activity and chance to observe
   interactive style during structured task. Also whether and how the
   child asks for help.
 – Materials: Block puzzle and printed design to be duplicated.
 – Instructions:
       Child is asked to assemble interlocking blocks to construct the design
                                                                opportunity
       shown on the printed form. Purpose is solely to create opportunity for child
                                                         visual-
       to ask for help, not to measure his/her motor or visual-spatial skills.
                                                           you’
       Offer a couple blocks and prompt “Show me how you’d put these blocks
                                  picture.”                                 blocks,”
       together to look like this picture.” “Let me know if you need more blocks,”
       while remaining blocks should be kept on table and within site, but outside
          child’                              examiner’
       of child’s reach and on other side of examiner’s arm. Additional prompts:
                             blocks?”                                  more.”
       “Do you need more blocks?” or “Just let me know if you need more.”
 – Focus of Observation: Whether child indicates need for more pieces,
   and how he/she attempts to do so.




Administration Module 4
(2) Telling a Story From a Book (Optional)
 – Purpose: Assess ability to follow and comment on sequential story in a
   picture book and to generate spoken language.
 – Materials: Either of the two picture books may be used.
 – Instructions:
                                                                            it
       Prompt “Have a look at this book. It tells a story in pictures. See, it starts
           with…
       out with… (describe the first picture in the book). Can you tell me the story
                                           I’         turn.”
       as we go along? You go first, then I’ll take a turn.” Should offer no more
       than two specific prompts to get him/her started e.g., “I wonder what
                 next.”
       happens next.”
                                                                            I’
       After child describes books for few minutes “That was great. Now I’d like to
              turn.”
       take a turn.”
       Stay within spirit of story.
       Note facial expressions demonstrated.
 – Focus of Observation: Goal is to obtain spontaneous language and
                                                                 Also
   communication, and a sense of what captures his/her interest. Also
   child’
   child’s ability to convey continuity in a story.




Administration Module 4
(3) Description of a Picture (Optional)
 – Purpose: Generate sample of language and/or other communicative
   behaviors.
 – Materials: American montage scene and resort scene.
 – Instructions:
                 Let’
       Prompt “Let’s look at this picture now. Can you tell me about it? What is
                           picture?”
       happening in this picture?”
                                                                     beginning,
       Examiner should be enthusiastic and interested, but at the beginning, should
                                                                encourage
       not offer substantive information about the picture (to encourage language).
                                                      doesn’
       If after general prompts and questions, child doesn’t respond, fails to provide
       more than isolated specific labels of objects or people, or only mentions one
                                                                         sentence.
       statement beyond labeling, examiner should model a complex sentence.
                                                                    friends,
       If child relates picture to his/her own experiences (family, friends, activities),
                                                               conversation.
       this should be encouraged as opportunity to generate conversation.
                                                   What’ this?”           this?”
       If necessary, then ask specific questions “What’s this?” “Who is this?” “What
              doing?”                       here?”
       is he doing?” “What is happening here?”
       May then repeat with second picture as necessary.
                                                      child’
 – Focus of Observation: Goal is to obtain example of child’s
   spontaneous language and communication, as well as sense of what
   captures his/her interest.
Administration Module 4
(4) Conversation and Reporting
                                                                     back- and-
 – Purpose: Assess ability to carry out minimal conversation with back-and-
   forth interchange and to describe events or situations for which there are
                                                            language
   no current visual cues. Also opportunity for additional language sample,
        participant’                      non-
   and participant’s ability to recount a non-routine event is evaluated.
 – Materials: None.
 – Instructions:
                                                                             sufficient
        To carry out conversational interchange, examiner must provide sufficient leads,
        guides, and prompts on a topic.
                                                                     participant’
        Conversations cannot be centered exclusively around the participant’s strongest
        interests (e.g., power tools), however, but should include some discussion of age-age-
                                                                     sports)
        appropriate topics of interests (e.g., music, pets, outings, sports) that are not
        stereotyped or circumscribed.
                       question- and-
        Should avoid question-and-answer style, instead deliberate effort to use conversational
        approach – examiner must show interest and involvement and respond with
                      hand- over”                               to- and-
        appropriate ‘hand-over” prompts to provide press for to-and-for interchange.
                                                                            point
        To emphasize reciprocal nature of task, examiner should make point of including brief
        statements about his/her own interests, activities, or feelings, and then wait to see if
        the participant can build upon or follow up on such comments.
                                                                     non-
        Participant should also be given opportunity to describe a non-routine event (e.g.,
                                                                           introduce
        vacation or celebration). Specific questions may be needed to introduce a topic.
                                                               examiner’
 – Focus of Observation: Extent to which child builds on the examiner’s
                                                          back- and-
   statements, and makes leading statements to facilitate back-and-forth
   conversation.




Administration Module 4
(5) Current Work or School (Optional)
                               full-
 – If participant is in school full-time, does not have a job, and has never been
    employed (including working as a volunteer), omit the employment questions
    and proceed to the questions about school.
 – Purpose: Evaluate how the participant describes his/her current
   situation, and whether he/she understanding his/her role in
   determining what will happen in the future.
 – Materials: None.
 – Instructions:
                           matter- of-
        Ask questions in a matter-of-fact manner.
        Generally speaking, questions work best in order written.
 – Focus of Observation: First set is to obtain general information about
                                                              background
   whether the participant is employed, in order to provide background
                                                             participant
   information for the questions that follow. Of interest if participant has
   had to leave jobs, and if so, for what reason. These questions also
                                     participant’
   provide opportunity to evaluate participant’s understanding of the
   possibility for future employment. If not employed, second set
   designed to determine what his/her school experience is or was like,like,
   and to explore whether he/she has a realistic understanding of the the
   training or experience necessary for future employment.




Administration Module 4
(6) Social Difficulties and Annoyance
 – Purpose: Assess insight into personal social difficulties, and
   sense of responsibility for his/her own actions.
 – Materials: None.
 – Instructions:
        Ask questions in a matter-of-fact manner.
        Generally speaking, questions work best in order written.
 – Focus of Observation: Participant’s perception of social
   difficulties, his/her insight into the nature of these problems and
   whether he/she has made any attempt to change his/her own
   behavior in order to fit in with others more smoothly. Attention
   should be paid to participant’s understanding of appropriateness
   and implications of his/her feelings.
Administration Module 4
(7) Emotions
 – Purpose: Examiner should probe until participant has given
   detailed descriptions of two emotions, the contexts in which
   they arise, and what his/her experience of these emotions is
   like.
 – Materials: None.
 – Instructions:
                           matter-of-
        Ask questions in a matter-of-fact manner.
        Generally speaking, questions work best in order written.
        If uncomfortable ending segment on negative note, examiner may
                                                                peaceful.
        want to follow up with questions about being relaxed or peaceful.
                             Two-
 – Focus of Observation: Two-fold: (a) identify what events elicit
   different emotions (and particularly whether they are social or
   not), and (b) to observe how he/she describes his/her emotions.




Administration Module 4
(8) Demonstration Task
 – Purpose: Assess ability to communicate about familiar series of actions
   using gestures with accompanying language to report on familiar event.
 – Materials: Hand towel and soap.
 – Instructions:
        Tooth-                                                            me.” Let’
        Tooth-brushing. “Now I want you to play a pretend game with me.” “Let’s
                            sink… ..”
        pretend this is the sink…..” “Now I want you to teach me how you brush
                                                                          You’
        your teeth. Show me and tell me. Start right at the beginning. You’ve just
        come into the bathroom now what do you do?”do?”
                                                                         entirely
        If child does not understand the task you may demonstrate an entirely
        different event e.g. driving a car.
        Hand-              face-                     doesn’
        Hand-washing or face-washing. If child still doesn’t understand task, or fails
                                                                real’
        to coordinate gestures, reset scene with props, actual ‘real’ soap and towel
        this time.
 – Focus of Observation: Determine how child represents familiar
   actions in gesture, particularly through use of his/her body to represent
                                                                  report
   an object, or in miming the use of a pretend object. Also, a report of a
   familiar event.




Administration Module 4
(9) Cartoons (Optional)
 – Purpose: Observe way child narrates story, uses gesture to enact
   events, and integrates gesture with gaze and language.
 – Materials: Series A cartoons (story involving fisherman, cat & pelican)
                                                              coconuts).
   and Series B cartoons (story about two monkeys and some coconuts).
 – Instructions:
                                                                       story
       Participant is told that he/she will now be shown a very brief story in
                                                                    pictures.
       cartoons and then asked to retell it without looking at the pictures. As
       examiner presents each set of cartoons, he/she should only offer a brief
                                                                     terms.
       statement describing the setting of the cartoons in general terms.
                                                                          to
       After each set has been presented, participant should be asked to push
       his/her chair back from the table, stand up, and tell the story. Particularly
                                                                          hands
       important he/she is away from table and has nothing in his/her hands so
       that he/she is able to gesture freely.
       May ask the child to tell the story to the parent or caregiver.
 – Focus of Observation: Use of gesture, and its coordination with
                                                                    additional
   speech; further observe his/her response to humor; taking an additional
   language sample; obtaining sense of his/her degree of insight andand
   flexibility in adapting a narrative to the audience; and noting any
   comments on affect or relationships.
Administration Module 4
 (10) Break
              Two-
 – Purpose: Two-fold: (a) give participant a break from demands of
   assessment, and (b) observe his/her behavior in less structured
   circumstances. May be at any time during schedule, and multiple
   breaks may be taken if necessary.
 – Materials: Shape puzzle, drawing paper, markers, pin art, spin top
                                                                   select
   pen, small radio, current copies of newspaper and magazine and select
                                  Play.”
   materials from “Make Believe Play.”
 – Instructions:
                   Let’        break.”
        Prompt “Let’s take a break.” Point out specific materials and express hope
        that participant can find something of interest among them. Then move
        chair back and away, disengaging from participant.
                                                                         offered,
        Once participant is settled and everything possible has been offered,
                                                                           participant
        examiner should work on his/her notes for several minutes. If participant
        initiates, respond briefly.
                                                                  interaction.
        Goal is to create occasion for participant to initiate an interaction.
 – Focus of Observation: Multiple foci: (a) how the participant occupies
                                                               examiner
   him/herself during free time, (b) how he/she responds to examiner’s
   withdrawal from interaction, (c) if and how he/she initiates and
                                                                 examiner.
   participates in unstructured conversation or interaction with examiner.




Administration Module 4
 (11) Daily Living (Optional)
  – Purpose: Questions can be used to obtain factual information
                             socio-
    and background for the socio-emotional questions, and to
             participant’
    evaluate participant’s understanding and views regarding
    money, residential arrangements and leisure activities.
  – Materials: None.
  – Instructions:
                                  of- fact-
        Ask questions in a matter of-fact-manner.
        Generally speaking, questions work best in order written.
  – Focus of Observation: Multiple Foci: (a) provide factual
                        participant’
    information about participant’s level of financial responsibility,
    (b) establish where living and how arrangement arrived at, and
                                                                plans
    (c) indicate extent to which participant is realistic about plans
    for independence and complexities of various living
    arrangements. Are optional, and if sufficient information has
    already been obtained about insight and responsibility, these
    inquiries about positive topics (e.g., saving money to achieve
    goal, favorite activities etc.) are not needed.




Administration Module 4
 (12) Friends and Marriage
  – Purpose: Goal of questions is to obtain detailed description of one or
                                                                friendships,
    more complex relationships participant would describe as friendships,
    and more general description of his/her understanding of concept of
                                                                    long-
    friendship and the idea of establishing a family or building a long-term
    relationship as a couple.
  – Materials: None.
  – Instructions:
                           matter- of-
        Ask questions in a matter-of-fact manner.
        Generally speaking, questions work best in order written.

  – Focus of Observation: Focus is not on whether or not participant has
    friends, but on how he/she understands the concept of friendship
                                                                    how
    and/or marriage and the nature of these relationships, and on how
                                                              Marriage
    he/she perceives his/her own role in these relationships. Marriage
                            participant’
    questions also focus on participant’s understanding of why a person
                               long-
    might want to be a part of long-term relationship, and on his/her
                                                         relationship.
    understanding of his/her own possible role in such a relationship.
Administration Module 4
(13) Loneliness
 – Purpose: Provide another opportunity to assess
   participant’
   participant’s insight into his/her social situation, and the
   ability to describe his/her emotional reaction to it.
 – Materials: None.
 – Instructions:
                           matter- of-
       Ask questions in a matter-of-fact manner.
       Generally speaking, questions work best in order
       written.
 – Focus of Observation: These questions address whether
   the participant understands the concept of loneliness, and
   how he/she feels it pertains to him/her.




Administration Module 4
(14) Plans and Hopes
 – Purpose: Provide opportunity for participant to describe
   any goals or aspirations that he/she may have.
 – Materials: None.
 – Instructions:
                          matter- of-
       Ask questions in a matter-of-fact manner.
       Generally speaking, questions work best in order
       written.
 – Focus of Observation: This question is intended to
   provide a positive end to the interview and to obtain
   information about what the participant anticipates in the
   future.




Administration Module 4
(15) Creating a Story
                                      play-
 – Purpose: Observe creativity in a play-like situation that is appropriate
   for older children, adolescents and adults.
 – Materials: Six items with a definite purpose and six items with no clear
   purpose.
 – Instructions:
       Prompt “Now you and I are going to make up stories using some of these
       objects.” Participant’
       objects.” Participant’s task is to use five items to make up a story, newscast,
       or commercial.
       Examiner should first model task choosing five items and making up a simple
       narrative, primarily using items in ways for which they are not intended (e.g.,
                                           Examiner’
       using a toy parasol as a basket). Examiner’s story should be simple enough
       so as not to inhibit participant
                                            actor”
       One object should be used as the “actor” in the story (e.g., Mr. Flame woke
               morning,”
       up one morning,” using a candlestick).
       Examiner should not replace their chosen five items, but rather instruct the
       participant to choose from the remaining seven items.
                             Participant’
 – Focus of Observation: Participant’s creative use of objects in telling a
   novel story or creating a newscast or commercial.
Coding Conventions
0 =   Behavior of type specified is not present
      (not necessarily “normal”)

1 =   Behavior of type specified is present, but not sufficiently
      clear, severe, frequent, or marked to code “2”

2 =   Behavior of type specified is definitely present and meets
      specific mandatory criteria
3 =   Behavior present to a degree that interferes with
      functioning

7 =   Definite abnormality in general area of coding, but not of
      type specified

8 =   Not applicable

9 =   Unknown/missing




ADOS Scoring
See guides at top of each heading – to code that
section by developmental, chronological age
standards…
standards…
          item’
Read each item’s coding instructions carefully
                       over-              item’
General guidelines are over-ruled by each item’s
coding guidelines
Code only what you see during the ADOS
When in doubt between 2 codes, code down
 – Debating between a 1 or a 2, code 1




ADOS Scoring Issues
Low and high threshold items
 – High threshold (constant opportunities, should
   happen a lot)
      Eye contact
      Facial expressions
                 (2-                     good”
 – Low threshold (2-3 clear examples is “good”)
      Gestures (wide variation in how people use)
Need for environmental support – how hard do
you have to work to make behaviors occur?
       effects”
“Floor effects” – no opportunities for a behavior
to occur
Live ADOS
Administration
Module 3 or 4




Module 3 / 4
Administration
 Don’
 Don’t let it be too easy
                 don’
  – Keep at it; don’t rush
    Don’
  – Don’t be too nice or too structured
  – Make sure that there is some time when
    it’
    it’s fun as well
  – Potential to add new tasks (strange
    stories; be a celebrity on the cell phone)




Some Coding Conventions
0 =   Behavior of type specified is not present
      (not necessarily “normal”)
1 =   Behavior of type specified is present, but not sufficiently
      clear, severe, frequent, or marked to code “2”

2 =   Behavior of type specified is definitely present and meets
      specific mandatory criteria
3 =   Behavior present to a degree that interferes
      with functioning
7 =   Definite abnormality in general area of coding, but not of
      type specified

8 =   Not applicable

9 =   Unknown/missing
ADOS Scoring
See guides at top of each heading – to code that
section by developmental, chronological age
standards…
standards…
          item’
Read each item’s coding instructions carefully
                       over-              item’
General guidelines are over-ruled by each item’s
coding guidelines
Code only what you see during the ADOS
When in doubt between 2 codes, code down
 – Debating between a 1 or a 2, code 1




ADOS Scoring Issues
Low and high threshold items
– High threshold (constant opportunities, should
  happen a lot)
     Eye contact
     Facial expressions
                (2-                     good”
– Low threshold (2-3 clear examples is “good”)
     Gestures (wide variation in how people use)
Need for environmental support – how hard do
you have to work to make behaviors occur?
       effects”
“Floor effects” – no opportunities for a behavior
to occur




ADOS Algorithm
 Transfer selected scores from protocol
 Convert scores
           2’
  – 3’s to 2’s
  – Numbers other than 1, 2, or 3 to 0
 Cut-
 Cut-off scores
 ADOS Diagnosis and Overall Diagnosis
Classifications on ADOS
  For ASD and Autism ADOS classifications, child
                             areas:
  must meet cutoffs in all 3 areas:
   – Communication Total
   – Reciprocal Social Interaction Total
   – Reciprocal Social Interaction + Communication Total


   The ADOS results in a classification,
   not a diagnosis.




Classifications on ADOS
Example:
ASD cut-off on Communication Total,
Autism cut-off on Social Interaction Total,
Autism cut-off on Communication + Social Interaction Total
Classification = ASD

Example:
ASD cut-off on Communication Total,
ASD cut-off on Social Interaction Total,
Nonspectrum cut-off on Communication + Social Interaction
Total Classification = Nonspectrum




Calculating Reliability
                      inter-
   Goal: At least 80% inter-rater
   agreement or agreement with consensus

   Protocol Reliability =
    Number Agree / Total Number of Items

   Algorithm Reliability =
   Number Agree on Algorithm /
   Total Number of Algorithm Items
              ADOS Clinical
               Workshop
                2nd Day!




ADOS Module 1 Activities
Preverbal / Single Words
1. Free Play                         6. Responsive Social Smile
2. Response to Name                  7. Anticipation of a Social
3. Response to Joint                     Routine
   Attention                         8. Functional and
4. Bubble Play                           Symbolic Play
5. Anticipation of a                 9. Birthday Party
   Routine with                      10. Snack
   Objects




Administration Module 1
 (1) Free Play
               Warm-
  – Purpose: Warm-up activity
                                                    (pop-
  – Materials: Several materials placed on table (pop-up toy, board book,
    toy telephone, four pieces of yarn, textured block) and several toys on
                          jack-in-the-
    the floor (music box, jack-in-the-box, dump truck, baby doll, letter
            medium-
    blocks, medium-size ball, two identical cars, two pairs of small balls,
    two pairs of small utensils, four small plates)
  – Instructions:
        Toys should already be in place.
        Tell parent you want to give child few minutes to adjust to room – engage
        parent in conversation by asking “Are these the kinds of toys your child likes
                        home?”
        to play with at home?” Purpose is to give child time to adjust and to
        observe child without initially providing structure from either parent or
        examiner.
                                                                        begin
        After short period (at least 3 minutes) of free play, you may begin other
                                      Name,”                      Attention,”
        items such as “Response to Name,” “Response to Joint Attention,” or
                            Smile.”
        “Responsive Social Smile.”
  – Focus of Observation: Spontaneous engagement, joint referencing,
    giving and showing, exploration of materials, functional and/or symbolic
    use of toys and/or any repetitive actions or behaviors
Administration Module 1
(2) Response to Name
                     child’
 – Purpose: Assess child’s response to name.
 – Materials: Activity best conducted when child engaged in free play.
 – Instructions:
        Be sure you are positioned so that child has to turn in order to look at you.
                              3-                child’
        From a distance of 3-5 feet, call the child’s name.
        If he/she does not respond or responds without orienting to you, repeat the
        press for a total of four attempts.
                                                                       call     child’
        If the child still does not clearly respond, ask the parent to call the child’s
                                                                               child
        name – if after two attempts the parent is still not able to get the child to
        orient to him/her, you may ask the parent “Is there any way you can get
                                                     them?”
        him/her to look at you without touching them?”
                                                                     necessary
        If still no response, encourage parent to use any method necessary to get a
        response, including touching.
                                          child’
 – Focus of Observation: Observe the child’s response to hierarchy of
                                                              intervention
   auditory stimuli. Focus is both on the sounds and level of intervention
   required to get a response, and also on how the child responds.




Administration Module 1
(3) Response to Joint Attention
                      child’
 – Purpose: Assess child’s use of eye contact with facial orientation, verbalization,
                                                                 object.
   and pointing, in order to draw his/her attention to a distant object.
                Remote-
 – Materials: Remote-controlled animal or car.
 – Instructions:
                                                                         room
        Child should be at the table, sitting, facing the front of the room and engaged in
        toy/material of interest, but not of particular interest.
        Bunny/car should already be placed on a table or chair (at what you anticipate to be
        child’
        child’s eye level) 65o to front and right or left of the child and at a distance of 4-5 feet
                                                                                             4-
        away.
                  child’                                                                      (child’
        Call the child’s name and touch him/her to get his/her attention saying “Look, (child’s
        name)”
        name)” as you shift toward the toy and then back to child – can repeat for a total of
                                                            that!”
        four attempts with an additional “Look, look at that!” for the fifth attempt.
                 doesn’                                        child’
        If child doesn’t shift in 5 attempts, add a point to child’s visual field.
                       doesn’
        If child still doesn’t shift, go ahead and activate toy waiting to see if child will shift to
                                                                        child
        activation alone. Then bring toy in front of child to see if child will request subsequent
        activation.
 – Focus of Observation: Whether or not child follows shift alone or requires
   point.




Administration Module 1
 (4) Bubble Play
                                                                           to
 – Purpose: Elicit EC and vocalization with pointing or reaching in order to direct
                                                                opportunity
   attention of parent or examiner to a distant object. Also an opportunity for
                                                                    elicited.
   requesting. Unusual sensory behaviors and movements may be elicited.
 – Materials: Bubble gun and liquid.
 – Instructions:
                                                                          know
         While child is engaged in toy/material of interest, let parent know interest in seeing if
         the child will notice bubbles without being told.
         Produce stream of bubbles and see if child notices them, and if so, if he/she requests
                                                                   (verbalization,
         their continuation through verbal or nonverbal means (verbalization, gesture, EC).
                                                                       give
         After noticing any attempts at initiation of joint attention, give child multiple
         opportunities to request more bubbles while maintaining control of bubble juice.
                                                     child’
 – Focus of Observation: Context for observing child’s affect, initiation of joint
                                                                   while
   attention, shared enjoyment, requesting, and motor behaviors while bubbles
                                                         spontaneous
   are present. Initiation of joint attention requires a spontaneous shift in gaze
                                                                     than
   from object to person to object with no apparent purpose other than to share
   interest or pleasure.
Administration Module 1
 (5) Anticipation of a Routine with Objects
                      child’
  – Purpose: Assess child’s anticipation and initiation of the repetition of
    an action routine with objects.
  – Materials: Balloon.
  – Instructions:
         Blow up large balloon slowly, exaggerating your behavior as you do so.
                                                             go”
         Inflate, alert child (e.g., deliberate “Ready, set, go”) before you release it
         so that it will fly around the room.
                                                                        to
         After balloon lands, wait for the child to bring it to you, or to indicate in
         some other way that he/she wants it to be blown up again.
         Repeat at least two more times to observe requests.
                                                                       routine
         If child is afraid of balloon, remove it and try to establish routine with one
                 cause- and-
         of the cause-and-effect toys.
  – Focus of Observation: Affect, initiation of joint attention, shared
    enjoyment, requesting and motor behavior during the activity.




Administration Module 1
 (6) Responsive Social Smile
  –                     child’
      Purpose: Assess child’s smile in response to purely social overture.
  –   Materials: Activity takes place any time during session.
  –   Instructions:
                        child’
         After getting child’s attention by calling his/her name, try to elicit a smile by
                                                                          tummy,”
         smiling and making a positive statement (e.g., “Look at that tummy,” or
                      bubbles?”
         “Who likes bubbles?”) or by making silly face or funny noise.
                                                                            smile
         Any visual, verbal, and/or vocal means may be used to elicit a smile at first,
         as long as touching the child is not implied.
                  doesn’
         If child doesn’t respond after a couple of attempts, ask parent “Can you
         show me how you get him/her to smile, without touching them?” them?”
                                                                         evoke
         If unsuccessful, encourage parent to touch child in order to evoke a smile.
                                                                           smiling;
         In order to be coded, (a) must initiate when child not already smiling; (b)
                                                                         (c)
         must be clear change in facial expression resulting in smile; (c) child must
                                                                   interaction.
         definitely direct a smile to the person who initiates the interaction.
  – Focus of Observation: Smile in response to purely social smile by
    examiner or parent, or familiar noise which implies contact, or to being
    touched.




Administration Module 1
 (7) Anticipation of Social Routine
                        child’
  – Purpose: Assess child’s anticipation of, request for, and participation
    in a social routine.
                                        peek-
  – Materials: Baby blanket for use in peek-a-boo; or tickling game.
  – Instructions:
                                                                         child’
         From about a foot away, hold blanket in between your face and child’s and
              Where’ (child’ name)?”
         say “Where’s (child’s name)?” Then pull blanket down with some
                                    Peek- boo”        child’
         excitement saying either “Peek-a-boo” or the child’s name in conjunction
         with tickling or touching him/her. Watch for him/her to behave in way that
                                                                        do
         suggests he/she wants you to continue or is waiting for you to do it again.
  – Focus of Observation: Affect and attempts to initiate the repetition
                                                                 extent
    of the routine. Notice social directedness of behavior and extent to
                                                                  and
    which child integrates gaze, facial expression, vocalization, and gesture
    in actions to the examiner or parent/caregiver.
Administration Module 1
 (8) Functional and Symbolic Imitation
                      child’
  – Purpose: Observe child’s imitation of simple actions with real objects and with
    non-
    non-meaningful placeholders for same objects.
  – Materials: Toy frog, car, cup, airplane, flower, and cylindrical block.
  – Instructions:
                                                                          it’   frog”
          Initially use the frog or the car as example stating “Look, it’s a frog” with
                                                           it”
          accompanying sound effects. Then “You do it” with reinforcement. A total of 3
          attempts may be made to teach the child to imitate your actions with car or frog, with
          physical assistance offered on only one attempt.
                                                                It’                   plane)”
          For each trial, pick up specified object and state “It’s a (cup, flower, plane)” with
          demonstration and sound effect followed by “You do it.”   it.”
                                                                              object
          After imitating actual object, want symbolic representation of object just presented
                                                                                 etc.).”
          with cylindrical block stating, “Now this is a (cup, flower, plane, etc.).”
                                                                         action
          Final stage is to use placeholder to represent a different action that the child has not
          yet seen or demonstrated. If child is unable to demonstrate, go back to using a real
                                                                                  to
          object then proceed through same sequence. Once child is able to demonstrate
          symbolic representation of object has not yet seen, the task is complete.
          If fails to imitate at any of the four real objects, discontinue activity.
  – Focus of Observation: Use of miniatures and placeholder in imitation of
                                                           enjoyment.
    familiar actions including social awareness and shared enjoyment.




Administration Module 1
(9) Birthday Party
                                                                            play.
 – Purpose: An opportunity for child to engage in symbolic and functional play.
                                                                          cup,
 – Materials: Baby doll with eyes that open and shut, plate, fork, knife, cup,
           Play- Doh,      candles,”
   napkin, Play-Doh, four “candles,” and blanket.
 – Instructions:
        Should be carried out at a slow pace to allow child to initiate or join in doll play.
                                         here’     baby,” It’       baby’             Let’
        Verbal prompts include “Look, here’s the baby,” “It’s the baby’s birthday! Let’s have a
                                baby.”                          Here’                  cake.”
        birthday party for the baby.” Make cake while stating “Here’s the birthday cake.” Put
                                                          candles,”
        one of the candles in cake stating “Here are the candles,” then give child second
        candle and leave others within reach. Pretend to light candles, shaking out the match
                          hot.”                             now?”           doesn’
        and stating “Oh, hot.” Then, “What should we do now?” If child doesn’t respond, say
         Let’              Birthday,”                                                     doesn’
        “Let’s sing Happy Birthday,” and then do so. At end clap and cheer. If child doesn’t
                                                   Let’           candles,”
        spontaneously blow out candles prompt “Let’s blow out candles,” with deliberate four
                    What’ next?”
        steps (1) “What’s next?” (2) Open mouth (3) Put in blowing position and (4) blow.
                                                                          baby’ hungry,”
        When blown out, clap, cheer and hand baby fork stating “The baby’s hungry,” “The
                                     cake,” Let’           baby,” Yum,”
        baby wants some birthday cake,” “Let’s feed the baby,” “Yum,” as necessary. Follow
                                                                            as
        same sequence for cup and juice prior to knocking over the cup as if by accident and
                                                                              do?”
        stating “Oh, no! I spilled the juice. What a mess! What should we do?” End sequence
        is to put baby to bed: “Okay, the birthday party is over. Now what will the baby do?” do?”
                                               Baby’                                 sleep,”
        while placing blanket near to baby; “Baby’s tired. Time for baby to go to sleep,” and
                     baby.”
        “Night night baby.”
                                                           script”
 – Focus of Observation: Interest and ability to join in “script” of sequential
                                                                animate
   pretend play with attention to any representation of doll as animate being,
                                                                    will
   spontaneous contributions to party, and if not, whether he/she will imitate.




Administration Module 1
 (10) Snack
  – Purpose: An opportunity for child to make requests in familiar context.
                                                                                  cookies
  – Materials: Small cup, water/juice in clear container, two kinds of small cookies
    or crackers/pretzels in two different containers with lids that are difficult to
    open .
  – Instructions:
                                    It’             snack”
          Initial prompt is to say “It’s time for a snack” while placing one of each type of snack
                                                                                   crackers/pretzels.”
          on plate in front of child and continuing with “We have cookies and crackers/pretzels.”
          After child has eaten, hold containers at a distance and out of reach from child and
                              want?”
          ask “What do you want?” Wait. Watch for pointing, reaching, offering plate, making
                                                                    Cookies”      Crackers”
          EC or vocalizing to request more. If no request, say “Cookies” or “Crackers” while
          holding each up again.
                                                                             offer
          Continue snack with multiple opportunities to request. Add in offer of drink or juice if
          he/she is thirsty and follow same procedure.
  – Focus of Observation: If and how child indicates preference and requests
                                                              reaching,
    food in familiar context with attention to gaze, gesture, reaching, facial
                                                                   examiner.
    expression and vocalization to communicate a request to the examiner.
ADOS Module 2 Activities
Phrase Speech
1. Construction Task                  8. Description of a
2. Response to Name                       Picture
3. Make Believe Play                  9. Telling a Story from a
4. Joint Interactive Play                 Book
5. Conversation                       10. Free Play
6. Response to Joint                  11. Birthday Party
   Attention                          12. Snack
7. Demonstration Task                 13. Anticipation of a
                                          Routine with Objects
                                      14. Bubble Play




Administration Module 2
  (1) Construction Task
                            warm-
   – Purpose: Serves as warm-up activity and chance to observe
     interactive style during structured task. Also whether and how the
     child asks for help.
   – Materials: Block puzzle and printed design to be duplicated.
   – Instructions:
         Child is asked to assemble interlocking blocks to construct the design
                                                    warm-
         shown on the printed form. Purpose is a warm-up activity and to create
                                                                       motor
         opportunity for child to ask for help, not to measure his/her motor or
         visual-
         visual-spatial skills.
                                                                ’
         Offer a couple blocks and prompt “Show me how you’d put these blocks
                                                             you
                                     picture.”                               blocks,”
         together to look like this picture.” “Let me know if you need more blocks,”
         while remaining blocks should be kept on table and within site, but outside
            child’                              examiner’
         of child’s reach and on other side of examiner’s arm. Additional prompts:
                                blocks?”                                 more.”
         “Do you need more blocks?” or “Just let me know if you need more.”
   – Focus of Observation: Whether child indicates need for more pieces,
     and how he/she attempts to do so.




Administration Module 2
 (2) Response to Name
                      child’
  – Purpose: Assess child’s response to name.
  – Materials: Activity best conducted when child engaged in free play.
  – Instructions:
        Be sure you are positioned so that child has to turn in order to look at you.
                              3-                child’
        From a distance of 3-5 feet, call the child’s name.
        If he/she does not respond or responds without orienting to you, repeat the
        press for a total of four attempts.
                                                                       call     child’
        If the child still does not clearly respond, ask the parent to call the child’s
                                                                               child
        name – if after two attempts the parent is still not able to get the child to
        orient to him/her, you may ask the parent “Is there any way you can get
                                                     them?”
        him/her to look at you without touching them?”
                                                                     necessary
        If still no response, encourage parent to use any method necessary to get a
        response, including touching.
                                           child’
  – Focus of Observation: Observe the child’s response to hierarchy of
                                                               intervention
    auditory stimuli. Focus is both on the sounds and level of intervention
    required to get a response, and also on how the child responds.
Administration Module 2
    Make-
(3) Make-Believe Play
 – Purpose: Observe creative or imaginative play with objects in an
                                                   child’
   unstructured task with materials appropriate to child’s interest.
 – Materials: Family set of human dolls and dog with accompanying
                             match”
   furniture and props that “match” dolls.
 – Instructions:
       Materials are laid out and child is told “This is a family, with a mother, a
                                                                       dog,
       father, and a young boy/girl, and a baby. Here is their pet dog, and here
                                                                          while?”
       are some of their things. Could you play with these now for a while?”
                                                              demonstrate.
       If child does nothing or cannot get started, okay to demonstrate.
       Throughout should comment, show interest and encourage child without without
                                           What’              now?”
       telling him/her what to do e.g., “What’s happening now?” However, it is
                               child’
       critical to distinguish child’s own creative use of materials from response to
       examiner’                                  examiner’
       examiner’s specific prompts or copying examiner’s actions.
 – Focus of Observation: Extent to which child produces sequences of
   actions that involve using materials beyond their most obvious
                                                                  they
   intention, particularly how child casts the dolls and pretends they are
   interacting with each other.




Administration Module 2
(4) Joint Interactive Play
 – Purpose: Assess degree and quality of coordination of behavior
   and affect with examiner in joint interactive play.
                               Make-           Play.”
 – Materials: Materials from “Make-Believe Play.”
 – Instructions:
                                         make-
       After sufficient time to initiate make-believe play, examiner
                                                 too?”         I’
       redefines activity by saying “Can I play too?” or “Now I’d like to join
                may?”
       you if I may?” and immediately proceeds to manipulate objects to
       produce a press for joint interactive play.
                                                                      affect.
       Important examiner enter into spirit of play and show ample affect.
 – Focus of Observation: Reciprocity shown by the child in
   interactive play. Goal is for the child (not the examiner) to
   develop the interaction and to provide a novel initiative that
                                            examiner’ overtures.
   goes beyond a direct response to the examiner’s overtures.




Administration Module 2
(5) Conversation
                                                                   back-
 – Purpose: Assess ability to carry out minimal conversation with back-
   and-
   and-forth interchange, and to generate a language sample in less
   structured circumstance.
                 Make-       Play,”           Party,”         Play.”
 – Materials: “Make-Believe Play,” “Birthday Party,” or “Free Play.”
 – Instructions:
               conversation-
       Goal is conversation-like interchange regardless of complexity.
       Offer simple comments about materials, allowing time response. If  If
                                                                         outside
       appropriate then add comments about related events or objects outside of
                                                                      with
       immediate context to see if child can maintain a conversation with visual
       support. At some point, stop maintaining conversation to see how initiate.
                                  child’
       Important to incorporate child’s interests.
                                                                   effort
       Should avoid question and answer style, instead deliberate effort to use
       conversational approach – examiner must show interest and involvement
                                         hand- over”
       and respond with appropriate “hand-over” prompts to provide press for to- to-
       and-
       and-for interchange.
                                                                       whenever
       Open questions, comments, or interpretations should be used whenever
       possible.
                                                               examiner’
 – Focus of Observation: Extent to which child builds on the examiner’s
                                                          back- and-
   statements, and makes leading statements to facilitate back-and-forth
   conversation.
Administration Module 2
(6) Response to Joint Attention
                      child’
 – Purpose: Assess child’s use of EC with facial orientation, verbalization, and
                                                             object.
   pointing, in order to draw his/her attention to a distant object.
                Remote-
 – Materials: Remote-controlled bunny or car.
 – Instructions:
                                                                         room
        Child should be at the table, sitting, facing the front of the room and engaged in
        toy/material of interest, but not of particular interest.
        Bunny/car should already be placed on a table or chair (at what you anticipate to be
        child’
        child’s eye level) 65o to front and right or left of the child and at a distance of 4-5 feet
                                                                                             4-
        away.
                  child’                                                                  (child’
        Call the child’s name and touch him/her to get their attention saying “Look, (child’s
        name)”
        name)” as you shift toward the toy and then back to child – can repeat for a total of
                                                            that!”
        four attempts with an additional “Look, look at that!” for the fifth attempt.
                 doesn’                                          child’
        If child doesn’t shift in five attempts, add a point to child’s visual field.
                       doesn’
        If child still doesn’t shift, go ahead and activate toy waiting to see if child will shift to
                                                                        child
        activation alone. Then bring toy in front of child to see if child will request subsequent
        activation.
 – Focus of Observation: Whether or not child follows shift alone or requires
   point




Administration Module 2
(7) Demonstration Task
 – Purpose: Assess ability to communicate about familiar series of actions
   using gestures with accompanying language to report on familiar event.
 – Materials: Hand towel and soap.
 – Instructions:
        Tooth-                                                            me.” Let’
        Tooth-brushing. “Now I want you to play a pretend game with me.” “Let’s
                            sink… ..”
        pretend this is the sink…..” “Now I want you to teach me how you brush
                                                                          You’
        your teeth. Show me and tell me. Start right at the beginning. You’ve just
        come into the bathroom now what do you do?”do?”
                                                                         entirely
        If child does not understand the task you may demonstrate an entirely
        different event, e.g. driving a car.
        Hand-              face-                     doesn’
        Hand-washing or face-washing. If child still doesn’t understand task, or fails
                                                                real’
        to coordinate gestures, reset scene with props, actual ‘real’ soap and towel
        this time.
 – Focus of Observation: Determine how child represents familiar
   actions in gesture, particularly through use of his/her body to represent
                                                                  report
   an object, or in miming the use of a pretend object. Also, a report of a
   familiar event.




Administration Module 2
(8) Description of a Picture
 – Purpose: Generate sample of language and/or other communicative
   behaviors.
 – Materials: Feast scene and resort scene.
 – Instructions:
                 Let’
       Prompt “Let’s look at this picture now. Can you tell me about it? What is
                          picture?”
       happening in this picture?”
                                                                    beginning,
       Examiner should be enthusiastic and interested, but at the beginning, should
                                                                encourage
       not offer substantive information about the picture (to encourage language).
                                                      doesn’
       If after general prompts and questions, child doesn’t respond, fails to provide
       more than isolated specific labels of objects or people, or only mentions one
                                                                        sentence,
       statement beyond labeling, examiner should model a complex sentence, e.g.,
                                                                   see?”
       “Oh look at this. I see a man playing golf. What can you see?” or “These
                         sailboat.”
       people are on a sailboat.”
                                                  What’ this?”           this?”
       If necessary, then ask specific questions “What’s this?” “Who is this?” “What is
           doing?”                      here?”
       he doing?” “What is happening here?”
       May then repeat with second picture as necessary.
                                                      child’
 – Focus of Observation: Goal is to obtain example of child’s spontaneous
                                                                  his/her
   language and communication, as well as sense of what captures his/her
   interest.
Administration Module 2
 (9) Telling a Story From a Book
 – Purpose: Assess ability to follow and comment on sequential
   story in a picture book and to generate spoken language.
 – Materials: Either of the two picture books may be used.
 – Instructions:
         Prompt “Have a look at this book. It tells a story. See, it starts out
         with…
         with… (describe the first picture in the book). Can you look at it,
                          story?”
         and tell me the story?” Should offer a few specific prompts to get
                                                         next.”
         him/her started e.g., “I wonder what happens next.”
         After child describes books for few minutes, say “That was great.
               I’               turn.”
         Now I’d like to take a turn.”
 – Focus of Observation: Goal, like preceding, is to obtain
   spontaneous language and communication, and a sense of what
                                   child’
   captures his/her interest. Also child’s ability to convey continuity
   in a story.




Administration Module 2
 (10) Free Play
  – Purpose: Create relaxed situations with no demands, a break.
                                                     (pop-
  – Materials : Several materials placed on table (pop-up toy, board book,
    toy telephone, four pieces of yarn, textured block) and several toys on
                          jack-in-the-
    the floor (music box, jack-in-the-box, dump truck, baby doll, letter
            medium-
    blocks, medium-size ball, two identical cars, two pairs of small balls,
    two pairs of small utensils, four small plates).
  – Instructions:
          Place toys out as specified in manual.
                                                                           alone
          Tell parent want to give child few minutes to play and explore alone –
          engage parent in conversation by asking “Are these the kinds of toys your
                                      home?”
          child likes to play with at home?” Purpose is to distract parent and give
                                                                       either
          child chance to adjust without instruction or intrusion from either parent or
          examiner.
          You may also ask the parent, “Can you see if you can get him/her interested
          in some of these toys?”
                             toys? ”
  – Focus of Observation: Spontaneous engagement, joint referencing,
                         Self-
    giving and showing; Self-exploration of materials, functional and/or
    symbolic use of toys and/or any repetitive actions or behaviors.




Administration Module 2
 (11) Birthday Party
  –   Purpose: An opportunity for child to engage in symbolic and functional play.play.
  –                                                                             cup,          Play-
      Materials: Baby doll with eyes that open and shut, plate, fork, knife, cup, napkin, Play-
      Doh,        candles,”
      Doh, four “candles,” and blanket.
  –   Instructions:
           Should be carried out at a slow pace to allow child to initiate or join in doll play.
                                            here’     baby,” It’       baby’             Let’
           Verbal prompts include “Look, here’s the baby,” “It’s the baby’s birthday! Let’s have a
                                   baby.”                           Here’                 cake.”
           birthday party for the baby.” Make cake while stating “Here’s the birthday cake.” Put
                                                             candles,”
           one of the candles in cake stating “Here are the candles,” then give child second
           candle and leave others within reach. Pretend to light candles, shaking out the match
                             hot.”                             now?”           doesn’
           and stating “Oh, hot.” Then, “What should we do now?” If child doesn’t respond, say
            Let’              Birthday,”                                                     doesn’
           “Let’s sing Happy Birthday,” and then do so. At end clap and cheer. If child doesn’t
                                                      Let’           candles,”
           spontaneously blow out candles prompt “Let’s blow out candles,” with deliberate four
                       What’ next?”
           steps (1) “What’s next?” (2) Open mouth (3) Put in blowing position and (4) blow.
                                                                             baby’ hungry,”
           When blown out, clap, cheer and hand baby fork stating “The baby’s hungry,” “The
                                        cake,” Let’           baby,” Yum”
           baby wants some birthday cake,” “Let’s feed the baby,” “Yum” as necessary. Follow
                                                                               as
           same sequence for cup and juice prior to knocking over the cup as if by accident and
                                                                                 do?”
           stating “Oh, no! I spilled the juice. What a mess! What should we do?” End sequence
           is to put baby to bed: “Okay, the birthday party is over. Now what will the baby do?” do?”
                                                  Baby’                                 sleep,”
           while placing blanket near to baby; “Baby’s tired. Time for baby to go to sleep,” and
                         baby.”
           “Night night baby.”
  –                                                            script”
      Focus of Observation: Interest and ability to join in “script” of sequential pretend play
                                                                       spontaneous
      with attention to any representation of doll as animate being, spontaneous contributions to
      party, and if not, whether he/she will imitate.
Administration Module 2
 (12) Snack
  – Purpose: An opportunity for child to make requests in familiar context.
  – Materials: Small cup, water/juice in clear container, two kinds of small
                                                                  lids
    cookies or crackers/pretzels in two different containers with lids that are
    difficult to open.
  – Instructions:
                                   It’             snack”
         Initial prompt is to say “It’s time for a snack” while placing one of each type of snack
                                                                                  crackers/pretzels.”
         on plate in front of child and continuing with “We have cookies and crackers/pretzels.”
         After child has eaten, hold containers at a distance and out of reach from child and
                             want?”
         ask “What do you want?” Wait. Watch for pointing, reaching, offering plate, making
                                                                   Cookies”      Crackers”
         EC or vocalizing to request more. If no request, say “Cookies” or “Crackers” while
         holding each up again.
                                                                            offer
         Continue snack with multiple opportunities to request. Add in offer of drink or juice if
         he/she is thirsty and follow same procedure.
  – Focus of Observation: If and how child indicates preference and
                                                              gesture,
    requests food in familiar context with attention to gaze, gesture, reaching,
                                                                     the
    facial expression and vocalization to communicate a request to the
    examiner.




Administration Module 2
 (13) Anticipation of a Routine with Objects
                      child’
  – Purpose: Assess child’s anticipation and initiation of the repetition of
    an action routine with objects.
  – Materials: Balloon.
  – Instructions:
         Blow up large balloon slowly, exaggerating your behavior as you do so.
         Inflate, hold directly in front of child alerting him/her (e.g. deliberate
                        go”
         “Ready, set, go”) before you hold the balloon over your head and release it
         so that it will fly around the room.
                                                                         to
         After balloon lands, wait for the child to bring it to you, or to indicate in
         some other way that he/she wants it to be blown up again.
         Repeat at least two more times to observe multiple requests.
                                                                       routine
         If child is afraid of balloon, remove it and try to establish routine with one
                 cause- and-
         of the cause-and-effect toys.
  – Focus of Observation: Affect, initiation of joint attention, shared
    enjoyment, requesting and motor behavior during the activity.




Administration Module 2
 (14) Bubble Play
                                                                           to
  – Purpose: Elicit EC and vocalization with pointing or reaching in order to
                                                                Also
    direct attention of parent or examiner to a distant object. Also an
                                                                movements
    opportunity for requesting. Unusual sensory behaviors & movements may
    be elicited.
  – Materials: Bubble gun and liquid.
  – Instructions:
         While child engaged in toy/material of interest, let parent know interested in seeing if
         the child will notice bubbles without being told.
         Produce stream of bubbles and see if child notices them, and if so, if he/she requests
                                                                   (verbalization,
         their continuation through verbal or nonverbal means (verbalization, gesture, EC).
                                                                       give
         After noticing any attempts at initiation of joint attention, give child multiple
         opportunities to request more bubbles while maintaining control of bubble juice.
                                                      child’
  – Focus of Observation: Context for observing child’s affect, initiation of
                                                                behaviors
    joint attention, shared enjoyment, requesting, and motor behaviors while
                                                                  spontaneous
    bubbles are present. Initiation of joint attention requires a spontaneous
                                                                     purpose
    shift in gaze from object to person to object with no apparent purpose
    other than to share interest or pleasure.
Some Coding Conventions
0 =   Behavior of type specified is not present
      (not necessarily “normal”)
1 =   Behavior of type specified is present, but not sufficiently
      clear, severe, frequent, or marked to code “2”
2 =   Behavior of type specified is definitely present and meets
      specific mandatory criteria
3 =   Behavior present to a degree that interferes with
      functioning
7 =   Definite abnormality in general area of coding, but not of
      type specified

8 =   Not applicable

9 =   Unknown/missing




ADOS Scoring
See guides at top of each heading – to code that
section by developmental, chronological age
standards…
standards…
          item’
Read each item’s coding instructions carefully
                       over-              item’
General guidelines are over-ruled by each item’s
coding guidelines
Code only what you see during the ADOS
When in doubt between 2 codes, code down
 – Debating between a 1 or a 2, code 1




Live ADOS
Administration
Module 1 or 2
Module 1 / 2
Administration
 Different elements of developmental
 testing with young children
                          with’
  – Importance of ‘being with’ the child
  – Need to keep pace with the child
  – Expect to match activity level of the child
                                   flexible-
  – Awareness of the need to be flexible-
    with the materials, with the space, with
    yourself




Modules 1 / 2
Administration
 Create a social world – engage!
 Behavior and response of child in part
             examiner’
 depends on examiner’s sensitivity to
 respond – knowing when to act and
 when not to act
            open-
 Begin with open-ended
                      examiner’
 Rely on hierarchy of examiner’s behavior
 Language sample




ADOS Scoring
See guides at top of each heading – to code that
section by developmental, chronological age
standards…
standards…
          item’
Read each item’s coding instructions carefully
                       over-              item’
General guidelines are over-ruled by each item’s
coding guidelines
Code only what you see during the ADOS
When in doubt between 2 codes, code down
 – Debating between a 1 or a 2, code 1
ADOS Scoring Issues
 Low and high threshold items
 – High threshold (constant opportunities, should
   happen a lot)
      Eye contact
      Facial expressions
                 (2-                     good”
 – Low threshold (2-3 clear examples is “good”)
      Gestures (wide variation in how people use)
 Need for environmental support – how hard do
 you have to work to make behaviors occur?
        effects”
 “Floor effects” – no opportunities for a behavior
 to occur




ADOS Algorithm
 Transfer selected scores from protocol
 Convert scores
           2’
  – 3’s to 2’s
  – Numbers other than 1, 2, or 3 to 0
 Cut-
 Cut-off scores
 ADOS Diagnosis and Overall Diagnosis




Classifications on ADOS
 For ASD and Autism classifications, child
 must meet cutoffs in all 3 areas:
                            areas:
  – Communication subtotal
  – Reciprocal Social Interaction subtotal
  – Reciprocal SI + Communication Total Score
 ASD on Communication, Autism on SI, Autism
 on Total: Classification = ASD
 ASD on Communication, ASD on SI,
 Nonspectrum on Total = Nonspectrum
Using the ADOS
Algorithms
                 classification,
 ADOS results in classification, not
 diagnosis

 ADOS was not designed to make
 distinctions between Atypical
          PDD-
 Autism, PDD-NOS, and Asperger
 Syndrome




Administrative Skill
                      examiner’
 ADOS dependent on examiner’s
 experience as well – clinically relevant
 skill set including:
  – Timing
          child’
  – Using child’s interests & strengths
  – Warmth and authority
  – Confidence and humility
  – Incorporation of family
  – Awareness of alternative approaches




Autism Diagnostic
Observation Schedule
(ADOS)

Psychometric Studies
New Algorithms? Yes!
   Psychometric studies in manual are useful.
   BUT, new algorithms have been developed
   to improve both the sensitivity and
   specificity of classification for Modules 1, 2
   and 3.
   Gotham, Risi, Pickles & Lord (2007)
   Forms? Not yet available through WPS.




Revised ADOS Algorithms
   Greater comparability across ADOS
   modules; each algorithm has 14 items of
   similar content
   One total includes codes for social,
   communication, and restricted repetitive
   behaviors
   Improved sensitivities and specificities
   Improved predictive validity as compared
   to previous algorithms

Gotham et al., 2007




Participants

   Previous validity studies were based on
   small samples
   Current validity studies included
     n = 912 cases with autism
                        non-
     n = 439 cases with non-autism ASD
                        non-
     n = 279 cases with non-spectrum disorders
               non-
    (including non-specific MR, language disorders, ODD,
       ADD and/or ADHD, Down syndrome, mood and/or
       anxiety disorders)

Gotham et al., 2007
      Sample Description
      (means and ranges)
                            Mod 1            Mod 2          Mod 3

      Autism      Age       55 (14-144)
                               (14-          80 (28-143)
                                                (28-        101 (42-183)
                                                                (42-

                  VMA       15 (1-65)
                               (1-           42 (13-102)
                                                (13-        82 (35-264)
                                                               (35-

      PDD         Age       41 (15-107)
                               (15-          61 (28-130)
                                                (28-        100 (45-172)
                                                                (45-

                  VMA       20 (1-68)
                               (1-           40 (18-84)
                                                (18-        100 (39-264)
                                                                (39-

      NS          Age       44 (14-129)
                               (14-          70 (37-143)
                                                (37-        104 (51-192)
                                                                (51-

                  VMA       23 (1-54)
                               (1-           45 (26-70)
                                                (26-        90 (32-184)
                                                               (32-




      Revised ADOS Algorithm
      Developmental Cells

                            Module 1             Module 2     Module 3

Age                <5 Words         Single        Phrases      Fluent
                                    Words



 <5




 5-12

Gotham et al., 2007




      Sensitivities and
      Specificities (Autism vs. NS)
                                               Sensitivity Specificity

      Mod 1, no words, NVMA > 15                     95        94

      Mod 1, some words                              97        91

      Mod 2, younger                                 98        93

      Mod 2, older                                   98        90

      Mod 3                                          91        84

      Gotham et al., 2007
 Sensitivities and Specificities
 (Non-
 (Non-Autism ASD vs. NS)
                                           Sensitivity Specificity

 Mod 1, no words, NVMA > 15                       82                79

 Mod 1, some words                                77                82

 Mod 2, younger                                   84                77

 Mod 2, older                                     83                83

 Mod 3                                            72                76

 Gotham et al., 2007




                            Inter-
Interclass Correlations for Inter-
           Test-
Rater and Test-Retest Reliability

                                                   Social-      Restricted,
           n           Social   Communication   communication    repetitive



Inter-    97            .93         .84             .92            .82
rater
(all)


Live-     62            .92         .80             .90            .86
live

Live-     35            .92         .82             .91            .72
video

Test-     27            .78         .73             .82            .59
retest




 Autism Diagnostic
 Observation Schedule
 (ADOS)

 What We Have Learned?
Research Findings
  Appropriate use of the ADOS
   – Giving the right Module is important


  Differentiating between autism and
  other developmental disabilities




Klein-
Klein-Tasman, Risi, & Lord:
The Impact of Module Choice
  Participants: 138 consecutive referrals to the DDC
  at the University of Chicago or to UMACC

  Clinical diagnoses:
   - Autism (n = 77)
     PDD-
   - PDD-NOS (n = 61)

  Ages 1 year, 11 months to 11 years, 9 months.

  Wide range of intellectual abilities (ratio nonverbal
  IQ ranged between 34 to 137 and ratio verbal IQ
  ranged from 34 to 131)
Klein-Tasman et al., 2007




Procedure
 One module was designated by the examiner as
  preferred”              examiner’
 “preferred” based on the examiner’s estimate of
 spontaneous expressive language level.

 In random order, clinicians administered an
  easier”              difficult”
 “easier” and a “more difficult” module.

       easier”      more”
 Both “easier” and “more” difficult modules of
 the ADOS were administered in a single
 session.
Klein-Tasman et al., 2007
Autism Classification
  For Modules 1 / 2:
  Administration of an easier module
              under-
  resulted in under-classification of
  autism but participants generally
                spectrum-
  remained on spectrum- ASD

  For Modules 2 / 3:
  No difference in classification
Klein-Tasman et al., 2007




ASD Classification
 For Modules 1 / 2: No clear effects of giving the
 wrong module.

                                           PDD-
 For Modules 2 / 3: More participants with PDD-NOS
 diagnoses were classified as Nonspectrum on the
  easier”
 “easier” module administered.

                                           PDD-
 For Modules 2 / 3: More participants with PDD-NOS
 diagnoses were classified as Autism on the “more
 difficult”
 difficult” module administered.

                   PDD-
 Participants with PDD-NOS diagnoses did not
 consistently score in the ASD range.
Klein-Tasman et al., 2007




ASD, or at least, some aspects of
ASD, fall on continuous
dimensions, which we are forced
to categorize in order to yield
definable groups.
Take home message:

1. The structure you provide or fail
   to provide, and the social and
   language demands you place on
   a participant have an effect on
   the observations you make and
   the extent to which the
   participant shows impairment.




Take home message:

2. The ADOS was not developed
               PDD-
   to identify PDD-NOS per se,
   but there is a defined
    intermediate”
   “intermediate” category that
   is not exactly stable. Thus,
   the need for new algorithms
   to address this problem.




Take home message:

3. Always do a language sample!

4. Administration of the ADOS
   should always be only one part
   of a more comprehensive
   evaluation.
         Guidelines for Selecting a
         Module
              Module                     Expressive Language Level
                                        Minimum                   Maximum
                     1                  No speech              Simple phrases


                     2                 Three-word              Verbally fluent
                                     phrases/ not yet
                                      verbally fluent

                     3               Verbally fluent           Toys not helpful
                                     (Child/younger
                                       adolescent)
                     4             Verbally fluent
                                 (Adolescent/adult)




        How does the ADOS
        classification system work
        with an individual with
        mental retardation?




        Autism criteria applied to 61 cases
        over 36 months of age with
        severe/profound MR (Risi et al., 2006)
Diagnostic     True        True         False        False      Sensitivity   Specificity
 Criteria    Positives   Negatives     Positives   Negatives    (95% CI)      (95% CI)
                (n)         (n)          (n)          (n)
ADI-R and
ADOS (Aut)      41          9             9           2          95%           50%
                                                                (84-99)       (26-74)
ADI-R and
ADOS            41          9             9           2          95%           50%
(ASD)                                                           (84-99)       (26-74)
ADI-R                                                            95%           44%
                41          8            10           2         (84-99)       (22-69)

ADOS (Aut)                                                       100%           17%
                43          3            15           0         (92-100)       (4-41)

ADOS                                                             100%           11%
(ASD)           43          2            16           0         (92-100)       (1-35)
    PDD-
    PDD-NOS criteria applied to 18 cases
    over 36 months of age with
    severe/profound MR (Risi et al., 2006)

Diagnostic      True        True       False        False     Sensitivity   Specificity
 Criteria     Positives   Negatives   Positives   Negatives   (95% CI)      (95% CI)
                 (n)         (n)        (n)          (n)
ADI-R
(S+1             7           2           7           2         78%            22%
domain)                                                       (40-97)        (3-60)
and ADOS
(ASD)
ADI-R
(S+1             8           2           7           1          89%           22%
domain)                                                       (52-100)       (3-60)
ADOS                                                            89%           11%
(ASD)            8           1           8           1        (52-100)       (0-48)




        Clarifying ASD and MR
             A good developmental history, with
             specific focus on patterns indicative of
             autism, is important.

             Focus on social behaviors, social
             directedness of communication

             Repetitive mannerisms are not as
             reliable




        Deviance Versus Delay
             Extreme uneven delay is deviance
             – Walks but understands no words out of
               context by age 2 years
             – Walks but says no spontaneous,
               meaningful words by age 3 years
        How well does the ADOS
        work with very young
        children?




  Autism criteria applied to 270 cases
  under 36 months of age (Risi et al., 2006)
Diagnostic       True        True        False         False      Sensitivity   Specificity
 Criteria      Positives   Negatives    Positives    Negatives    (95% CI)      (95% CI)
                  (n)         (n)         (n)           (n)
ADI-R and
ADOS (Aut)       131          94           14           31          81%          87%
                                                                   (74-87)      (79-93)
ADI-R and
ADOS             134          82           26           28          83%          76%
(ASD)                                                              (76-88)      (67-84)
ADI-R            134          78           30           28          83%          72%
                                                                   (76-88)      (63-80)

ADOS (Aut)       158          64           44            4          98%          59%
                                                                   (94-99)      (49-69)

ADI-R or
ADOS (Aut)       161          48           60            1          99%          44%
                                                                  (97-100)      (35-54)




         ADOS Diagnosis
         Denver Toddler Study
        Ages: 21-50 mos.
                                                              (n
                                           Clinical Diagnosis (n=106)

             ADOS Diagnosis                  Autism                  Not Autism

                   Autism                  33 (85%)                      1 (2%)

               Not Autism                   6 (15%)                    66 (98%)

         χ2= 78.18, p <.00. False positives on ADOS = 1; false negatives on ADOS = 6
Both ADOS and ADI
Denver Toddler Study

                                      (n
                   Clinical Diagnosis (n = 93)

 ADOS + ADI           Autism         Not Autism

 Both: Autism       27 (75%)           1 (2%)

 One: Autism         9 (25%)          9 (16%)
 Not Autism
                         0            47 (83%)
  on Either




Conclusions from Toddler
Study
Using both the ADI and ADOS is a very effective way
of qualifying subjects. No false negatives and only 1
false positive.
Tools are fairly comparable; ADOS is slightly better
Children who do not receive a clinical diagnosis of
autism, but meet criteria on one (but not both) of the
tools, tend to be functioning at a lower
developmental level (<16 months). Children with
false positives on ADI tend to have a difficult
temperament. Children with false positives on ADOS
tend not to initiate many joint attention behaviors.




Remember…
 The ADOS has not been standardized
 on children with developmental levels
 younger than 18 months.
     A toddler module is coming!
 If you use it, interpret with caution.
                     over-
 Module 1 may be over-inclusive.
Using the ADOS in
Clinics & Schools




Intended Use of ADOS
 ADOS is an important part of a
 comprehensive autism evaluation.
                   classification.
 ADOS results in a classification.
  – Not a diagnosis by itself.
                  DSM-
 ADOS is based on DSM-IV.
  – Subject to the limitations of our current
    diagnostic systems.
 ADOS as a measure of change over
 time?




Important Elements of a
Diagnostic Assessment
 Diagnostic information
                           (ADI-
  – Interview with parents (ADI-R)
      Developmental history
      Pervasiveness of behaviors
  – Assessment of child
      ADOS
  – Observation in relevant environments
 Measures Often Used in
 Diagnostic Evaluations for ASD
Autism measures:                Other measures:
  ADI-
  ADI-R                           Vineland-
                                  Vineland-II
  ADOS
                                  Differential Abilities Scales (DAS)
Checklists:                       Mullen Scales of Early Development
  Social Responsiveness Scale
  Social Communication            Communication and Symbolic
  Questionnaire                   Behavior Scales (CSBS)
  CBCL or BASC                    CELF- CELF-
                                  CELF-4, CELF-P2
                                  Sequenced Inventory of
                                  Communication Development (SICD)
                                  Reynell
                                  PPVT
                                  Preschool Language Scales (PLS)




Incorporating ADOS Results
into Evaluation Reports
    Description of ADOS (standardized,
    which module, types of activities,
                            cut-
    classification based on cut-offs)
    Relevant testing behaviors
    Use items to talk about areas of skill
    strength and weakness
    Scores are not helpful to report




 Evaluation Reports
 (cont.)
    ADOS results in classification, not
    diagnosis
     – Incorporate results of developmental
       history interview, functional behavior
       assessment, and standardized
       communication and cognitive tests into
       eligibility or diagnostic statements.
The process of working
with parents to establish a
diagnosis for their child is
often as important as the
diagnosis itself.




Getting children and families
started in intervention programs
with appropriate goals and
methods is the purpose of
diagnosis and assessment.




Using ADOS for Program
Planning
 Modules 1 & 2:
 – Breaking down social behaviors
 – Social overtures
     Requests
     Directing attention
     Giving
     Comments/giving information/showing
      – Quality
      – Frequency
Program Planning (cont.)

 Contexts of overtures – requests,
 motivation, social interaction
 Social responses
 Reciprocity (play, vocal, use of object)
 Basic aspects of social behavior (eye
 contact, facial expressions,
 vocalization, gesture, use of objects)




Program Planning (cont.)

 Modules 3 & 4
  – Teachers have found observing the ADOS
    quite useful in programming; this is less
    the case for parents (for Modules 3 and
    4)
  – Not very worthwhile to directly teach
    answers to specific questions
  – Gain a sense of level of support needed
    to have effective communication




Administration Do’s
 Arrangement of 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).
 – Have bunny set out and covered in the spot where
   you’
   you’ll want it to be for Response to Joint Attention.
 Make sure you have all the materials available
 and ready before you start.
 – Have a stash of extras.
 Make sure your equipment works.
 – Bubble maker, remote car or bunny, balloons that can
   be blown up.
Administration Do’s
 Have the proper snack materials.
 – Juice or water that can be poured in a disposable cup
   rather than giving the child a juice box.
                  containers-
 – Two identical containers- not individually wrapped
   items (e.g. bought from a machine).
 – Always ask the parent ahead of time if the child has
   food restrictions (if so, can they provide some
   materials for you to put in the containers?).
                                       that’
 – If the child does not want to eat, that’s OK!
 Select the correct module.
 Understand the difference between social
 responses and social overtures/initiations.




Administration Do’s
                  world”                test”
 Set up a “social world” rather than a “test” or just an
 observation of the child playing.

                                      order.”
 You CAN administer the tasks “out of order.”

 If the child gets scared of the balloon, stop and later try
 another type of social routine with object (e.g., Jack in the
 Box).

 There should only be one examiner (not 2 people at the table
 with the child trying to get his/her attention, etc.).

 If there is another person observing or helping, that person
 should not be the person to do Response to Name (but can
 be a great help for uncovering the bunny and cleaning up).




Common ADOS Errors:
Administration
  Not reading the manual; just relying on the protocol
  in carrying out each task
  Non-
  Non-standard administration
   –   Materials
   –   Activities
   –                                   don’
       Skipping questions or tasks you don’t think apply (Mod 3)
   –   Giving the wrong module
  Errors in prompting
   – Too much or too little
   – Not following the specified hierarchy
  Not taking notes, relying on observer to take the
  notes and score
  No caregiver present for Module 1 and 2
Common ADOS Errors:
Coding
 Giving everything a 2, because the child is
 clearly autistic.
 Under-
 Under-coding, because the child is doing
                            autism.”
 well “for someone with autism.”
                   3’    2’      8’   0’
 Not converting 3’s to 2’s (or 8’s to 0’s) on
 the algorithm
 Neglecting to read each code and
 description carefully to operationalize
 behaviors.
                      impressions”
 Coding based on “impressions” rather than
 observable behaviors.




Summary
 ADOS is a standardized instrument;
 creates contexts to observe ASD
 behaviors
 ADOS is one part of a comprehensive
 evaluation
 ADOS must be used properly
 – Choice of module
 – Standardized administration




Where to go from here?
 Preparation and further training for
 clinical/school use:
 –   Extensive practice with variety of children
 –   Read manual again
 –    Shadow”               ADOS-
     “Shadow” a seasoned ADOS-examiner
 –   Refer to ADOS fidelity checklists
 Receive further training
 –   ADOS Research Training
 –   Follow-
     Follow-up training
 –   FAQ’
     FAQ’s and Bulletin Board
 ADOS should be used only by people who
 frequently assess individuals with ASD.
  Important Information!
   University of Michigan Autism and
   Communication Disorders Center (UMACC)
               ADI- FAQs:
    – ADOS and ADI-R FAQs:
      www.umaccweb.com/education/faqs.html

                ADI-
    – ADOS and ADI-R Discussion Board:
       http://www.umaccweb.com/smf/index.php
       http://www.umaccweb.com/smf/index.php

   Western Psychological Services (WPS)
                           FAQs:
    – ADOS Information and FAQs:
       www.wpspublish.com




   University of Michigan Autism and
Communication Disorders Center (UMACC)
           http://www.umaccweb.com
                (734) 936-8600