Autism Diagnostic Observation Schedule™, Second Edition (ADOS™-2)
Allows you to accurately assess and diagnose autism spectrum disorders across age, developmental level, and language skills
12 months through adulthood
Standardized behavior observation and coding
Toddler Module provides ranges of concern reflecting the extent to which a child demonstrates behaviors associated with ASD. Modules 1 through 4 provide cutoff scores for autism and autism spectrum classifications. Modules 1 through 3 also provide a Comparison Score indicating level of autism spectrum-related symptoms compared to children with ASD who are the same age and have similar language skills.
Level C required.
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Autism Diagnostic Observation Schedule™, Second Edition (ADOS™-2)
Safety Warning CHOKING HAZARD - Small parts. Not for children under 3 years.
MODULES 1 THROUGH 4 BY CATHERINE LORD, PHD, MICHAEL RUTTER, MD, FRS, PAMELA C. DILAVORE, PHD, SUSAN RISI, PHD, KATHERINE GOTHAM, PHD, AND SOMER L. BISHOP, PHD
TODDLER MODULE BY CATHERINE LORD, PHD, RHIANNON J. LUYSTER, PHD, KATHERINE GOTHAM, PHD, AND WHITNEY GUTHRIE, MS
This revision improves an instrument already viewed as the “gold standard” for observational assessment of autism spectrum disorders (ASDs). With updated protocols, revised algorithms, a new Comparison Score, and a Toddler Module, the ADOS-2 provides a highly accurate picture of current symptoms, unaffected by language. It can be used to evaluate almost anyone suspected of having ASD—from 1-year-olds with no speech to adults who are verbally fluent.
Like its predecessor, the ADOS-2 is a semistructured, standardized assessment of communication, social interaction, play, and restricted and repetitive behaviors. By observing and coding these behaviors, you can obtain information that informs diagnosis, intervention, treatment planning, and educational placement.
The ADOS-2 includes five modules, each requiring just 40 to 60 minutes to administer. The individual being evaluated is given only one module, selected on the basis of his or her expressive language level and chronological age.
- Toddler Module—for children between 12 and 30 months of age who do not consistently use phrase speech
- Module 1—for children 31 months and older who do not consistently use phrase speech
- Module 2—for children of any age who use phrase speech but are not verbally fluent
- Module 3—for verbally fluent children and young adolescents
- Module 4—for verbally fluent older adolescents and adults
Each module engages the examinee in a series of activities involving interactive stimulus materials (all included in the ADOS-2 Kit). To illustrate, activities in Module 3 are listed below:
Joint Interactive Play
Description of a Picture
Telling a Story From a Book
Conversation and Reporting
Social Difficulties and Annoyance
Friends, Relationships, and Marriage
Creating a Story
Standardized Administration, Coding, and Scoring
Each ADOS-2 module has its own Protocol Booklet, which structures the administration and guides you through coding and scoring. As you administer activities, you observe the examinee and take notes. Immediately afterward, you code the behaviors observed. Then you use the algorithm form for scoring.
In Modules 1 through 4, algorithm scores are compared with cutoff scores to yield one of three classifications: autism, autism spectrum, or non-spectrum. The difference between autism and autism spectrum classifications is one of severity, with the former indicating more pronounced symptoms. In the Toddler Module, algorithms yield “ranges of concern” rather than classification scores.
Improved Protocol Booklets, Revised Algorithms, and a New Comparison Score
Administration and coding procedures for the ADOS-2 are functionally identical to those for the ADOS. Modules 1 through 4 retain the same basic activities and codes, though some codes have been expanded and several new codes have been added. Protocol Booklets for these modules have been significantly improved—they now provide clearer, more explicit administration and coding instructions.
Algorithms for Modules 1 through 3 have been revised to achieve more accurate and useful results and to provide a more uniform basis for comparing results across the three modules used with children and young adolescents.
A new Comparison Score for Modules 1 through 3 allows you to look at a child’s overall level of autism spectrum–related symptoms in relation to those of children diagnosed with ASD who are the same age and have similar language skills. This score also makes it easier to monitor an individual’s symptoms over time.
The New Toddler Module
The Toddler Module is designed specifically for children between 12 and 30 months of age who do not consistently use phrase speech. Observations are coded immediately following administration, and the codes are converted to algorithm scores. Toddler Module algorithms provide “ranges of concern” rather than cutoff scores. These ranges help you form clinical impressions, but they avoid formal classification—which may not be appropriate at such a young age. The Toddler Module quantifies risk for ASD and provides guidance if continued monitoring is needed.
The Most Accurate Picture of Current ASD Symptoms
With improved algorithms, the ADOS-2 demonstrates strong predictive validity. It gives you a highly accurate picture of current ASD-related symptoms, based on real-time observations. Physicians, clinical psychologists, school psychologists, speech–language pathologists, and occupational therapists can use ADOS-2 results to inform diagnosis, intervention, educational placement, and treatment planning. Because it can be used with a wide range of children and adults, the ADOS-2 is an essential addition to any hospital, clinic, or school that serves individuals with developmental disorders.
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Chapters 3 and 7 of the ADOS-2 Manual present case examples for using Modules 1 through 4 and the Toddler Module. The case examples include a variety of completed ADOS-2 protocols/algorithms and examples of how to include ADOS-2 results in written reports. Cases range from a toddler exhibiting delays in physical development and social communication to an adult experiencing academic and social difficulties in college. Below is an excerpt from the case example for Module 2.
Module 2: “Harry”
Harry is a 6-year-old boy who received a diagnosis of ASD from a statewide early intervention project when he was 2 years old. Harry and his family were recruited to participate in a genetics study of ASD. As part of the study protocol, Harry’s family participated in a research evaluation to confirm Harry’s diagnosis of ASD. Harry’s parents completed a parent interview and a number of questionnaires. Harry was administered a cognitive test (Differential Ability Scales, Second Edition [DAS-2; Elliot, 2007]) and the ADOS-2.
On the DAS-2, Harry received a Verbal Cluster score of 70 and a Nonverbal Cluster score of 90, indicating Borderline verbal abilities and Average nonverbal abilities. He was observed to use primarily phrase speech. Although Harry often used sentences that included several words, such as “Where are you going, Daddy?” or “I don’t want to go to school,” he did not use complex sentences that included multiple clauses (e.g., “I don’t want to go to school tomorrow because I am too tired”). Module 2 was selected as the appropriate module on the basis of Harry’s expressive language level.
Harry’s mother was present for the administration of Module 2 while Harry’s father met separately with another clinician to complete the parent interview portion of the research evaluation. A description of Harry’s social and communicative behavior during the ADOS-2 is provided in the excerpt from his evaluation report, presented next.
The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), Module 2 was administered to Harry for diagnostic purposes as part of a research protocol for a study of the genetics of autism. The ADOS-2 is a semi-structured, standardized assessment instrument that includes a number of play-based activities designed to obtain information in the areas of communication, reciprocal social interactions, and restricted and repetitive behaviors associated with a diagnosis of ASD. Module 2 of the ADOS-2 is designed for children with phrase speech whose speech is not yet “fluent” (that is, who are not yet consistently combining two relatively complex ideas together in sentences to talk about objects or events that are not present). Module 2 includes activities such as a construction task, interactive play with a family of dolls, a demonstration task, looking at a book and pictures, a pretend birthday party, bubbles, and a snack.
Harry was excited to transition into the more play-based tasks of the ADOS-2 from the cognitive tests that were administered first. He immediately began exploring the various toys that were set out for him. Harry’s language during the ADOS-2 consisted primarily of short phrases. He said things like, “It’s a cat,” as he was pointing to a picture of a cat on the music box, and “I like more,” and “I like two,” when he was requesting things. Harry sometimes echoed things that other people said, such as “Ooh, nice!” or “Alright.” At times, it was quite easy to understand what Harry was saying, but at other times his articulation made it difficult to understand him. He also occasionally mixed up his pronouns, such as saying, “You do it,” to mean that he wanted to do it. Harry had difficulty participating in conversational exchanges with the examiner. Although he was able to answer simple questions about familiar topics (e.g., How old are you? Do you have any pets?), he did not elaborate on his brief answers or ask questions of the examiner when provided opportunities to do so. This made it difficult to build a conversation with Harry.
Harry sometimes integrated his verbal communication with other modes of nonverbal communication, such as looking at the examiner, smiling, and saying, “Wow,” when he saw something he liked. At other times, he did not use eye contact when talking to people or interacting with them. Harry used a few gestures, such as pretending to brush his teeth when asked to teach this activity to the examiner and blowing a kiss to a baby doll when his mother prompted him to do so. He did not spontaneously use gestures at other times when communicating with the examiner or his mother.
In terms of Harry’s social reciprocity during the ADOS-2, he was sometimes quite interested in interacting with the examiner or his mother. He made a variety of overtures to ask for things and occasionally to express interest or draw attention to something that he was enjoying. Harry had a tendency to be repetitive when initiating interactions with other people, however, such as by saying the same phrase in the same way (e.g., saying “You do it, mommy?” with an exaggerated sing-song intonation to ask for permission). Harry also exhibited a strong interest in University of Michigan football, and he insisted on bringing up things about the football team, even when it was clear that the examiner was trying to change the subject.
While Harry was often responsive to the examiner’s attempts to talk to him or play with him, he showed less interest in social interaction when he was involved in repetitive play activities. At one point, Harry became very interested in putting small objects into a teapot, then dumping them out and starting over again. When the examiner tried to join Harry and put something into the teapot, he stomped and yelled, “No!” and took it out. On another occasion, Harry spent several minutes putting blocks into a box repetitively. He became quite distressed and frustrated when the examiner tried to interrupt him; he flapped his hands while protesting loudly.
Harry exhibited some imaginative play during the ADOS-2. He enjoyed the “Birthday Party” and spontaneously pretended to feed cake to the baby doll. He also rocked the baby doll in a blanket and hugged her as he pretended to put her to bed. Harry had more difficulty playing creatively with the family of dolls. He became so engrossed in playing repetitively with the teapot and the small objects that the repetitive play may have prevented him from using the objects in a more imaginative way.
Summary and Recommendations
Harry’s Overall Total score on the ADOS-2 Module 2 algorithm for children aged 5 years or older was consistent with an ADOS-2 Classification of autism. His ADOS-2 Comparison Score further indicated that, on the ADOS-2, he displayed a high level of autism spectrum–related symptoms as compared with children who have ASD and are of the same chronological age and language level. For the genetics research project protocol, diagnostic classification of the participants was based on the results of the ADI-R, the ADOS-2, and the clinical impression of the principal investigator (a developmental pediatrician experienced in ASD assessment and diagnosis). Harry’s scores on the ADI-R met cutoffs for autism as well. The senior research clinician reviewed Harry’s charts (including the results of cognitive testing), read the results of the ADI-R, watched a video of the ADOS-2 Module 2 administration, and met with the clinicians who conducted the parent interview and child assessment. On the basis of all of the available information, the clinician gave Harry an overall diagnosis of autism and assigned him to the ASD (as opposed to the non-ASD) diagnostic group in the genetics research project. Behavioral observations from the ADOS-2 were used to identify specific intervention targets for Harry’s speech therapy program, such as responding to others’ comments to improve conversational skills. The ADOS-2 was also important in highlighting that Harry’s interests were quite restricted, leading to the goal of increasing his variety of play behaviors.