Diagnostic Role of Autism Diagnostic Observation Schedule (ADOS) in Clinic Settings...

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Diagnostic Role of Autism Diagnostic Observation Schedule (ADOS) in Clinic

Settings: Strengths and Limitations

Karmen Koesterer, EdM, MA

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Disclosures

Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

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Autism Diagnostic Observation

Schedule (ADOS-2)

•Semi-structured interview/ schedule of activities – Designed to facilitate social interactions and demonstration of social

communicative skills

•Modules: Toddler, 1, 2, 3, & 4 – Selected based on approximate age and language level

•Subjective interviewer rated items – Scores of 0, 1, 2, 3; higher scores are more characteristic of ASD

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Pros & Cons of ADOS-2

• Direct, standardized observations

• Allows for examiner judgment

• Captures in vivo interaction quality

• Items are rated by trained evaluator

• Difficult to obtain training and supervision

• Subjectivity in rating • Limited amount of

time to capture symptoms

• Does not consider history or self report

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Mod 4 Original Validation Sensitivity = 90, Specificity = 93

Autism Non-autism ASD Non-spectrum

N 16 [177] 14 [170] 15 [90]

Communication Total

Mean (SE) 5.06 (1.91) [3.85 (1.58)] 3.21 (1.25) [2.85 (1.45)] 0.67 (1.54) [1.32 (1.34)]

Range 2-8 [0-8] 1-5 [0-6] 0-6 [0-6]

Social Interaction Total

Mean (SE) 10.31 (2.55) [8.38 (2.63)] 7 (2.6) [6.5 (2.49)] 1.13 (1.77) [3.09 (2.5)]

Range 3-14 [3-14] 4-11 [0-14] 0-6 [0-11]

Stereotyped Behavior and Restricted Interests

Mean (SE) 1.94 (1.48) [1.75 (1.55)] 1.07 (1.49) [0.91 (1.0)] 0.2 (0.56) [0.33 (0.65)]

Range 0-5 [0-8] 0-5 [0-4] 0-2 [0-3]

Adapted from: Lord, Rutter, DiLavore, Risi, Gotham, & Bishop (2012) (p. 240)

[Adapted from: Hus & Lord (2014) (p. 24)]

[Mod 4 Reanalysis Sensitivity = 89.6, Specificity = 72.2]

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Reanalysis of Mod 4 Algorithm Hus, & Lord (2014)

N= 393, 437 Cases

• Communication

Domain: 4 items

(max. score = 8)

– Scores of 2-4 were

most common (about

23% each)

– Scores of 7-8 were

rare (2.9%)

1. Stereotyped Language:

score 1 in about half of

cases

2. Conversation: score 1 in

about half of cases

3. Descriptive Gestures:

>50% scored 0

4. Emphatic Gestures: score

1 in about half of cases

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Reanalysis of Mod 4 cont.

• Social Interaction

domain: 7 items (max.

score = 14)

– Scores of 6-8 were most

frequent (12-16% each)

– <9% received scores of

12-14

1. Eye Contact

2. Facial Expressions: score of

1 in about 70%

3. Comments on Empathy

4. Responsibility score of 1 in

about 40%

5. Quality of Social Overtures:

score of 1 in about 70%

6. Quality of Social Response:

score of 1 in about 70%

7. Amount of Reciprocal

Social Communication

score of 1 in about 40%

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Reanalysis of Mod 4 cont.

• IQ was weakly but significantly correlated

with algorithm totals

–Verbal IQ r = -.28; n = 324; p<.001

–NV IQ r = -.21; n = 314; p<.001

–Correlations were reduced when those

with IQs < 70 were removed (r = -.17 & -

.09 for VIQ and NVIQ)

–No significant correlation when sample

was restricted to IQs >85

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9

McLean HOSPITAL

Harvard Medical School

Massachusetts General Hospital

Massachusetts Institute of Technology

GAGAN JOSHI, MD

Director, Autism Spectrum Disorder Program Massachusetts General Hospital Assistant Professor of Psychiatry Harvard Medical School Boston, Massachusetts USA

ASD & Associated

Psychopathology

ASD D IAGNOSTIC SCL

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MGH AUTISM SPECTRUM DISORDERS DSM-IV DIAGNOSTIC SYMPTOM

CHECKLIST©

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MGH AUTISM SPECTRUM DISORDER DSM-5 DIAGNOSTIC SYMPTOM CHECKLIST©

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Demographics

Total Participants 84

Age (years)

Mean (Range) 21.8 ±9.6 (8-57)

Adults (≥18) 50 (60%)

Youth (<18) 34 (37%)

Pre-adolescents (≤12) 9 (11%)

Gender

Male 65 (77%)

Female 19 (23%)

Values expressed as N (%)

or Mean ±Standard

Deviation

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Results

ASD+

ADOS+

ASD+

SRS+

[≥Moderate severity]

ASD+

Structured Interview+

[KSADS]

Sex

Male 58 (89%) 41 (68%) 23 (100%)

Female 14 (74%) 14 (70%) 10 (100%)

Age

≥18 years 39 (83%) 26 (57%) N/A

<18 years 33 (89%) 29 (88%) 33 (100%)

IQ

<85 6 (100%) 6 (100%) 4 (100%)

>115 26 (87%) 21 (78%) 10 (100%)

Values expressed as

N (%) or Mean

±Standard Deviation

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MASSACHUSETTS GENERAL HOSPITAL

!MEDICAL SCHOOL

!

D S M - b a s e d A S D D i a g n o s t i c S C L

ASD by

DSM based ASD Dx SCL

(N=123)

95%

(117/123)

ASD by SRS Screen-positive for ASD

(T-score ≥60)

(N=117)

Sensitivity=95%

Concurrent Validity Diagnostic Correspondence with

SRS

95%(117/123) of the

ASD diagnosed by ASD

Dx.SCL

also SRS screen+ for

ASD (T-score≥60)

Excellent diagnostic agreement of ASD Dx SCL with SRS

ASD Diagnosed by

DSM-based ASD Dx SCL

(N=83)

86%

(71/83)

ASD Dx by

ADOS (ADOS+ASD)

(N=71)

Diagnostic Correspondence

=86%

71/83 of the

clinically diagnosed

subjects with ASD

(CDI+ASD)

also met criteria for

ASD on the ADOS

Diagnostic Correspondence with

ADOS

Acceptable agreement of DSM-based ASD Dx.SCL with ADOS

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MASSACHUSETTS GENERAL HOSPITAL

!MEDICAL SCHOOL

!

D S M - b a s e d A S D D i a g n o s t i c S C L

ASD by

DSM based ASD Dx SCL

(N=123)

ASD by

SRS (SRS+ASD; screen-positive=T-score ≥60)

(N=117)

95%

(117/123)

Sensitivity=95%

95%(117/123) of the ASD diagnosed by

ASD DxSCL+

also SRS screen positive for ASD (T-

score≥60)

Excellent diagnostic agreement of

ASD Dx SCL with SRS

Concurrent Validity:

Diagnostic Correspondence with SRS Screen-

positive ASD

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MASSACHUSETTS GENERAL HOSPITAL

!MEDICAL SCHOOL

!

D S M - b a s e d A S D D i a g n o s t i c S C L

ASD Diagnosed by

DSM-based ASD Dx SCL

(N=83)

Acceptable agreement of DSM-based ASD Dx SCL with ADOS

ASD Dx by

ADOS (ADOS+ASD)

(N=71)

86%

(71/83)

71/83 of the clinically diagnosed subjects with ASD

(CDI+ASD)

also met criteria for ASD on the ADOS

Diagnostic Correspondence=86%

Concurrent Validity:

Diagnostic Correspondence with ADOS

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ADOS Negative Age Group (years) Gender IQ ASD-SCL ASD +

SRS+

KSADS

Pre-adolescent (9) Female N/A SCD + PDD-NOS

Youth (15) Female 102 ASD + Autistic

Youth (16) Female 135 ASD + PDD-NOS

Adult (23) Female 102 ASD + N/A

Adult (52) Female 88 AuD + N/A

Pre-adolescent

(11)

Male 109 ASD + PDD-NOS

Adult (20) Male 102 AuD N/A N/A

Adult (27) Male 116 ASD + N/A

Adult (30) Male 122 AuD - N/A

Adult (30) Male 122 AuD - N/A

Adult (55) Male 113 AsP + N/A

Adult (57) Male 114 AsP - N/A

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Conclusions

•Utility of ADOS-2 in clinical setting

•Utility of other screening tools (SRS)

•Utility of ASD Diagnostic Symptom Checklist (SCL)

–Pros-Cons

–Use with high functioning individuals

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T h e A l a n a n d L o r r a i n e B r e s s l e r

C l i n i c a l a n d R e s e a r c h P r o g r a m

for Aut ism Spect rum Disorder

Massachusetts General Hospi ta l

Boston MA

Joseph Biederman, MD

Janet Wozniak, MD

Atilla Ceranoglu, MD

Lynn Grush, MD

Amy Yule, MD

Carrie Vaudreuil, MD

Robert Doyle, MD

A c k n o w l e d g m e n t s

Yvonne Woodworth, BA

Daniel Kaufman, BS

Ryan Kilcullen, BA

Abigail Belser, BA

Philia Henderson, BA

Stefani Callinan, BS

Melissa De Leon

Sheeba A. Anteraper, PhD

Kaustubh R. Patil, PhD

Stephen Faraone, PhD

Ronna Fried, EdD

Karmen Koesterer EdM, MA

Maura Fitzgerald, MA

Maribel Galdo, LCSW

Phone: (617) 726-7899 Email: MGHASDprogram@Partners.org Facebook:

Facebook.com/BresslerMGH

Web Link: http://www.massgeneral.org/psychiatry/services/autism_conditions.aspx