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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: [email protected] Facebook:
Facebook.com/BresslerMGH
Web Link: http://www.massgeneral.org/psychiatry/services/autism_conditions.aspx
