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Using the ADOS to Aid in the Diagnosis of "Fuzzy" Autism Spectrum Cases

Julia Szarko, Ph.D. School Psychologist Central Bucks School District

[email protected]

March 4, 2010 NASP 2010 Annual Convention

Today's Schedule

· · · · ·

Issues with Diagnosis of Autism Autism Diagnostic Recommendations ADOS Show and Tell Case Studies Questions and Discussion

Diagnostic Assessments for Individuals with ASD

· Presentation sponsored by PA Dept of

Public Welfare · Autism Diagnostic Workshop ­ presented by UPMC, Western Psychiatric Institute and Clinic (2007) · Presented recommendations by PA Assessment and Diagnostic Expert Workgroup (2006)

Diagnostic Issues

· 75 to 88 percent of children with Autistic Disorder

show signs of this condition in the first two years of life, with 31 to 55 percent displaying symptoms in their first year (Young & Brewer, 2002). · Intensive early intervention results in improved outcomes for children with ASD (Ozonoff & Rogers, 2003; Rogers, 2001; Rogers, 1998) · Consensus that such early intensive intervention is essential (Mastergeorge, Rogers, Corbett, & Solomon, 2003).

Delay in Diagnosis

· United Kingdom survey revealed the average age of diagnosis for

children with Autistic Disorder was about 5.5 years of age (Howlin & Asgharian, 1999). It is also not unusual for children with milder forms of ASD (i.e., Asperger's Disorder) to go undiagnosed until after school entry. Among this group the average age of diagnosis has been reported to be 11 years of age.

· Research has suggested that school psychologists (especially

those working in rural settings) have difficulty recognizing autism and distinguishing it from other exceptionalities (Spears, Tollefosn, & Simpson, 2001).

Howlin and Moore (1997)

Parents who received an early diagnosis were more satisfied with the diagnostic process than parents who wait longer Parents who received clear cut diagnosis of Autism or Asperger's syndrome were more satisfied with the diagnostic process than parents receiving a more vague diagnosis of autistic traits, features and tendencies

Initial parent concerns: Communication abnormalities (40%); Social Development (20%)

Receipt of Formal Diagnosis: 8% on the first visit, 40% after referral to see 2nd professional, majority after 3rd visit with professional 49% parents surveyed unsatisfied with the process of evaluation

Thirteen Month Delay Between Evaluation and Autism Diagnosis in Children (CDC Medial Relations-press release, May 10th 2006)

Journal of Developmental and Behavioral Pediatrics - Autism supplement (April, 2006)

Children diagnosed in metropolitan Atlanta: initially evaluated at an average of 4 years; not diagnosed with an ASD until an average of 5-1

Children with more severe symptoms of Autism evaluated and diagnosed almost two years sooner that children with milder forms

76% of children diagnosed with an ASD were identified at medical facilities such as clinics and hospitals, 24% were identified at schools.

70% of healthcare professionals did not use a standardized diagnostic instrument when assigning the first ASD diagnosis PA data: significant disparity in age of diagnosis according to race. Study reported poor white children received a diagnosis at age 6.3 years and poor black children at 7.9 (Mandell, Listerud 2002)

Recommendations of the workgroup

Appropriate evaluation requires a multidisciplinary team approach that examines multiple domains of functioning and provides a Profile of the child's strengths and weaknesses. The standard of care for an autism evaluation should include three stages: conduct a medical and developmental history; completing a comprehensive developmental evaluation that addresses cognitive, language, adaptive, play, affective, sensory, behavioral and motor skills; and for uncertain cases,a specialized diagnostic evaluation, completed by a highly skilled clinician, using gold standard tools Information from all stages of the evaluation must be integrated into recommendations for intervention or educational programming

PA diagnostic workgroup Algorithm


Parental, clinician or care provider concerns ·High Risk status ·Red Flags


Confirm concerns of ASD Obtain demographic information Early Intervention/Special Education Involvement: 1) Confirm or refer 2) Ensure coordination 3) Follow up

Comprehensive Evaluation

Stage 1

Collect referral, historical & Initial assessment information ·Trained intake staff ·Records review ·Interviews ·Checklist / Questionnaires

Consistent with ASD?

Monitor as needed

Stage 2

Conduct comprehensive developmental Evaluation

Trained team of clinicians Stage 1 data Observations Developmental Assessments ASD specific Assessments Medical Assessments

ASD diagnosis Confirmed?

Stage 3

Conduct specialized Diagnostic Evaluation Qualified / highly trained clinician(s) Stages 1&2 data Natural environment observation Specialized evaluation tools (i.e.,ADOS,ADI-R, FBA)

·Curriculum based assessments to intervention Plan ·Monitor

Stage 1

· Stage 1 of the autism evaluation process


­ ­ ­ ­ review of the child's records interviews with parents observations of the child administration of various evaluation measures

· May recommend additional (brief) autism-specific questionnaires (e.g.,

Modified Checklist for Autism in Toddlers (M-CHAT), Social Communication Questionnaire, or others). · Based on the information from Stage 1, the evaluation team will determine what type of Comprehensive Developmental Evaluation is appropriate (more specific investigation of ASD?)

· Behavioral History

­ ­ ­ ­ ­

Stage 1

Social skills and Peer interaction Play skills Repetitive behaviors/routines Sensory issues Problem behaviors-inattention, hyperactivity, self-stimulation /others

· Examples of Instruments

­ CBCL (subscales of withdrawal, DSM related subscales) ­ M-CHAT (children 18-30 months) ­ Social Communication Questionnaire (children over age 4 years, language age over 2 years) ­ Autism Spectrum Rating ScalesTM (15 item screener)

· Provides a thorough developmental diagnostic

evaluation, that includes a summary of the child's strengths and weaknesses · Results and observations may support whether the child is at risk or meets criteria for an Autism Spectrum Disorder · Results of the evaluation guides recommendations and selection of appropriate interventions

Stage 2

Stage 2

· Examples of instruments:

­ Emotional/Behavioral (Broad Band) · BASC-II · CBCL ­ Social (Narrow Band) · Autism Spectrum Rating ScalesTM (Goldstein, Naglieri) · Childhood Autism Rating Scale · Gilliam Autism Rating Scale - 2 · Social Communication Questionnaire · Social Responsiveness Scale

Stage 3

· Only necessary for children whose diagnostic status is still

unclear at the end of Stage 2 or when the treatment team would like further clarification of the child's strengths and weaknesses to help guide treatment. · May be conducted by a single clinician who has specialized training in formal diagnostic evaluations (e.g., a licensed psychologist, developmental/ behavioral pediatrician or child psychiatrist) and extensive clinical experience. · The team of clinicians should be led by or supervised by a physician or psychologist licensed in Pennsylvania to make a diagnosis of autism.

Stage 3

· Often involve administration of very

specialized instruments such as the ADI-R (Autism Diagnostic Interview-Revised) and the ADOS (Autism Diagnostic Observation Schedule). · Caution must be taken to assure appropriate training and supervision of personnel who will administer these complex tools. · The evaluation should include observation of the child and family in different settings.

Autism Diagnostic Observation Schedule (ADOS)

(Lord, Rutter, DiLavore, & Risi, 1999a, 1999b)

· Considered to be part of the "gold standard" in the

diagnosis of ASD. · Standardized, semi-structured interactive play assessment of social behavior. · Makes use of "planned social occasions" that facilitates observation of the social, communication, and play or imaginative use of material behaviors related to the diagnosis of ASD.

Autism Diagnostic Observation Schedule (ADOS)

Autism Diagnostic Observation Scale The ADOS consists of four modules. · Module 1 is designed for individuals who are preverbal or who speak in single words, · Module 2 for those who speak in phrases, · Module 3 for children and adolescents with fluent speech, · Module 4 for adolescents and adults with fluent speech. · Administration of the ADOS requires 30 to 45 minutes and provides social-communication sequences that involve "presses" for particular social behaviors. Because its primary goal is accurate diagnosis, the authors suggest that it may not be a good measure of treatment effectiveness or developmental growth (especially in later modules). · Psychometric data indicates substantial interrater and testretest reliability for individual items, and excellent interrater reliability within domains and internal consistency

Case Studies: ASD Upon Reevaluation

· Speech and Language Impairment · Emotional Disturbance · Specific Learning Disability

Case Studies: Ruling Out ASD

· Selective Mutism · Emotional Disturbance · Specific Learning Disability


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