Co-Occurring ADHD in Autistic Children

Comorbid ADHD in Autism

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders with onset of symptoms in early childhood. There is an overlap in the clinical presentation of ASD and ADHD with epidemiological studies indicating an increase in prevalence rates of ASD and ADHD over the past decade. Symptoms associated with both disorders often result in significant behavioral, social, and adaptive problems across home, school, and community settings  Research suggests that when ADHD is comorbid with ASD, the risk for increased severity of psychosocial problems increases. More severe externalizing, internalizing  and social problems, as well as more impaired adaptive functioning, have been reported in children with comorbid ASD and ADHD than children identified with only ASD.

Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that comorbidity between these disorders is relevant and occurs frequently. For example, studies conducted in the US and Europe indicate that children with ASD in clinical settings present with comorbid symptoms of ADHD with rates ranging between 37% and 85%. However, little is known, about comorbidity rates in nonclinical (community) populations of children. Consequently, there is a major need in the field of autism research to better understand how often clinically significant ADHD symp­toms co-occur with ASD in nonclinical populations, and whether the comorbidity of ADHD with ASD is related to differences in other behavioral characteristics.

 Current Research

A study published in the journal Autism examined rates of parent-reported clinically significant symptoms of ADHD in a community sample of school-aged children (4-8 years) with ASD. The researchers hypothesized that children with ASD and comorbid ADHD would exhibit a more severe behavioral phenotype than those with only ASD. Specifically, they speculated that the comorbid group would have lower cognitive functioning, greater delays in adaptive functioning, higher rates of internalizing problems, and more severe social impairment than children with only ASD when these groups were of similar age. Participants included a sample of 153 children 4 to 8 years of age, consisting of the following classification groupings: Non-ASD (n = 91), ASD-Only (n = 44), and ASD+ADHD (n = 18). Children were evaluated on measures of cognitive functioning, internalizing psychopathology, social functioning and autism mannerisms, and adaptive behavior.

 Results

Data analysis indicted significant between-group differences. Results revealed that mean scores were in the “healthy” range for the Non-ASD group, in the mild to moderately impaired range for the ASD-Only group, and in the severely impaired range for the ASD+ADHD group on measures of social functioning and adaptive functioning, representing a continuum of impairment across groups. Children with ASD and ADHD also had lower cognitive functioning than the ASD-Only group. There were no group differences in parent ratings of symptoms of internalizing psychopathology (mood and anxiety disorders), with none of the groups demonstrating elevated rates of internalizing problems. The researchers suggest that an explanation for this finding may be that symptoms of inattention or hyperactiv­ity may obscure symptoms of anxiety in younger school-aged children. In addition, internalizing problems may be difficult to distinguish in young children with ASD as they may not be aware­ of their internal emotional states and may have difficulty expressing their emotional condition to others due to their ASD-related communication impairment.

The overall results of this study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in comparison with children identified with only ASD. These findings suggest that ADHD comorbidity may constitute a distinctive subtype of ASD and that these children may be at higher risk of social impairment and adjustment problems. The findings are also consistent with other research reports of more severe social problems and maladaptive behav­iors in children with comorbid ASD and ADHD than children with only ASD.

                                                                              Implications 

The findings of the study have important implications for practitioners in health care, mental health, and educational contexts. Overall, 29% of children with ASD also exhibited clinically significant levels of ADHD. Although lower than rates in clinical samples, the rate of comorbid ADHD indicates that young school-age children with ASD should be assessed for ADHD. If clinically significant ADHD symptoms are identified, and social development does not appear to be responding to intervention, changes in the intervention pro­gram (e.g. intensity, strategies, and goals) may be required. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given. Thus, an assessment of ADHD characteristics should be included whenever inattention and/or impulsivity are indicated as presenting problems. It is imperative that practitioners recognize the high co-occurrence rates of these two disorders as well as the potential increased risk for social and adaptive impairment associated with comorbidity of ASD and ADHD. More research is needed to further clarify the behavioral characteristics of children with co-occurring ASD and ADHD so that specialized treatments and interventions may be designed to improve outcomes and quality of life for this subgroup of children. This is important because children who present with the two disorders may have a higher risk for sub-optimal outcomes and may benefit from different treatment methods or intensities than those with identified with only ASD.

Key References and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Colombi, C., & Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed Autism and ADHD. Autism Research and Treatment, 1-5. 

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Kuhlthau K., Orlich F., Hall T.A., et al. (2010). Health- Related Quality of Life in children with autism spectrum disorders: results from the autism treatment network. Journal of Autism and Developmental Disorders, 40(6), 721–729.

Loveland K. A., Tunali-Kotoski, B. (2005), The school age child with autism. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 247-287). New York: Wiley.

Murray M.J., (2010). Attention-deficit/hyperactivity disorder in the context of autism spectrum disorders. Current Psychiatry Reports, 12(5), 382–388.

Rao, P. A., & and Landa, R. J. (2014). Association between severity of behavioral phenotype and comorbid attention deficit hyperactivity symptoms in children with autism spectrum disorders. Autism, 18, 272-280.

Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children With Autism Spectrum Disorder. Pediatrics, 130, S91-97. DOI: 10.1542/peds.2012-0900G

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Gross Motor Skills in Children with Autism

Gross Motor Performance in Children with Autism

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in (a) social communication and (b) restricted and/or repetitive behaviors or interests that varies in severity of symptoms, age of onset, and association with other disorders. Although motor impairment is not a part of the diagnostic criteria for ASD, research suggests that many autistic children experience delays in motor development. Gross motor skills are fundamental skills necessary for movement competence and considered the basic building blocks for more complex motor skill development. When present, gross motor problems may interfere with performance in many developmental and functional domains across home and school contexts. Consequently, researchers are increasingly considering the importance of motor function in the assessment and treatment of children with ASD.

                                                                          Research

A study published in the Journal of Child and Adolescent Behavior focused on assessing the gross motor skill performance of 21 children with ASD (M=7.57 years) and 21 age matched typically developing children (M=7.38 years) using the Test of Gross Motor Development-2 (TGMD-2). The TGMD-2 is a norm and criterion-referenced test that measures performance of 12 gross motor skills. Scores are recorded on two subtests, locomotor subtest (run, gallop, hop, leap, jump, and slide) and object-control subtest (strike, dribble, catch, kick, throw, and roll), An overall gross motor quotient score (combination of all 12 gross motor skills) can also obtained. Scores are described as very superior, superior, above average, average, below average, poor, and very poor. The researchers hypothesized that children with ASD would show motor delays in overall gross motor quotient scores, and locomotor and object control standard scores when compared to their age matched typically developing peers as measured with TGMD-2.

                                                                           Results

Statistical analysis revealed a significant performance difference between children with ASD and typically developing children on the TGMD-2. For the locomotor subtest, 67% children with ASD received poor standard scores and 40% of scores were very poor. Approximately 60% children with ASD had poor standard scores and 33% of scores were very poor on object control skills. For overall gross motor quotient scores, 81% children with ASD were below 79 and classified as poor, and approximately 76% children scored below 70 and received very poor ratings. 

Children scoring at or below the 30th percentile were considered developmentally delayed as indicated in the Individuals with Disabilities Education Act (IDEA). Based on this criterion, 91% of children with ASD in the current study were considered developmentally delayed in terms of their gross motor skill performance and in need of early supportive interventions. In contrast, the majority of typically developing children’s standard scores (96%) fell in the average or higher range.

                                                                      Implications

The results of this study have several important implications for educators, therapists, and practitioners and the design of effective early intervention programs for children with ASD. For example, locomotion and object control skills are fundamental motor skills in which children interact with their environment and other children. Developing a therapeutic intervention that includes these gross motor skills may have a positive effect on children’s cognitive functioning, language development, social communicative skills, and contribute positively to daily life skills. Consequently, it is vital that we understand the gross motor performance of children with ASD. Finally, the significance of motor proficiency for autistic children should not be overlooked in assessment practice. Clinicians and practitioners should give increased attention to the assessment of motor skills and their impact on the adaptive behavior and well-being of children with ASD. A comprehensive discussion of assessment domains (e.g. communication, social, motor, sensory, academic) can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Liu T, Hamilton M, Davis L, ElGarhy S (2014) Gross Motor Performance by Children with Autism Spectrum Disorder and Typically Developing Children on TGMD-2. J Child Adolesc Behav 2: 123. doi:10.4172/jcalb.1000123

https://www.spectrumnews.org/news/motor-difficulties-in-autism-explained/

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

Evidence-Based Practice for Children with Autism

Evidence-Based Practice for Autism

Supporting children with autism spectrum disorder (ASD) requires individualized and effective intervention strategies. It is very important for families, teachers, administrators, and school-based support personnel to be knowledgeable about evidence-based approaches to adequately address the needs of students with autism and to help minimize the gap between research and practice. Although the resources for determining best practices in autism are more extensive and accessible than in previous years, school professionals face the challenge of being able to accurately identify these evidence-based strategies and then duplicate them in the classroom and other educational settings

The rapid growth of the scientific literature on ASD has also made it difficult for practitioners to stay up-to-date with research findings. Unfortunately, many proponents of ASD treatments make claims of cure or recovery, but provide little scientific evidence of effectiveness. These interventions appear in books and on websites that describe them as “cutting-edge therapies” for autism. Consequently, school-based personnel and families need to have a reliable source for identifying practices that have been shown, through scientific research, to be effective with children and youth with ASD. Evidence-based research provides a starting point for determining what interventions are most likely to be effective in achieving the desired outcomes for an individual.

Developing and implementing effective interventions and treatment for students with autism requires that they be evidence-based and supported by science. All interventions and treatments should be based on sound theoretical constructs, robust methodologies, and empirical studies of effectiveness. An evidence-based practice can be defined as a strategy, intervention, treatment, or teaching program that has met rigorous peer review and other standards and has a history of producing consistent positive results when experimentally tested and published in peer-reviewed professional journals. It excludes evidence that is supported by anecdotal reports, case studies, and publication in non-refereed journals, magazines, internet, and other media outlets.

Systematic Research Reviews

Systematic research reviews play an important role in summarizing and synthesizing the knowledge base for determining what interventions are most likely to be effective in achieving the desired outcomes for children and youth with ASD. There are two major resources available to professionals that provide a listing, along with systematic reviews, of evidence-based interventions and practices for students with ASD: the National Autism Center’s (NAC; 2015) second phase of the National Standards Project (NSP-2), which reviewed research studies to identify established interventions for individuals with ASD, and the National Professional Development Center on Autism Spectrum Disorders (NPDC on ASD, 2015; Wong et al., 2014), which also analyzed numerous research studies and identified evidence-based practices for students with autism. Although both reviews were conducted independently, their findings are very similar and reflect a convergence across these two data sources. According to the NAC and NPDC, the following are evidence-based interventions/practices for ASD:

Behavioral Interventions: These interventions are based on behavioral principles and are designed to reduce problem behavior and teach functional alternative behaviors.

Cognitive Behavioral Intervention: Cognitive behavioral interventions are designed to change negative or unrealistic thought patterns and behaviors with the goal of positively influencing emotions and life functioning.

Modeling: This intervention relies on an adult or peer providing a demonstration (live and video) of a target behavior to the person learning a new skill, so that person can then imitate the model.

Naturalistic Interventions: These interventions primarily involve child-directed interactions to teach real-life skills (communication, interpersonal, and play skills) in natural environments. Examples include incidental teaching, milieu teaching, and embedded teaching.

Parent-Implemented Intervention: Parents provide individualized intervention to their child to improve/increase a wide variety of skills such as communication, play, or self-help, and/or to reduce challenging behavior. Parent training can take many forms, including individual training, group training, support groups, and training manuals.

Pivotal Response Training (PRT): PRT is a naturalistic intervention model that targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations.

Peer-Mediated Instruction: Teachers/service providers systematically teach typically developing peers to interact with and/or help children and youth with ASD to acquire new behavior, communication, and social skills. Common names include peer networks, circle of friends, and peer-initiation training.

Scripting: This intervention involves developing a verbal and/or written script about a specific skill or situation which serves as a model for the child with ASD.

Self-Management: Self-management strategies involve teaching individuals with ASD to evaluate and record the occurrence/nonoccurrence of a target behavior and secure reinforcement. The objective is to be aware of and regulate their own behavior so they will require little or no assistance from adults.

Social Narratives: These interventions identify a target behavior and involve a written description of the situation under which specific behaviors are expected to occur. The most well-known story-based intervention is Social Stories™.

Social Skills Training: Social skills training involves group or individual instruction designed to teach learners with ASD ways to appropriately interact with peers, adults, and other individuals.

Visual Support: Any visual display that supports the learner engaging in a desired behavior or skills independent of prompts. Examples of visual supports include pictures, written words, schedules, maps, labels, organization systems, scripts, and timelines.

Systematic reviews synthesize the results of multiple studies and provide professionals with summaries of the best available research evidence to help guide decision-making and support intervention practice. It must be stated, however, that these ratings are not intended as an endorsement or a recommendation as to whether or not a specific intervention is suitable for a particular child with ASD. Because no two individuals are alike, no one program exists that will meet the needs of every person with autism. Additionally, children with autism learn differently than typical peers or children with other types of developmental disabilities. 

The success of the intervention depends on the interaction between the age of the child, his or her developmental level and individual characteristics, strength of the intervention, and competency of the professional. Each child is different and what works for one may not work for another. Research findings are only one component of evidence-based practice to consider when selecting interventions. The selection of a specific intervention should be based on goals developed from a comprehensive developmental assessment as well as professional judgment and the values and preferences of parents, caregivers, and the individual with ASD.

References

National Autism Center (2015). Findings and conclusions: National standards project, 

phase 2. Randolph, MA: Author.

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.

Adapted from Wilkinson, L. A. (2017).  A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

👉 Clickhere to read a free preview of “A Best Practice Guide…”

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools, and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Predictors of Aggression in Autism

Predictors of Aggression in Autism

Aggression is a clinically significant feature of many children and adolescents with autism spectrum disorder (ASD). Children with ASD frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. These co-occurring problems often exacerbate the core symptoms of ASD and can lead to significant functional impairment. Among these problems, physical aggression appears to be especially challenging, and has been associated with serious negative outcomes in both the general population and among individuals with ASD. For example, challenging behaviors can interfere with interventions and the child’s ability to succeed at school. They may cause a child to be excluded from community activities, such as after-school programs, scouting and sports. Fear of aggressive incidents may also keep families at home, increasing their sense of isolation and decreasing their quality of life.

                                                                                 Research

Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with ASD. Consequently, it is unclear whether findings from the general population are applicable to children and adolescents with ASD. In an effort to investigate the extent of the problem in children and adolescents with ASD, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. Participants in the study ranged in age from 2 to 17 years, with a mean age of 5.91 years. The term “aggression” referred specifically to physical aggression and included biting, hitting, or other physical aggression directed towards others. A number of diagnostic, medical, and behavioral measures were collected at enrollment and at regular follow-up intervals. Measures of interest included: (a) aggression, (b) sleep disturbance, (c) sensory problems, (d) communication and social functioning, (e) self-injury and gastrointestinal problems, (f) cognitive functioning, and (g) verbal/nonverbal status. Data analyses were completed in order to identify the variables most strongly associated with aggression.

    What are the Predictors of Aggression?

The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with ASD. The results also indicate that age-related decreases in aggression in children with ASD are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with ASD.

In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with ASD. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that children with ASD who demonstrate self-injury may be at risk for more severe behavioral problems.

Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with ASD, indicating may underlie (and exacerbate) aggressive behavior patterns for many children with ASD. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.

Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.

Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.

In terms of potential sex differences, the results indicate that girls and boys with ASD were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without ASD, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the ASD population.

 Implications

This study provides evidence that challenging behavior may be much more prevalent among children with ASD than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the ASD phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in children with ASD. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of ASD. Programs for children with ASD should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention.

More research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with ASD.  

References

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Hill, A.P., Zuckerman, K.E., Hagen, A.D., Kriz, D.J., Duvall, S.W., Santen, J., Nigg, J., Fair, D., & Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample. Research in Autism Spectrum Disorders, 8, 1121-1133.

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd Edition). London & Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Best Practice Review: The Autism Diagnostic Observation Schedule (ADOS)

Best Practice Review: ADOS

One of the most widely used observation instruments for the assessment of autism is the Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 2008). The ADOS is a semi-structured assessment of social interaction, communication, play, and imaginative use of materials for individuals who may have autism or an autism spectrum disorder (ASD). The goal of the ADOS is to provide a hierarchy of “presses” (social structures) that elicit behaviors in standardized contexts relevant to ASD.

The ADOS requires clinical training and practice in observation and scoring, as well as administering the standard activities. Clinical experience related to ASD and skill in working with children is recommended. It should be noted that the ADOS classification system does not assign a diagnosis. The ADOS has thresholds for social interaction, communication and communication-social interaction (total). An individual may reach the threshold on all three scales but not receive a clinical diagnosis of ASD, because of late presentation of difficulties or no restricted/repetitive behaviors or interests. The authors stress the importance of using the ADOS in conjunction with a developmental history, corroborating information from other sources, and the use of clinical judgment (Lord et al, 2008).

Administration and Scoring

The ADOS is standardized in terms of the materials used, the activities presented, the examiner’s introduction of activities, the hierarchical sequence of social presses provided by the examiner, and the way behaviors are coded or scored. The ADOS consists of four “modules,” each of which can be administered in 30-45 minutes. The appropriate module is selected and administered depending on the individual’s verbal ability. Module 1 is used for children who are preverbal or have single-word language. Module 2 is appropriate for individuals with phrase speech abilities. Module 3 is used for children and adolescents who are verbally fluent. Verbally fluent adolescents and adults are assessed with Module 4. More than one module can be administered if the examiner determines that a more or less advanced module is appropriate. The manual provides guidelines for selecting the most appropriate module and general instructions for administration and scoring and interpreting an individual’s results.

ADOS classifications are based on specific coded behaviors that are included in a scoring algorithm using the DSM-IV diagnostic criteria, resulting in a Communication score, a Reciprocal Social Interaction score, and a Total score (a sum of the Communication and Reciprocal Social Interactions scores). ADOS items regarding play and stereotyped behaviors are also coded but are not included in the diagnostic algorithm due to the difficulty in accurately assessing these characteristics in a limited period of time (Lord et al., 2008). Behaviors are coded using a 0- to 3-point coding system, with a 0 indicating that the behavior is not abnormal in the way specified in the coding description, 2 indicating a definite difference, and a 3 indicating that a behavior is abnormal and interferes in some way with the child’s functioning. Scores are compared with an algorithm cut-off score for autism or the more broadly defined ASD in each of these areas. If the child’s score meets or exceeds cut-offs in all three areas, they are considered to meet criteria for that classification on the measure. An ADOS autism classification requires meeting or exceeding each of the three thresholds (social, communication, social-communication total) for autism. If thresholds for autism are not met, an ADOS classification of ASD is appropriate when the three ASD thresholds are met or exceeded. In all cases, the ASD thresholds are lower for ASD than those of autism (Lord et al., 2001, 2008).

ADOS-2

The ADOS-2 is a revision of the original ADOS and like its predecessor is a semi-structured, standardized observational assessment tool designed to assess autism spectrum disorders in children, adolescents, and adults (Lord, Rutter, DiLavore, Risi, Gotham, & Bishop, 2012). The second edition includes updated protocols, revised algorithms, a new Comparison Score, and a Toddler Module. Administration and coding procedures for the ADOS-2 are functionally the same as those for the ADOS. One of five different modules (Modules 1, 2, 3, 4 or the Toddler Module) is chosen based upon expressive language level and chronological age. In Modules 1 through 4, algorithm scores are compared with cutoff scores to yield one of three classifications: autism, autism spectrum (ASD), or non-spectrum. In the Toddler Module, algorithms yield "ranges of concern" rather than classification scores. A new Comparison Score or severity metric for Modules 1 through 3 allows the examiner to compare a child's overall level of autism spectrum-related symptoms to that of children diagnosed with ASD who are the same age and have similar expressive language skills. 

Psychometric Properties

The psychometric data used in the derivation of the diagnostic algorithms were obtained from individuals diagnosed with autism, pervasive developmental disorder not otherwise specified (PDD-NOS), and non-spectrum disorders in order to maximize diagnostic agreement. Individuals with a diagnosis of Asperger’s Disorder were not included in the validation sample (Lord et al., 2008). The manual provides a range of sensitivity and specificity data across modules for Autism and ASD vs. non-spectrum disorders. The instrument has sensitivity in the upper 90% range and specificity in the upper 80% to lower 90% range (Lord et al., 2008). The ADOS was very effective in discriminating individuals with either autism or ASD from those with non-spectrum disorders, while differentiation of autism and ASD resulted in specificities of .68 to .79. Agreement between raters for diagnostic classification when assessing individuals with autistic disorder, ASD, and non-spectrum disorders ranged from 81% to 93% for the four modules. Internal consistency for all domains and modules ranged from .47 to .94. The lower results were found for stereotyped behaviors and restricted interests in module 3. Test-retest reliability indicates excellent stability for the “Social Interaction” and “Communication” domains, and for their combined total, together with good stability for the “Stereotyped Behaviors and Restricted Interests” over an average period of nine months. In total, there seems to be significant evidence for sensitivity and specificity for the ADOS in differentiating children with autism and ASD from children with non-spectrum disorders (Lord et al., 2001, 2008). When comparing the ADOS to the ADOS-2, sensitivity and specificity values appear largely comparable or improved with the new algorithms.

Research

Various studies have examined the effectiveness of ADOS as it is used in clinical practice. For example, Mazefsky and Oswald (2006) examined the diagnostic utility and discriminative ability of the ADOS using a clinical population of 75 children referred to a specialty diagnostic clinic over a 3 year time span. They reported 77% agreement between ADOS classification and team diagnosis, with most discrepancies being in autism versus ASD. The authors note that their results (lower sensitivity) likely reflect the participation of children who present for assessments in common clinical practice. In contrast, the symptom presentation of the children used in the original studies to develop the psychometric properties of the ADOS included “prototypical” representations of the disorders and excluded those with questionable diagnoses. This suggests that clinical expertise and experience with children with ASD is an essential supplement to the ADOS and other assessment instruments for the less “‘clear-cut” cases often seen in typical practice.

A current study also investigated the diagnostic validity of the ADOS in a clinical sample (Molloy, Murray, Akers, Mitchell, & Manning-Courtney, 2011). ADOS classifications were compared to final diagnoses given to 584 children referred for evaluation for a possible ASD in a children’s medical center. Sensitivities were moderate to high on the algorithms, while specificities were substantially lower than reported in the original ADOS validity sample. The authors concluded that the higher number of false positives was likely attributable to the composition of their clinical sample which included many children with a broad range of developmental and behavioral disorders. The results of this study also suggest that clinical populations for which the ADOS is regularly used may be substantially different from the research samples on which it was normed. As a result, it is especially important that the ADOS not be used as a “stand-alone” assessment so as to minimize misclassification in clinical settings where there are children with many other developmental or behavioral disorders.

The role of the ADOS in the assessment of ASD in school and community settings has received attention as well. The perceived advantages and disadvantages of the ADOS were examined via a national survey of practicing school and clinical psychologists (Akshoomoff, Corsello, & Schmidt, 2006). Perceived advantages of the ADOS included its strength in capturing ASD-specific behaviors and the standardized structure provided for observation, while diagnostic discrimination and required resources were the most commonly identified disadvantages. Respondents listing advantages of the ADOS indicated that it captured ASD behaviors, both generally and specifically, and that it was a good measure for identifying behaviors that are difficult to observe or probe in other situations. Respondents indicated that a disadvantage of the ADOS is that it tends to over classify other diagnostic groups as ASD and does not discriminate well within ASD subgroups. Of those that indicated resources as a disadvantage, nearly all indicated time of administration as a disadvantage.

Conclusion

The Autism Diagnostic Observation Schedule (ADOS) is one of the few standardized diagnostic measures that involves scoring direct observations of the child’s interactions and accounts for the developmental level and age of the child. It has the most empirical support among observation-based diagnostic assessment procedures for autism and is recommended in several best practice guidelines as an appropriate standardized diagnostic observation tool (National Research Council, 2001; Wilkinson, 2016). The ADOS offers the practitioner a standardized observation of current social-communicative behavior with excellent interrater reliability, internal consistency and test–retest reliability on the item, domain and classification levels for autism and non-spectrum disorders. Psychometric properties reflect consistent differentiation of autism and ASD from non-spectrum individuals, with less reliable differentiation of autism from ASD (Lord et al., 2001, 2008).

Practitioners should consider the following points when using of the ADOS in clinical and school settings.

1. It is important to distinguish between an ADOS classification and an overall diagnosis of autism. The ADOS is intended to be but “one source” of information used in making a diagnosis of ASD. Because coding is made from a single observation, it does not include information about onset or early developmental history. ADOS algorithms include items coding social behaviors and communication but do not offer an adequate opportunity to measure restricted and repetitive behaviors (though such behaviors are coded if they occur). This means that the ADOS alone cannot be used to make complete standard diagnoses (see Wilkinson for a description of assessment domains and recommended measures).

2. The goal of the ADOS is to provide standardized contexts in which to observe the social-communicative behaviors of individuals across the life-span in order to assist in the diagnosis of autism and other ASD. It provides information only on current behavior and was not developed to measure changes over time. Therefore, the ADOS domain or total scores are not a good measure of response to treatment or of developmental gains, especially in the later modules (Lord et al., 2008).

3. The usefulness of the ADOS is related to the examiner’s clinical skills and experience with the instrument. Training and practice in administering the activities, scoring, and observation is required. The ADOS should be administered by an experienced clinician with appropriate training who can use both quantitative and qualitative information to form a clinical impression from the standard activities.

4. Studies suggest that clinical populations for which the ADOS is used may be substantially different from the research samples on which it was normed. As the authors caution, the instrument is not meant to be used as a “stand-alone” assessment. Supporting information from a developmental history, additional observational information or a detailed parent interview are needed for a comprehensive diagnosis. This is especially important in any clinical and school settings where children with various other developmental or behavioral disorders are referred and evaluated.

5. Agreement between clinical diagnostic decisions and standardized diagnostic measures is difficult for children with less typical presentations of autism. As a result, diagnostic measures are likely to have difficulty with specificity and sensitivity for children with ASD on the higher end of the spectrum. Further research on the ADOS is needed with a broader range of children typically seen in clinical and school settings.

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

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References and Further Reading

Aiello, R., Ruble, L., & Esler, A. (2017). National Study of School Psychologists’ Use of Evidence-Based Assessment in Autism Spectrum Disorder. Journal of Applied School Psychology, 33(1), 67-88. DOI: 10.1080/15377903.2016.1236307

Akshoomoff, N, Corsello, C., & Schmidt, H. (2006). The role of the Autism Diagnostic Observation Schedule in the assessment of autism spectrum disorders in school and community settings. The California School Psychologist, 11, 7-19.

Campbell, J. M., Ruble, L. A., & Hammond, R. K. (2014). Comprehensive Developmental Approach Assessment Model. In L. A. Wilkinson (Ed.), Autism spectrum disorders in children and adolescents: Evidence-based assessment and intervention (pp. 51-73). Washington, DC: American Psychological Association.

Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P C, et al. (2000). The Autism Diagnostic Observation Schedule-Generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30, 205-223.

Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (2008). Autism Diagnostic Observation Schedule Manual. Los Angeles: Western Psychological Services.

Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule, second edition. Torrance, CA: Western Psychological Services.

Mazefsky, C.A., & Oswald, D.P. (2006). The discriminative ability and diagnostic utility of the ADOS-G, ADI-R, and GARS for children in a clinical Setting. Autism, 10, 533–49.

McCrimmon, A. & Kristin Rostad, K. (2014). Test Review: Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) Manual (Part II): Toddler Module. Journal of Psychoeducational Assessment, 32, 88–92.

Molloy, C. A., Murray, D. S., Akers, R., Mitchell, T., & Manning-Courtney, P. (2011). Use of the Autism Diagnostic Observation Schedule (ADOS) in a clinical setting. Autism, 15, 143-162.

National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press.

Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2005). Evidence-based assessment of autism spectrum disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 523–540.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London & Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L.A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools, Second Edition. London & Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© Lee A. Wilkinson, PhD

Autism Books for Adults

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Honored as an Award-Winning Finalist in the “Health: Psychology/Mental Health” category of the 2016 Best Book Awards, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT is an essential self-help book for adults on the higher end of the spectrum looking for ways to understand and cope with their emotional challenges and improve their psychological well-being. Family members, friends, and others touched by autism will also find this self-help book a valuable resource.

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Lee A. Wilkinson, PhD is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT, both published by Jessica Kingsley Publishers. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).