SECTION A: PERSISTANT IMPAIRMENT IN SOCIAL INTERACTIONS ACROSS MULTIPLE SETTINGS

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1 Please place a checkmark ( ) in the box for each behavior, based on whether it describes this child/adolescent, never or rarely (0), sometimes (1), often (2), or almost always (3) Key to scoring items: 0 Not present; no problem; normal appearing 1 Mildly abnormal, occurs infrequently (not stigmatizing) 2 Moderately abnormal, occurs moderately often (noticeable) 3 Severely abnormal, occurs far more than normal (can t be ignored; highly stigmatizing) Never or Rarely: No problem 0 Sometimes: small problem 1 Often: big problem 2 Almost always: severe problem 3 SECTION A: PERSISTANT IMPAIRMENT IN SOCIAL INTERACTIONS ACROSS MULTIPLE SETTINGS A1. Impairment in reciprocal social interactions (a) Abnormal social approach and inability to engage in reciprocal conversations Examples: odd greetings; misses that others have different feelings/emotions; needs to talk about specific topics of interest with little awareness of others wants/needs; lack of give-andtake in interactions (b) Limited interest in sharing others interests, emotions, or affect Examples: limited interactions with others; little showing, sharing; displays little recognition of others emotions _ (c) An inability or apparent disinterest in initiating or responding to social interactions Examples: fails to initiate social interactions; doesn t respond to overtures; isolated, parallel play or lack of cooperative play after 3rd birthday _ A2. Impairment in nonverbal communication during social interactions. (a) Code here if the child is verbal, but unable to integrate speech with gesture and/or other nonverbal forms of communication (i.e., eye contact, facial expression and body language) [if the child is nonverbal, please assign a score based on remaining forms of communication described here.] Examples: inability to integrate eye contact, facial expression, or gesture with speech when communicating; exaggerated gestures with speech can be coded here if out of social context; 1

2 _ (b) Atypical eye contact/body language, or minimal use of gestures Examples: brief fleeting eye contact; gaze aversion; lack of or deficits in nonverbal communication; body language out of sync with verbal exchanges; minimal pointing to reflect desires; lack of conventional gestures like head nodding for yes or shaking for no, or waving goodbye, hugging, etc. Other (c) Inability to express emotion; or facial expressions/nonverbal communication are inappropriate for social context Examples: flat affect; few facial expressions (or one expression consistently); facial expressions and nonverbal communication out of social context Other A3. Difficulty in understanding relationships; deficits in the development and maintenance of friendships (a) Inability to adjust behavior to fit in the social context Examples: missing social cues; inability to grasp social customs (b) Difficulties in sharing in imaginative play Examples: inability to engage in imaginative play or role play; difficulty engaging in joint interaction; only play with causeand-effect toys (e.g., pop-up toys) or repetitive play with toys; scripted play Other (c) Appears to be uninterested in children his/her own age Examples: prefers to be alone; uncomfortable with or dislikes interacting with children his/her own age; dislikes children of the same age; keeps a distance from them; prefers to associate with younger or older children or adults SECTION B: RESTRICTED INTERESTS/ACTIVITIES AND REPETITIVE PATTERNS OF BEHAVIOR B1. Stereotyped motor movements, repetitive use of objects or speech 2

3 (a) Simple motor stereotypies Examples: hand or arm flapping; hand posturing; body rocking; head nodding; waving objects, opening and closing cupboards repeatedly; turning lights on and off repeatedly etc. (b) Insistence that toys/preferred items are displayed in a certain pattern Examples: lining up toys by shape, color, or displaying them in a certain pattern (triangle; circle) (c) Echolalia Examples: immediately repeating others speech; delayed reciting of previous video passages (e.g., movies, commercials), or songs; or repeats previous conversations (d) Idiosyncratic speech Examples: reversed pronouns; made-up words; nonfunctional speech; mechanical speech; monotone; little inflection in voice; high-pitched; low whispered voice B2. Need for sameness, must adhere to routines, engages in ritualized patterns of behavior (verbal and nonverbal) (a) Becomes upset when small changes occur Examples: becomes upset or irritated if toys or preferred items out of order; backpack is rearranged; bedroom is rearranged (b) Difficulty with transitions, changing activities Example: unable to move easily from one activity to another; gets stuck on preferred activities; inflexible; rigid (c) Rigid, with inflexible thought patterns Example: tends to dominate conversations with preoccupations; must finish his/her thought; if interrupted cannot move on; must do things same way even if shown an easier way 3

4 (d) Ritualized way of talking/speaking Examples: greets others in same way with the expectation of a particular response; inability to move on if the expected response is not provided (e) insists on taking the same route in the car/bus, or insists on eating only preferred foods Example: detour to school or grandma s house causes anxiety or upset; new foods introduced cause distress B3. Narrow, fixated, interests with abnormal intensity of focus (a) Strong need to carry unusual objects with him/her Examples: string, sandpaper, sandwich bags, candy wrappers, wire, upset if object not available (b) Narrow circumscribed interests, or unusual objects on which the child perseverates Examples: train schedules; maps; weather reports; garage doors; drainpipes; string; parts of videos or audio recordings; B4. Over-reactive or under-reactive to sensory input or unusual interest in sensory aspects of environment (a) Under-reactive to certain stimuli (not sensitive) Examples: high pain or cold tolerance (seemingly unaffected) (b) Over-reactive to specific stimuli (sensory sensitivity) Examples: overly sensitive to certain sounds, such as vacuum cleaner, babies crying, self-flushing toilets, or automatic hand dryers; sights, such as bearded men; touch, such as tags in 4

5 clothing (c) Need to smell or touch objects Examples: sniffs toys and play materials, or others hair; touches certain surfaces or textures; run hands over table legs; touches parts of others bodies (e.g., mother s legs or hose) (d) Visual Inspection/Peering Examples: peers through fingers at light fixture; peers into shadows in the corners of room; peers at objects spinning (wheels; disks; tops); lines things up visually (e.g., lowers eyes to table height to scan things horizontally); watches things fall repeatedly (e.g., dirt, feathers, foam rubber) SECTION C: LEVEL OF SUPPORT FOR SECTION A (Social Interactions/Communication) AND B (Restricted and Repetitive Behaviors) Key to scoring need for support: 0=No supports necessary (symptoms manageable) 1=Minimal supports in place (may need OT, a ST, b social skills training) 2=Moderate supports in place (may need I.E.P c., for behavior, speech and occupational therapies, shared aide) 3=Maximum supports in place (one-on-one aide; home ABA) No Support (0) Minimal Support (1) Moderate support (2) Maximum support (3) (a) Social (friendships; peers) (b) Academic/occupational (school; work) (c) Community (church; restaurants; groups; clubs) a Occupational therapy; b Speech therapy; c Individual Educational plan 5

6 Scoring Algorithm Date: / / Symptoms Severity Mean Social Deficits Social Symptoms Present (Count: range 0-9) Sum of Social Symptom Severity (Range 0-27) Mean Symptom Severity (Sum/9: Range 0-3) Restricted Patterns of Interest Restricted Patterns Symptoms present (Count: Range 0-15).. Sum of Restricted patterns Symptom Severity (Range 0-45) Mean Restricted Patterns Severity (Sum/15: Range 0-3) A. Autism Symptom Count (Sum of A&B) B. Weighted Severity Mean (Sum of Mean A & B/2) C. Impairment Index (Support Required: Range 0-9).... 6

7 Description The OSU Autism Rating Scale DSM-5 (OARS-5) was developed to provide three types of summary scores: (A) a Autism Symptom Count, based on clinical interview; (b) a Weighted Mean Severity score based on severity of autism symptoms, derived from the clinical interview; (c) and an Impairment Index ranging from 0 to 9, based on the level of supports needed due to severity. In addition, we developed a Clinical Global Impression Scale based on the well-known NIMH CGI scale. This also has summary scores: (a) A global severity scale for autism spectrum disorder (ASD) and (b) an improvement scale for ASD. How to Rate The OARS-5 contains the signs and symptoms of autism spectrum disorder described in the Diagnostic and Statistical Manual of Mental Disorders 5 th Edition (DSM-5). These should be rated with the degree of impairment the patient/client experiences for the given symptom. Generally, the symptoms should be elicited in a semi-structured interview with the patient s/client s primary caregiver. We estimate the interview at about 30 minutes (the first interview may take longer). While scoring, try to take both frequency/duration and degree of impairment into account as well as how much the item interferes with relationships, learning, and/or activities of daily living and how much extra support is needed. Thus, rituals or preoccupations that severely interfere with most attempts to transition or that are present most of the time should be scored 2 or 3. Conversely, a ritual or preoccupation that is very mild, occupies little time, and interferes only mildly with daily events may be scored as 1. Scoring OSU Autism Rating Scale-5: 1. Total Symptom count. Each symptom that is present (i.e., scored as 1, 2, or 3) is tallied in the symptom count. If the subject is nonverbal, we have adopted the convention of counting that as a symptom. Thus for nonverbal subjects, a 3 in the right column for item #1(a) and 2(a) should be treated as positive and at the highest rating for that symptom. 2. Weighted Severity Mean. For all verbal subjects, clinicians should rate each of the items following the caregiver s description of the particular problem with a rating of 0, 1, 2, or 3. Both the Social Interaction and the Restricted Patterns of Interest subscales are averaged and a Total Weighted Mean is derived. * For nonverbal subjects, the items that specifically refer to idiosyncratic speech should be rated a 3 if other ASD symptoms are present, to reflect the greatest level of impairment. Items receiving a rating of 3 in the event that a subject is nonverbal includes, items #A1(a) and #A2 (a). * Please note that if no other ASD symptoms are present, then verbal items should be rated 0 3. Impairment Index. The DSM-5 requires that a part of the diagnostic process include the evaluation of an individual s level of impairment and need for outside supports when managing the skills of daily living. In Section C of the OARS-5, following a discussion with the child/adolescent s caregiver, clinicians will rate the level of support ranging from 0 (no support) to 3 (maximum support). 7

8 OSU Global Severity Scale for Autism In addition to the OARS-5, OSU has developed an Autism Clinical Global Impression ( OSU Autism CGI ) scale, which has separate subscales for symptom severity and for global improvement. These are rated in a similar way to the NIMH CGI Severity scale (Guy, 1976), but the focus is autism spectrum symptom severity and improvement. Symptoms frequently associated with autism spectrum such as irritability, compulsions, hyperactivity, and self injurious behavior, should also be considered in the CGI ratings even if not listed in the DSM-5 symptoms. 1. Not present; no ASD in evidence OSU Autism CGI-Severity Scale 2. Barely evident, ASD symptoms minimal might pass for normal on casual acquaintance 3. Mild ASD symptoms; obvious abnormality but can function in most situations. 4. Moderate ASD symptoms; unable to function in some unfamiliar situations without support 5. Moderately severe ASD; symptoms very evident; needs some support in many situations, even some familiar; symptoms restrict activity (e.g., experiences considerable difficulty with transitions and this interferes with daily activities). 6. Severe ASD; symptoms very evident at all times; needs 1:1 support or close supervision much of time; perhaps serious associated symptoms such as self-injury or compulsions that intrude on others. 7. Classic autism/asd; symptoms evident to all and present in all situations; may need continual supervision or residential care; associated symptoms (e.g., extreme compulsions, self-injury) may be extremely intrusive to others or detrimental to self. Today s score: OSU Autism GGI-Improvement Scale 1. Very much improved (symptoms minimal if present; confined to few settings) 2. Much improved; treatment worth continuing; makes a difference on quality of life and/or daily activities. 3. Minimally improved; barely better than random or natural fluctuation in clinical state 4. No change; within range of random changes or natural fluctuations. 5. Minimally worse; modestly worse than random or natural fluctuation in clinical state 6. Much worse; definitely worse than usual behavior or activities of daily living impaired 7. Very much worse; marked worsening to behavior, or activities of daily living, or quality of life much worse 8

9 Today s score: Use and Copy Privileges The OARS-5 and accompanying Autism CGI scales are copyrighted but available for free use without written permission, and we welcome others to download and use them. The scales are in a developmental phase, and we invite feedback from other investigators and clinicians. Refinements may be posted on the web page from time to time. Eventually, we hope to publish an evaluation and possible refinement based on feedback from colleagues. Please forward any comments to one of the developers: (a) Jill A. Hollway, jill.hollway@osmc.edu; (b) L. Eugene Arnold, L.Arnold@osumc.edu; or Michael Aman, aman.1@osu.edu. A big thank- you for all feedback Copyright 2017, Jill A. Hollway, L. Eugene Arnold, Michael G. Aman; Ohio State University, Columbus, Ohio. No charge or permission needed to download and use as is with appropriate credit, but in the interests of standardization, wording may not be changed without permission. Reference: Hollway, J.A., Arnold, L.E., & Aman, M.G. (2017, September). OSU Autism Rating Scale DSM-5 (OARS-5). Ohio State University; Columbus, Ohio: Author. 9