The ADOS, AStandardized Instrument for the Diagnosis of Children with Autism. Lord, Rutter, DiLavore, Risi (1999)

Transcription

1 The ADOS, AStandardized Instrument for the Diagnosis of Children with Autism Lord, Rutter, DiLavore, Risi (1999) What Is Autism? Developmental disorder Affects communication, reciprocal social interactions and play, interests, and behavior Symptoms are present prior to 3years of age Lifelong It affects development One in aspectrum of Pervasive Developmental Disorders 1

2 DSM-IV/ ICD-10 Criteria for Autism Spectrum Disorder Atotal of 6items from groups A, B, & C Including at least 2 items from group A And including at least 1 item from group B And including at least 1 item from group C DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder A. Qualitative impairment in social interaction as manifested by at least 2of the following Marked impairment in the use of multiple nonverbal behaviors, such as eye to eye gaze, facial expression, body postures, and gestures to regulate social interactions 2

3 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder A. Qualitative impairment in social interaction as manifested by at least 2of the following (cont) Failure to develop peer relationships appropriate to developmental level Markedly impaired in seeking to share own pleasure with others Lack of social/emotional reciprocity 3

4 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder B. Qualitative impairments in communication as manifested by at least one of the following Adelay, or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative forms of communication such as gesture or mime) 4

5 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder B. Qualitative impairments in communication as manifested by at least one of the following (cont) Marked impairment in the ability to initiate or sustain aconversation with others, despite adequate speech Stereotyped or repetitive use of language, or idiosyncratic language 5

6 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder B. Qualitative impairments in communication as manifested by at least one of the following (cont) Lack of varied, spontaneous make believe play or social imitative play appropriate to developmental level 6

7 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder C. Restricted, repetitive and stereotyped patterns of behavior as manifested by at least one of the following Encompassing preoccupation with one or more stereotyped and restricted patterns of interest abnormal in either intensity or focus An apparent compulsive adherence to specific nonfunctional routines or rituals DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder C. Restricted, repetitive and stereotyped patterns of behavior as manifested by at least one of the following (cont) Stereotypes and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole body movements) Persistent preoccupation with parts of objects 7

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9 DSM-IV/ICD-10 Criteria for Autism Spectrum Disorder Abnormal or impaired development, prior to age 3, manifested by delays or abnormal functioning in at least 1of the following Social interaction Language as used in social communication Symbolic and imaginative play v Not better accounted for by Rett s or Childhood Disintegrative Disorder Autism Spectrum Disorders Childhood Disintegrative Disorder Features much like autism (3 domains) Very rare Must have normal development to 2years Must lose receptive language and social skills May lose motor and adaptive skills 9

10 Autism Spectrum Disorders Asperger Disorder Social deficits like autism Circumscribed interests and sometimes other repetitive behaviors like autism By exclusion Not autism Not language-delayed Not mentally handicapped Autism Spectrum Disorders Atypical autism/pdd-nos Must have social deficits like autism Must have either or both communication or repetitive behaviors like autism By exclusion Must have social deficits May not have communication deficits or not have restricted, repetitive behaviors May have late onset 10

11 ASD, or, at least, some aspects of ASD, fall oncontinuous dimensions, which we are forced to categorize in order to yield definable groups. Discriminating ASD fromother disorders is easiest for school age childrenwith some language, who are not fluent speakers. As we move up and down the age span, and up and down levels of mental retardationand language delay, discriminations become more difficult. Childhood Disintegrative Disorder Autism Asperger s Disorder 11

12 Different goals and priorities for different purposes Diagnosis and classification Measuring change Reasons for Accurate Diagnosis Access appropriate intervention services Establish developmental levels Determine patterns of strengths and weaknesses Educate parents Develop individualized intervention program 12

13 Factors that predict outcome Expressive language level Language comprehension Nonverbal problem solving Fine motor skills Intelligibility Factors that predict outcome Mood disorders Aggression Flexibility/social understanding Academic Achievement Adaptive skills 13

14 Factors that predict outcome Advocacy and flexibility Parents Community State Schools Important Elements of a Diagnostic Assessment Diagnostic Information Interview with parents (ADI-R) developmental history pervasiveness of behaviors Assessment of Child (ADOS) Create context to observe diagnostic behaviors Include parents 14

15 Diagnostic measures Goal: classification Reliable across time Diagnosis reflects core symptoms Relationship to gold standards/validity Diagnostic measures Goal: description Inter-rater reliability high for items (narrow range) Items represent core symptoms of ASD Validity: Predictive power for overall diagnosis 15

16 Autism Is adevelopmental Disorder Autism affects development Autism is affected by development Both positive (abnormal) behaviors, and negative(the absence of normal) behaviors arerequired to make a diagnosis of ASD. This means that developmental level and contextual effects (in what kind of circumstances does the child or adult function?) can both have significant effects on diagnostic judgments. 16

17 The ADOS creates a social world in which behaviors related to the autism spectrum can be observed: ADOS as aclinical instrument: Autism: Diagnostic Problems Overlap between developmental delays and autism 17

18 ADOS Response to Diagnostic Problems 1. Specificity of Abnormalities Detailed descriptions of actual behaviors Operationalized criteria Focus on key situations Training of investigators Comparison to relevant control groups Diagnostic Problem: Variability in how people interpret the definitions of autism 18

19 ADOS Response to Diagnostic Problems 2. Standardization Of procedures Of rating scales Of age focus Of summarization 3. Validation using alternative approaches The goal of the ADOS is to provide standardized information concerning the diagnosis of autism in the areas of: social behavior use of vocalizations/speech and gesture in social situations play/interests 19

20 The ADOS is standardized by: Tasks andactivities Materials Behavior of the examiner Behaviors to be observed How the individual sbehaviors are quantified How the diagnosis is achieved Training of examiner Standards for achieving andmaintaining reliability Diagnostic Problem: Developmental changes in autism ADOS Response to Problem: Longitudinal studies 20

21 ADOS as aclinical instrument: Structured and unstructured activities Guidelines for hierarchy of examiner s behavior Dependent on examiner s experience and sensitivity (to act and not to act) General Strategy: Make notes during administration (include a language sample) Code immediately after Video available for detailed study 21

22 Guidelines for Selecting amodule Module Expressive Language Level Minimum Maximum 1 No speech Simple phrases Three-wordphrases/ andnot yetverbally fluent Verbally fluent (Child/younger adolescent) Verbally fluent (Adolescent/adult) Verbally fluent Toysnot helpful ADOS Observation/ Coding Module 1Activities Preverbal/ Single Words 1. Free Play 6. Responsive Social Smile 2. Response to Name 3. Response to Joint Attention 7. Anticipation of asocial Routine 8. Functional and Symbolic Imitation 4. Bubble Play 9. Birthday Party 5. Anticipation of aroutine withobjects 10.Snack 22

23 ADOS Observation/ Coding Module 2Activities Phrase Speech 1. Construction Task 8. Description of apicture 2. Response to Name 9. Telling a Story from a Book 3. Make-Believe Play 10. Free Play 4. Joint Interactive Play 11. Birthday Party 5. Conversation 12. Snack 6. Response to Joint Attention 13. Anticipation of a Routine with Objects 7. Demonstration Task 14. Bubble Play ADOS Observation/ Coding Module 3Activities Fluent Speech Child/ Adolescent 1. Construction Task 8. Conversation/ Reporting 2. Make-Believe Play 3. Joint Interactive Play 9. Socioemotional Questions: Emotions 10.Socioemotional Questions: Social Difficulties/ Annoyance 4. Demonstration Task 11. Break 5. Description of apicture 12.Socioemotional Questions: Friends/Loneliness/ Marriage 6. TellingaStory from abook 13. Creating astory 7. Cartoons 23

24 ADOS Observation/ Coding Module 4Activities Fluent Speech Adolescent/ Adult 1. ConstructionTask* 8. DemonstrationTask 2. Telling a Story from abook 9. Cartoons* 3. DescriptionofaPicture* 10.Break 4. Conversation/Reporting 11. Daily Living* 5. Socioemotional Questions: CurrentWork/School* 6. Socioemotional Questions: SocialDifficulties/ Annoyance 7. Socioemotional Questions: Emotions *denotes optional 12. SocioemotionalQuestions: Friends/Loneliness/ Marriage 13.PlansandDreams 14.Creating a Story Some Coding Conventions 0 = Behavior of type specifiedis not present (NBnot necessarily normal ) 1 = Behavior of type specifiedis present, but not sufficientlysevere, frequent, or marked to code 2 2 = Behavior of type specifiedis definitely present and meetsspecific mandatory criteria 3 = Behavior present toadegreethat interferes with functioningor ordinarylife 7 = Definite abnormalityingeneral area of coding, but not of typespecified 8 = Not applicable 24

25 Why Separate Cut-Offs: Speech and gesture as tools for communication that may incur specific deficits Autism as a pervasive social deficit Tips for administration and coding 25

26 ADOS Psychometrics Description of Subjects in Validity Analyses: Means and Standard Deviations Module 1 Lower Autistic Matched Autistic PDD-NOS Non- Spectrum N (males, females) 20(16,4) 20(18,2) 17(11,6) 17(12,5) Chronological Age Verbal Mental Age Nonverbal Mental Age

27 Description of Subjects in Validity Analyses: Means and Standard Deviations Module 2 N(males, females) Chronological Age Verbal Mental Age Nonverbal Mental Age Autistic PDD-NOS Non- Spectrum 21(15,6) 18(15,3) 16(9,7) Description of Subjects in Validity Analyses: Means and Standard Deviations Module 3 Autistic PDD-NOS Non- Spectrum N(males, females) 20(19,2) 20(17,3) 18(11,7) Chronological Age Verbal Mental Age Nonverbal Mental Age

28 Description of Subjects in Validity Analyses: Means and Standard Deviations Module 4 Autistic PDD-NOS Non- Spectrum N(males, females) 16(14,2) 14(11,3) 15(12,3) Chronological Age Verbal Mental Age Nonverbal Mental Age Sensitivities, specificities and total positive predictive values for different comparisons across modules Module 1 (n=54) Module 2 (n=55) Module 3 (n=59) Module 4 (n=45) Autism and PDD vs. nonspectrum se spec Autism vs. PDD andnonspectrum se spec PDD vs. nonspectrum se spec Autism vs. nonspectrum se spec

29 Distribution of participants byadosdiagnosis and overall clinical diagnosis Module 1 CLINICAL CLASSIFICATION ADOS DIAGNOSIS Autism PDD-NOS Other LOWER AUTISM AUTISM PDD-NOS NONSPECTRUM Distribution of participants byadosdiagnosis and overall clinical diagnosis Module 2 CLINICAL CLASSIFICATION ADOS DIAGNOSIS Autism PDD-NOS Other AUTISM PDD-NOS NONSPECTRUM

30 Distribution of participants byadosdiagnosis and overall clinical diagnosis Module 3 CLINICAL CLASSIFICATION ADOS DIAGNOSIS Autism PDD-NOS Other AUTISM PDD-NOS NONSPECTRUM Distribution of participants byadosdiagnosis and overall clinical diagnosis Module 4 CLINICAL CLASSIFICATION ADOS DIAGNOSIS Autism PDD-NOS Other AUTISM PDD-NOS NONSPECTRUM

31 Interclass correlations for inter-rater and test retest reliability n Social Communication Restricted, repetitive Socialcommunication Interrater (all) Livelive Livevideo Testretest ADOS:What We Have Learned 31

32 Research Findings Giving the right Module is important Differentiating between autism and other developmental disabilities Is ADOS overinclusive? Bonnie Klein Study: For Modules 1and 2, if given wrong module: Made little difference for children with clinical diagnoses of autism When given Module 2, increased autism classifications for children with clinical diagnoses of PDD-NOS Made little difference for children with clinical diagnoses outside ASD 32

33 Klein results: In Modules 3and 4, if given wrong module: If given themore advanced module, classifications of nonspectrum moved to ASD and autism; classifications of ASD moved to autism If given the less advanced module, classifications of autism moved to ASD and nonspectrum; classifications of ASD moved to nonspectrum Bishop & Norbury (2002): SLI and PI children Gave all children Module 3, regardless of language level Used children s school diagnoses as the gold standard Found poor agreement between the ADOS and the SCQ Did not run correlations between scores 33

34 Implications of Bishop & Norbury Sample focused on children who provide diagnostic challenges ADOS may be overinclusive: SLI students ADOS is good at categorizing children who are definitely autistic or nonautistic; less good at PDD-NOS/milder symptoms (Lord et al., 2000) ADOS Diagnosis Denver Toddler Study Clinical Diagnosis (n=106) ADOS Diagnosis Autism Autism 33 (85%) Not Autism 1(2%) Not Autism 6(15%) 66 (98%) 2 =78.18,p<.00. False positiveson ADOS=1; false negativeson ADOS= 6 34

35 ADI Diagnosis Denver Toddler Study Clinical Diagnosis (n=93) ADI Diagnosis Autism Not Autism Autism 28 (78%) 3(5%) Not Autism 8(22%) 54 (95%) 2 =52.21, p<.00. False positives on ADI=3; false negatives on ADI=8. Both ADOS and ADI Denver Toddler Study Clinical Diagnosis (n =93) ADOS + ADI Both: Autism One: Autism Not Autism on Either Autism 27 (75%) 9(25%) 0 Not Autism 1(2%) 9(25%) 47 (83%) 35

36 Conclusions from Toddler Study Using both the ADI and ADOSis a very effective way of qualifying subjects. No falsenegatives and only 1 falsepositive. Tools are fairly comparable; ADOS is slightly better Children who do not receive a clinical diagnosis of autism, but meet criteria on one(but not both) of the tools, tend to befunctioning at alower developmental level (<16 months). Children withfalse positives on ADI tend to have a difficult temperament. Children with false positives on ADOS tend notto initiate many joint attention behaviors. Next Steps in ADOS Research Can we accurately represent severity within different domains of autism, as proposed by DSM IV and ICD-10? Further refinement of the ADOS 36

37 Validity and Diagnosis Study Currently recruiting Attempting to develop severity ratings Refining diagnostic instruments More efficient Capturing extremes in the continuum Better differentiating autism from other disorders Proposed groupings for establishingseverity Proposed Subsets <5 Nonverbal Some Language Fluent

38 DSM-IV/ICD- 10 Social reciprocity Communication Restricted, repetitive behaviors PROPOSED REVISION Social reciprocity and communication Restricted and repetitive behaviors Expressive language level at age 5 Onset by age 3?? Summary Good progress Much room for improvement Efficiency and accessibility Organization of information Representing continuous dimensions According to purpose: Severity (within and across domains) Certainty of caseness Extend breadth of scope Links with neurobiology and genetics 38

39 Using ADOS in Clinics and Schools Intended Use of ADOS ADOS is an important part of a comprehensive autism evaluation. ADOS results in aclassification. Not adiagnosis by itself. ADOS is based on DSM-IV. Subject to the limitations of our current diagnostic systems. ADOS is not atreatment measure. 39

40 Important Elements of a Diagnostic Assessment Diagnostic Information Interview with parents (ADI-R) developmental history pervasiveness of behaviors Assessment of Child ADOS Observation in relevant environments Functional behavior assessment ADOS and program planning: Teachers have found observing the ADOS quite useful in programming; this is less the case for parents (for Modules 3 and 4) Not very worthwhile to directly teach answers to specific questions Gain a sense of level of support needed to have effective communication 40

41 Using ADOSfor Programming Breaking down social behaviors Social overtures Requests Directing attention Giving Comments/give information/showing Quality Frequency Programming recommendations, con t Contexts of overtures food, balloon, bunny, social interaction Social responses Reciprocity (play, vocal, use of object) Basic aspects of social behavior (eye contact, facial expressions, vocalization, gesture, use of objects) 41

42 Incorporating ADOS results into Evaluation Reports Description of ADOS (standardized, which module, types of activities, classification based on cut-offs) Relevant testing behaviors Use codes to talk about areas of skill strength and weakness Evaluation reports, con t ADOS results in classification, not diagnosis incorporate results of developmental history interview, functional behavior assessment, and standardized communication and cognitive tests into eligibility statements. 42

43 Using ADOS results in IEP and treatment goals Areas of personal weakness related to ASD Behavioral descriptions Present Level of Educational Performance (PLEP) Quantify ADOS behaviors through data collection in other settings Sample IEP goal using ADOS results Goal areas: Social Development Behavior Emotional Development Communication 43

44 Writing agoal Present Level of Performance Student strength: Related to goal area Taylor enjoys being around other students and his increased his cooperation in joining into group games this year. Writing IEP Goals PLEP Current performance in goal area Taylor currently has difficulty engaging in social interactions with others. On arecent administration of the ADOS, Taylor achieved scores indicating significant difficulty in Communication and Reciprocal Social Interaction domains. Include data from other, more growth-sensitive measures Include comparisons with typical peers 44

45 Writing IEP goals PLEP Statement of needs Areas in need of development included using gestures, joint attention (paying attention to the same thing at the same time), and initiating interactions with others. Sample IEP goal, con t Annual Goal: Social Development Time Conditions Task Criterion for performance By December 2004, while in general social settings,taylor will engage in social interactions with peers at a rate of 80% of those of his peers. 45

46 Sample IEP goal, con t Objectives Should follow a plan for generalization Increase rate of social interactions in practice/social group (sp. ed.) settings Increase rate in gen. ed. settings with help from adult Increase rate independently, across settings As applies, decrease inappropriate attempts at contact ADOS can help identify these areas As applies, increase rate of responding to a peer s attempt at interaction Summary ADOS is a standardized instrument; creates contexts to observe ASD behaviors ADOS is one part of acomprehensive evaluation ADOS results in a Classification ADOS must be used properly Choice of Module Standardized administration ADOS is only as good as our current diagnostic system 46

47 U-M Autism and Communication Disorders Center (UMACC) (734)