Autism Diagnostic Observation Schedule-2 (ADOS-2)

Assessment Report

Assessment report for: Xxx Xxx

Date of birth: XX.XX.XXXX

Date of assessment: XX.XX.XXXX

Age on assessment date: 9 years XX month XX days

Administered by: XXX

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ADOS-2: Module 3

The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2; Lord, Luyster, Gotham, &
Guthrie, 2012; Lord, Rutter et al., 2012) is a semi-structured, standardized measure of
communication, social interaction, play/imagination, and restricted/repetitive behaviours. The
ADOS-2 is used with individuals who have been referred because of a possible Autism Spectrum
Disorder (ASD), and is often referred to as the “gold standard” observational assessment for ASD
(Kanne, Randolph, & Farmer, 2008). Module 3 is designed for use with verbally fluent children
and adolescents, and describes a standardised interview/observational assessment consisting of
14 activities with 29 accompanying ratings. It takes approximately 60 minutes to complete.

The schedule offers opportunities to:

• Observe participants’ spontaneous social communicative behaviour, given a situation that

provides a press to communicate or interact.
• Assess participants’ ability to behave in appropriate ways, given the demands of a
situation (e.g. tell a story, teach a task).
• Provide a standard context for the collection of an extensive language sample.
• Observe the participants’ sense of humour, imagination and creativity (within this
particular setting).
The examiner’s ability to encourage and to some extent, structure the task orientated aspects of
the schedule, without directly prompting specific behaviours, is critical in allowing the participant
to exhibit her or her own level of social behaviour.

Diagnosis of Autism Spectrum Disorders in verbally fluent adolescents or adults requires more
than the relatively brief observation provided by this schedule. Thus, this schedule is intended for
use in addition to a standardised interview (such as the Autism Diagnostic Interview- Revised)
with the parent/caregiver that covers a broader range of behaviours and specifically addresses
the history of behavioural development.

Language & Communication

Xxx used complex speech in a largely correct fashion and the rhythm, rate, volume and intonation
of her speech were appropriate throughout the assessment.

Xxx spontaneously offered some information relating to herself and her family (for example, she
said “my dad likes football” and “I’ve been to a pizza restaurant”). However, her spontaneous
offering of information was limited in frequency, and much of her speech either stereotyped
and/or related to her specific interests.

The examiner attempted to engage Xxx in reciprocal conversations on a range of different topics
(for example, animals, food, holidays, books and school subjects). Xxx provided some leads for
the examiner to follow but tended to follow her own train of thought rather than engaging in
reciprocal to-and-fro interactions.

The examiner spoke about her interests and experiences throughout the assessment, and Xxx
demonstrated inconsistent social curiosity. Although Xxx did not acknowledge some of the
examiner’s comments, she spontaneously picked up on opportunities to enquire further on two
occasions (asking the examiner about her favourite pizza topping and the name of her cat). On
one occasion she spontaneously asked the examiner “are you married?” but when the examiner
replied with “yes”, Xxx did not show further interest, immediately asking “can we do something
else now?”.

Xxx did not provide any spontaneous sequential accounts of non-routine events during the
assessment. During the ‘Demonstration Task’ she was prompted to provide sequential account
of a routine event (describing the way in which she brushes her teeth). Xxx provided a very limited
verbal account, even with specific prompts from the examiner.
Overall, Xxx’s spontaneous gesture use was limited. She used brief, prompted descriptive
gestures when asked to show and tell the examiner how she brushes her teeth as part of the
‘Demonstration Task’. During the ‘Cartoons’ task, she was shown a series of six pictures with a
story about a fisherman and a cat, and was asked to retell the story to the examiner. Xxx used
spontaneous descriptive gestures whilst retelling the story, but these were exaggerated.

Reciprocal Social Interaction

At times Xxx used well-integrated eye contact, particularly when sharing her enjoyment.
However, throughout the whole assessment her use of eye gaze was inconsistent and poorly
modulated.

Xxx directed occasional facial expressions to the examiner. For example, she directed a smile
when playing with the ‘Pin Art’ toy during the ‘Break’ task, and an exaggerated look of disgust
when the examiner said she would rather have cheese on her pancakes than chocolate. However,
during the ADOS-2 her facial expressions (both directed and non-directed) were limited in
frequency and range.

Although Xxx expressed some shared enjoyment during the assessment (for example, during the
‘Description of a Picture’ task) this was limited in frequency and quality of clear pleasure. Most
of Xxx’s shared enjoyment was related to her own speech and actions rather than the more
interactive aspects of the assessment. Xxx seemed happy for the examiner to join in with play on
her own terms but showed reluctance when the examiner suggested new ideas.

Xxx demonstrated a limited ability to identify and describe her emotions. During the ‘Emotions’
questions, she told the examiner that “being with you” makes her happy, and when asked to
describe this feeling, she said “it feels like you want to spy… a warm feeling”. When asked what
makes her angry Xxx said “well, I’ll have to check” and was unable to explain what ‘angry’ means.
She reported that “escalators and spiders” make her scared and when asked to describe this
feeling, Xxx said “should I do this, should I not? Should I do this, should I not?”, but did not
demonstrate further insight when prompted. When asked what makes her sad, Xxx said
“sometimes a movie, sometimes a song” in a stereotyped manner, and described this by saying
“it feels like you think it might happen in future”.

Xxx did not spontaneously identify emotions in others at any time during the assessment. During
the ‘Loneliness’ questions Xxx said that she does not think other people feel lonely, and during
the ‘Social Difficulties & Annoyance’ questions she told the examiner that she never does anything
that annoys others.

Xxx demonstrated limited insight into typical social relationships. She reported that she has a
best friend at school (Lxxx), who is also nine years old. Xxx explained that Lxxx is her friend
“because we’ve never played separately before” but went on to say that they do not see each
other outside of school. When asked to describe the difference between a friend and someone
she sits next to in class, Xxx said “a friend is someone that loves to be with you, someone who sits
next to you doesn’t really bother”. She said that she has different types of friends, including
“playing friends”, “learning friends”, “talking friends”, “club friends”, “out of range friends” (who
go to a different school) and “a gang of bullies”. The examiner asked Xxx whether bullies are a
type of friend, and she said “yes”. When asked to explain the different types of friends, Xxx said
“well a learning friend, you sit here and you say ‘what’s eight times eight?’ and I’ll say ‘see if you
can work it out for yourself’”. She said “I don’t have many playing friends” and told the examiner
that she is “always the leader” when she plays with Lxxx. Xxx said that she would like to have
more “playing friends”.

When asked how it is possible to tell when someone is a friend, she said “putting someone before
you and looking at them inside”. The examiner asked her to explain this, and Xxx said “I can sense
if they’re a good person or a bad person… look, shall I demonstrate? You say ‘I don’t want to play
with you’ [standing very close to the examiner and insisting that she said this] and I can see that
you’re a bad person”. Xxx seemed unclear about whether she has ever been teased or bullied,
but said “my mum says there are not very nice people in the world, is that true? Am I a nice
person?”.

When asked whether she would like to have a relationship or get married in future, Xxx said “no”.
She said that some people might choose to get married “because they love each other” and that
“raising children” might be difficult. When asked what might be nice about getting married or
being in a relationship, Xxx said “maybe your partner will die”. The examiner attempted to clarify
why this might be nice, and she said “no, I don’t like death… can we do something else now?”. Xxx
reported that she worries that her mother and father might die, and asked “do other people worry
about growing up?”. The examiner tried to explore whether this is something she worries about,
and Xxx said “no, but I don’t want to grow up”. When prompted, she explained that she does not
want to grow up because “I might lose my imagination”.

Xxx made frequent attempts to initiate and maintain the examiner’s attention throughout the
ADOS-2. However, many of her overtures were stereotyped, related to her specific interests
and/or poorly integrated into the immediate social context. For example, she said “do you know
how much help I need to save the planet?” and “I just love the great outdoors” when this was not
relevant to the particular task or topic. When drawing a picture of the examiner during the ‘Break’
task, she said “you look good but I thought you were going to wear a suit”, “you have beautiful
lips” and “do you always wear black?”. Although a lot of her verbal and non-verbal
communication appeared to have social intent, Xxx also made undirected, poorly integrated
comments which were related to her specific interests. For example, she said “I don’t care if the
volcano does as much eruptive violence as this world… I do care about the planet” and “I need the
whole world to help me… without any trees we wouldn’t have any crops”. Xxx spoke about planet
Mars “dying” and referred to magnets and carbon dioxide, but some of her speech was
unintelligible and she did not repeat the phrases when prompted to do so by the examiner.

Many of Xxx’s social responses were stereotyped. For example, during the ‘Break’ task she said
“I’ve done playing, shall we tidy up together?” and when the examiner commented that she liked
Xxx’s drawing, she said “what? You mean this terrible piece of art?”. When she accidentally broke
the cocktail umbrella during the ‘Creating a Story’ task, she said “oh no, I’m super duper sorry
about that”. On several occasions she asked “can we do something else now?” and “do you have
more girls toys?”. At times Xxx did not acknowledge the examiner’s comments at all (for example,
when she said “I like reading books”, Xxx appeared to ignore this comment and continued to talk
to herself about saving the planet).

Although Xxx engaged in verbal and non-verbal behaviours with reciprocal intent, her reciprocal
social communication was slightly limited. The interactions tended to be on Xxx’s terms, which
led to a one-sided rapport. However, Xxx was co-operative and absolutely delightful to assess.

Imagination & Creativity

Xxx demonstrated limited imagination and creativity during the assessment. In the ‘Make Believe
Play’ task her play appeared slightly stereotyped and repetitive. She used the three characters as
self-initiating agents (for example, making one of the male characters say “you’re a very beautiful
woman” to the female character) but used almost all items in a literal manner. Xxx demonstrated
rigidity in her play and became resistant when the examiner attempted to introduce new ideas as
part of the ‘Joint Interactive Play’ task. For example, Xxx pretended that two of the characters
fell in love and were going on a trip to the library. When the examiner attempted to join in with
the third character, she said “no, I said he was going to be the villain” and took the character from
the examiner. When the examiner asked “which one can I be?” she held all three of the characters
and said “you can be the mop”. Xxx then showed some limited imagination by pretending that
the toy mop was a person called ‘Leah’ and made a dress from a piece of material.

During the ‘Make Believe Play’ and ‘Joint Interactive Play’ tasks Xxx’s narratives were based
around a library. She named two of the characters “Dxxx” and “Mxxx” and demonstrated a lack
of flexibility around this. When the examiner attempted to introduce the idea that they could all
go on an adventure, Xxx said “they’re going back to the library”. As the ADOS-2 is designed to
assess for flexibility in play, the examiner said “we went to the library yesterday so I think we
should go somewhere new”. Xxx responded to this by saying “ok, we can go to Mount Everest but
we need to go to the library to get a book about it first”. She then enacted a library scene in which
the characters tried to find a book on Mount Everest but did not develop the story beyond this.

Xxx participated in the ‘Creating a Story’ task, which involves making up a story with five different
objects. She selected a feather, a cocktail umbrella, a miniature candle, a piece of sponge and a
spikey ball. Xxx used the miniature candle and cocktail umbrella as intended, and showed some
creativity using the spikey ball as a person’s head, a feather as their hair and the piece of sponge
as their body. She changed the name of the character from Amy to Lucy, and then to Leah. Xxx
set her story in a haunted house but the narrative was brief and difficult to follow.

Xxx did not use any other creative comments or actions during the assessment (for example,
during the ‘Telling a Story From a Book’ task she did not elaborate beyond the pictures when
narrating the story).

Restricted & Repetitive Behaviour

Xxx used stereotyped speech frequently. For example, she said “I don’t mind if you get it right or
wrong, what’s important is that you try” and referred to the sofa in the room as “a pretty little
thing”. Xxx picked up one of the blocks in the ‘Construction Task’ and said “I think this might be
what you’re looking for” and during the ‘Loneliness’ questions she said “I feel lonely when I don’t
know who to play with and my friends are absent… do you know what absent means?”. Xxx also
used repetitive speech. For example, during the ‘Telling a Story From a Book’ task she said “the
frogs fly beyond the houses, they fly beyond the trees, they fly beyond the town, they fly beyond
hills…”. Immediate echolalia was observed on one occasion (she immediately repeated the
examiner saying “and then” using exactly the same intonation).

Xxx engaged in clear sensory seeking behaviour. She repeatedly returned to one of the sofas in
the room and rubbed the soft blanket back and forth simultaneously with both hands for
extended periods of time. She did not display any unusual, idiosyncratic or negative responses to
specific sensory stimuli during the ADOS-2.

Xxx did not engage in any hand/finger mannerisms during the assessment, nor did she engage in
any self-injurious behaviour.

Xxx engaged in some behaviours which appeared to be compulsive in nature. For example, during
the ‘Joint Interactive Play’ task she told the examiner what to say (“you say, it’s nice to meet you”)
and corrected her when she did not comply using the exact phrasing. During the same task, Xxx
made one of the characters hold a miniature book and said “she read and read and read and read
and read and read and read and read…”. When the examiner attempted to interrupt her, Xxx
continued to say this.

Xxx referred to planets, mountains and volcanoes and saving the planet repeatedly throughout
the assessment. This was poorly integrated into the immediate social context and occasionally
interfered with social communication.
Other Behaviours

Xxx did not engage in any anxious, negative or disruptive behaviour during the assessment. She
was clearly overactive throughout the ADOS-2 and found it difficult to remain seated. At times,
the level of activity interfered with the assessment. Xxx was highly distractible, often flitting from
one activity to another after very brief periods of time. Her engagement in answering questions
improved considerably when she was simultaneously engaged in another task (for example,
drawing and playing with the ‘Pin Art’ toy).

Summary

The results of the Autism Diagnostic Observation Schedule (ADOS-2) undertaken with Xxx are as
follows: