ADOS Assessment

The ADOS is more than an assessment, it’s a rich source of information that can help plan and provide support for autistic individuals.

To use the ADOS or not?

The ADOS has come under increasing scrutiny as we learn more about autism and neurodivergence in general, and it is widely recognised that it is not always appropriate in the assessment process. For example, the authors acknowledge that it is not always appropriate for older children/adults with minimal language (although an adapted version of ADOS is currently being trialled for use with this population, the AADOS), it is not validated for use with people with severe mutism, extreme anxiety, severe developmental delay, or severe behavioural difficulties (Lord et al., 2012). Tony Attwood and Michelle Garnett do not use it as part of the diagnostic process for autistic women as research conducted by Langmann et al, in 2017 found Module 4 had lower rates of diagnostic accuracy with females, older individuals and gifted and talented people. This highlights the need for clinical judgement about what assessment tools to use in different situations, and the need for clinicians to have extensive experience, up to date knowledge, and a deep understanding of autism as we are all unique individuals, regardless of our neurotype and one size never fits all.

Benefits of the ADOS

Although the ADOS is not appropriate in certain situations, it is a tool that can provide a wide, holistic picture of a person, regardless of the diagnostic outcome. Before I trained in administering the ADOS, I was used to speech and language therapy assessments, which often focus on one element, e.g., following instructions, understanding vocabulary, and do not always provide a wide, rounded picture of a person (apologises to therapists who might not agree with me!). There are many things that I really like and value about the ADOS, and I find information that it provides on areas that do not contribute to the diagnostic conclusion, such as emotions, extremely helpful in terms of understanding more about the person and thinking about future support. It can also show a person’s strengths very clearly and help think about conditions that enable them and give them the same opportunities that others have to reach their potential and enjoy life.

I find information gathered in an ADOS incredibly helpful in terms of support, far more so than other assessments I use. However, this also depends on its use. If clinicians treat the ADOS as a tool to simply tell you that it is likely the person is autistic or not, then they will miss the rich information that the ADOS can give you about a person. The ADOS will become a narrow, diagnostic tool that says yes or no, and it will not be of any other value. Recently, in the sad times we are in of long waiting lists for assessment, ADOS reports are often short and say very little other than to confirm autistic features or not. The ADOS is not always held in such high regard as other assessments, such as developmental history tools, and perhaps the fact that it is carried out by quite a wide range of different professions might make some people view it as an easy assessment that anyone can do. This in turn, might make some people see it as having little value, and as the underdog in the assessment process.

Using ADOS Findings to Plan & Provide Support

Observations and information gathered during an ADOS can tell you about strengths and differences individuals have in a range of areas and help identify areas to support. For example:

• Attention control and executive function skills, e.g., planning, prioritising, integrating information and problem solving.

• Thinking style, e.g., a focus on details, needing time to consider the context, evaluate situations and consider them from different perspectives, difficulty leaving information incomplete, e.g., in conversations, stories and tasks.

• Joint Attention, e.g., thinking and talking about the same topic, sharing interest and enjoyment with each other.

• Recognising emotions and using language to talk about feelings. Many neurodivergent people have difficulties recognising what emotions feel like inside the body, i.e., they have interception difficulties, and difficulties using language to label and discriminate between emotions and to tell others how they feel, i.e., Alexithymia. https://www.kelly-mahler.com/resources/videos/interoception-the-new-topic-in-autism/

• Use of language for a wide range of different purposes, e.g., to tell stories, to initiate interactions, to request, to show interest, to ask and answer questions.

• Social communication and interactions. Society is becoming more aware of the fact that people have different communication and interaction styles. The ADOS can give more information on this, which can help others understand differences.

• Play, e.g., how a child plays, how easy it is to play with them, what they like to play with.

• Reciprocity, having others in mind.

• Sensory processing differences. The ADOS is not a sensory assessment, but it can provide some information through observation and personal account, e.g., people sometimes talk about sensory experiences that make them feel anxious.

• Difficulties managing uncertainty. This is another area that people talk about, and that the clinician sometimes observes, e.g., difficulty transitioning from one activity to another, difficulty managing an unfamiliar environment.  

• Activity levels and impulse control. The ADOS can provide information on possible features of attention differences, e.g., ADHD, sometimes it is very obvious!

• Anxiety, feeling self-conscious & demand avoidance.  Being self-conscious is not a diagnostic feature of autism, but many autistic people feel very self-conscious in certain situations and do not like to be the focus of attention. Anxiety is very common for neurodivergent people, and sometimes it shows in needing to know what we are going to do in the assessment, needing certainty, finding open tasks stressful as there is not a right or a wrong answer, finding social interactions stressful. It sometimes shows needing to control what we do and difficulty following the clinician’s direction and instructions, e.g., sitting under rather than at the table, using assessment resources in the way that they want to use them rather than in the way the clinician instructed. https://www.autism.org.uk/advice-and-guidance/topics/behaviour/demand-avoidance

• Perfectionism. I have a particular interest in perfectionism and always look at how individuals respond to mistakes, how meticulous they are when they do certain tasks, correcting themselves, trying to find the best way to phrase what they want to say, anxiety about not doing things well enough. Many of the people I work with therapeutically are perfectionists and it can be very damaging.

• Non-verbal & verbal communication, e.g., integrating eye contact, facial expressions, gestures, and language.

• Imagination. Many autistic people have incredible imaginations and are extremely creative.

This is not an exhaustive list, but I hope it shows the range of areas the ADOS can tell you about and highlights how helpful this can be in terms of support at nursery, school, work and home.