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A Thorough Presentation of Autism Diagnostic Observation Schedule (ADOS-

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 A Thorough Presentation of
Autism Diagnostic Observation
Schedule (ADOS-2)

Papaefstathiou Elpis
University of Macedonia, Greece

ABSTRACT

The Autism Diagnostic Observation Schedule (ADOS-2; Lord et al., 2012) is

considered the gold standard observational instrument for use in the diagnosis
and/or classification of autism and ASD. In this specific chapter, the process of
assessment will be described, which involves direct observation and
engagement of children and adults for whom an ASD is suspected.
Specifically, at first, an emphasis will be put on ADOS structure, namely the five
different modules for the assessment of individuals with different expressive
language ability and age. Each module will be presented separately as well as
the criteria for choosing the appropriate one for each individual’s assessment.
Despite the differences among the five modules, there are also enough
similarities. One major similarity is the fact that they consist of the same three
sections: Observation, Coding, Algorithm and Classification. Concerning the first
one, Observation; the process of administration will be presented, including the
activities of each module and some general guidelines for the examiners. The
Coding refers to the opportunity for specific behaviors to be coded according to
pre-set operationalized criteria. These behaviors will be also listed in this article.
Finally, in the Algorithm and Classification section information concerning the
transformation of scores, the cut-off points and comparison tables will be
provided.
Then, the advantages of ADOS-2 will be elaborated as a diagnostic tool and a
brief review of studies concerning its psychometric properties will be reported.

Key Words: Algorithm, DSM-5, Internal Consistency, Inter-rater Reliability,

Predictive Validity, Reliability, Restrictive Repetitive Behaviors, Sensitivity, Social
Affect, Specificity, Test-retest Reliability

1
INTRODUCTION

The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2; Lord et al.,
2012) is considered the gold standard observational instrument for use in the diagnosis and/or
classification of autism and autism spectrum disorders (ASD). ADOS-2 is a semi-structured,
standardized assessment of communication, social interaction, play/imaginative use of materials,
and restricted and repetitive behaviors for individuals of possible ASD. This assessment tool is a
revision of the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore, & Risi,
1999).
The main purpose of this chapter is to get specialists familiar with ADOS-2 and
especially with its structure and its principles of use concerning administration. Also, some
findings regarding its psychometric properties and the advantages and disadvantages for its
clinical use will be mentioned.

BACKGROUND
As the number of ASD diagnoses is constantly increasing (2010 Principal Investigators &
CDC, 2014) and due to the fact that ASD is considered a heterogeneous disorder, the need for
diagnostic measurement with high diagnostic accuracy is more than ever imperative. Moreover, it
seems that factors such as gender, level of language abilities, cognitive functioning play affect the
symptomatology of ASD. For these reasons, the diagnostic process sometimes is extremely
challenging.
ADOS was first developed in 1980 and it was mainly used for research diagnoses. It was
considered as a reliable tool (Lord et al., 2000). ADOS-2 released in 2012, extending the age
range with the addition of the Toddler Module. It is, also, a well-established diagnostic
instrument, considered the ¨gold standard¨ for collecting standardized and objective information
about social communication and restrictive and repetitive behaviors. It was designed in order to
improve the accuracy of the diagnostic algorithms of the previous edition. Many studies have
demonstrated the diagnostic accuracy of ADOS-2 as it is highly reliable and valid for the
assessment of ASD in children, adolescents and adults.

Structure of ADOS

Materials
ADOS-2 includes five assessment modules for the assessment of individuals with
different expressive language ability and age (Table 1). Specifically:
The Toddler Module is designed for toddlers who are 12 to 30 months of age and who
do not use phrase speech consistently.
Module 1 for children 31 months and older and who do not use phrase speech
consistently. For this Module there are two algorithms: Few to No Words, and Some Words.
Module 2 is designed for children of any age who use phrase speech, but they are not
verbally fluent. For this Module there are two algorithms: Younger than 5 years, and Aged 5
Years or Older.
Module 3 is for verbally fluent children and young adolescents (approximately 16 years
or younger).
Module 4 is designed for verbally fluent older adolescents and adults.

Each module has its own Protocol Booklet that provides order and structure for the
administration, coding and scoring (Lord et al., 2012).

2
 There is also a kit. This kit is a large container that includes all the appropriate materials
for the five modules that are necessary for the administration such as toys, picture books, snacks,
interview questions and others. Many of the materials are used across differed modules and are
selected purposely in order to attract the attention of the individual. The duration of the
administration ranges between 40 to 60 minutes (Lord et al., 2012).

Activities of each Module

ADOS-2 includes planned social activities called ¨presses¨ (Murray, 1938). Although the
activities across the Modules differ, the general principles remain the same. Their main goal is to
provide interesting, standard contexts in which the individual will desire to participate in social
interactions. The number of activities differs from module to module. The order of activities and
materials can be varied according to the individual needs. In tables 2, 3, 4, 5 and 6 activities of
each module are presented separately (Lord et al., 2012).

Principles of Use

Training
It is noted that ADOS-2 requires specific education, training and experience due to the
fact that it is a structured observational tool. Moreover, examiners should be familiar with the
procedure of assessment, the activities, the materials and the codes in order to focus their
attention on specific behaviors related to ASD that are possible to be elicited during the
administration. Also, a variety of specialists with a master’s degree in psychology, school
counselling, occupational therapy, speech–language pathology, social work, education, special
education, or related field can administer this tool (Lord et al., 2012).

Selecting the Appropriate Module

Only one of the five modules is administered for every individual (Lord et al., 2012).
Concerning the right module choice the examiner selects the one that is appropriate for the
individual according to his/her expressive language skills at first and then to his/her chronological
age. A wrong Module choice can affect scores (Klein-Tasman, Risi, & Lord, 2007). The
evaluation of individual’s expressive level can be done, by taking a verbatim language sample at
the beginning of the ADOS-2 after the individual is relaxed and settled. However, in cases where
there is no evidence and there is a doubt is better to be conservative and the Module with fewer
language demands to be administered. Then the examiner can add tasks from the next one
Module if they are appropriate. Information about an individual’s expressive language is helpful,
but the decision for the use of the appropriate Module must be based on the examiner’s
observation.
Specifically, Phrase Speech is defined as the use of non-echoed, three-word utterances
that usually contains a verb and that are spontaneous and meaningful. So, for children within the
range of no speech at all up to the use of simple phrases Module T or 1 is administered (according
their chronological age Toddler Module for children 12-30 months and Module 1 for 31 months
and older), while for children with three-word phrases Module 2. Module 2 is considered to be
the appropriate Module for children that are not verbally fluent, regardless their chronological
age. Also, it is the one that is administered for children under 3 years old.
Modules 3 and 4 are for verbally fluent individuals, meaning that they can produce a
range of flexible sentence types, beyond the immediate context with logical connections within a
sentence, although they can make some grammatical errors. This expressive language level is
equivalent of a typical 4-year-old. Usually, a 10-minute speech sample is enough to identify the
use of complex sentences. Module 3 is administered for verbally fluent children and younger

3
adolescents (under 16 years of age), while Module 4 for verbally fluent adolescents and adults
with a minor level of independence in terms of relationships and goals. The difference between
these two Modules lies in the greater use of toys in Module 3, while in Module 4 it depends on
interview questions and conversation.
However, there are situations where older individuals (e.g. older adolescents or adults)
are not verbally fluent and so Module 3 or 4 cannot be administered. Taking into account that
Modules T, 1, and 2 are developed for young children and so their activities and materials may
not be appropriate for older adolescents and adults that are not verbally fluent, examiners should
make some adjustments to the presentation of activities and selection of materials. This is
appropriate for these Modules in order to be less childish and be administered in older individuals
that are not verbally fluent.

Administration
ADOS-2 is designed to be administered by one examiner. A parent or a caregiver must be
present during the administration for the Toddler Module, Modules 1 and 2. Administration
includes the delivery of specific activities in a semi-structured way. The examiner should modify
his/her behavior according to a hierarchy of social presses in order to elicit from the individual
specific behaviors. In contrast with the most diagnostic measures, the administration of ADOS-2
is relative flexible as it does not have to follow a rigid order of the tasks.
For the testing area a space for free play, a table and chairs for the examiner and the
individual to sit are necessary to exist for the more structures part of ADOS-2. During free play,
the individual interact with the materials spontaneously or he/she is prompted to interact with the
examiner or the parent.
During the administration of ADOS-2, notes should be taken for each task based on
observations in order to extract the overall ratings (codes) immediately after the administration
(Lord et al., 2012). Behavioral, language observations should be noted throughout the
administration. For this reason, examiners should be familiar with the process of administration
and all the ADOS-2 codes, so that they can observe behaviors that are relevant for coding without
reading or keeping an eye on the manual during this time. There are some key reminders in the
protocol booklets in order to help examiners draw their attention to specific behaviors during
administration and some areas called Specify for some coding items, where the examiner provide
detailed description for the behavior that is assessed. Also, examiners can use note-taking
strategies during administration, in order to provide enough information and complete the coding
(Table 7).

Coding
Due to the fact that the main aim of ADOS-2 is the interactive social behavior between
the examiner and the individual that is being assessed, only one person can administer it and take
notes, as a second observer is likely to miss some subtle points of interaction (Lord et al., 2012).
They can, also, record the administration, so that they can re-examine some behaviors later.
However, coding must be completed immediately after administration.
In the Coding section of the Protocol Booklet there are some categories of domains that
ADOS assess: a) Language and communication, b) reciprocal social interaction, c) play and
imagination, d) stereotyped behaviors and restricted interests, and e) other behaviors. Each
domain includes the titles of the items and the specific aspects of behavior that are rated in each
Module along with explanations of the numerical rates that can be assigned for each item.
Examiners should assign ratings based on notes and their lists of behavioral evidence during the
observation.
A higher score indicates a more significant impairment for the behavior described by a
specific item. Ratings usually range from 0 to 2 or 3, where 0 indicates no evidence of abnormal
behavior as it is defined in the specific item, 1 indicates mildly abnormal or unusual behavior, 2

4
definite abnormal behavior and 3 markedly abnormal behavior. Also, ratings 8 or 9 are assigned
when an item is not applicable or cannot otherwise be coded. Most of the items require
considering all behaviors during observation while a few items are based on a one solely
observation during a specific activity (Lord et al., 2012). After the coding, items are grouped by
domain. These are: Communication, Reciprocal Social Interaction, and Restricted and Repetitive
Behaviors.

Algorithms and Classification

Once the items have been coded, they are converted to algorithm scores and used to
complete a diagnostic algorithm. Specifically, there is a selection of specific items that are
summed and then they are compared to predetermined cut-off scores. There are different
diagnostic algorithms for each module and for specific age ranges and language levels within
modules. Algorithms are divided into two domains: Social Affect (which includes social and
communication skills) and Restricted and Repetitive Behaviors. This is consistent with the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) ASD
diagnostic criteria. There is one diagnostic cut-off for the combined domain total.
All the Modules except from the Toddler one use cut-off scores for the classification. On
the other hand, Toddler Module provides ranges of concern. Moreover, Modules 1, 2 and 3 offer
a Comparison Score which provide the participant’s level of ASD symptomatology, compared
with that of other ASD children of same language level and chronological age. Also, it can be
used to define the individual’s level and possible changes over time. Comparison Scores range
from 1 to 10 and is divided into four interpretive categories regarding the level of ASD
symptomatology in order to facilitate clinical interpretation. These categories are:

• High level of autism spectrum-related symptoms: For an 8 to 10 Comparison

Score, indicating high level of autism spectrum-related symptoms. It corresponds to a
classification of autism representing the highest Overall Total scores and the greatest degree
of ASD symptoms.

• Moderate level of autism spectrum-related symptoms: For a 5 to 7 Comparison

Score, indicating a moderate level of autism spectrum-related symptoms. It corresponds to a
classification of either autism spectrum or autism, indicating a presence of numerous ASD
symptoms.

• Low level of autism spectrum-related symptoms: For a 3 to 4 Comparison Score,

indicating a relatively low level of autism spectrum-related symptoms. It corresponds to a
classification of non-spectrum or autism spectrum, meaning that several symptoms of
concern were observed that are either indicative of mild ASD or there is a number of ASD-
like symptoms in individuals without ASD.

• Minimal-to-no evidence of autism spectrum-related symptoms: For a 1 to 2

Comparison Score, indicating Minimal-to-no evidence of autism spectrum-related
symptoms. It corresponds to a classification of non-spectrum where although some unusual
behaviors may have been noted but are either not ASD-specific or not of clinical concern.

So, an autism or an autism spectrum diagnosis is received when an individual’s score on

the algorithm exceed a total cut-off score of the combined Social Affect and Repetitive
Restriction Behavior domain score (Oosterling et al., 2010; Lord & Rutter, 2012; Hus & Lord,
2014).

Psychometric Properties

5
 ADOS-2 has been tested on a wide range and large number of people. It is considered a
valid and reliable measure (Gotham et al., 2007). Regarding Reliability, ADOS-2 consistency for
the Toddler Module and Modules 1 to 3 was high for the SA domain and moderate for the RRB
domain, while for Module 4 was high for the communication and social interaction domains but
low for RRB domain (Lord et al., 2012).
Test-retest reliability, concerning Toddler Module and Modules 1 to 3 was moderate to
high. Also, regarding the inter-rater reliability, there was a high agreement in diagnostic
classification for the same Modules. I
Ιnternal consistency and test-retest values were lower, probably due to the fact that the
time during ADOS-2 administration is limited for this kind of behaviors to be observed.
When it comes to its predictive validity, comparing the ADOS-2 with ADOS, sensitivity
and specificity were largely improved with the new algorithms (Lord et al., 2012).
Medda, Cholemkery and Freitag (2019) found a satisfactory diagnostic accuracy for all
modules for diagnosing autism and non-autism spectrum combined versus non-ASD. This is very
important as it reflects the DSM-5 criteria. Especially, for Module 3 and 4 a better sensitivity and
specificity was found compared to the ADOS when differentiating autism from non-ASD.
Regarding Module 3 and differentiating autism from non-ASD diagnostic validity was similar to
the previous ADOS edition but also higher specificity was found. On the other hand, lower
specificity was found when differentiating autism spectrum from non-ASD. These results are also
in accordance also with the findings of Kamp-Becker et al., (2013). For Module 4 an increase was
found in sensitivity and a decrease in specificity of ADOS-2 when differentiating autism from
non-ASD and similar a high sensitivity and a reduced specificity for autism and non-autism
spectrum combined versus non-ASD when compared with ADOS. Despite this, in Hus and Lord
(2014) study sensitivity for Module 4 was slightly lower in both algorithms and specificity was
increased. Additionally, it is supported that there is an overlap of symptoms between ASD and
psychosis, due to the fact that social communication difficulties are not solely prominent on ASD
(Maddox et al., 2017; Chisholm et al., 2015). This fact leads to a high rate of false positives
diagnoses, ending up to the conclusion that ADOS-2 should not be used as a stand-alone
diagnostic measure
It should be noted that ADOS-2 was standardized in populations without sensory or
motor impairments, so it is prerequisite for individuals to walk independently and is free of
hearing or visual impairments in order to interact with the materials and take part in the activities
during the assessment. In addition, it was designed in a way which language abilities and
chronological age do not interfere with social and communication abilities (Lord et al., 2012).

Advantages and Issues of ADOS-2

The format of the ADOS-2 is differed from the majority of other standardized assessment
tools. The important fact is that the assessment is a dynamic process in ADOS-2. For example,
examiners should not be attached to the manual during the administration. Social interaction with
the examinee is its main goal. The flexible structure with the use of naturalistic presses
contributes to this goal at its maximum.
One of the many advantages of ADOS-2 is the fact that it can be used with a wide range
of individuals concerning their developmental and language level. Especially, after the inclusion
of the Toddler Module, this contributes to the efforts of indentifying the very early signs of ASD.
ADOS-2 is appropriate for administration across the lifespan, from children as young as 1 year up
to adulthood.
As it is known, expressive language level consider to be the strongest predictor in ASD,
as it affects all the aspects of social interaction and play. That is why ADOS-2 consists of
different modules for individuals with varying levels of expressive language. So, it was designed
in a way which language abilities and chronological age do not interfere with social and
communication abilities, so the results are independent of these domains.

6
 While raw scores are affected by age, development and language level, the Comparison
Scores quantify the severity of core ASD symptoms as it is intended to represent a continuous
dimension of the autism spectrum symptomatology (Hedley et al., 2016; Shumway et al., 2012).
This makes ADOS-2 less affected by language and cognitive functioning and that explains the
improvement of its sensitivity and specificity. The Comparison Score can be used to define the
individual’s level and possible changes over time due to the changes in age, in intellectual and
communicative functioning. It does not represent the individual’s clinical profile in a group of
typical development individuals. It can be used to understand an individual’s level of ASD
symptomatology, by comparing individual’s Overall Total score with the score of children with
ASD of the same chronological age and language level. It is assigned even for individuals that do
not meet classification for autism or autism spectrum. Also, it is beneficial in assessing
intervention effectiveness and in identifying the domains that need intervention (Esler et al.,
2015). However, Comparison Scores must be interpreted with caution. Both Comparison Score
and classification are not the same as clinical diagnosis. They just indicate greater severity of
autism spectrum-related symptoms.
Certainly, the ADOS-2 results are crucial as they can define the medical diagnoses, the
special education classification and the treatment planning in several domains (e.g. occupational
and speech therapy).
Despite all these positives sides of the ADOS-2, there are some limitations. First of all
Module 4 was not updated in contrast to the rest of the Modules.
Also, regarding the Coding Section most guidelines for the items that are coded are vague
using expressions such as ¨most¨, ¨sometimes¨, ¨seems to be¨, ¨slightly¨, ¨frequent¨, ¨occasional¨,
¨several¨, ¨some¨, ¨little¨ etc. leaving space for subjective interpretation (Kamp-Becker et al.,
2018). This kind of interpretation may lead examiners to assign less appropriate codes for the
behaviors that are assessed.
Another crucial point is that although, ADOS-2 includes Modules 1 and 2 for use with
children with limited language, their materials and activities are not appropriate for adolescents
and adults that are not verbally fluent (Berument et al., 2005). Most studies include algorithms for
individuals up to 12 years old. So the interpretation of these two modules must be with caution
when are administered to older individuals (Gotham et al., 2007; 2008). For these reasons, an
adaptation regarding adults with restricted language for these two Modules is crucial to be made.
This would provide to adults with ASD the access to adult service systems and the appropriate
prevention programs (Bal et al., 2020).
A major issue is the ADOS-2 diagnostic accuracy when it comes to clinical settings, as it
is still unclear whether it accomplishes the same level of accuracy with lab-based settings. Most
of the studies examine sensitivity and specificity, while objectivity, accuracy, reliability and
utility in clinical settings need to be more investigated. The fact that the specificity in clinical
samples is lower than the research ones seems very crucial, as many false-positive diagnoses have
been found in some studies (Kamp-Becker et al., 2017; Maddox et al., 2017). Furthermore,
concerning the studies about the psychometric properties of ADOS-2 there are results that
indicate low and highly variable inter-rated agreement (Kamp-Becker et al., 2018; Zander et al.,
2016).
Although, there are many studies that have investigated the psychometric properties of
ADOS-2, only few of them have included adolescents and adults. Diagnosing ASD in adulthood
is a challenge for clinicians due to the lack of developmental information and the camouflage of
symptoms in high-functioning individuals (Lai & Baron Cohen, 2015). It is important to
recognize ASD symptoms in adults with mild ASD forms. However, ADOS-2 is recommended as
a valid instrument to assess these adults (De Bildt et al., 2015; Fusar-Poli et al., 2017).
Differences among studies about psychometric properties of ADOS-2 are probably
attributed to sample characteristics. First of all, all these studies included highly variable sample
sizes. Especially, low sample sizes create limitations to the interpretation of the findings (Medda,
Cholemkery, & Freitag, 2019). Another factor that contributed to these results is the different
mean age of the samples. The absence of Intellectual disability of individuals with ASD in the
samples of different studies, also, seems to increase specificity and to decrease specificity
(Pugliese, et al., 2015). Certainly, more studies with larger sample sizes that include the whole

7
ASD spectrum are necessary. Likewise, studies with individuals with intellectual disability and
language impairments must be included.

CONCLUSION

Certainly, ADOS-2 is an effective clinical and research diagnostic tool for ASD but we
should keep in mind that ADOS-2 results consist only one part of a full diagnostic evaluation
procedure, as it assesses specific behaviors in a limited duration. Also, all behaviors assessments
are vulnerable to subjectivity. There are specific behaviors that are not always observable during
an assessment. For this reason more information is required. Information from ADOS-2 could be
integrated with information from clinical assessment and developmental history. A multi-
disciplinary team can conduct assessments in different domains of functioning (e.g. cognitive and
language abilities) based on different sources such as a developmental history, more observations,
caregiver interviews or questionnaires as long as the administration of other diagnostic tools and
information from different contexts (e.g. school). So, specialists should not be based solely on the
results and information from ADOS-2, regarding an individual’s clinical diagnosis. Also, they
could be less dependent on ADOS-2 scores and cut-offs and use more all the clinical information
that ADOS-2 provides in order to maximize diagnostic accuracy.
In the end, the usefulness of the instrument depends upon the clinical skills of the
administrator. Clinical skills are crucial for decisions considering the administration of the
ADOS-2 such as the duration of each task (e.g. conservation). That is why examiners should be
extremely familiar with typical and atypical development across all ages and ASD indicative and
subtle behaviors.

8
 REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (DSM-5®). American Psychiatric Pub.
Bal, V. H., Maye, M., Salzman, E., Huerta, M., Pepa, L., Risi, S., & Lord, C. (2020). The
adapted ADOS: A new module set for the assessment of minimally verbal adolescents
and adults. Journal of Autism and Developmental Disorders, 50(3), 719-729.
https://doi.org/10.1007/s10803-019-04302-8
Berument, S. K., Starr, E., Pickles, A., Tomlins, M., Papanikolauou, K., Lord, C., &
Rutter, M. (2005). Pre-linguistic Autism Diagnostic Observation Schedule adapted for
older individuals with severe to profound mental retardation: a pilot study. Journal of
Autism and Developmental Disorders, 35(6), 821-829. DOI: 10.1007/s10803-005-0027-
4
Chisholm, K., Lin, A., Abu-Akel, A., & Wood, S. J. (2015). The association between
autism and schizophrenia spectrum disorders: A review of eight alternate models of co-
occurrence. Neuroscience & Biobehavioral Reviews, 55, 173-183.
https://doi.org/10.1016/j.neubiorev.2015.04.012
De Bildt, A., Sytema, S., Meffert, H., & Bastiaansen, J. A. (2016). The Autism
Diagnostic Observation Schedule, Module 4: Application of the revised algorithms in an
independent, well-defined, Dutch sample (n= 93). Journal of Autism and Developmental
Disorders, 46(1), 21-30. DOI 10.1007/s10803-015-2532-4
Esler, A. N., Bal, V. H., Guthrie, W., Wetherby, A., Weismer, S. E., & Lord, C. (2015).
The autism diagnostic observation schedule, toddler module: standardized severity
scores. Journal of autism and developmental disorders, 45(9), 2704-2720.
https://doi.org/10.1007/s10803-015-2432-7
Fusar-Poli, L., Brondino, N., Rocchetti, M., Panisi, C., Provenzani, U., Damiani, S., &
Politi, P. (2017). Diagnosing ASD in adults without ID: accuracy of the ADOS-2 and the
ADI-R. Journal of autism and developmental disorders, 47(11), 3370-3379.
https://doi.org/10.1007/s10803-017-3258-2
Gotham, K., Risi, S., Dawson, G., Tager-Flusberg, H., Joseph, R., Carter, A., Hepburn,
S., McMahon, W., Rodier, P., Hyman, S. L., Sigman, M., Rogers, S., Landa, R., Spence,
M. A., Osann, K., Flodman, P., Volkmar, F., Hollander, E., Buxbaum, J., ... & Lord, C.
(2008). A replication of the Autism Diagnostic Observation Schedule (ADOS) revised
algorithms. Journal of the American Academy of Child & Adolescent Psychiatry, 47(6),
642-651. https://doi.org/10.1097/CHI.0b013e31816bffb7
Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The Autism Diagnostic Observation
Schedule: revised algorithms for improved diagnostic validity. Journal of autism and
developmental disorders, 37(4), 613-627. https://doi.org/10.1007/s10803-006-0280-1
Hedley, D., Nevill, R., Uljarević, M., Butter, E., & Mulick, J. A. (2016). ADOS-2
Toddler and Module 1 standardized severity scores as used by community practitioners.
Research in Autism Spectrum Disorders, 32, 84-95.
https://doi.org/10.1016/j.rasd.2016.09.005
Hus, V., & Lord, C. (2014). The autism diagnostic observation schedule, module 4:
revised algorithm and standardized severity scores. Journal of autism and developmental
disorders, 44(8), 1996-2012. DOI 10.1007/s10803-014-2080-3

9
Kamp-Becker, I., Albertowski, K., Becker, J., Ghahreman, M., Langmann, A.,
Mingebach, T., Poustka, L., Weber, L., Schmidt, H., Smidt, J., Stehr, T., Roessner, V.,
Kucharczyk, K., Wolff, N., & Stroth, S. (2018). Diagnostic accuracy of the ADOS and
ADOS-2 in clinical practice. European child & adolescent psychiatry, 27(9), 1193-1207.
https://doi.org/10.1007/s00787-018-1143-y
Kamp-Becker, I., Langman A., Stehr T., Custodis K., Poustka L., & Becker, K. (2017).
Diagnostic accuracy of the ADOS-2 taking account of gender effects. Z
KinderJugendpsychiatr Psychother, 44, 1-15. DOI: 10.1024/1422-4917/a000492
Klein-Tasman, B. P., Risi, S., & Lord, C. E. (2007). Effect of language and task demands
on the diagnostic effectiveness of the autism diagnostic observation schedule: The
impact of module choice. Journal of Autism and Developmental Disorders, 37(7), 1224-
1234. DOI 10.1007/s10803-006-0266-z
Lai, M. C., & Baron-Cohen, S. (2015). Identifying the lost generation of adults with
autism spectrum conditions. The Lancet Psychiatry, 2(11), 1013-1027.
https://doi.org/10.1016/S2215-0366(15)00277-1
Lord, C., Luyster, R.J., Gotham, K., & Guthrie, W. (2012). Autism diagnostic
observation schedule–2nd edition (ADOS-2). [Manual: Toddler Module]. Torrance, CA:
Western Psychological Services.
Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P. C., Pickles,
A., & Rutter, M. (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(3), 205-223.
https://doi.org/10.1023/A:1005592401947
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. (2012). Autism
diagnostic observation schedule–2nd edition (ADOS-2). Los Angeles, CA: Western
Psychological Corporation, 284.
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. (2012). Autism
diagnostic observation schedule–2nd edition (ADOS-2). [Manual:Modules 1-4].
Torrance, CA: Western Psychological Services.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (1999).
ADOS. Autism diagnostic observation schedule. Manual. Los Angeles: WPS.
Lord, C., & Rutter, M. (2012). Autism Diagnostic Observation Schedule-2nd edition. Los
Angeles: Western Psychological Services.
Maddox, B. B., Brodkin, E. S., Calkins, M. E., Shea, K., Mullan, K., Hostager, J.,
Mandell, D. S., & Miller, J. S. (2017). The accuracy of the ADOS-2 in identifying
autism among adults with complex psychiatric conditions. Journal of autism and
developmental disorders, 47(9), 2703-2709. https://doi.org/10.1007/s10803-017-3188-z
Medda, J. E., Cholemkery, H., & Freitag, C. M. (2019). Sensitivity and specificity of the
ADOS-2 algorithm in a large german sample. Journal of autism and developmental
disorders, 49(2), 750-761. https://doi.org/10.1007/s10803-018-3750-3
Murray, H. A. (1938). Explorations in personality. New York: Oxford.
Oosterling, I., Roos, S., de Bildt, A., Rommelse, N., de Jonge, M., Visser, J.,
Lappenschaar, M., Swinkels, S., van der Gaag, R. J., & Buitelaar, J. (2010). Improved
diagnostic validity of the ADOS revised algorithms: A replication study in an

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independent sample. Journal of autism and developmental disorders, 40(6), 689-703.
DOI 10.1007/s10803-009-0915-0
Pugliese, C. E., Kenworthy, L., Bal, V. H., Wallace, G. L., Yerys, B. E., Maddox, B. B.,
White, S. W., Popal, H., Armour, A. C., Miller, J., Herrington, J. D., Schultz, R. T.,
Martin, A., & Anthony, L. G. (2015). Replication and comparison of the newly
proposed ADOS-2, module 4 algorithm in ASD without ID: A multi-site study. Journal
of Autism and Developmental Disorders, 45(12), 3919-3931.
https://doi.org/10.1007/s10803-015-2586-3
Shumway, S., Farmer, C., Thurm, A., Joseph, L., Black, D., & Golden, C. (2012). The
ADOS calibrated severity score: relationship to phenotypic variables and stability over
time. Autism Research, 5(4), 267-276. https://doi.org/10.1002/aur.1238
Zander, E., Willfors, C., Berggren, S., Choque-Olsson, N., Coco, C., Elmund, A.,
Moretti, A. H., Holm, A., Jifält, I., Kosieradzki, R., Linder, J., Nordin, V., Olafsdottir,
K., Poltrago, L., & Bölte, S. (2016). The objectivity of the Autism Diagnostic
Observation Schedule (ADOS) in naturalistic clinical settings. European child &
adolescent psychiatry, 25(7), 769-780. https://doi.org/10.1007/s00787-015-0793-2
2010 Principal Investigators, & Centers for Disease Control and Prevention (CDC.
(2014). Prevalence of autism spectrum disorder among children aged 8 years-autism and
developmental disabilities monitoring network, 11 sites, United States, 2010. Morbidity
and mortality weekly report. Surveillance summaries (Washington, DC: 2002), 63(2), 1-
21.

11
KEY TERMS AND DEFINITIONS
Algorithm: A method that uses the test results to identify a health condition.

DSM-5: Diagnostic and Statistical Manual of Mental Disorders is the taxonomic and diagnostic
tool published by the American Psychiatric Association (APA) for psychiatric diagnoses.

Internal Consistency: A measure of reliability that reflects the extent to which items within an
instrument measure various aspects of the same characteristic or construct.

Inter-rater Reliability: The degree of agreement between raters.

Predictive Validity: The extent to which the diagnostic tool’s algorithms identify individuals on
the autism spectrum.

Reliability: The consistency with which a diagnostic tool estimates what it is designed to
measure.

Restrictive Repetitive Behaviors: The one of the two algorithms domains. It includes items
pertaining ¨Restrictive Repetitive Behaviors¨.

Sensitivity: The proportion of positive diagnosis that are correctly identified.

Social Affect: The one of the two algorithms domains. It includes items pertaining
¨Communication¨ and ¨Reciprocal Social Interaction¨.

Specificity: The proportion of negative diagnosis that are correctly identified.

Test-retest Reliability: The extent to which a tool yields consistent results when administered in
two different occasions.

APPENDIX
Table 1. Selecting the Appropriate Module

Expressive Language Chronological Age Range ADOS-2 Module

Level

No Speech 12 to 30 months Toddler

up to
Simple Phrases
31 months and older 1

Phrase Speech
Any age 2
up to
Fluent Speech

12
 Child/Younger adolescent
Fluent Speech
Older adolescent/adult
(Source: Lord et al., 2012)
Table 2. Toddler Module Activities
Activities Purpose
1. Free Play Creation of a relaxed
atmosphere and assessment of
the independent use of toys
and the presence of repetitive
behaviors
1a. Free Play Ball
Observation of how the child
responds to a new toy.
2. Blocking Toy Play Observation of the child’s
reaction to an unusual social
situation in which the
examiner interfere with
his/her access to a toy.
3. Response to Name Assessment of the child’s
response to his/her name
3
4
Focus of the Observation
and Behaviors that are
assessed
a. Spontaneously seeking
engagement with
parent/examiner.
b. Direction of affect to
others.
c. Exploration of materials
(symbolically/functionally)
d. Does the child stay with
activities?
e. How the child responds to
the introduction of a ball and
whether he/she initiates or
responds to common games
with it.
How the child reacts to a
social ambiguous situation in
which the examiner
intentionally prevents access
to a toy. Also observation of
eye contact, facial
expressions, vocalizations and
motor response.
Consistency of the child’s
response and how he/she
responds (eye contact,
looking at examiner’s face,
vocalization)
13
4. Bubble Play
4a. Bubble Play-Teasing Toy
Play
5. Anticipation of A routine
With Objects
5a. Anticipation of A routine
With Objects-Unable Toy
Play
6. Anticipation of a Social
Routine
7. Response to Joint Attention Assessment of the child’s
response to the use of gaze
coordinated with facial
orientation, vocalization and
pointing.
8. Responsive Social Smile
9. Bath Time
To elicit eye contact and
vocalization from the child in
coordination with his/her
pointing/reaching. Also it
may elicit sensory behaviors,
facial expressions and shared
enjoyment.
Observation of how the child
responds to an unusual social
interaction.
Assessment of the child’s
anticipation and initiation of
the repetition of an action
routine with objects.
Observation of the child’s
reaction to an unusual social
situation
Assessment of the child’s
anticipation of, request for,
and participation in a social
routine.
Assessment of the child’s
smiling in response to a social smile in 4 presses.
overture.
Opportunity for engagement
in functional and symbolic
play.
The child’s affect, initiation
of joint attention, shared
enjoyment, requesting, motor
behavior and unusually
sensory behaviors.
How the child reacts to a
social ambiguous situation in
which the examiner
intentionally prevents access
to a toy. Also observation of
eye contact, facial
expressions, vocalizations and
motor response.
The child’s affect, initiation
of joint attention, shared
enjoyment, requesting, motor
responses (repetitive
mannerisms).
How the child reacts to a
social ambiguous situation in
which the examiner
intentionally appears unable
to complete a play activity.
Also observation of eye
contact, facial expressions,
vocalizations and motor
response.
Evaluation of the child’s
affect and his/her attempts to
initiate repetition of the
routine. Also, the extent to
which he/she integrates gaze,
facial expression,
vocalization, gesture and
behaviors indicative of shared
enjoyment.
Evaluation of whether the
child follows a shift in gaze
alone or when it is
accompanied by pointing.
Evaluation of the child’s
Evaluation of the child’s
interest and ability to join in
the social script. The extent,
to which he/she treats a doll
as a representation of an
14

9a. Bath Time-Ignore
10. Functional and Symbolic
Imitation
11. Snack
(Source: Lord et al., 2012)
Table 3. Module 1 Activities
Activities
1. Free Play
2. Response to Name
3. Response to Joint Attention Assessment of the child’s
4. Bubble Play
Observation of the child’s
response to a lack of social
input.
Assessment of the child’s
assessment of imitation of
simple actions.
To make the child requests.
Purpose
Creation of a relaxed a. Spontaneously seeking
atmosphere and assessment of engagement with
the independent use of toys. parent/examiner.
Assessment of the child’s
response to his/her name
response to the use of gaze
coordinated with facial
orientation, vocalization and
pointing.
To elicit eye contact and
vocalization from the child in
animate being, contributes to
the script or imitates actions.
Also, shared enjoyment,
overtures and reciprocity.
Observation of the child’s
response when the parent is
ignoring him/her.
The use of miniature objects
and a placeholder in imitation
of familiar actions, including
whether these acts are carried
out with social awareness and
shared enjoyment.
How the child indicates a
preference. Use of gaze,
gesture, reaching, facial
expression, vocalization and
overtures.
Focus of the Observation
and Behaviors that are
assessed
b. Direction of affect to
others.
c. Exploration of materials
(symbolically/functionally)
d. Does the child stay with
activities?
Consistency of the child’s
response and how he/she
responds (eye contact,
looking at examiner’s face,
vocalization)
Evaluation of whether the
child follows a shift in gaze
alone or when it is
accompanied by pointing.
The child’s affect, initiation
of joint attention, shared
15

5. Anticipation of A routine
With Objects
6. Responsive Social Smile
7. Anticipation of a Social
Routine
8. Functional and Symbolic
Imitation
9. Birthday Party
10. Snack
(Source: Lord et al., 2012)
Table 4. Module 2 Activities
Activities
coordination with his/her
pointing/reaching. Also it
may elicit sensory behaviors,
facial expressions and shared
enjoyment.
Assessment of the child’s
anticipation and initiation of
the repetition of an action
routine with objects.
Assessment of the child’s
smiling in response to a social smile in 4 presses.
overture.
Assessment of the child’s
anticipation of, request for,
and participation in a social
routine.
Assessment of the child’s
assessment of imitation of
simple actions.
To engage in symbolic and
functional play.
To make the child requests.
Purpose
enjoyment, requesting, motor
behavior and unusually
sensory behaviors.
The child’s affect, initiation
of joint attention, shared
enjoyment, requesting, motor
responses (repetitive
mannerisms)
Evaluation of the child’s
Evaluation of the child’s
affect and his/her attempts to
initiate repetition of the
routine. Also, the extent to
which he/she integrates gaze,
facial expression,
vocalization, gesture and
behaviors indicative of shared
enjoyment.
The use of miniature objects
and a placeholder in imitation
of familiar actions, including
whether these acts are carried
out with social awareness and
shared enjoyment.
Evaluation of the child’s
interest and ability to join in a
¨script¨. The extent, to which
he/she treats a doll as a
representation of an animate
being, contributes to the script
or imitates actions. Also,
shared enjoyment, overtures
and reciprocity.
How the child indicates a
preference. Use of gaze,
gesture, reaching, facial
expression, vocalization and
overtures.
Focus of the Observation
and Behaviors that are
assessed
16
1. Construction Task
2. Response to Name
3. Make-Believe Play
4. Joint Interactive Play
5. Conversation
6. Response to Joint Attention Assessment of the child’s
7. Demonstration Task
8. Description of a Picture
9. Telling a Story from a
Book
10. Free Play
Warm-up activity.
Observation of the child’s
interactive behavior and how
he/she asks for help.
Assessment of the child’s
response to his/her name
Observation of the child’s
creative/imaginative use of
miniature play objects in a
unstructured task.
The degree and quality of the
child’s coordination of
behavior and affect.
Assessment of the child’s
ability to carry out a simple
conversation with back-and-
forth interchange, regardless
the level of complexity.
response to the use of gaze
coordinated with facial
orientation, vocalization and
pointing.
Assessment of the child’s
ability to communicate about
a familiar series of actions
using gesture with
accompanying language, and
to report on a routine event.
Production of a sample
language and other
communicative behaviors.
Assessment of the child’s
ability to follow and comment
on a sequential story in a
picture book and the
production of a narrative.
Assessment of the
How the child attempts to ask
for more pieces, if he/she
does.
Consistency of the child’s
response and how he/she
responds (eye contact,
looking at examiner’s face,
vocalization)
Evaluation of the production
of imaginative sequence of
actions. Also, observation of
social overtures, spontaneous
language, facial expressions,
gestures.
Observation of the reciprocity
and shared enjoyment.
Whether the child provides
ideas for the play and follows
examiner’s ideas.
The extent, to which the child
builds on examiner’s
statements, asks questions and
makes leading statements.
Evaluation of whether the
child follows a shift in gaze
alone or when it is
accompanied by pointing.
How the child represents
familiar actions in gesture
through the use of his/her
body to represent an object.
To obtain a sample of the
child’s spontaneous language
and communication, as well
as a sense of what captures
his/her interest.
To obtain a sample of the
child’s spontaneous language
and communication, as well
as a sense of what captures
his/her interest. Also,
assessment of the child’s
ability to convey continuity in
a story and to involve another
person in telling the story.
a. Spontaneously seeking
17

11. Birthday Party
12. Snack
13. Anticipation of A routine
With Objects
14. Bubble Play
(Source: Lord et al., 2012)
Table 5. Module 3 Activities
Activities
1. Construction Task
2. Make-Believe Play
independent use of toys and
the presence of repetitive
behaviors.
To engage in symbolic and
functional play.
To make the child requests.
Assessment of the child’s
anticipation and initiation of
the repetition of an action
routine with objects.
To elicit eye contact and
vocalization from the child in
coordination with his/her
pointing/reaching. Also it
may elicit sensory behaviors,
facial expressions and shared
enjoyment.
Purpose
Warm-up activity. How the individual attempts
Observation of the to ask for more pieces, if
individual’s interactive he/she does.
behavior and how he/she asks
for help.
Observation of the
individual’s
engagement with
parent/examiner.
b. Direction of affect to
others.
c. Exploration of materials
(symbolically/functionally)
d. Does the child stay with
activities?
Evaluation of the child’s
interest and ability to join in a
¨script¨. The extent, to which
he/she treats a doll as a
representation of an animate
being, contributes to the script
or imitates actions. Also,
shared enjoyment, overtures
and reciprocity.
How the child indicates a
preference. Use of gaze,
gesture, reaching, facial
expression, vocalization and
overtures.
The child’s affect, initiation
of joint attention, shared
enjoyment, requesting, motor
responses (repetitive
mannerisms).
The child’s affect, initiation
of joint attention, shared
enjoyment, requesting, motor
behavior and unusually
sensory behaviors.
Focus of the Observation
and Behaviors that are
assessed
Evaluation of the production
of imaginative sequence of
18

3. Joint Interactive Play
4. Demonstration Task
5. Description of a Picture
6. Telling a Story from a
Book
7. Cartoons
8. Conversation and
Reporting
9. Emotions
creative/imaginative use of
miniature play objects in an
unstructured task.
The degree and quality of the
individual’s coordination of
behavior and affect.
Assessment of the
participant’s ability to
communicate about a familiar
series of actions using gesture
with accompanying language,
and to report on a routine
event.
Production of a sample
language and other
communicative behaviors.
Production of a sample
language and other
communicative behaviors.
To narrate a story, use
gestures, to integrate gaze and
language and to comment on
characters’ emotions.
Assessment of the
participant’s ability to engage
in a conversation with back-
and-forth interchange and to
describe an non-routine event
outside the immediate
context.
Assessment regarding the
content of the conversation
about emotions and personal
actions. Also, observation of
social overtures, spontaneous
language, facial expressions
and gestures.
Observation of the reciprocity
and shared enjoyment.
Whether the individual
provides ideas for the play
and follows examiner’s ideas.
How the participant
represents familiar actions in
gesture through the use of
his/her body to represent an
object.
To obtain a sample of the
individual’s spontaneous
language and communication,
as well as a sense of what
captures his/her interest.
To obtain a sample of the
participants’ spontaneous
language and communication,
as well as a sense of what
captures his/her interest. Also,
evaluation of his/her response
to conventional humour,
his/her comments about
characters’ feeling and the
story’s continuity.
Observation of the
participant’s use of gestures
and its coordination with
speech. Also, his/her response
to humour, his/her flexibility
in adapting a narrative to the
audience. Finally, the
comments about emotions
and relationships.
The extent, to which the
participant builds on
examiner’s statements.
Particular attention to how
he/she comments about
emotions and relationships
and his/her communication
(gaze, facial expression,
intonation, gesture).
Identification of the
events/objects that elicit
different emotions (social or
19

10. Social Difficulties and
Annoyance
11. Break
12. Friends, Relationships,
and Marriage
13. Loneliness
14. Creating a Story
(Source: Lord et al., 2012)
Table 6. Module 4 Activities
Activities
1. Construction Task*
2. Telling a Story from a
Book
experiences.
Assessment of the
individual’s insight into
personal social difficulties
and sense of responsibility for
his/her actions.
Observation of the
participant’s behavior in less
structured circumstances.
To obtain information
regarding participant’s
relationships and a general
description of his/her
understanding concerning the
concept of friendship/getting
married/long-term
relationship.
Assessment of participant’s
insight into his/her social
situation and his/her ability to
describe his/her emotional
reaction to it.
Observation of participant’s
creativity.
Purpose
Warm-up activity. How the individual attempts
Observation of the to ask for more pieces, if
individual’s interactive he/she does.
behavior and how he/she asks
for help.
To recount a sequential story
and to make comments about
relationships and affect.
not). How the participant
describes emotions (facial
expressions, insight into
typical social relationships).
Evaluation of the participant’s
perception concerning social
difficulties and his/her
attempts to change his/her
behavior.
How the participant occupies
him/herself during free time
and how he/she responds to
examiner’s withdrawal.
Evaluation of the articipant’s
understanding of the
friendship concept and other
social relationships, as long as
the nature of them. Also, the
reasons of why a person
might want to be involved in
these and his/her possible role
in these.
Evaluation of the participant’s
understanding of the concept
of loneliness and how he/she
feels about loneliness.
Evaluation of the participant’s
creative use of objects.
Focus of the Observation
and Behaviors that are
assessed
To obtain a sample of the
participants’ spontaneous
language and communication,
as well as a sense of what
captures his/her interest. Also,
evaluation of his/her response
to conventional humour,
his/her comments about
20

3. Description of a Picture*
4. Conversation and
Reporting
5. Current Work or School*
6. Social Difficulties and
Annoyance
7. Emotions
8. Demonstration Task
9. Cartoons*
Production of a sample
language and other
communicative behaviors.
Assessment of the
participant’s ability to engage
in a conversation with back-
and-forth interchange and to
describe a non-routine event
outside the immediate
context.
Evaluation of how the
participant describes his/her
current situation, and his/her
insight and understanding on
his/her role about the future.
Also, it elicits information
about ¨Responsibility¨ and
relationships.
Assessment of the
individual’s insight into
personal social difficulties
and sense of responsibility for
his/her actions.
Assessment regarding the
content of the conversation
about emotions and personal
experiences.
Assessment of the
participant’s ability to
communicate about a familiar
series of actions using gesture
with accompanying language,
and to report on a routine
event.
To narrate a story, use
gestures, integrate gaze and
language and to comment on
characters’ emotions.
characters’ feeling and the
story’s continuity.
To obtain a sample of the
individual’s spontaneous
language and communication,
as well as a sense of what
captures his/her interest.
The extent, to which the
participant builds on
examiner’s statements.
Particular attention to how
he/she comments about
emotions and relationships
and his/her communication
(gaze, facial expression,
intonation, gesture).
To obtain information about
participant’s current and
previous situation and to
evaluate whether he/she has
realistic perceptions for future
employment.
Evaluation of the participant’s
perception concerning social
difficulties and his/her
attempts to change his/her
behavior. Especially, the
appropriateness and
implications of his/her
feelings.
Identification of the
events/objects that elicit
different emotions (social or
not). How the participant
describes emotions (facial
expressions, insight into
typical social relationships).
How the participant
represents familiar actions in
gesture through the use of
his/her body to represent an
object.
Observation of the
participant’s use of gestures
and its coordination with
speech. Also, his/her response
to humour, his/her flexibility
in adapting a narrative to the
21

10. Break
11. Daily Living*
12. Friends, Relationships,
and Marriage
13. Loneliness
14. Plans and Hopes
15. Creating a Story
*optional
(Source: Lord et al., 2012)
Table 7. Recommended Note-Taking Strategies
Most Common Behaviors that are Assessed
Asking for information
Complex Mannerism
Descriptive Gesture
Directed/Undirected Vocalization
Eye Contact
Observation of the
participant’s behavior in less
structured circumstances.
To obtain information about
participant’s socio-emotional
background and his/her
understanding regarding
money, residential
arrangements and leisure
activities.
To obtain information
regarding participant’s
relationships and a general
description of his/her
understanding concerning the
concept of friendship/getting
married/long-term
relationship.
Assessment of participant’s
insight into his/her social
situation and his/her ability to
describe his/her emotional
reaction to it.
To elicit descriptions of
participant’s goals and to
provide a positive end to the
interview.
Observation of participant’s
creativity.
Indicative Shorthand notation
AI
CM
DG
Dir/Un Voc
EC
audience. Finally, the
comments about emotions
and relationships.
How the participant occupies
him/herself during free time
and how he/she responds to
examiner’s withdrawal.
To obtain information about
participant’s financial
responsibility and whether
he/she is realistic about
his/her future concerning
¨independence¨.
Evaluation of participant’s
understanding of the
friendship concept and other
social relationships, as long as
the nature of them. Also, the
reasons of why a person
might want to be involved in
these and his/her possible role
in these.
Evaluation of the participant’s
understanding of the concept
of loneliness and how he/she
feels about loneliness.
To obtain information about
what the participant
anticipates for the future.
Evaluation of the participant’s
creative use of objects.
22
 Emotional/Emphatic Gestures EG

Facial Expression FE

Spontaneous initiation of Joint Attention IJA

Offers Information OI

Point Pt

Request Req

Shared Enjoyment SE

Social Overture SOV

(Source: Lord et al., 2012)

23

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