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Autism Diagnostic Evaluation

This document contains an evaluation form for an ADOS assessment. It includes sections for identifying information about the examinee, scores for the modules assessing language/communication, reciprocal social interaction, and restricted/repetitive behaviors. The form also includes spaces to record the overall ADOS classification, overall diagnosis, and ADOS-2 comparison severity scores.

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7K views2 pages

Autism Diagnostic Evaluation

This document contains an evaluation form for an ADOS assessment. It includes sections for identifying information about the examinee, scores for the modules assessing language/communication, reciprocal social interaction, and restricted/repetitive behaviors. The form also includes spaces to record the overall ADOS classification, overall diagnosis, and ADOS-2 comparison severity scores.

Uploaded by

jhebeta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ID: ________________________________ Date of Birth: ________________________

Gender: _________________________________ Date of Evaluation: ___________________

Examiner: _______________________________ Chronological Age: ___________________

ADOS Module 4
ADOS Algorithm for DSM-5/ICD-10 Autism Diagnosis
(convert scores of 3 on the protocol to 2, and treat all scores other than 0-3 as 0)

Language and Communication


Conversation (A-8) _______
Emphatic or Emotional Gestures (A-10)_______

Reciprocal Social Interaction


Unusual Eye Contact (B-1) _______
Facial Expressions Directed to Examiner (B-2) _______
Communication of Own Affect (B-5) _______
Insight into Typical Social Situations and Relationships (B-7) _______
Quality of Social Overtures (B-9) _______
Quality of Social Response (B-11) _______
Amount of Reciprocal Social Communication (B-12) _______
Overall Quality of Rapport (B-13) _______

Social Affect Total _______

Restricted and Repetitive Behaviours


Speech Abnormalities Associated with Autism (A-2) _______
Stereotyped/Idiosyncratic Use of Words or Phrases (A-4) _______
Unusual Sensory Interest in Play Material/Person (D-1) _______
Hand and Finger and Other Complex Mannerisms (D-2) _______
Excessive Interest in or References to Unusual or Highly Specific
Topics or Objects or Repetitive Behaviours (D-4) _______

Restricted and Repetitive Behaviour Total _______

Social Affect and Restricted and Repetitive Behaviour Total _______


(Cut-off = 8)

Diagnosis
ADOS Classification: ______________________________

Overall Diagnosis: _________________________________


ADOS-2 Comparison (Severity) Score
Raw Totals
CSS
Overall Score SA Domain RRB Domain
1 0-2 0-1 0
2 3-5 2-3 -
3 6-7 4 -
4 8 5 -
5 9 6 1
6 10-11 7-8 2
7 12-13 9-10 3
8 14-15 11-12 4
9 16-19 13-15 5
10 20-29 16-20 6-10

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