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54-586: The Autism Diagnostic Interview and the Autism Diagnostic Observation Schedule are both considered gold standard tests for autism. Useful for diagnosing autism, planning treatment, and distinguishing autism from other developmental disorders. The interview covers the referred individual's full developmental history, is usually conducted in an office, home or other quiet setting by a psychologist, and generally takes one to two hours. The caregivers are asked 93 questions, spanning

108-592: A concurrent diagnosis of ASD) scored in the autism spectrum range on the ADOS total score. False positives have also been found in school-age subjects who have high anxiety or trauma-related disorders; in these cases, the ADOS-2 scores related to repetitive and restrictive behaviors (RRB) are usually lower than typical for ASD. A 2018 Cochrane systematic review included 12 studies of ADOS diagnostic accuracy in pre-school children (Modules 1 and 2). The summary sensitivity

162-861: A diagnosis in individuals with a mental age of at least 18 months.This would enable clinicians to use the interview to differentiate autism from other disorders which can appear in early childhood. The main goals in revising the ADI were to make the interview more efficient, shorter, and more appropriate for younger children. The majority of the revisions made involved the organization of the interview. The questions were divided into five distinct sections and early and current behavior were consolidated in each section. Research led to some modifications of specific interview questions. Modifications included both making some questions focus more on autism-specific aspects of behaviors and making other questions more generalized to improve efficiency. Also, some additional questions were added to

216-420: A frequency of 1 in 40000. There is evidence that adults with schizophrenia demonstrate an increased incidence of autistic features compared to the general population, resulting in higher ADOS scores, though schizophrenia patients also experience positive symptoms of psychosis (e.g. hallucinations, delusions, formal thought disorders). A 2016 study found that 21% of children with a diagnosis of ADHD (and without

270-456: A jury, and presentation skill of a speaker. Variation across raters in the measurement procedures and variability in interpretation of measurement results are two examples of sources of error variance in rating measurements. Clearly stated guidelines for rendering ratings are necessary for reliability in ambiguous or challenging measurement scenarios. Without scoring guidelines, ratings are increasingly affected by experimenter's bias , that is,

324-539: A new Toddler Module (T) for assessing children aged 12 to 30 months. The scoring algorithm was also revised to align with the recent changes in the DSM-5 diagnostic criteria. While the ADOS-G had separate sections for social and communication behaviors, the ADOS-2 combined these into a single domain to represent social affect, and added a new domain to assess restrictive and repetitive behaviors (RRB). The ADOS consists of

378-531: A scoring algorithm classifies the individual with autism, autism spectrum disorder, or non-spectrum. The toddler module algorithm yields a "range of concern" rather than a definite classification. The toddler module is appropriate for children 12–30 months who use little to no phrase speech and are able to walk independently. This module consists of eleven primary activities: Module 1 is appropriate for children 31 months and older who use little or no phrase speech. This module consists of ten activities: Module 2

432-637: A series of structured and semi-structured tasks that generally takes 30-60 minutes to administer. During this time, the examiner provides a series of opportunities for the subject to show social and communication behaviors relevant to the diagnosis of autism. Each subject is administered activities from the module that corresponds to their developmental and language level. The ADOS should not be used for formal diagnosis with individuals who are blind , deaf , or otherwise seriously impaired by sensory or motor disorders, such as cerebral palsy or muscular dystrophy . Following task administration and observation coding,

486-438: A series of structured and semi-structured tasks that involve social interaction between the examiner and the person under assessment. The examiner observes and identifies aspects of the subject's behavior, assigns these to predetermined categories, and combines these categorized observations to produce quantitative scores for analysis. Research-determined cut-offs identify the potential diagnosis of autism spectrum disorder, allowing

540-405: A set of items (e.g., do two interviewers agree about the depression scores for all of the items on the same semi-structured interview for one case?) as well as raters x cases (e.g., how well do two or more raters agree about whether 30 cases have a depression diagnosis, yes/no—a nominal variable). Kappa is similar to a correlation coefficient in that it cannot go above +1.0 or below -1.0. Because it

594-459: A standardized assessment of autistic symptoms. The Autism Diagnostic Interview-Revised (ADI-R), a companion instrument, is a structured interview conducted with the parents of the referred individual to cover the subject's full developmental history. The ADI-R has lower sensitivity but similar specificity to the ADOS. The ADI-R and ADOS are both considered gold standard diagnostic tests for autism. However, neither of these tests are required by

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648-458: Is a companion instrument by the same core authors. It is a semi-structured set of observations and is conducted in an office setting as a series of activities involving the referred individual and a psychologist or other trained and licensed examiner. Autism Diagnostic Observation Schedule The Autism Diagnostic Observation Schedule ( ADOS ) is a standardized diagnostic test for assessing autism spectrum disorder. The protocol consists of

702-606: Is a matter of a practical assessment in each case. Krippendorff's alpha is a versatile statistic that assesses the agreement achieved among observers who categorize, evaluate, or measure a given set of objects in terms of the values of a variable. It generalizes several specialized agreement coefficients by accepting any number of observers, being applicable to nominal, ordinal, interval, and ratio levels of measurement, being able to handle missing data, and being corrected for small sample sizes. Alpha emerged in content analysis where textual units are categorized by trained coders and

756-442: Is a reliable agreement between raters. There are three operational definitions of agreement: These combine with two operational definitions of behavior: The joint-probability of agreement is the simplest and the least robust measure. It is estimated as the percentage of the time the raters agree in a nominal or categorical rating system. It does not take into account the fact that agreement may happen solely based on chance. There

810-425: Is an improvement over Pearson's r {\displaystyle r} and Spearman's ρ {\displaystyle \rho } , as it takes into account the differences in ratings for individual segments, along with the correlation between raters. Another approach to agreement (useful when there are only two raters and the scale is continuous) is to calculate the differences between each pair of

864-647: Is appropriate for children six years old or younger who speak in phrases but have not yet developed fluent verbal language. This module consists of fourteen activities: Module 3 is appropriate for children or young adolescents who are verbally fluent. This module consists of fourteen activities: Module 4 is appropriate for older adolescents and adults. While similar to module 3, module 4 relies more heavily on questions and verbal responses rather than non-verbal actions observed during play. This module consists of ten to fifteen activities. Activities marked by an asterisk are optional: The social communication difficulties that

918-427: Is completed, the interviewer determines a rating score for each question based on their evaluation of the caregiver's response. A total score is then calculated for each of the interview's content areas. When applying the algorithm, a score of 3 drops to 2 and a score of 7, 8, or 9 drops to 0 because these scores do not indicate autistic behaviors and, therefore, should not be factored into the totals. In order to create

972-463: Is defined as, "the proportion of variance of an observation due to between-subject variability in the true scores". The range of the ICC may be between 0.0 and 1.0 (an early definition of ICC could be between −1 and +1). The ICC will be high when there is little variation between the scores given to each item by the raters, e.g. if all raters give the same or similar scores to each of the items. The ICC

1026-499: Is no "intrinsic" agreement and (b) to increase as the "intrinsic" agreement rate improves. Most chance-corrected agreement coefficients achieve the first objective. However, the second objective is not achieved by many known chance-corrected measures. Kappa is a way of measuring agreement or reliability, correcting for how often ratings might agree by chance. Cohen's kappa, which works for two raters, and Fleiss' kappa, an adaptation that works for any fixed number of raters, improve upon

1080-433: Is ordinal. If more than two raters are observed, an average level of agreement for the group can be calculated as the mean of the r {\displaystyle r} , τ , or ρ {\displaystyle \rho } values from each possible pair of raters. Another way of performing reliability testing is to use the intra-class correlation coefficient (ICC). There are several types of this and one

1134-420: Is some question whether or not there is a need to 'correct' for chance agreement; some suggest that, in any case, any such adjustment should be based on an explicit model of how chance and error affect raters' decisions. When the number of categories being used is small (e.g. 2 or 3), the likelihood for 2 raters to agree by pure chance increases dramatically. This is because both raters must confine themselves to

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1188-732: Is the degree of agreement among independent observers who rate, code, or assess the same phenomenon. Assessment tools that rely on ratings must exhibit good inter-rater reliability, otherwise they are not valid tests . There are a number of statistics that can be used to determine inter-rater reliability. Different statistics are appropriate for different types of measurement. Some options are joint-probability of agreement, such as Cohen's kappa , Scott's pi and Fleiss' kappa ; or inter-rater correlation, concordance correlation coefficient , intra-class correlation , and Krippendorff's alpha . There are several operational definitions of "inter-rater reliability," reflecting different viewpoints about what

1242-412: Is used as a measure of agreement, only positive values would be expected in most situations; negative values would indicate systematic disagreement. Kappa can only achieve very high values when both agreement is good and the rate of the target condition is near 50% (because it includes the base rate in the calculation of joint probabilities). Several authorities have offered "rules of thumb" for interpreting

1296-482: Is used in counseling and survey research where experts code open-ended interview data into analyzable terms, in psychometrics where individual attributes are tested by multiple methods, in observational studies where unstructured happenings are recorded for subsequent analysis, and in computational linguistics where texts are annotated for various syntactic and semantic qualities. For any task in which multiple raters are useful, raters are expected to disagree about

1350-446: Is usually higher or lower than the other by a consistent amount, the bias will be different from zero. If the raters tend to disagree, but without a consistent pattern of one rating higher than the other, the mean will be near zero. Confidence limits (usually 95%) can be calculated for both the bias and each of the limits of agreement. There are several formulae that can be used to calculate limits of agreement. The simple formula, which

1404-426: The DSM-5 for an autism diagnosis. The original ADOS was created by Catherine Lord , Michael Rutter , Pamela C. DiLavore and Susan Risi in 1989. The protocol consisted of 8 tasks meant to assess the individual’s social and communicative behaviors. Behaviors were rated on the following scale: Some ratings could also be assigned a rating of 7, indicating observed behaviors not otherwise specified. In response to

1458-548: The ADI-R is required for both conducting and scoring the interview. Training usually takes 2 or more months to complete depending on the person's clinical experience and interviewing skills. There are separate training procedures based on whether the ADI-R will be conducted for clinical or research purposes. To use the instrument as a clinician, there are training videos and workshops for administration and scoring. The ADI-R DVD Training Package offered by WPS provides clinical training in

1512-445: The ADI-R. Both inter-rater reliability and internal consistency were good across all behavioral areas investigated in the interview. The interview was also found to have adequate reliability across time. Research comparing ADI-R results of autistic children and children with other developmental disorders suggested that individual questions on the interview were slightly more valid when discriminating autism from intellectual disability than

1566-409: The ADOS and ADOS-2 seek to measure are not unique to ASD; there is a heightened risk of false positives in individuals with other psychological disorders. In particular, an increased false positive rate has been observed in adults with psychosis ; while case reports indicate that such false positives may also occur in cases of childhood-onset schizophrenia , which is an exceptionally rare entity with

1620-464: The ADOS-Generic (ADOS-G) to assess a broader developmental range of individuals. The ADOS-G introduced a modular format, allowing different protocols to be used depending on developmental and language factors. It became commercially available in 2001 through Western Psychological Services. The second edition, published in 2012, included updated norms, improved algorithms for Modules 1 to 3, and

1674-499: The Autism Diagnostic Interview, published in 1989, was used mainly for research purposes. The ADI was developed in response to four major developments in the field of diagnosing autism which led to a need for updated diagnostic tools. These developments included improvements in the diagnostic criteria, the need to differentiate between autism and other developmental disorders that appear similar early in life, and

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1728-437: The algorithm as a whole. However, further research has led to overall acceptance of the ADI-R algorithm. The social communication questionnaire (SCQ) is a brief, 40-item, true/false questionnaire, completed by parents regarding the behavior of their child. It parallels the ADI-R in content and is used for brief screening to determine the need to conduct a full ADI-R interview. The autism diagnostic observation schedule (ADOS),

1782-601: The algorithm for diagnosis, the writers chose questions from the interview that were most closely related to the criteria for diagnosis of Autism Spectrum Disorder in the DSM-IV and the ICD-10 . An autism diagnosis is indicated when scores in all three behavioral areas meet or exceed the specified minimum cutoff scores. These cutoff scores were determined using the results of many years of extensively reviewed research. Extensive training and knowledge about autism spectrum disorder and

1836-499: The approach included versions that could handle "partial credit" and ordinal scales. These extensions converge with the family of intra-class correlations (ICCs), so there is a conceptually related way of estimating reliability for each level of measurement from nominal (kappa) to ordinal (ordinal kappa or ICC—stretching assumptions) to interval (ICC, or ordinal kappa—treating the interval scale as ordinal), and ratio (ICCs). There also are variants that can look at agreement by raters across

1890-400: The cost of a 14% reduction in sensitivity; however, due to overlapping confidence intervals, that result could not be considered statistically significant. Inter-rater reliability In statistics, inter-rater reliability (also called by various similar names, such as inter-rater agreement , inter-rater concordance , inter-observer reliability , inter-coder reliability , and so on)

1944-400: The desire, in the area of psychology, for standardized diagnostic instruments. The original ADI could be used on individuals with a chronological age of at least five years and a mental age of at least two years, but autism spectrum disorder is usually diagnosed much earlier than this age. This finding led Rutter, LeCouteur, and Lord to revise the ADI in 1994 so that it could be used to determine

1998-420: The factors that lead to a diagnosis . The first section of the interview is used to assess the quality of social interaction and includes questions about emotional sharing, offering and seeking comfort, social smiling, and responding to other children. The communication and language behavioral section investigates stereotyped utterances, pronoun reversal , and social usage of language. Stereotyped utterances are

2052-408: The few words or sounds that the individual uses and repeats most often. The restricted and repetitive behaviors section includes questions about unusual preoccupations, hand and finger mannerisms, and unusual sensory interests. Finally, the assessment contains questions about behaviors such as self-injury, aggression, and over activity which would help in developing treatment plans. After the interview

2106-503: The interview was revised. The ADI-R has also been tested thoroughly for reliability and validity using inter-rater reliability , test-retest reliability and internal validity tests. The results of this research have led to the ADI's acceptance among both researchers and clinicians for decades. The ADI-R is often used in conjunction with other related instruments to determine an autism diagnosis. The writers have published psychometric results that indicate both reliability and validity of

2160-484: The interview, including more specific questions about ages when abnormal behaviors began. Other items were removed in order to increase the interview's ability to diagnose autism at a younger age. These question revisions also led the writers to revise the scoring algorithm and cut-off scores as there were more questions added to some sections. Questions from the original version of the ADI that were found, through research, to be unreliable or not applicable were removed when

2214-411: The investigator is able to obtain all of the information required to determine a valid rating for each behavior. For this reason, parents and caretakers usually feel very comfortable when taking part in this interview because what they have to say about their children is valued by the interviewer. Also, taking part in this interview helps parents obtain a better understanding of autism spectrum disorder and

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2268-436: The joint probability in that they take into account the amount of agreement that could be expected to occur through chance. The original versions had the same problem as the joint-probability in that they treat the data as nominal and assume the ratings have no natural ordering; if the data actually have a rank (ordinal level of measurement), then that information is not fully considered in the measurements. Later extensions of

2322-447: The level of agreement, many of which agree in the gist even though the words are not identical. Either Pearson 's r {\displaystyle r} , Kendall's τ , or Spearman 's ρ {\displaystyle \rho } can be used to measure pairwise correlation among raters using a scale that is ordered. Pearson assumes the rating scale is continuous; Kendall and Spearman statistics assume only that it

2376-431: The limited number of options available, which impacts the overall agreement rate, and not necessarily their propensity for "intrinsic" agreement (an agreement is considered "intrinsic" if it is not due to chance). Therefore, the joint probability of agreement will remain high even in the absence of any "intrinsic" agreement among raters. A useful inter-rater reliability coefficient is expected (a) to be close to 0 when there

2430-579: The need for diagnostic tools for autism in younger children, researchers developed the Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS). The PL-ADOS adapted the content and format of the original ADOS to rely less on verbal communication. It consisted of 12 tasks, retaining only the free/unstructured playtime from the original ADOS and adding new activities designed to be less dependent on speech. In 2000, Lord and her colleagues introduced

2484-535: The observed target. By contrast, situations involving unambiguous measurement, such as simple counting tasks (e.g. number of potential customers entering a store), often do not require more than one person performing the measurement. Measurement involving ambiguity in characteristics of interest in the rating target are generally improved with multiple trained raters. Such measurement tasks often involve subjective judgment of quality. Examples include ratings of physician 'bedside manner', evaluation of witness credibility by

2538-451: The risk of bias to be properly evaluated. The authors could not identify any studies for the ADOS-2; the scope of the review was limited to preschool age children (mean age under 6 years), which excluded studies of Modules 3 and 4 from the meta-analysis. One included study examined the additive sensitivity and specificity of the ADOS used in combination with the ADI-R; that study found an 11% improvement in specificity (compared to ADOS alone) at

2592-432: The three main behavioral areas, about either the individual's current behavior or behavior at a certain point in time. The interview is divided into five sections: opening questions, communication questions, social development and play questions, repetitive and restricted behavior questions, and questions about general behavior problems. Because the ADI-R is an investigator-based interview, the questions are very open-ended and

2646-539: The two methods (inter-rater agreement), but also to assess these characteristics for each method within itself. It might very well be that the agreement between two methods is poor simply because one of the methods has wide limits of agreement while the other has narrow. In this case, the method with the narrow limits of agreement would be superior from a statistical point of view, while practical or other considerations might change this appreciation. What constitutes narrow or wide limits of agreement or large or small bias

2700-410: The two raters' observations. The mean of these differences is termed bias and the reference interval (mean ± 1.96 ×  standard deviation ) is termed limits of agreement . The limits of agreement provide insight into how much random variation may be influencing the ratings. If the raters tend to agree, the differences between the raters' observations will be near zero. If one rater

2754-449: The two ratings on the horizontal. The resulting Bland–Altman plot demonstrates not only the overall degree of agreement, but also whether the agreement is related to the underlying value of the item. For instance, two raters might agree closely in estimating the size of small items, but disagree about larger items. When comparing two methods of measurement, it is not only of interest to estimate both bias and limits of agreement between

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2808-499: The use of the ADI-R. Researchers are required to attend specific research training and establish their reliability in using the ADI-R in order to use it for research purposes. The standard of practice is to attend an in-person ADI-R research training workshop and establish research reliability with the authors or their colleagues. The ADI-R was developed by Michael Rutter , Ann LeCouteur , and Catherine Lord and published by Western Psychological Services in 2003. The original version of

2862-497: Was 0.94 (95% CI 0.89 to 0.97), with sensitivity in individual studies ranging from 0.76 to 0.98. The summary specificity was 0.80 (95% CI 0.68 to 0.88), with specificity in individual studies ranging from 0.20 to 1.00. The studies were evaluated for bias using the QUADAS-2 framework; of the 12 included studies, 8 were evaluated as having a high risk of bias, while for the remaining four there was insufficient information available for

2916-410: Was given in the previous paragraph and works well for sample size greater than 60, is For smaller sample sizes, another common simplification is However, the most accurate formula (which is applicable for all sample sizes) is Bland and Altman have expanded on this idea by graphing the difference of each point, the mean difference, and the limits of agreement on the vertical against the average of

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