The ADOS-2 in Adult Community Mental Health Settings

Background:  

For adults with possible ASD, the ADOS-2 is likely to be the instrument of choice to gather observations about social communication and restricted interests and behaviors.  While insufficient on its own for a diagnosis, it might be the most standardized and objective information available about ASD related characteristics, especially when early developmental history is unavailable.  Because evidence suggests many adults with ASD have unmet psychiatric care needs, it is thus particularly critical to know how to identify adults with ASD and ensure they are receiving needed services.  To that end, it is critical to know how the ADOS-2 performs in different care settings, include CMH centers.  

Objectives:  To examine the utility of the ADOS-2 to distinguish individuals with ASD from individuals with other diagnoses receiving CMH services.

Methods:  Consumers of services at three large CMH centers in Philadelphia (n = 1134) were screened for social communication impairments with the Social Responsiveness Scale, Adult version (SRS-A) and the Autism Spectrum Disorders in Adults Screening Questionnaire (ASDASQ).  Of these, a sample stratified to heavily recruit participants with SRS-A scores >60 was recruited to participate in a clinical evaluation that included an ADOS-2, brief clinical interview about ASD related characteristics not assessed by the ADOS-2, social history questions from the KIDDIE-SADS-Present and Lifetime Version (K-SADS-PL), and the Overview and Psychosis modules of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID).  The clinical evaluation team remained blind to results from the SRS-A and ASDASQ.  The ADOS-2 was always administered first, and scored independently of subsequent information gathered.  After the full evaluation, clinical case conferences were conducted for all participants to make a final determination of ASD.

Results:  To date, 58 in-person evaluations have been conducted.  An additional 35 evaluations are expected by May 2016.  Results from clinical case conferences suggested that 2 of the 58 had an ASD (3.45%); 43 had some form of psychosis (74.14%).  However, 22 participants obtained ADOS-2 scores above the cutoffs suggestive of ASD; 2 were the individuals with ASD, 16 were individuals with psychosis, and the remaining 4 had existing mood disorder diagnoses and suspected personality disorders.  From clinical observation, it was often the negative symptoms of psychosis that resulted in elevated ADOS-2 scores. 

Conclusions:  Social communication impairments are not specific to ASD, and of course the ADOS-2 is not intended to be used as the sole source of data in a diagnostic evaluation.  However, our data suggest that ADOS-2 scores may yield a very high rate of false positives in adults with complex mental health issues.  Across these CMH settings, 20/56 (35.7%) of our sample obtained elevated ADOS-2 scores, although clinical case conference judgment determined the client did not have ASD.  The high rate of false positives on the ADOS-2 among adults with complex psychiatric issues suggests the ADOS-2 may not be a helpful tool for discriminating ASD in this population, or at least must be considered in the context of other developmental and clinical information.