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J Autism Dev Disord. 2009 May ; 39(5): 693–705. doi:10.1007/s10803-008-0674-3.

Standardizing ADOS Scores for a Measure of Severity in Autism

Spectrum Disorders

Katherine Gotham1, Andrew Pickles2, and Catherine Lord1

1University
of Michigan Autism and Communication Disorders Center, Ann Arbor, Michigan
2Division of Epidemiology and Health Science, University of Manchester, United Kingdom

Abstract
The aim of this study is to standardize Autism Diagnostic Observation Schedule (ADOS) scores
within a large sample to approximate an autism severity metric. Using a dataset of 1415
individuals aged 2–16 years with autism spectrum disorders (ASD) or nonspectrum diagnoses, a
subset of 1807 assessments from 1118 individuals with ASD were divided into narrow age- and
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language-cells. Within each cell, severity scores were based on percentiles of raw totals
corresponding to each ADOS diagnostic classification. Calibrated severity scores had more
uniform distributions across developmental groups and were less influenced by participant
demographics than raw totals. This metric should be useful in comparing assessments across
modules and time, and identifying trajectories of autism severity for clinical, genetic, and
neurobiological research.

Keywords
autism spectrum disorders; Autism Diagnostic Observation Schedule (ADOS); severity

Currently, levels of impairment in children with autism spectrum disorders (ASD) are
measured largely in terms of language delay, cognitive functioning, or behavioral issues
such as aggression. While these are important factors in overall adaptive functioning, they
are not core features of the autism spectrum. Measuring the relative severity of autism-
specific features could contribute to our ability to accurately describe ASD phenotypes
across samples and across time in clinical and treatment research. An ASD severity metric
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could be useful for categorizing samples into more homogeneous groups in genetic and
other neurobiological studies; it would also address a need to document severity as part of
clinical assessment.

At this point, measures that provide autism severity ratings, such as the Childhood Autism
Rating Scale (CARS; Schopler, Reichler, & Renner, 1986), the Gilliam Autism Rating Scale
(GARS; Gilliam, 1995), or the Autism Behavior Checklist (ABC; Krug, Arick, & Almond,
1980), tend to yield scores that are either strongly correlated with IQ or that do not
correspond to standard measures of diagnosis (Gilliam, 1995; Volkmar et al., 1988; Spiker,
Lotspeich, Dimiceli, Myers, & Risch, 2002; South et al., 2002; Szatmari, Bryson, Boyle,
Streiner, & Duku, 2003). The Social Responsiveness Scale (SRS; Constantino et al., 2003)
provides a method for quantifying social impairment that has shown relative independence

Correspondence concerning this article should be addressed to Katherine Gotham, UMACC, 1111 East Catherine Street, Ann Arbor,
MI 48109-2054; kog@[Link].
Disclosure: C. Lord receives royalties for the ADOS; profits related to this study were donated to charity.
 Gotham et al. Page 2

from participant characteristics such as IQ. SRS scores are based on parent or teacher report,
however, and thus a complementary measure of ASD severity that offers the opportunity to
take into account the observations of an experienced clinician would be desirable.
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For genetic, neuroscience, and intervention research, severity of core autism features often
has been estimated using primary phenotyping measures, the Autism Diagnostic
Observation Schedule (ADOS; Lord et al., 2000) and the Autism Diagnostic Interview-
Revised (ADI-R; Rutter, LeCouteur, & Lord, 2003). While it is true that higher ADI-R and
ADOS scores indicate that an individual has a greater number of items representing core
deficits and/or greater severity of impairment, scores were not normalized for this purpose
and vary in the degree to which they are correlated with both IQ and chronological age.
Attempts to indicate severity using ADI-R item scores selected to operationalize ICD-10
criteria for the disorder proved successful in predicting the number of affected relatives of
verbal probands, but not for nonverbal probands (Pickles et al., 2000). One limitations of
ADI-R scores as a severity metric is that nonverbal children are not scored on roughly 25%
of the total ADI-R items, and so communication domain summary scores are restricted by
non-random missing data.

The ADOS, a semi-structured autism diagnostic observation, has shown strong predictive
validity against best estimate diagnoses (Gotham, Risi, Pickles, & Lord, 2007), making it a
common choice among phenotyping measures. In each of four developmental- and
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language-level dependent modules, a protocol of social presses is administered by a trained

examiner, and then behavioral items relevant to ASD are scored on a 4-point scale, with 0
indicating ‘no abnormality of type specified’ and 3 indicating ‘moderate to severe
abnormality.’ Specific items comprise an algorithm for each module; these items are
summed and compared to thresholds, which results in a classification of “autism,” “autism
spectrum disorder,” or “nonspectrum.”

Because the ADOS has been used to catalogue ASD features in large samples, ADOS raw
totals are a common stand-in for a measure of autism severity. This instrument was created
for diagnostic purposes, and thus was not specifically designed to facilitate longitudinal and
cross-sectional comparison of data. As an individual gains language skills, he or she
potentially moves through ADOS modules, making raw scores not directly comparable
across time. Additionally, effects of age and language level on domain total and algorithm
scores have been observed (Joseph, Tager-Flusberg, & Lord, 2002; de Bildt et al., 2004;
Gotham et al., 2007).

In 2007, the original ADOS algorithms were revised in part for the purpose of increasing the
comparability across modules 1–3. Algorithms with the same number of items and of similar
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content across modules were created (Gotham et al., 2007). These revisions resulted in
improved specificity of the measure among more impaired populations, while generally
maintaining or improving predictive validity among individuals of other developmental
levels (e.g., fluent speakers). The algorithm domain structure now includes a Social Affect
(SA) and a Restricted, Repetitive Behavior (RRB) domain for each of the five
developmentally-based algorithms corresponding to modules 1–3. Comparability of item
content and total item number across these algorithms was intended to improve the
interpretability of longitudinal comparisons using the measure. Still, items are necessarily
developmentally graded across modules, making calibration necessary to compare algorithm
totals.

Some effects of participant characteristics still exist within and across ADOS modules as
well. Revised algorithm totals met the goal of independence from chronological age and
decreased association with verbal IQ, with the exception of Module 1 scores (Gotham et al.,

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2007). A replication of the algorithm revisions in an independent dataset again found low
correlations between raw scores and age, verbal IQ, and nonverbal IQ, though significant
associations remained between verbal IQ and Social Affect domain total scores for Module
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1 recipients with few or no single words and Module 2 recipients aged 5 or older (Gotham et
al., 2008).

True normalization of severity of autism would require a representative population, but to

date, population studies have been too small, e.g., Brick Township (Bertrand et al., 2001),
have not used the ADOS (Chakrabarti & Fombonne, 2005; CDC, 2007), or have collected
samples older than most clinically assessed children (Baird et al, 2006). Acknowledging
these limitations, in the present study we elected to standardize ADOS scores using a large
“convenience” sample of individuals with ASD. Our goals were to reduce remaining
participant demographic effects to the greatest possible degree, and generate standard scores
that would approximate a severity metric for the construct of ‘autism spectrum’ as it is
measured on the ADOS. This metric ideally will be useful in (1) allowing comparison of
assessments across modules and time; (2) providing a means of assessing the relationship
between severity in ASD and verbal and nonverbal IQ; and (3) identifying different
trajectories of autism severity independent of verbal IQ both for clinical purposes and for
phenotypic subgrouping in genetic and neurobiological research. We hope that calibrated
severity scores can then be replicated in smaller population-based studies and tested for
validity in predicting treatment responsiveness and other clinical outcomes in children with
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ASD.

Our first approach to developing a severity metric was to calibrate ADOS algorithm totals
using eight age/language cells chosen on the basis of theoretically-driven expectations for
specific age ranges with similar developmental impairments. This would have allowed a
‘prefix’ on the severity score that indicated age and language level out of the eight possible
groups (ranging from young Module 1’s with no words to fluent speakers, aged 5–10).
Within each cell, raw totals were converted to Z-scores, which were then converted to a 100-
point scale. This method yielded calibrated scores that fanned out, with increasing
variability of individuals’ ADOS totals over time and age. Thus, an alternative approach was
chosen in which a greater number of age/language cells were used, and severity scores
within each cell were based on the raw total percentiles that corresponded to each of three
possible ADOS diagnostic classifications. This method is described in more detail below.

Methods
Participants
Analyses were conducted on data from 1415 individuals, of which 355 individuals with
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ASD diagnoses had repeated measure data. The final dataset included 2195 assessments,
where ‘assessment’ is defined as contemporaneous ADOS data and a best estimate clinical
diagnosis. Autism diagnoses were assigned to 1187 assessments (54% of entire sample); 599
assessments were given diagnoses of non-autism ASD (27% of the sample, including n=12
with Asperger Disorder, n=3 with Childhood Disintegrative Disorder, and n=584 with
Pervasive Developmental Disorder, Not Otherwise Specified, or PDD-NOS), and 409 had
non-ASD developmental delays (19%). Contemporaneous verbal IQ data was available for
2007 assessments (91.4% of the entire sample) and nonverbal IQ data for 1989 assessments
(91.0%). Please refer to Table 1 for a detailed description of the dataset by revised algorithm
group.

Chronological ages in the sample ranged from 2 to 16 years (see Table 1 for age range by
algorithm group). Recipients of ADOS Module 4 (older adolescents and adults with fluent
speech) were not included in these analyses because of smaller sample size and the different

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relevance of age equivalents in adults. Females comprised 22% of the dataset (N=478
assessments). Ethnicities represented by these data include 14% African American (N=306
assessments); 3% Asian American (N=58); 77% Caucasian (N=1699); 0.5% Native
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American (N=10); 2% biracial (N=40); and other (N=20) or race not specified (N=62)
totaling 4% of assessments. Twenty-three percent of the sample reported maternal education
at the graduate or professional level; 56% of mothers had a bachelor’s degree or some
college education, and 21% of mothers had a high school degree or less.

Within the nonspectrum sample of 409 assessments, 111 had a primary diagnosis of a
language disorder (27% of nonspectrum total), 80 were assessments with nonspecific
intellectual disability (20%), 56 with Down syndrome (14%), 55 with oppositional defiant
disorder, ADD and/or ADHD (13%), 31 with mood and/or anxiety disorders (8%), 29 with
Fetal Alcohol Spectrum Disorders (7%), 24 with non-ASD genetic and/or physical
disabilities such as Fragile X, Williams syndrome, or mild cerebral palsy (6%), and 23 had
an early delay that clinicians were not comfortable categorizing (5%).

The majority of participants were self-, school-, or physician-referred clinic patients at the
University of Michigan Autism and Communication Disorders Center (UMACC) or the
University of Chicago Developmental Disorders Clinic. The rest participated in a
longitudinal study conducted through the Treatment and Education of Autistic and
Communication Handicapped Children (TEACCH) Centers at the University of North
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Carolina, Chapel Hill, and the University of Chicago clinic, or received diagnostic
evaluations through recent, ongoing studies at UMACC, including those focused on
participants with non-ASD developmental delays, ASD-affected sibling pairs, or children
between 12 and 36 months of age who failed a social-communication screener. Out of 399
participants with repeated assessments through clinic reevaluations or longitudinal research,
301 individuals had 2 or 3 ADOS assessments (57% with autism, 31% with PDD-NOS, and
12% NS), and 98 individuals had between 4 and 8 assessments (58% with autism, 33% with
PDD-NOS, and 9% NS). Individuals with longitudinal data did not differ significantly in
gender, race, or maternal education from those with only one assessment point, however
they had significantly lower mean verbal IQs (M=49.6, SD=27.8) and nonverbal IQs
(M=73.0, SD=23.8) at first assessment than did single assessments (verbal IQ M=68.2,
SD=32.8; nonverbal IQ M=77.9, SD=27.5); verbal IQ t(1351)=9.7, p<.001 and nonverbal
IQ t(1334)=3.0, p<.01.

Measures and Procedure

The most typical research protocol across sites and projects was the initial administration of
the ADI-R and the Vineland Adaptive Behavior Scales, 1st (VABS; Sparrow, Balla, &
Cicchetti, 1984) or 2nd edition (Vineland II; Sparrow, Cicchetti, & Balla, 2005), to a parent
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or caregiver, followed by a child evaluation in which psychometric testing preceded the

ADOS. The second most common protocol was a re-evaluation consisting of psychometric
testing and an ADOS. In both cases, a clinical diagnosis was made by a psychologist and/or
psychiatrist after review of all data. The ADI-R was available for 1700 assessments (77% of
sample) and the Vineland for 1710 assessments (78%). The ADOS was administered and
scored by a clinical psychologist or trainee who met standard requirements for research
reliability. The Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS;
DiLavore, Lord, & Rutter, 1995) was given in 418 assessments (19%) and the piloted
ADOS-T (Luyster et al., submitted), a toddler version of the ADOS, was given in 82
assessments (4%); for both measures, identical items were recoded to Module 1 algorithm
scores. A developmental hierarchy of cognitive measures, most frequently the Mullen Scales
of Early Learning (MSEL; Mullen, 1995) and the Differential Ability Scales (DAS; Elliot,
1990), determined IQ scores.

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Clinic-referred participants received oral feedback and a written report without financial
compensation. Participants recruited only for the purpose of research received financial
compensation and a written summary of evaluation results. Institutional Review Boards at
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the University of Chicago or the University of Michigan approved all procedures related to
this project.

Mapping a standardized severity metric onto raw ADOS scores

Severity scores were created by dividing the pool of assessments from individuals with ASD
into narrowly defined age and language cells, and standardizing raw total scores from the
revised algorithms (Gotham et al., 2007) within these cells. In order to maximize the number
of cases available for standardization, assessments missing data from any one item from
either the Social Affect (SA) or Restricted Repetitive Behavior (RRB) domains of the
revised ADOS algorithms were retained by adding to the domain total an average item score
from that participant’s existing domain data. The ASD sample alone was used for raw total
standardization: this included all assessments corresponding to a best estimate diagnosis of
autism or ASD, as well as data from 13 individuals who had ADOS data with a
contemporaneous nonspectrum diagnosis but who were later diagnosed with ASD. This
subsample (N=1807 assessments from 1118 individuals) was separated into groups based on
the five revised algorithms used with children: Module 1 No Words, Module 1 Some Words,
Module 2 Younger than 5; Module 2 Age 5 and Older; and Module 3. Within each of these
five developmental cells, distributions of summed Social Affect and Restricted Repetitive
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Behaviors totals were generated separately for every one-year age group between 2 and 16
years; these age cells were collapsed when possible in order to create the fewest number of
age- and language-level-determined ‘calibration cells’ with similar raw total score
distributions. Younger age cells were purposely kept distinct to anticipate developmental
changes and more frequent assessments in young children as they transition from
toddlerhood to preschool to school programs. Age cells with similar distributions were
collapsed only within the same algorithm. Eighteen calibration cells resulted (see Figure 1).

Within each of these 18 cells, raw ADOS totals were mapped onto a 10-point severity
metric. After considering a variety of approaches, severity scores 1–3 were set so as to
represent the distribution of raw scores receiving a nonspectrum ADOS classification within
that calibration cell, severity scores 4–5 represented ASD-classification ADOS totals, and 6–
10 represented raw totals receiving an autism classification within that cell. ADOS
classification thresholds were determined by the revised algorithm relevant to each
calibration cell. The range of raw totals corresponding to each point on the severity metric
was determined by the percentiles of available data associated with each severity point
within a classification range. Lower severity scores are associated with less autism
impairment. Table 2 shows the raw score range corresponding to each severity point within
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each calibration cell.

Design and Analysis

Distributions of raw totals and severity scores were compared to assess whether severity
score distributions across age/language cells were more uniform than raw score
distributions. Linear regression models were analyzed to compare the relative independence
of severity scores and raw totals from participant characteristics, such as chronological age,
verbal and nonverbal IQ, and verbal and nonverbal “current” mental ages. Several
assessments with longitudinal data were then chosen to exemplify various patterns of
severity change over time across diagnostic groups.

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Results
Comparing distributions of severity scores and raw ADOS totals by calibration cell
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In line with the goal of increasing comparability across modules and developmental levels,
severity scores for ASD participants were expected to have a more uniform distribution
across age- and language-level calibration cells than would raw totals. Distributions of raw
ADOS totals were generated for each of the 18 calibration cells (Figure 2) and compared to
the distribution of severity scores for each cell (Figure 3).

Distributions of severity scores showed increased comparability across the age/language

cells, though they were not uniform. The means and standard deviations of both severity
scores and raw totals are listed by age/language cell in Table 3.

Severity score distributions exhibited a ceiling effect that is inherent to the metric. By
ensuring that scores 6–10 correspond to approximate fifths of the ASD participants who
received scores in the autism classification range, roughly 20% of participants received the
maximum score of ‘10’ (in this dataset, 19.3% of participants with an autism classification
on the ADOS have a severity score of ‘10,’ which is 16.5% of all participants). Though
some overlap exists, severity scores showed expected heterogeneity of distribution across
the three diagnostic groups: autism, PDD-NOS, and nonspectrum (see Figure 4).
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Relative independence of severity score from participant characteristics

Multiple linear regression analyses were performed separately for the dependent variables
severity score and raw total to examine whether participant characteristics such as age and
IQ would be less associated with severity scores than they were with raw scores. For ASD
assessments with complete contemporaneous demographic data (N=1369), potential
predictors were entered into a structured hierarchical model, in which Block 1 included
verbal and nonverbal IQ and mental age variables (which are known to affect the expression
of ASD symptoms; Lord & Spence, 2006), and Block 2 included age, gender, maternal
education, and race (variables that could affect ASD symptoms but that often have had non-
significant effects when Block 1 variables are controlled). Whereas 44% of the variance in
raw totals was explained by this model, only 12% of variance was explained for severity
scores using these covariates. Verbal IQ and one maternal education variable (mothers with
graduate/professional degrees versus all others) emerged as significant predictors for both
severity score and raw score. Nonverbal IQ, verbal mental age, nonverbal mental age,
chronological age, and gender were not significant predictors of either severity scores or raw
totals for ASD participants. When covarying for these variables, as well as verbal IQ and
maternal education, there was a trend for African American participants to have lower
severity scores than other racial groups combined (B=−.35; β = −.06, p=.04), but this is not
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easily interpreted due to the confounding effects of possible referral bias. For all ASD
assessments with racial affiliation data (N=1749), mean severity score for African-American
participants was 7.4 (SD=1.8) compared to 7.3 (SD=2.2) for the combined other participant
groups, t(1747)=−.71; p=.48.

Verbal IQ and the graduate/professional maternal education variable were then entered into
Forward Stepwise models (see Table 4), at which point maternal education was excluded
from the model as a predictor of severity score, though retained as a predictor of raw score.
Standardization reduced the effect of verbal IQ, the most influential participant
characteristic on ADOS scores. Verbal IQ explained 43% of the variance in raw totals in the
model, but accounted for only 10% of the variance in severity scores in this model. This
represents a change from a large effect size (R=0.67) for verbal IQ on ADOS scores to an
effect size just outside the accepted range for ‘small’ (R=0.32; see McCarthy et al.,
1991;Cohen, 1988). The effect of maternal education on raw total scores was likely an

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artifact of recruitment biases (Graduate/ Professional raw total M=14.9, SD=7.2; other
maternal education levels raw total M=15.4, SD=7.2; t(1887)=1.13, p=.26).
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When the initial hierarchical block models were applied to the full sample (ASD and
nonspectrum assessments combined), significant predictors of severity scores included
verbal IQ, gender (with males the more severe group), and maternal education; significant
predictors of raw totals included verbal IQ, nonverbal mental age, gender, chronological
age, and maternal education (these statistics are available from the authors). This again
indicates that, when severity scores are applied to a clinical referral population, they are less
influenced by participant characteristics than are raw ADOS totals.

Case summaries
Four children with ASD diagnoses and longitudinal data were chosen to exemplify patterns
in severity score change over time. Their scores by chronological age are plotted in Figure 5,
with ADOS module and raw total score displayed for each time point.

Case 1—“Adam,” a Caucasian male, was seen at 45 months of age as part of a clinical
research project. He received a diagnosis of autism at that time. He was evaluated with
ADOS Module 2 until age 13, when he received Module 3. His mental ages were 34 months
nonverbal and 21 months verbal at first assessment, and 165 months nonverbal and 111
months verbal at final assessment at age 13 (NVIQ: 71 at first, 107 at last; VIQ: 44 first, 80
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last). Despite his increase in IQ, Adam showed a persistently severe trajectory, with scores
varying between 8 and 10 over seven assessments.

Case 2—“Bianca,” a Caucasian female, was first seen at age 48 months as a clinical
referral, at which point she received a diagnosis of autism. She was evaluated with ADOS
Module 2 until age 5, when she received Module 3. Her mental ages were 46 months
nonverbal and 56 months verbal at first assessment, and 107 months nonverbal and 120
months verbal at her 8.5-year-old assessment (NVIQ: 80 at first, 107 last; VIQ: 108 first,
126 last). Bianca showed decreasing autism severity over time, with scores dropping from 9
to 4 across six assessments.

Case 3—“Cara,” an African American female, was first seen as part of a research project at
age 3. She received a diagnosis of autism. She was evaluated consistently using ADOS
Module 1. Her mental ages were 16 months nonverbal and 8 months verbal at first
assessment, and 51 months nonverbal and 11 months verbal at her last assessment at age 10
(NVIQ: 47 at first, 40 last; VIQ: 23 first, 20 last). Despite the stability of her IQ scores over
time, Cara showed worsening autism severity, with scores increasing from 5 to 10 over four
assessments.
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Case 4—“Daniel,” a Caucasian male, was first seen at 34 months of age as a clinical
referral and was given a nonspectrum diagnosis; at 46 months of age he received a PDD-
NOS diagnosis which then remained stable over time. He was evaluated with ADOS
Module 1 in his assessments through age 5; at age 10 he received Module 3. His mental ages
were 38 months nonverbal and 36 months verbal at first assessment, and 162 months
nonverbal and 142 months verbal at final assessment at age 10 (NVIQ: 112 at first, 129 at
last; VIQ: 105 first, 113 last). Daniel showed consistently mild severity scores varying
between 1 and 3 over four assessments.

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Discussion
The calibrated severity metric based on ADOS raw totals offers a method of quantifying
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ASD severity with relative independence from individual characteristics such as age and
verbal IQ. It should have utility in various genetic, neurobiological, and clinical research
endeavors, including treatment trials, that otherwise would use unstandardized ADOS raw
totals. Calibrated scores have more uniform distributions across age- and language-groups
compared to raw totals, making it possible to compare children’s scores longitudinally
across distinct algorithms. In part because of the modular system of the ADOS,
chronological age, nonverbal IQ, and verbal and nonverbal mental age did not predict either
raw totals or severity scores in this sample. The severity metric builds on this modular
system to reduce the influence of participants’ verbal IQ, which accounted for 10% of the
variance in severity scores versus 43% of the variance in raw totals, a reduction from a large
to medium effect size. The remaining influence of verbal IQ on the severity metric can be
seen in the drift of mean scores toward greater severity in older age groups with lower
language levels (Modules 1 and 2). This apparent age effect seems likely to be explained by
lower verbal IQ in the older children without fluent speech. Though this effect has not been
eliminated entirely, the calibrated metric is better able to measure autism severity beyond
verbal impairment than are raw ADOS totals.

Calibrating scores within narrowly-defined age/language cells achieved the reduction in

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verbal IQ effects within the new metric and corrected for artificial variability in individuals’
scores across time. Unfortunately, a greater number of calibration cells precludes a user-
friendly age/language ‘prefix’ to the severity score, as mentioned in the introduction. The
method described here necessarily defines autism severity in relation to individuals of
similar age and language ability. When using these scores clinically and for research, one
must keep in mind the age/language level of the child/sample, as there clearly will be
developmental and adaptive functioning differences among children with the same severity
score on this 10-point scale. This is true of all standardized scores. Calibrated severity scores
do not measure functional impairment, but are intended to provide a marker of severity of
autism symptoms relative to age and language level. The module a child can be given
depends on his/her expressive language level, and thus will continue to be an important
indicator of adaptive functioning for most children.

The dataset described here included children from various areas in the United States, both
urban and rural. Participants represented both consecutive clinic referrals and research
participants. While this is likely a representative sample for a North American clinical
research center, it is worth examining how referral bias might have influenced these
calibrated scores. Though the dataset was large (N=1807 assessments from children with
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ASD), its division into age/language cells for calibration resulted in a few small cell sizes.
For example, children under age 5 who are not language delayed are unlikely to be referred
for an evaluation unless they exhibit notable ASD symptomatology, so we would expect
these cells to have a more limited distribution in the higher end of the range of ADOS
scores. Another referral bias involved the tendency for children of higher severity to have
more clinic reevaluations than those with less pronounced features of ASD. Indeed, the
mean severity scores across the 18 calibration groups ranged from 6.64 (in young children
with fluent speech) to 8.10 (in older children with phrase speech only), indicating that
severity scores are still somewhat influenced by developmental level and referral bias.

After attempting a number of methods for standardizing ADOS scores, we believe that the
present method of using ADOS diagnostic classifications to ‘anchor’ severity scores best
controls for recruitment effects that would be present in any large clinical research sample,
and therefore results in a metric more likely to be generalizable across datasets. If a cell in

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this calibration sample had predominantly high- or low-scoring children, this restricted
range would only be assigned to severity scores associated with one classification (autism,
ASD, or nonspectrum), allowing for more variability in other datasets across the other
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possible classifications. Ideally this method circumvents to some degree the inevitable
effects of recruitment. Anchoring severity scores to ADOS classification instead of clinical
diagnosis also avoids conflicting dimensional and diagnostic assignment. Within the present
method, severity scores reflect ADOS raw totals regardless of the participant’s diagnosis, so
a child with a non-ASD best estimate diagnosis potentially could receive a score of 6 on the
metric while a child with autism receives a 3, if the former child showed more autistic
symptomatology relative to his/her age and language within that 45 minute assessment than
did the child with autism.

More work is needed to test the validity and utility of this calibrated severity metric. Module
change, especially into Module 3 (fluent speech), may inflate an individual’s severity score.
Some longitudinal variation in these scores is expected, but the purpose of the metric is to
measure change beyond typical variation in ASD. For this reason, the fact that
approximately 20% of ASD assessments with ‘autism’ ADOS classifications receive the
highest severity score of 10, creating a ceiling effect, was preferred over drawing out the
distribution of the metric with the result of less meaningful differences between scores. We
hope to further examine patterns of severity score change over time in a longitudinal sample,
identifying trajectory classes and the risk variables that predict class membership.
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Another future direction is to calibrate the Social Affect and Restricted, Repetitive Behavior
(RRB) domains of the revised ADOS algorithms separately in order to measure severity
within these symptom domains. This process will need to employ a different method of
mapping raw scores onto a severity metric, due to the fact that each domain has a smaller
range of possible raw totals than the overall score (with a maximum of only 8 points for the
RRB domain).

Limitations
Although based on a large sample, this is not a metric of symptom severity in a “true” ASD
population because ADOS data on such samples do not exist at present. As larger population
studies become available, the metric should be recalibrated within those samples for a more
accurate reflection of the distribution of ADOS scores in the ASD population.

These results also may be influenced by the historical period in which some of the data were
collected. This sample grew over a 16-year period in which patterns in ASD identification
evolved. As greater numbers of children are identified at earlier ages (thus including milder
cases at younger ages), it is possible that severity scores might have been assigned
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differently to raw totals if only recently collected data were used.

Conclusion
The ADOS calibrated severity metric represents a step towards achieving greater
comparability of scores across time, age, and module, and is less influenced by verbal IQ
than raw scores. Therefore, it should provide a better measure of ASD severity than other
methods currently available, including ADOS raw total scores. This metric must be
replicated in a large independent sample. To test the validity of the metric, calibrated scores
should be used to track observed changes in ASD severity against sources of convergent
validity.

Calibrated scores could be used to predict outcome, changes in adaptive skills over time, and
associations between severity of core features and clinical characteristics such as behavior
problems, peer relationships, and school achievement. This metric may also prove useful in

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interpreting results from studies of the effectiveness of interventions, and in characterizing

samples for genetic and neurobiological research. An important reminder, however, is that
the calibrated severity metric is based on a relatively brief, office-based observation with a
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clinician, and thus is only one part of a necessarily broader picture of the strengths and
difficulties of a child with ASD.

Acknowledgments
We gratefully acknowledge the help of Susan Risi, Kathryn Larson, Cristina Popa, and Mary Yonkovit, as well as
the families that participated in this research. This study was funded by the National Institute of Mental Health
(Validity of Diagnostic Measures for Autism Spectrum Disorders: NIMH RO1 MH066469) and an Autism Speaks
Predoctoral Training Fellowship.

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Figure 1.
Age by language level calibration cells.
Note. N’s denote the number of ASD participants within each cell.
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Figure 2.
Distributions of ADOS raw total scores by age/language cells (ASD assessments only).
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Figure 3.
Distributions of calibrated severity scores by age/language cells (ASD assessments only).
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Figure 4.
Distributions of calibrated severity scores by diagnostic group.
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Figure 5.
Case summaries of longitudinal severity scores.
Note. Parentheses by individual data points indicate (Module, Raw Score) for each
assessment. Caption. The calibrated severity metric allows change across time and module
to be evaluated in a standardized fashion in children of varying age and verbal ability. Adam
and Daniel follow relatively consistent trajectories despite module changes, while a marked
change in severity is apparent in Cara’s scores despite seemingly small increases in raw total
within the same module. Bianca’s decreasing raw totals alone indicate a drop in ASD
severity, but the clinical import of this is obscured by her module change and increasing
chronological age. Severity scores are not necessarily more stable than raw totals, but were
created to allow the change or consistency in these cases to be interpreted more readily than
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perceived patterns in raw total scores.

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Table 1
Sample Description

Module 1, No Words Module 1, Some Words Module 2, Younger than 5 Module 2, 5 or Older Module 3
Gotham et al.

DX N Mean SD Range N Mean SD Range N Mean SD Range N Mean SD Range N Mean SD Range

age 475 52.59 27.49 24–174 281 56.63 24.99 25–162 89 48.55 7.34 27–59 164 98.46 32.03 60–196 178 103.23 29.35 48–185
viq 448 25.38 14.03 2–92 254 46.66 19.69 10–137 81 77 20.73 28–132 155 52.64 19.33 20–107 156 87.56 23.22 31–155
nviq 442 52.34 21.20 2–144 253 65.82 20.54 14–122 77 90.44 22.87 52–170 155 77.25 23.98 24–131 158 92.98 23.57 34–155
vma 453 11.39 19.05 1–291 251 25.29 30.59 0–353 82 42.94 50.09 21–357 157 54.91 53.34 13–354 151 87.50 44.66 3–369
nvma 443 24.33 10.31 5–96 254 35.10 15.04 13–110 78 46.94 18.45 17–152 146 71.84 29.42 28–194 149 93.70 31.55 25–167
Autism ADI social 419 21.28 530 2–30 212 19.21 6.43 0–30 68 16.12 4.83 3–27 107 22.32 5.90 0–30 116 19.55 5.21 6–30
ADI comm-V 5 17.40 4.09 12–22 74 15.05 4.50 0–24 64 15.41 3.99 3–22 101 18.18 4.11 0–26 116 16.99 4.30 7–25
ADI comm-NV 419 11.74 2.34 0–14 212 9.89 3.35 0–14 68 8.57 2.93 0–14 107 10.36 3.25 0–14 116 9.27 3.27 2–14
ADI-RR 419 4.79 1.72 0–10 212 5.41 2.20 0–10 68 6.34 2.59 1–12 107 7.04 2.67 0–12 116 7.50 2.72 2–12
ADOS SA 475 17.29 2.34 5–20 281 14.87 3.38 1–20 89 12.93 3.45 2–20 164 14.47 3.39 6–20 178 11.39 3.87 0–20
ADOS RR 475 4.92 2.02 0–8 281 4.43 2.00 0–8 89 4.51 1.98 0–8 164 5.12 1.95 0–8 178 3.44 1.94 0–8

age 76 38.03 13.48 24–107 114 43.84 17.78 24–175 108 42.77 9.98 24–59 51 78.96 18.33 60–129 250 101.98 31.26 42–195
viq 74 35.68 15.67 7–75 107 66.78 20.02 11–129 83 84.50 20.57 2–149 44 63.93 17.56 28–102 230 100.93 21.19 49–164
nviq 73 58.09 22.04 15–99 105 79.19 21.49 24–133 84 94.44 22.72 2–159 46 74.39 21.55 31–118 225 98.48 21.16 14–153
vma 75 12.96 6.69 2–47 104 33.80 46.33 11–357 81 64.04 88.86 18–354 45 57.93 61.65 26–371 226 110.88 73.26 39–498
nvma 73 20.34 6.72 7–34 105 40.10 47.87 16–507 80 41.66 13.3 23–91 44 59.07 13.05 34–90 208 102.30 36.22 37–190
PDD-NOS ADI social 72 15.15 5.67 3–25 94 11.57 6.49 1–28 65 10.72 5.11 2–25 33 14.82 7.23 4–29 174 14.93 7.43 0–29
ADI comm-V 0 … … … 58 10.41 4.97 2–25 53 11.19 4.64 0–21 32 12.44 4.04 3–19 174 12.75 5.4 0–24
ADI comm-NV 72 9.94 2.95 2–14 94 6.26 3.97 0–14 64 5.88 3.58 0–14 33 6.03 3.44 0–12 174 6.59 3.80 0–14

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ADI-RR 72 3.56 2.23 0–9 94 3.94 2.38 0–10 65 4.45 2.62 0–10 33 4.73 3.01 1–12 174 5.39 3.06 0–12
ADOS SA 76 13.69 4.24 1–20 114 9.17 4.11 0–19 108 8.37 3.81 0–18 51 9.11 4.36 0–19 250 7.73 4.06 0–19
ADOS RR 76 3.10 1.94 0–8 114 3.17 1.96 0–8 108 3.39 2.07 0–8 51 3.27 1.9 0–8 250 2.19 1.62 0–7

age 60 39.55 19.33 24–129 107 42.10 19.23 24–129 57 43.98 7.38 27–59 44 95.95 30.64 61–184 141 107.35 29.59 50–192
viq 57 40.96 18.72 14–83 90 68.07 23.74 11–117 51 85.33 21.83 2–140 44 58.09 19.06 17–103 135 91.69 22.28 26–163
Non-
spectrum nviq 55 58.80 28.72 13–132 89 70.52 23.74 15–116 49 92.04 20.46 2–133 44 61.93 24.13 24–118 136 89.85 22.23 35–151
vma 57 13.77 5.63 1–26 87 27.62 8.34 13–52 50 56.62 75.44 17–356 43 50.14 13.94 20–77 134 103.18 61.51 32–492
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Module 1, No Words Module 1, Some Words Module 2, Younger than 5 Module 2, 5 or Older Module 3

DX N Mean SD Range N Mean SD Range N Mean SD Range N Mean SD Range N Mean SD Range

nvma 55 20.62 8.67 4–47 86 29.29 8.55 15–52 46 41.67 9.90 19–73 44 56.59 16.65 26–93 132 95.02 32.57 34–189
ADI social 51 11.33 7.09 0–26 78 7.63 5.60 0–24 45 9.67 5.12 1–21 36 13.19 6.58 4–28 130 9.24 6.81 0–24
Gotham et al.

ADI comm-V 0 … … … 38 5.53 3.32 0–13 43 9.70 5.04 1–21 34 11.00 5.09 2–23 130 8.27 5.46 0–24
ADI comm-NV 51 7.73 4.22 0–14 78 4.29 3.26 0–12 45 5.22 3.68 0–14 36 6.17 4.08 0–14 130 4.32 3.72 0–14
ADI-RR 51 2.59 1.94 0–8 78 2.32 1.73 0–8 45 4.04 3.31 0–11 36 4.25 2.54 0–10 130 3.65 2.69 0–11
ADOS SA 60 8.36 5.82 0–20 107 4.71 3.91 0–17 57 3.56 2.77 0–15 44 4.16 3.14 0–10 141 3.90 2.94 0–14
ADOS RR 60 1.88 1.87 0–7 107 1.40 1.49 0–7 57 1.49 1.42 0–5 44 1.63 1.64 0–5 141 0.98 1.15 0–5

Note. All ages in months. viq=Verbal IQ; nviq=Nonverbal IQ; vma=Verbal Mental Age; nvma=Nonverbal Mental Age; ADI social=ADI-R Social Total; ADI-R comm-V=ADI-R Communication Total for
Verbal Subjects; ADI-R comm-NV=ADI-R Communication Total for Nonverbal Subjects; ADI-RR=ADI-R Restricted, Repetitive Behaviors Total; ADOS SA=revised algorithm Social Affect domain,
ADOS RR=revised algorithm Restricted, Repetitive Behavior domain

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Table 2
Mapping of ADOS raw totals onto calibrated severity scores.

Raw ADOS Totals

Module 1, No Words Module 1, Single Words Module 2, Phrases Module 3, Fluent

Gotham et al.

ADOS Calibrated
Class- Severity 2 3 4–5 6–14 2 3 4 5–6 7–14 2 3 4 5–6 7–8 9–16 2–5 6–9 10–16
ification Score yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs

1 0–6 0–6 0–3 0–3 0–3 0–4 0–2 0–2 0–2 0–2 0–3 0–3 0–3 0–2 0–2 0–3 0–2 0–3

NS 2 7–8 7–8 4–6 4–6 4–5 5–6 3–4 3–4 3–5 3–5 4–5 4–5 4–5 3–5 3–5 4 3–4 4

3 9–10 9–10 7–10 7–10 6–7 7 5–7 5–7 6–7 6 6 6 6–7 6–7 6–7 5–6 5–6 5–6

4 11–13 11–14 11–12 11–13 8–10 8–9 8–9 8–10 8–9 7–8 7–8 7 8 8 8 7 7 7

ASD 5 14–15 15 13–15 14–15 11 10–11 11–Oct 11 10–11 9 9 8–9 - - - 8 8 8

6 16–19 16–20 16–19 16–19 12–13 12–14 12–15 12–16 12–18 10–11 10–12 10–13 9–14 9–14 9–14 9–11 9–10 9–10

7 20–21 21–22 20–21 20–22 14–16 15–17 16–18 17–19 19–20 12 13–14 14–16 15–16 15–17 15–17 12 11–12 11–12

AUT 8 22 23 22–23 23–24 17–19 18–19 19–20 20–21 21 13–14 15–16 17–18 17–20 18–21 18–20 13–15 13–14 13–14

9 23–24 24 24–25 25 20–21 20–21 21–22 22–23 22–23 15–17 17–18 19–20 21–22 22–23 21–23 16–17 15–17 15–17

10 25–28 25–28 26–28 26–28 22–28 22–28 23–28 24–28 24–28 18–28 19–28 21–28 23–28 24–28 24–28 18–28 18–28 18–28

Caption. To derive an ADOS calibrated severity score from a raw total, clinicians should first identify the relevant column from Table 2 based on the examinee’s ADOS module / revised algorithm and
chronological age within that module/algorithm group. The examinee’s raw ADOS total is then located within the relevant column. The corresponding Calibrated Severity Score is the number in the second
column from the left that falls within the same row as the examinee’s raw total. It is worth noting that Calibrated Severity Scores are assigned even to those raw totals that do not meet classification
thresholds of ASD or Autism on the ADOS, since clinical judgment can overrule the measure classification and result in a spectrum diagnosis.

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Table 3
Raw Score and Calibrated Severity Score Means and Standard Deviations by Age/Language Cell (ASD assessments only)

Algorithm Raw Calibrated Severity

Total Score Scores
Gotham et al.

Group Age / Language Cell N M SD N M SD

1 Mod 1, NW, Age 2 203 20.13 4.83 203 7.29 2.11

2 Mod 1, NW, Age 3 141 21.63 3.85 141 7.56 1.85

3 Mod 1, NW, Ages 4–5 130 21.96 3.63 130 7.87 1.48

4 Mod 1, NW, Ages 6–14 86 22.35 3.34 86 7.88 1.45

5 Mod 1, SW, Age 2 96 15.64 5.77 96 7.02 2.45

6 Mod 1, SW, Age 3 118 15.85 5.37 118 6.99 2.26

7 Mod 1, SW, Age 4 82 17.13 5.95 82 7.21 2.16

8 Mod 1, SW, Ages 5–6 68 18.84 4.71 68 7.48 1.72

9 Mod 1, SW, Ages 7–14 40 20.68 4.24 40 7.97 1.77

10 Mod 2, Phrases, Age 2 43 13.27 4.14 43 7.37 2.08

11 Mod 2, Phrases, Age 3 63 14.57 5.01 63 7.38 2.04

12 Mod 2, Phrases, Age 4 94 14.43 5.93 94 6.73 2.44

13 Mod 2, Phrases, Ages 5–6 103 16.84 5.78 103 7.45 1.99

14 Mod 2, Phrases, Ages 7–8 53 18.49 5.22 53 7.79 1.71

15 Mod 2, Phrases, Ages 9–16 59 19.16 4.48 59 8.10 1.37

16 Mod 3, Fluent, Ages 2–5 71 12.16 4.87 71 6.80 2.59

17 Mod 3, Fluent, Ages 6–9 236 11.66 5.19 236 6.64 2.55

18 Mod 3, Fluent, Ages 10–16 121 12.48 4.94 121 7.09 2.45

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Note. Mod 1, NW=ADOS Module 1, No Words algorithm; Mod 1, SW=ADOS Module 1, Some Words Algorithm.
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Table 4
Multiple Linear Regression Models for Calibrated Severity Scores and ADOS Raw Totals in ASD Assessments

DV=Severity Score
(ASD only, N=1465)
Gotham et al.

R2 F change df B SE B β

Step 1a .10 164.78 1,1463

Constant* 8.5 .11

Verbal IQ* −.02 .001 −.32

DV=Raw Total
(ASD only, N=1465)

R2 F change df B SE B β

Step 1 .43 1101.66 1,1463

Constant* 24.14 .24

Verbal IQ* −.12 .004 −.66

Step 2 b .44 10.42 1,1462

Constant* 24.05 .24

Verbal IQ* −.12 .004 −.67

Mat Ed* .94 .29 .07

Note. DV=Dependent variable; Mat Ed=Dummy coded variable separating mothers with graduate or professional education to those of all other educational levels.
a

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All other variables excluded from the stepwise forward model.
b
Change in R2=.004 for Step 2 (p<.001)
*
p<.001
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