European Child & Adolescent Psychiatry

, Volume 25, Issue 7, pp 769–780 | Cite as

The objectivity of the Autism Diagnostic Observation Schedule (ADOS) in naturalistic clinical settings

  • Eric Zander
  • Charlotte Willfors
  • Steve Berggren
  • Nora Choque-Olsson
  • Christina Coco
  • Anna Elmund
  • Åsa Hedfors Moretti
  • Anette Holm
  • Ida Jifält
  • Renata Kosieradzki
  • Jenny Linder
  • Viviann Nordin
  • Karin Olafsdottir
  • Lina Poltrago
  • Sven Bölte
Original Contribution


The Autism Diagnostic Observation Schedule (ADOS) is a first-choice diagnostic tool in autism spectrum disorder (ASD). Excellent interpersonal objectivity (interrater reliability) has been demonstrated for the ADOS under optimal conditions, i.e., within groups of highly trained “research reliable” examiners in research setting. We investigated the spontaneous interrater reliability among clinically trained ADOS users across multiple sites in clinical routine. Forty videotaped administrations of the ADOS modules 1–4 were rated by five different raters each from a pool of in total 15 raters affiliated to 13 different clinical sites. G(q,k) coefficients (analogous to intraclass correlations), kappas (ĸ) and percent agreement (PA) were calculated. The median interrater reliability for items across the four modules was G(q,k) = .74–.83, with the single ADOS items ranging from .23 to .94. G(q,k) for total scores was .85–.92. For diagnostic classification (ASD/non-spectrum), PA was 64–82 % and Fleiss’ ĸ .19–.55. Objectivity was lower for pervasive developmental disorder not otherwise specified and non-spectrum diagnoses as compared to autism. Interrater reliabilities of the ADOS items and domain totals among clinical users across multiple sites were in the same range as previously reported for research reliable users, while the one for diagnostic classification was lower. Differences in sample characteristics, rater skills and statistics compared with previous studies are discussed. Findings endorse the objectivity of the ADOS in naturalistic clinical settings, but also pinpoint its limitations and the need and value of adequate and continuous rater training.


Autism spectrum disorder Interrater reliability Diagnostic instrument 



We thank the Child and Adolescent Psychiatry of Stockholm County Council, Region Västra Götaland and Region Skåne, PRIMA Child and Adult Psychiatry, Tiohundra Norrtälje and Astrid Lindgren Children’s Hospital and Sachs’ Children and Youth Hospital, Stockholm County Council, for the generous cooperation in realizing this study. We also thank our funders Frimurare Barnhuset, Swedish Research Council, Stockholm County Council and finally Karolinska Institutet. Finally, we are especially grateful toward all the children and parents that participated in the project.

Compliance with ethical standards

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Supplementary material

787_2015_793_MOESM1_ESM.pdf (132 kb)
Supplementary material 1 (PDF 133 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Eric Zander
    • 1
    • 2
    • 3
  • Charlotte Willfors
    • 1
    • 2
  • Steve Berggren
    • 1
    • 2
  • Nora Choque-Olsson
    • 1
    • 2
    • 4
  • Christina Coco
    • 1
    • 2
    • 5
  • Anna Elmund
    • 6
    • 7
  • Åsa Hedfors Moretti
    • 8
  • Anette Holm
    • 9
  • Ida Jifält
    • 10
    • 11
  • Renata Kosieradzki
    • 12
    • 13
  • Jenny Linder
    • 14
  • Viviann Nordin
    • 5
  • Karin Olafsdottir
    • 15
  • Lina Poltrago
    • 6
  • Sven Bölte
    • 1
    • 2
  1. 1.Pediatric Neuropsychiatry Unit, Department of Women’s and Children’s Health, Center of Neurodevelopmental Disorders (KIND)Karolinska InstitutetStockholmSweden
  2. 2.Child and Adolescent Psychiatry, Center for Psychiatry ResearchStockholm County CouncilStockholmSweden
  3. 3.Neurodevelopmental Psychiatry Unit South East, Child and Adolescent PsychiatryStockholm County CouncilStockholmSweden
  4. 4.BUP Södertälje, Child and Adolescent PsychiatryStockholm County CouncilSödertäljeSweden
  5. 5.Neuropediatric Unit, Sachs’ Children and Youth HospitalStockholm County CouncilStockholmSweden
  6. 6.PRIMA Child and Adolescent PsychiatryStockholmSweden
  7. 7.CitypsykologhusStockholmSweden
  8. 8.BUP Sollentuna, Child and Adolescent PsychiatryStockholm County CouncilSollentunaSweden
  9. 9.Astrid Lindgrens Children’s HospitalKarolinska University Hospital Solna, Stockholm County CouncilSolnaSweden
  10. 10.Astrid Lindgrens Children’s HospitalKarolinska University Hospital Huddinge, Stockholm County CouncilHuddingeSweden
  11. 11.Pupil Health UnitTiohundraSweden
  12. 12.BUP Malmö, Child and Adolescent PsychiatryRegion SkåneMalmöSweden
  13. 13.Pupil Health Unit, Resource Team for Learning DisabledCity of MalmöSweden
  14. 14.Södra Älvsborg Hospital (SÄS)Child and Adolescent PsychiatryBoråsSweden
  15. 15.BUP Lund, Child and Adolescent PsychiatryRegion SkåneLundSweden

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