A Standardized

ADI-R Instrument for the

Diagnosis of
Individuals with
TRAINING Autism

Suzi Naguib, Psy.D.

Licensed Psychologist
Senior Trainer
Sunfield Institute

INTRODUCTION

Speaker Intro

Licensed Clinical Psychologist

Founder of Sunfield Center, Sunfield Institute

and Sprouted Sage Full Circle Intervention
Center

Independent ADOS-2 & ADI-R Trainer

Suzi Naguib, PsyD
Certified Parent-Child Interaction (PCIT) (She/her)
Therapist and Trainer
Licensed Psychologist
Passionate trainer and mentor
Senior Trainer

INTRODUCTION

Director
 NOTES

Sequence of training

Materials

Exam

REQUIRED MATERIALS
[Link]

ADI-R Manual Interview Booklet Algorithm Form

NOTES

Sequence of training

Materials

Exam
 TRAINING GOALS

Increase understanding of autism spectrum disorders

Discuss the administration & conceptualization of the ADI-R

Practice administration and coding of the ADI-R

Instruction on completion of algorithm

Discuss broader issues to consider when conducting a

comprehensive ASD evaluation
- Specific areas to assess
- Evaluation and clinical report structure

Directions on calculating and establishing reliability

LEARNING
OBJECTIVES

Describe administration of the ADI-R.

Identify behaviors that are indicative of a diagnosis of Autism.
Discuss and practice coding of the ADI-R.
Utilize the ADI-R algorithm to determine autism classification.
Accurately administer the ADI-R.
Accurately code and score the ADI-R.
Assess developmental history and current concerns to rule out autism.
Differentiate between a circumscribed interest and unusual
preoccupations when interviewing parents.
Obtain precise developmental information from parents needed to
determine which components of the ADI-R to administer.
Describe essential components of a comprehensive Autism evaluation.

WHAT THIS
TRAINING IS NOT

Equivalent to full preparation for clinical use of the ADI-R

A replacement for reading the ADI-R manual

More training, experience and practice will be needed

before you can use the ADI-R reliably to make diagnosis and
eligibility decisions
 OVERVIEW

Lecture

Video examples

Opportunity to practice
scoring & administration

View, code & score an entire

administration

TRAINING OUTLINE

● Introduction to the ADI-R On-Demand Training

● Download and print powerpoint slides
● Download and print training outline
● Overview of Autism
● Reason for Accurate Diagnosis
● Practice Coding
● Requires an ADI-R Interview Booklet
● Overview of the Algorithm
● Requires an Algorithm Form
● Practice Administration & scoring
● Requires an ADI-R Interview Booklet
● Video Administration
● Requires another ADI-R Interview booklet
● Independent Coding
● Administration and Coding Review
● Algorithm and Calculating Reliability
● Components of an ASD Evaluation
● Evaluation Process & Logistics
● Report Structure
● Information for Further Preparation and Training
 sunfield
institute

HOW TO CALCULATE YOUR

ADI-R PROTOCOL RELIABILITY

PROTOCOL RELIABILITY:

[Link] the total number of items administered. This number can vary for each
administration.
Do not count items coded '8,' '9,' or '998.'

2. The total number of items administered will be the divisor in your calculation.

3. Next, compare your scores with the consensus coded protocol.

• Count the number of items that you were in agreement with the consensus code (e.g.,
you scored a '1' and the consensus score was a '1').
• Scores of '2' and '3' are considered in agreement. (e.g., you scored a '2' and the
consensus score was a '3' or you scored a '3' and the consensus score was a '2').
For items 2-10 and 87: your score must be within 3 months of the consensus score.
For item 86: scores of 3 & 4 are considered in agreement.
4. The total number of items on which you 'agreed' with the consensus code will be the
dividend in your calculation. [i.e., total # of items scored minus your disagreements].

5. Next, divide the total number of 'agreements' (numerator) by the total number of items
administered (dividend).
6. Then, multiply by 100. This is your % agreement or reliability score on the protocol.

7. For example: You administered 140 items (Step 1) and you were in agreement with
consensus on 127 of the items administered (Step 3). You would divide 127 by 140 which
equals 0.907. Then you would multiply the answer by 100 which equals 90.7.

8. Reliability scores of 90% or higher on the ADI-R protocol are considered reliable.

sunfield
institute
[Link]

sunfield
institute

HOW TO CALCULATE YOUR

ADI-R ALGORITHM RELIABILITY

ALGORITHM RELIABILITY:

1. Before starting to check your reliability, make certain that:

• or ‘998' on the protocol have been changed to '0' on the algorithm.
Scores of '8,' '9,'
• Scores of '3' on the protocol should be entered as '2' on the algorithm.

• Count only items; do not count subtotals or domain totals in determining your
reliability.
• Count the total number of scored items on the algorithm. This number may vary. Use
the consensus coded algorithm to determine the total.
2. The total number of scored items on the algorithm will be the divisor in your calculation.

3. Next, compare your scores with the consensus coded algorithm.

4. The total number of items on which you 'agreed' with the consensus code will be the
dividend in your calculation.

5. Next, divide the total number of 'agreements' (numerator) by the total number of items
administered (denominator).
6. Then, multiply by 100. This is your % agreement or reliability score on the protocol.
7. For example: There algorithm items (Step 1) and you were in agreement
were 40 scored
with consensus on 36 of the items administered (Step 3). You would divide 36 by 40 which
equals 0.9. Then you would multiply the answer by 100 which equals 90.
8. Reliability scores of 90% or higher on the ADI-R algorithm are considered reliable.

# of items in agreement with consensus (from step 4)

X 100

total # items (from step 2)

sunfield
institute
[Link]

sunfield

ADI-R FIDELITY CHECKLIST

Rating Scale: 1=Not Present, 2=Emerging, 3-Present

Introducing the interview

Rating Organizes space and furniture (Kleenex available) Comments

Establishes rapport with parents

Lets parents know expectations and assessment process

administration of the ADI-R

Rating Examiner is familiar with content of the items and their probes Comments

Examiner is familiar with content of codes and distinctions for each item

Examiner uses ages and events as "landmarks" to facilitate the parents' memory

Examiner obtains adequate descriptions for coding, including clear, specific examples of child's behavior

Examiner follows hierarchy of probes (starts with bold probes, asks follow-up probes as necessary)

Examiner asks probes in a standardized fashion (asks questions worded closely to those indicated in the booklet;
questions are open-ended; avoids "leading the witness")

Examiner aggregates information across questions where appropriate (e.g., refers back to previous answers,
incorporates previous descriptions into later codes without asking redundant questions)

Examiner maintains natural flow to administration (does not pause for long periods of time to decide on a code)

Takes notes adequate for making scoring decisions

sunfield
institute
[Link]
OVERVIEW OF
AUTISM
DSM-5 TR AUTISM CRITERIA
Developmental disorder whose essential features include
- Persistent impairment in reciprocal social communication and
social interaction (Criterion A) *
- Restricted, repetitive patterns of behavior, interests, or
activities (Criterion B)

Symptoms are present from early childhood and limit or

impair everyday functioning (Criteria C and D) **

Lifelong

Changes with age and development ***

DSM-5 TR AUTISM CRITERIA

A. Persistent deficits in social communication and
social interaction across contexts, as
manifested by all of the following currently OR
BY HISTORY,
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors
used for social interaction
3. Deficits in developing, maintaining, and
understanding relationships *

DSM-5 TR AUTISM CRITERIA

B. Restricted, repetitive patterns of behavior,
interests, or activities as manifested by at least two
of the following currently OR BY HISTORY,
1. Stereotyped or repetitive speech, motor movements,
or use of objects
2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or
nonverbal behavior
3. Highly restricted, fixated interests that are abnormal
in intensity or focus
4. Hyper-or hypo-reactivity to sensory input or unusual
interest in sensory aspects of environment;
 DSM-5 TR AUTISM CRITERIA
C. Symptoms must be present in early
developmental period (but may not become fully
manifest until social demands exceed limited
capacities, or may be masked by learned strategies
in later life)

D. Symptoms cause clinically significant

impairment in current functioning

DSM-5 TR AUTISM CRITERIA

E. Disturbances not better explained by intellectual disability
or global developmental delay

Intellectual disability and autism frequently co-occur; to

make comorbid diagnosis of autism and ID, “social
communication should be below that expected for general
developmental level”
ID=similarly developed skills Autism = relative deficit + RRBs

AUTISM SPECIFIERS & MODIFIERS

Specifiers Modifiers Severity
Meant to indicate Meant to indicate specifiers indicate
possible another important support needs
etiological factors factor

Associated with With or without Social communication With Catatonia

medical/genetic intellectual impairment Requires support
diagnoses (e.g., ASD with Requires substantial Level of
(e.g., ASD with intellectual support Severity
Fragile X disabilities) Requires very (i.e., level of
syndrome Advise verbal and substantial support
and/or Seizures) nonverbal due to support required)
unevenness
Associated with With or without Repetitive behaviors
neurodevelopmental structural language Requires support
/mental/bx disorder impairment with level Requires substantial
(e.g., ASD with of language support
ADHD) e.g., ASD with Requires very
phrase speech) substantial
support
HETEROGENEITY
Autism may present differently in different groups

Age
Core symptoms manifest differently in a toddler vs a school aged
child vs an adult
Autism can look different in the same person across ages

Developmental and Language Level

Lower IQ and/or language abilities often mean different symptom
presentation compared to higher IQ and/or language abilities
We should not expect that Autism in a child with an IQ of 50 will look
the same as Autism in a child with an IQ of 130

DIAGNOSING AUTISM IS CHALLENGING

Differentiating between Autism and typical development
is rarely the referral question

Clinicians diagnosing Autism should have familiarity and

experience with a range of neurodevelopmental disorders
and psychiatric conditions

Intellectual Disability (ID) Global Devl Delay

Anxiety and Mood Disorders Language Disorders
Trauma and Attachment Disorders ADHD

COMPREHENSIVE VIEW

Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5
and Beyond. Journal of Autism and Developmental Disorders, 1-18.
ASSESSING SYMPTOMS IN NON-CORE DOMAINS
*Assessing symptoms in non-core domains is not only
important for differential diagnosis but also for
determining comorbid diagnoses (e.g., Autism and
ADHD, Autism and depressive disorder)

If Autism is an appropriate diagnosis, it is important to

describe the individual’s specific profile of strengths
and difficulties

WHERE ARE THEY ON THE SPECTRUM?

* DSM-5-TR severity indicators
and other quick indicators of
“severity” may not be clinically
useful or appropriate

It is likely more meaningful to

describe an individual’s
particular profile:
• Age
• Cognitive ability
• Language ability
• Adaptive functioning
• Academic functioning
• Social-communicative abilities
• RRBs
• Internalizing and/or
externalizing behavior
problems

IMPORTANCE OF PARENT INTERVIEW

Use of the ADI-R as part of the
evaluation is crucial to obtain
information about early development
and current functioning
Developmental history is
important to consider

DSM-5-TR: difficulties must be

present during the early
developmental period

Even with later referral, it is

important to establish history of
early difficulties in
social-communication
ONSET PATTERNS
Onset patterns vary significantly and represent an example
of heterogeneity

”Regressive” onset thought to occur in approximately 20-30%

of cases (Thurm et al., 2017, Pearson et al., 2018)
- Regression: typical development during the first 12-24 months,
followed by period of loss in language and/or
social-communication skills
- Rather than frank loss, very rare children may “plateau” or fail
to progress in skill acquisition
Children may also show abnormalities prior to regression
- “Later-onset”: symptoms are more subtle initially but may worse
from 2-3 years in “more-able” infants and toddlers (20% of
cases)

AUTISM AS A DEVELOPMENTAL DISORDER

What is manifested as
autism changes with
development

Development is
affected by having
autism

VARIABILITY WITHIN DOMAIN OVER

TIME REPETITIVE BEHAVIORS
 REASON FOR AN
ACCURATE
DIAGNOSIS

REASON FOR ACCURATE DIAGNOSIS

To access appropriate intervention services

To establish developmental levels

To determine patterns of strengths and challenges

To educate parents and teachers

To develop individualized behavioral and education

intervention programs

To measure change over time

35

THE DIAGNOSTIC EVALUATION

It is important to obtain multiple sources of
information including a medical assessment and
hearing screening

Autism can be diagnosed in children as young as 12

Months of age up through adulthood by experienced
clinicians or researchers using standardized
instruments
 INTRODUCTION
TO THE ADI-R

WHAT IS THE ADI-R

A semi-structured parent interview that takes approximately
2 to 2½ hours to administer and score (child/patient should
not be present during the interview)

It provides standard information in specific areas related to

the diagnosis of autism

Behaviors assessed are most often rare in non-affected

individuals

Responses are coded in an interview protocol booklet

Specific codes are transferred to Algorithm form for

classification

38

ADI-R DEVELOPED TO ADDRESS THE

FOLLOWING DIAGNOSTIC CHALLENGES
Differentiating between developmental delay
and autism *

Variability in definitions of autism **

Variability in definition due to developmental

changes in autism
RESPONSE TO DIAGNOSTIC CHALLENGE *
Specifying abnormality
- Detailed descriptions of actual behaviors
- Operationalized criteria **
- Focus on key situations ***
- Require training of interviewers

Standardization
- Of procedures, rating scales, age focus, and
summarization (algorithm)

40

INVESTIGATOR-BASED VS. RESPONSE BASED

INTERVIEWS
(SEMI-STRUCTURED VS. STRUCTURED)
Investigator-based Respondent-based

CONCEPT Investigator’s Subject’s

a. coverage Coverage wording of

STANDARDIZATION
b. concept probes

STYLE Conversational Questionnaire

TYPE of QUESTIONS Mainly open Closed

Use of personalized
TIMING Use of calendar dating
Anchor-points
Answers only to specified
SCOPE OF CODING All behavioral descriptions
questions
Subject’s “yes”/ “no” to
Investigator’s analysis of
WHAT IS CODED closed
behavioral descriptions
questions

41

INVESTIGATOR-BASED VS. RESPONSE BASED

INTERVIEWS
(SEMI-STRUCTURED VS. STRUCTURED)
Codes are based on
- Behavioral descriptions
- Not on informant’s “yes” or “no” response

It is essential to have sufficient knowledge about

ASD and relevant behavior in order to to make a
decision about codes *
ORGANIZATION OF THE ADI-R PROTOCOL
Background **

Early developmental history ***

Acquisition and loss of language and other skills

Communication and language ****

Social development and play

Unusual interests and behaviors

Various non specific behaviors plus special skills

43

ADI-R FORMAT *
Item Heading: #, name of item *

** Conceptual explanation of the item is CAPITALIZED (do not

read to parent) ***
- Includes relevant inclusion and exclusion criteria

Questions for parents in purple boxes

- Bolded questions must be asked unless this information
was already obtained
- Other questions may be asked as needed to understand
behavior and score ****

44

ADI-R ADMINISTRATION
Follow the standard probes and ask the additional probes
until the behavior can be coded or no more useful
information can be obtained
- May not need to ask all probes *
- May improvise questions if necessary but stay within the
standard bounds of item
- Use clinical judgment if behavior varies from the
conceptual description

Ask for detailed examples of behavior

Avoid leading questions, don’t offer examples

TIME FOCI
Because the interview is designed to be applicable across a
wide age range, there is a need to define the age period to
which ratings apply

This is done in three different ways, according to the type of

item
- “Current” and “Ever”
- “Current” and “Most Abnormal ages 4.0-5.0”
- Specific age periods

It is important to note that the duration of time that behaviors

must have been present to be coded is three months (with a
few exceptions)

46

TIME FOCI - CURRENT & EVER

This is used for items in which qualitative abnormalities
would be deviant at any age *
3-month rule: behaviors must be present for a period of 3
months to be considered present
CURRENT = 3 months immediately preceding the interview
EVER = any time during the individuals’ life including
CURRENT
Because the EVER category includes current behavior, it can
never be less than the CURRENT code

47

TIME FOCI - MOST ABNORMAL 4.0-5.0 YEARS

This is used for items that capture behaviors that are
influenced by maturational level

The age between 4-5 years was chosen for two reasons
- It is important to capture abnormalities present in early
development, as children may outgrow some
abnormalities that are diagnostic if present when
younger
- This time period was chosen to allow severely delayed
children to mature in order to make it easier to
distinguish developmental delay from ASD symptoms
TIME FOCI - OTHER TIME SPECIFICATIONS
- There are a few behaviors that are either relevant only
during certain specific age periods or that change their
qualities markedly with age

49

CODING CONVENTIONS

0 Behavior of type specified is not present (not necessarily “normal”)

Behavior of type specified is present, but not sufficiently severe,
1
frequent, or marked to code “2”
Behavior of type specified is definitely present and meets specific
2
mandatory criteria
Behavior present to a degree that interferes with functioning or
3
ordinary life
7 Definite abnormality in general area of coding, but not of type specified

8 Not applicable N/A

9 Missing or not known N/K

50

ADI-R ADMINISTRATION
If informant is only able to give an age range, then use
midpoint of range and round up to the nearest month.

Behaviors must be present for 3 months repeatedly and

consistently to be coded abnormal unless specified otherwise.

Code aspect of behavior only once

- Use conceptual descriptions to determine the appropriate
item
Change prior coding, as needed to take into account
information you receive throughout the interview.

Code ‘9’ (not known) if child has not encountered

circumstances to elicit behavior.
CODING INSTRUCTIONS
Codes are based on behavioral descriptions (not “yes” or “no”
answers), it is essential to have written sufficient details in
your protocol

All codes should be entered in the appropriate boxes before

moving on to next item of the interview

If you video-record the session, you may use this for detailed
study of interview, but codes need to be completed “on time,”
“live” during the face-to-face interview not after completion
of the interview or upon review of the audio or video record

52

SEQUENCE OF ADI-R & APPROACH TO COMMUNICATION

Introductory Questions, 1st Words & Phrases, Comprehension
(to get idea of present functioning)

Item #30: Decision point on current language

Item 30 = 0 if VERBAL Item 30 = 1 or 2 if NONVERBAL
(functional, daily use of 3-word (not at level ‘0’, depends on amount
phrases including verbs) of speech used on a daily basis)

Ask Item 31 and Items 32 – 41 Ask Item 31

(items suitable for subjects with
speech)

Ask Item 42 Then skip to Item 42

(gesture use all respondents) (gesture use all respondents)

Imitation and imaginative play

53

PRACTICE
CODING
CODING CRITERIA EXAMPLE
Item 30: Overall Level of Language*
Focus on:
- Spontaneous daily use of language
- Including echoed and stereotyped language

55

CODING CRITERIA EXAMPLE

Item 33: Stereotyped Utterance and Delayed Echolalia*
Focus on:
- Repetitive speech patterns
- Stereotyped content and/or nonsocial usage
- Phrases interspersed into more normal speech
- Self-commentary on person’s own actions
- Repetitive rerun of emotive or upsetting interchanges
- Routinized phrases used out of appropriate context

56

CODING CRITERIA EXAMPLE

Item 34: Social Verbalization / Chat *
Focus on:
- Social approach, not reciprocity
- Turn-taking
- Maintenance of interchange
- Social Quality
CODING CRITERIA EXAMPLE
Item 34: Social Verbalization / Chat *
Omar is 5 years, 1 month

Mother’s response: A little bit. Everyday Omar says “mommy

have good day at work”. He also stands at the window looking
out and occasionally comments on what he sees, like “doggie”
or “blue car!” He mainly uses language to get food! It’s been
like this since he started using words.

58

CODING CRITERIA EXAMPLE

Item 40: Intonation/Volume/Rhythm/Rate
FOCUS ON:
- Odd intonation or inappropriate pitch and stress
- Markedly flat and toneless or mechanical speech
- Consistently abnormal volume lacking modulation
- Poorly modulated rate or rhythm

59

CODING CRITERIA EXAMPLE

Item 42: Pointing to Express Interest
FOCUS ON:
- Pointing to “show” something (rather than to request
something)
- Pointing at a distance (rather than proximal)
- Coordination
- Head movement with eye gaze
- Object to person
- Spontaneity and variety
- Social quality
CODING CRITERIA EXAMPLE
Item 42: Pointing to Express Interest
Donovan is 5 years, 9 months

Parent’s response: Donovan points at things in books,

especially cars. He’ll also point at the cereal box on the top of
the refrigerator and looks back and forth from me and the
cereal. If I don’t understand what he wants he gets really
upset. It’s been like this since he was 4 years old.

61

CODING CRITERIA EXAMPLE

Item 52: Showing and Directing Attention
Focus on:
- Spontaneous directing of attention purely to share
interest

62

CODING CRITERIA EXAMPLE

Item 53: Offering to Share
Focus on:
- Clear spontaneous offering to share

VS

- Responses to prompting or relinquishing things if another

child tries to take them
CODING CRITERIA EXAMPLE
Item 53: Offering to Share
Gabriel is 4 years 7 months

Parent’s response: Gabriel does not like to share! He’ll do it if I

ask him to but that started only 3-4 months ago.

64

CODING CRITERIA EXAMPLE

Item 65: Friendships
Focus on:
- “0” coding requires that relationships be:
- With OWN age group
- SHARING of non-stereotyped activities
- Seen OUTSIDE PREARRANGED group settings (e.g.
club)
- Involving definite RECIPROCITY & MUTUAL
responsiveness

65

CODING CRITERIA EXAMPLE

Item 65: Friendships
Alana is 6 years, 1 month old

Parent’s response: Alana has a friend from school who comes

over sometimes when I arrange group play dates. She talks
about her and asks if she can come over a lot but I’m not sure
if her friend feels the same way
RESTRICTED & REPETITIVE BEHAVIORS *

Assigning Behaviors Across Items

- Preoccupations
- Circumscribed Interests
- Repetitive Behaviors
- Compulsions/Rituals
- Routines

67

DOUBLE CODING?

Different elements of the same behavior or behavioral

sequence can go into different codes, but the same specific
behavior cannot be coded in more than one place *

68

CODING CRITERIA EXAMPLE

Item 67: Unusual Preoccupations
Focus on:
- Interests that are ODD or PECULIAR in quality and
- UNUSUAL in their intensity and in their lack of social
features and
- REPETITIVE and STEREOTYPED in one or more of its
features or elements
CODING CRITERIA EXAMPLE
Item 68: Circumscribed Interests
Focus on:
- An interest that is NOT inherently peculiar or odd but
UNUSUAL in:
- its intensity
- lack of social features
- lack of progression over time

70

CODING CRITERIA EXAMPLE

Item 69: Repetitive use of objects
Focus on:
- An action or interest that is REPETITIVE and
STEREOTYPED:
- focused on parts of objects
- usage that is clearly unusual

- Focuses on something other than its intended function

71

CODING CRITERIA EXAMPLE

Item 70: Compulsions/Rituals
Focus on:
- Particular SEQUENCES of behavior that may include an
activity that must be performed in a certain way
- DISTRESS when sequence is prevented or interrupted
CODING CRITERIA EXAMPLE
Item 74: Difficulties with minor changes in own routines…
Focus on:
- Distress of SOMEONE ELSE introducing a change in
routine
- Distress in response to MINOR CHANGE that other
children would not find upsetting

73

CODING CRITERIA EXAMPLE

Item 76: Unusual Attachment to Objects
Focus on:
- Unusual interest in and dependence on an UNUSUAL
object
- DISTRESS upon separation from object; intrusion into
subject’s and/or family’s life

74

CODING CRITERIA EXAMPLE

Item: 77 Hand and Finger Mannerisms
Focus on:
- Rapid voluntary repetitive movements of the hands
and/or fingers
- Must occur outside of times of excitement
CODING CRITERIA EXAMPLE
Item: 77 Hand and Finger Mannerisms
Cameron is 3 years, 2 months

Parent’s response:
- Only for the last month or so he has been flicking his
fingers and holding them at an odd angle near his eyes.
He does this several times a day. It doesn’t seem to get in
the way of anything. We can usually distract him from
doing it.

76

WHERE IS THIS CODED?

Brendan spends long periods of time playing with hot wheels

cars. The play involves taking 2 at a time and running them
along a table or floor while closely watching the wheels at
eye-level

77

WHERE IS THIS CODED?

- Preoccupations - Difficulties with Minor
- Circumscribed Interests Changes in Own
- Repetitive Use of Objects Routines
- Compulsions/Rituals - Resistance to Trivial
- Unusual Sensory Changes in
Interests Environment
- Undue General - Unusual Attachment
Sensitivity to Noise - Hand and Finger
- Other Complex
Mannerisms
WHERE IS THIS CODED?

Sam seeks out dust and dirt in his environment - will run his
fingers across tables and windowsills and then sprinkle the
dust into the air and watch it fall. Sam will run away from
group activities to seek out dust. At friends’ homes, he will
find dust on their furniture, and this can be embarrassing.
He especially likes to watch the dust fall in the sunshine, and
he will rock back and forth on his feet while flicking his
hands while watching the dust. Left to his own devices, Sam
will play with dust for long periods of time. He will
sometimes eat dust or dirt.

79

WHERE IS THIS CODED?

- Preoccupations - Difficulties with Minor
- Circumscribed Interests Changes in Own
- Repetitive Use of Objects Routines
- Compulsions/Rituals - Resistance to Trivial
- Unusual Sensory Changes in
Interests Environment
- Undue General - Unusual Attachment
Sensitivity to Noise - Hand and Finger
- Other Complex
Mannerisms

WHERE IS THIS CODED?

Justin is very interested in rocks. He seeks them out when

parents are outside with him, on walks with him. When
outside at home, he will spend hours tossing rocks into the
pond. This is difficult to interrupt. He gathers rocks, and
parents find his pockets stuffed with them. He needs to take
the rocks out of his pockets each night and set them on his
nightstand. He becomes upset if his parents try to make him
throw the rocks away. The next day, his parents can throw
the rocks away, but he insists on putting that day’s rocks on
the nightstand each night.
WHERE IS THIS CODED?
- Preoccupations - Difficulties with Minor
- Circumscribed Interests Changes in Own
- Repetitive Use of Objects Routines
- Compulsions/Rituals - Resistance to Trivial
- Unusual Sensory Changes in
Interests Environment
- Undue General - Unusual Attachment
Sensitivity to Noise - Hand and Finger
- Other Complex
Mannerisms

ALGORITHM

ADI-R ALGORITHM

93 items on protocol

Up to 42 are systematically combined on the Diagnostic

Algorithms (separate sheet from protocol)

Diagnostic Algorithms (purple columns)

- 2 yrs, 0 mos. through 3 yrs, 11 mos.
- 4 yrs, 0 mos. and older
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ADI-R ALGORITHM

Current Behavior Algorithms

- For treatment or educational planning
- No “diagnostic” cutoff for Current algorithm
- 2 yrs, 0 mos. through 3 yrs, 11 mos.
- 4 yrs, 0 mos. through 9 yrs, 11 mos.
- 10 yrs, 0 mos. and older

Both Diagnostic and Current Behavior Algorithms are

completed using scores from one ADI-R interview

91

Page 2

Page 2
ADI-R ALGORITHM

Research from 2012 (Kim & Lord) suggests use of a new ADI-R
algorithm

⊡ Improved sensitivity and specificity

⊡ Specific to Toddlers and Preschoolers (ages 12 - 47
months)
⊡ Fewer algorithm items

Kim, H. & Lord, C. (2012).New Autism Diagnostic Interview-Revised Algorithms

for Toddlers and Young Preschoolers from 12 to 47 Months of Age. Journal of
Autism and Developmental Disorders, 42,82–93. DOI 10.1007/s10803-011-1213-1

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ADI-R ALGORITHM

Transfer specified scores from protocol on to algorithm

(caution: use correct column based on age of participant)

Enter item code exactly as in protocol

Then, in “convert to scores” column

- You must change all codes of ‘3’ to ‘2’
- Change codes of ‘7’, ‘8’, ‘9’ to ‘0’

Sum scores for each domain

Domain cut-off scores provided

- Must meet or exceed cut-offs in all four domains

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ADI-R ALGORITHM

Diagnostic algorithm allows for classification of participants

The ADI-R provides for a classification of Autism or

Non-spectrum

There is an alternative research cut-off for ASD

Despite providing “diagnostic cut-off’s, does not and can not

provide a diagnosis in isolation

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PRACTICE
ADMINISTRATION
You will now begin a practice administration of the ADI-R in
the role of the interviewer.

This administration will cover a condensed set of items

across 3 sections of the ADI-R Interview Protocol:

Early Development
(~13 Minutes)
Language and Communication Functioning
(~40 Minutes)
Social Development and Play
(~30 Minutes)

For each Item, you will be given 10-30 seconds to find the Item’s
page and ask the bolded questions out loud.

An on-screen timer will be provided to show you how long you

have until the parent response video automatically begins.

Visual Example:

During the parent response, feel free to take notes of relevant

information for coding.

After the response video concludes, you will be given 10-30

seconds to look at the codes and consider how you might code
that question based on the information provided by parents.

Visual Example:
 After the on-screen timer expires, coding information will
appear on the screen, along with further context to the
clinician’s coding choice.

Visual Example:

Asking the questions out loud is heavily recommended, but not

required for completion of this training.

While an on-screen timer is provided, you can pause at your

own discretion if you require more time.

The ADI-R Practice Administration will now begin.

VIDEO
ADMINISTRATION
MATERIALS NEEDED
- ADI-R Interview Booklet

- ADI-R Algorithm Form

TIME COMMITMENT
- Before starting this section of the training, please ensure that you
have 3 hours and 10 minutes to complete the following tasks (they
need to be completed in one sitting)
- The entire interview is 1 hr and 55 minutes
- This video consists of the first half of the interview (~65 min),
after which you will be asked to take a 15 minute break (we
recommend taking a break as we do in this interview)
- The following video will consist of the remainder of the
interview (~50 min)
- You will be given an additional 60 minutes to review your notes,
codes and complete scoring of the interview booklet and
algorithm form

REVIEW
Review background *

Regression **

Review Fidelity Checklist

IMPORTANT
Maintain control of the interview
- Redirect parents in a gentle and clinical manner if they
get off track

Avoid spending too long on any one question

- This can lead to fatigue for both the interviewer and
interviewee

Make sure to take notes and code each item prior to moving
on to the next item
IMPORTANT
Keep in mind that parents are often grieving, and this can be
a difficult interview for them
- Therefore it is important to use clinical sensitivity while
obtaining adequate descriptions
- Make sure to establish rapport

Focus on asking compulsory probes and questions

Read descriptions of each code in the protocol to help you get

a sense of what the item is looking for

Ask adequate follow-up questions that allow for descriptions

that are rich enough to code

Obtain behavioral descriptions (as this makes it easier to code

than answers to closed questions)

PREPARATION FOR ADMINISTRATION

Score protocols during the live administration

Remember, the workshop goals are to learn administration

procedures and rules for scoring
- There is less emphasis on achieving reliability

PREPARATION FOR ADMINISTRATION

Vera is 11 years old

Family has other children who have been diagnosed with

autism

This mom is a great reporter which makes this a good

training tape
PREPARATION FOR ADMINISTRATION
Go through your protocols and mark the items that should be
coded 8 based on age *

Note that current behavior = 3 months

If parent gives age ranges, take midpoint and round up

Code aspects of behavior only once

ADMINISTRATION

- The entire interview is 1 hr and 55 minutes

- This video consists of the first half of the interview (~65 min),
after which you will be asked to take a 15 minute break (we
recommend taking a break as we do in this interview)
- The following video will consist of the remainder of the
interview (~50 min)

- Remember that you will be scoring your protocol during

the administration, as you would if you were
administering it yourself.
-

- You should then take an additional 60 minutes to review

your codes and complete all scoring on the ADI-R and
complete the algorithm form before proceeding to “H -
Administration and Coding Review”