Associations between emotion and behavior codes and ADOS-2 scores in a sample of children referred for autism evaluation.
Momentary overactivity or anxiety during the ADOS-2 can raise or lower autism severity scores by about one point—factor this in before you decide.
01Research in Context
What this study did
The team watched the kids who were sent for an autism check-up. They noted every time a child showed overactivity, disruption, or anxiety during the ADOS-2.
Each child already had a calibrated severity score (CSS). The researchers asked: do these emotion codes push the score up or down?
What they found
In kids who met ASD criteria, high overactivity nudged the CSS upward. Surprisingly, clear anxiety nudged it downward.
Kids who did not meet ASD criteria showed no steady pattern. All shifts were tiny—about one point—but big enough to change a label.
How this fits with other research
Georgiades et al. (2011) first showed that emotional and behavioral problems are part of the preschool ASD picture, not extra clutter. W et al. now give numbers to that idea: those same problems can tilt the very tool we use to define ASD.
de Bildt et al. (2011) built the CSS so we could compare kids across age and module. This new paper warns that E-code noise can muddy that comparison—like a built-in measurement error we forgot to erase.
Bennett et al. (2008) found the ADOS can over-identify autism in Hispanic kids with mild social issues. W et al. add a second warning: even within one clinic, moment-to-moment child behavior can also sway the score.
Why it matters
A single CSS point can move a child across the autism cutoff. When you see "overactivity" or "anxiety" checked, mentally adjust: the real symptom level may be slightly lower or higher than the printed score. Note the codes in your report and, when borderline, pair the ADOS with parent data and your own clinical eye.
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Join Free →Open your last five ADOS-2 protocols—if E codes are checked, re-check the CSS cutoff in light of this one-point swing.
02At a glance
03Original abstract
While the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) is considered a "reference standard" measure to observe symptoms of autism spectrum disorder (ASD), little is known about the utility of its Other Abnormal Behaviors or "E codes." This study investigated the unique influence of each E code (overactivity, disruptive behavior, anxiety) on ADOS-2 scoring. Data from ADOS-2 administrations (Modules 1, 2, 3) were collected from 3364 children (mean age = 6.73 years) at an outpatient ASD clinic. For those with ASD, ADOS-2 Calibrated Severity Scores (CSS) were descriptively higher for those with overactivity and disruptive behavior, but lower for those with anxiety. For those without ASD, no patterns emerged when comparing means. After controlling for age, sex, and language level, multivariable linear models indicated the presence of overactivity was significantly associated with increased CSS for children with ASD compared to those without. No significant interaction was present for disruptive behavior. The presence of anxiety was significantly associated with increased Social Affect CSS only for those without ASD. All effect sizes were small. This is one of the first studies to evaluate the effect of each individual E code on ADOS-2 CSS. Unique differences emerged across diagnostic groups, suggesting implications for ADOS-2 interpretation.Lay SummaryThe Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) is a common assessment tool used during an autism evaluation. As part of the ADOS-2, the examiner rates "E codes," which are levels of hyperactivity, disruptive behavior, and anxiety during testing. These codes are not part of the final ADOS-2 score. While there is a lot of research on the ADOS-2, less is known about these E codes. This study looked at how the E codes might affect the final ADOS-2 scoring. Information came from 3364 in-person autism assessments (average age = 6.73 years) who were evaluated at an autism specialty clinic. For autistic children, ADOS-2 scores were higher (i.e. more autism-related behaviors) for those with overactivity and disruptive behavior, but lower for those with anxiety. For those without autism, there was no pattern. After accounting for the child's age, sex, and language level, there were unique results for each E code, depending on whether the child received an autism diagnosis. This study is important as it is one of the first to evaluate the effects of each E code on ADOS-2 scores and could impact how scores are interpreted when considering an autism diagnosis.
Autism : the international journal of research and practice, 2025 · doi:10.1177/13623613251355231