Autism Diagnostic Interview-Revised (ADI-R)

Anne Le Couteur, Catherine Lord, Michael Rutter, Western Psychological Services, 2003

GOALS

The Autism Diagnostic Interview-Revised (ADI-R) is a clinical diagnostic instrument for assessing autism in children and adults. The ADI-R provides a diagnostic algorithm for autism as described in both the ICD-10 and DSM-IV. The instrument focuses on behavior in three main areas: qualities of reciprocal social interaction; communication and language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages from about 18 months and above.

DESCRIPTION

The ADI-R is a standardized, semi-structured clinical review for caregivers of children and adults. The interview contains 93 items and focuses on behaviors in three content areas or domains: quality of social interaction (e.g., emotional sharing, offering and seeking comfort, social smiling and responding to other children); communication and language (e.g., stereotyped utterances, pronoun reversal, social usage of language); and repetitive, restricted and stereotyped interests and behavior (e.g., unusual preoccupations, hand and finger mannerisms, unusual sensory interests). The measure also includes other items relevant for treatment planning, such as self-injury and over-activity. Responses are scored by the clinician based on the caregiver's description of the child's behavior. Questions are organized around content area, and definitions of all behavioral items are provided. Within the area of Communication, for example, "Delay or total lack of language not compensated by gesture" is further broken down into specific behavioral items: pointing to express interest, conventional gestures, head nodding, and head shaking. Similarly, within the area of Reciprocal Social Interaction, lack of socio-emotional reciprocity and modulation to context include the following behaviors: use of other's body, offering comfort, inappropriate facial expressions, quality of social overtures, and appropriateness of social response.

All questions ask about current behavior, with the exception of a few behaviors that only occur during specific age periods. In these cases, specific age restrictions are given. For example, items inquiring about group play are coded only for behavior displayed between the ages of 4 and 10 years; questions about reciprocal friendships are scored only for children ages 5 and above; and questions about circumscribed interests are scored only for children ages 3 and above. In addition to asking about current behavior, each question focuses on the time period when the behaviors were likely to be most pronounced – generally, between the ages of 4 and 5 years.

The interview starts with an introductory question followed by questions about the subject's early development. The next 41 questions cover verbal and nonverbal communication. Questions 50 through 66 ask about social development and play. The next 13 questions deal with interests and behaviors. The final 14 questions ask about "general behavior," including questions about memory skills, motor skills, over-activity and fainting.

SCORING

The ADI-R interview generates scores in each of the three content areas (i.e., communication and language, social interaction, and restricted, repetitive behaviors). Elevated scores indicate problematic behavior in a particular area. Scores are based on the clinician's judgment following the caregiver's report of the child's behavior and development. For each item, the clinician gives a score ranging from 0 to 3. A score of 0 is given when "behavior of the type specified in the coding is not present"; a score of 1 is given when “behavior of the type specified is present in an abnormal form, but not sufficiently severe or frequent to meet the criteria for a 2”; a score of 2 indicates "definite abnormal behavior” meeting the criteria specified; and a score of 3 is reserved for "extreme severity" of the specified behavior. (The authors of the measure recode 3 as a 2 in computing the algorithm.) There are also scores of 7 (“definite abnormality in the general area of the coding, but not of the type specified”), 8 (“not applicable”), and 9 (“not known or not asked”) given under certain circumstances, which all are converted to 0 in computing the algorithm.

A classification of autism is given when scores in all three content areas of communication, social interaction, and patterns of behavior meet or exceed the specified cutoffs, and onset of the disorder is evident by 36 months of age. The same algorithm is used for children from mental ages 18 months through adulthood, with three versions containing minor modifications: 1) a life-time version; 2) a version based on current behavior; and 3) a version for use with children under the age of 4 years. The algorithm specifies a minimum score in each area to yield a diagnosis of autism as described in ICD-10 and DSM-IV. The total cutoff score for the communication and language domain is 8 for verbal subjects and 7 for nonverbal subjects. For all subjects, the cutoff for the social interaction domain is 10, and the cutoff for restricted and repetitive behaviors is 3.

PRACTICAL ISSUES

This interviewer-based instrument requires substantial training in administration and scoring. A highly trained clinician can administer the ADI-R to the parent of a 3- or 4-year old suspected of autism in approximately 90 minutes. The interview may take somewhat longer when administered to parents of older children or adults. Training workshops are available in the United States as well as internationally. The ADI-R and related materials are available from Western Psychological Services.

PSYCHOMETRIC PROPERTIES

Inter-rater and test-retest reliability, as well as internal validity, have been demonstrated for the ADI-R. A detailed bibliography (with abstracts) describing the psychometric properties of the ADI-R can be found on the University of Michigan Autism Communication and Disorders Center website.

Useful Links

Western Psychological Services (for ADI-R materials and information)

University of Michigan Autism Communication and Disorders Center:

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