When it comes to administering the Autism Diagnostic Observation Schedule, Second Edition (ADOS®-2) Toddler Module, So Hyun Kim, PhD is among the most skilled clinicians in the world.  As an autism researcher, she has published dozens of studies involving autism diagnostic instruments—some of which she has helped to develop or translate. She has worked with hundreds of toddlers and their families to identify autism and other developmental conditions. And she has trained thousands of practitioners to administer the ADOS-2.

Dr. Kim joins WPS in a series of practical WPS ProLearn™ workshops on administering the ADOS-2 Toddler Module. Here's a quick look at her tips for creating a compassionate and comprehensive autism assessment with toddlers. 

1. First, get familiar with the manual.  

The printed manual for the ADOS-2 Toddler Module is included in every ADOS-2 kit. It is a detailed, step-by-step guide and your best source for the methods and strategies to use when assessing autism in toddlers.

“It is thick, so it may be daunting in the beginning when you receive it and you’re trying to absorb information—but it does have really helpful information you need to know about the technicalities, how you administer certain tasks, what behaviors you’re looking for when you’re coding, and what each of the items means. It also has information about the diagnostic algorithm and how you can use that information within the bigger context of assessment,” Dr. Kim explains.

Familiarizing yourself with the manual will answer many of your questions in advance and save you time as you develop your own expertise.  

2. Start the assessment process by building rapport.

Depending on the age, personality, and background of the child, interacting with strangers can be stressful in the toddler years. To minimize that stress, Dr. Kim’s team conducts the autism assessment after the child has become comfortable in the clinical setting.

“The ADOS-2 should not be the very first thing kids do when they walk into the clinic,” she explains. “Many times, these kids are wary of new settings and unfamiliar people, so they might be a bit more clingy with their parent or caregivers in the beginning.”

After an initial warm-up where clinicians simply interact and play with the children, they’ll conduct broader developmental testing.

“Before we start the ADOS-2, we gain information about general development levels with children. During that time, they definitely do warm up and I can establish rapport. Then we take a break,” Dr. Kim says. “That way, by the time I start the assessment, they are more comfortable with me and I am way more comfortable with the toddler and their caregiver.” 

3. Create a child-friendly setting.

“Environmental arrangement is very important, regardless of the age of the participant,” Dr. Kim notes, “but for little ones, we want to maximize the environment so that it’s child friendly and is not distracting for toddlers.”

Lighting, comfortable furnishings, background sounds, and room temperature can make the experience feel more like play and therefore calming to young children. In addition, the movements, gestures, facial expressions, and tone of voice used by those in the clinic may also help a young child engage.

Children with certain life experiences may be particularly sensitive to environmental conditions; knowing about a child’s sensory sensitivities, family history, adverse experiences, and cultural background may help you adjust the setting to suit the child.  

4. Expect some variability in how autism characteristics present.  

The features of autism can look different at different ages, language levels, and cognitive abilities, Dr. Kim explains. Specialized training and a background in working with autistic children can make it easier to recognize subtle indications that are more common with younger children.

“Also, there can be huge variability in typically developing children during this time when development is very dynamic,” Dr. Kim says. “Some children may not walk until 15, 16, or 17 months, whereas some children may start walking at 9 or 10 months. Some of the delays you might see in young children with autism may be part of a typical variation in development.” 

5. Make plenty of room for parents in the evaluation process.

“It’s very helpful for parents to see what you did during the assessment, so nothing is a secret,” Dr. Kim says. “In every step of the assessment, parents are actively involved as our partners. They are watching how we deliver the developmental testing, and they are involved with the ADOS-2. That way, we can say, ‘Mom, remember he did XYZ during the ADOS-2? That is something he is struggling with,’ or ‘Mom, he did XYZ during developmental testing, and that is his strength.’”

Dr. Kim emphasizes that working closely with parents can require some additional skill. For example, it may be necessary to help parents find the most beneficial way to participate in testing.

“Some parents may be eager to show you things and may not give the child a lot of chance to show skills on their own, spontaneously. In that case, you might have to help them kind of sit back and relax a little bit,” she notes. “Some children might need caregivers’ input to feel more comfortable. In that case, you might invite the caregivers to be more involved. There is that balance you have to strike—and with practice, you’ll be able to find that sweet spot.” 

6. Practice, practice, practice.

Administering the ADOS-2 Toddler Module involves carrying out many tasks simultaneously. You’ll be interacting with the child, interacting with the parent, observing behavior, and documenting what goes on—all at once. 

“It does require clinical expertise and previous experience with autism and other developmental disorders,” Dr. Kim acknowledges. “I would say practice is the key. As you practice more, you’ll get the hang of it.”

It’s important to be familiar with how to carry out the tasks the test requires, including the steps involved in each task.  

 7. Hone your expertise by training with experts. 

It’s important to remember that you’re not alone. As you make your way through the manual and practice administering the ADOS-2 Toddler Module, keep in mind that there are ways to make your learning curve a little shorter.  One way is to look for a mentor.

“Shadowing a seasoned clinician can be really helpful,” Dr. Kim says. “If there are seasoned clinicians who have done the ADOS-2 quite a bit, doing consensus coding with them can be helpful, too.”

Another possibility is pursuing extra hands-on training opportunities like those offered through WPS ProLearn. The ADOS-2 Clinical Workshop and the ADOS-2 Training Video Program are excellent foundational training resources and are presented several times a year. Either course fulfills the pre-requisite for participation in the Toddler Module workshop, which provides more specific guidance on autism assessment with very young children.

“The Toddler Module workshop…has a didactic component. We teach you how to administer each task,” Dr. Kim notes. And you get practice watching the video administration.”

Another important aspect of the Toddler Module workshop is consensus coding, where the workshop participants practice coding behaviors alongside the workshop leader.

“Consensus coding is really the meat of the training. We go through each code so you can really learn about what behaviors are targeted for each of the codes,” Dr. Kim explains. “Then we will talk about the algorithm—how you get internal classification from the diagnostic algorithm and how that can really inform your global clinical impressions.” The workshop also includes guidance on report writing.   

Key Message

Assessing autism in toddlers is challenging. Even with a validated assessment measure, there are more materials to manage, the tasks can be complex and highly structured, and toddlers themselves have varied profiles and developmental needs.

With plenty of preparation and practice, however, you can create an engaging social world during the assessment—and you can learn to balance all the different elements of a comprehensive evaluation skillfully.  

Watch the full interview here.

Register here for the WPS ProLearn™ ADOS®-2 Toddler Module Workshop with Dr. So Hyun Kim. Please note that to participate in this workshop, you must have completed either the ADOS-2 Clinical Workshop or the ADOS-2 Training Video Program.