Autism spectrum disorder in ICD-11-a critical reflection of its possible impact on clinical practice and research.

This perspective article compares and contrasts the conceptualization of Autism Spectrum Disorder (ASD) in ICD-11 and DSM-5. By guiding the user through the ICD-11 text, it is argued that, in contrast to DSM-5, ICD-11 allows a high variety in symptom combinations, which results in an operationalization of ASD that is in favor of an extreme diverse picture, yet possibly at the expense of precision, including unforeseeable effects on clinical practice, care, and research. The clinical utility is questionable as this conceptualization can hardly be differentiated from other mental disorders and autism-like traits. It moves away from an observable, behavioral, and neurodevelopmental disorder to a disorder of inner experience that can hardly be measured objectively. It contains many vague and subjective concepts that lead to non-falsifiable diagnoses. This bears a large danger of false positive diagnoses, of further increased prevalence rates, limitations of access to ASD-specific services and of increasing the non-specificity of treatments. For research, the hypothesis is that the specificity of ASD will be reduced and this will additional increase the already high heterogeneity with the effect that replication of studies will be hampered. This could limit our understanding of etiology and biological pathways of ASD and bears the risk that precision medicine, i.e., a targeted approach for individual treatment strategies based on precise diagnostic markers, is more far from becoming reality. Thus, a more precise, quantitative description and more objective measurement of symptoms are suggested that define the clinical ASD phenotype. Identification of core ASD subtypes/endophenotypes and a precise description of symptoms is the necessary next step to advance diagnostic classification systems. Therefore, employing a more finely grained, objective, clinical symptom characterization which is more relatable to neurobehavioral concepts is of central significance.

Culturally sensitive stepped care for adolescent refugees: efficacy and cost-utility of a multicentric randomized controlled trial.

Adolescent refugees and asylum seekers (ARAS) are highly vulnerable to mental health problems. Stepped care models (SCM) and culturally sensitive therapies offer promising treatment approaches to effectively provide necessary medical and psychological support. To our knowledge, we were the first to investigate whether a culturally sensitive SCM will reduce symptoms of depression and PTSD in ARAS more effectively and efficiently than treatment as usual (TAU). We conducted a multicentric, randomized, controlled and rater-blinded trial across Germany with ARAS between the ages of 14 to 21 years. Participants (N = 158) were stratified by their level of depressive symptom severity and then equally randomized to either SCM or TAU. Depending on their severity level, SCM participants were allocated to tailored interventions. Symptom changes were assessed for depression (PHQ) and PTSD (CATS) at four time points, with the primary end point at post-intervention after 12 weeks. Based on an intention-to-treat sample, we used a linear mixed model approach for the main statistical analyses. Further evaluations included cost-utility analyses, sensitivity analyses, follow-up-analyses, response and remission rates and subgroup analysis. We found a significant reduction of PHQ (d = 0.52) and CATS (d = 0.27) scores in both groups. However, there was no significant difference between SCM and TAU. Cost-utility analyses indicated that SCM generated greater cost-utility when measured as quality-adjusted life years compared to TAU. Subgroup analysis revealed different effects for the SCM interventions depending on the outcome measure. Although culturally sensitive, SCMs did not prove to be more effective in symptom change and represent a more cost-effective treatment alternative for mentally burdened ARAS. Our research contributes to the optimization of clinical productivity and the improvement of therapeutic care for ARAS. Disorder-specific interventions should be further investigated.

Using machine learning to improve diagnostic assessment of ASD in the light of specific differential and co-occurring diagnoses.

BACKGROUND: Diagnostic assessment of ASD requires substantial clinical experience and is particularly difficult in the context of other disorders with behavioral symptoms in the domain of social interaction and communication. Observation measures such as the Autism Diagnostic Observation Schedule (ADOS) do not take into account such co-occurring disorders. METHOD: We used a well-characterized clinical sample of individuals (n = 1,251) that had received detailed outpatient evaluation for the presence of an ASD diagnosis (n = 481) and covered a range of additional overlapping diagnoses, including anxiety-related disorders (ANX, n = 122), ADHD (n = 439), and conduct disorder (CD, n = 194). We focused on ADOS module 3, covering the age range with particular high prevalence of such differential diagnoses. We used machine learning (ML) and trained random forest models on ADOS single item scores to predict a clinical best-estimate diagnosis of ASD in the context of these differential diagnoses (ASD vs. ANX, ASD vs. ADHD, ASD vs. CD), in the context of co-occurring ADHD, and an unspecific model using all available data. We employed nested cross-validation for an unbiased estimate of classification performance and made available a Webapp to showcase the results and feasibility for translation into clinical practice. RESULTS: We obtained very good overall sensitivity (0.89-0.94) and specificity (0.87-0.89). In particular for individuals with less severe symptoms, our models showed increases of up to 35% in sensitivity or specificity. Furthermore, we analyzed item importance profiles of the ANX, ADHD, and CD models in comparison with the unspecific model revealing distinct patterns of importance for specific ADOS items with respect to differential diagnoses. CONCLUSIONS: ML-based diagnostic classification may improve clinical decisions by utilizing the full range of information from detailed diagnostic observation instruments such as the ADOS. Importantly, this strategy might be of particular relevance for older children with less severe symptoms for whom the diagnostic decision is often particularly difficult.

Mapping Research Domain Criteria using a transdiagnostic mini-RDoC assessment in mental disorders: a confirmatory factor analysis.

This study aimed to build on the relationship of well-established self-report and behavioral assessments to the latent constructs positive (PVS) and negative valence systems (NVS), cognitive systems (CS), and social processes (SP) of the Research Domain Criteria (RDoC) framework in a large transnosological population which cuts across DSM/ICD-10 disorder criteria categories. One thousand four hundred and thirty one participants (42.1% suffering from anxiety/fear-related, 18.2% from depressive, 7.9% from schizophrenia spectrum, 7.5% from bipolar, 3.4% from autism spectrum, 2.2% from other disorders, 18.4% healthy controls, and 0.2% with no diagnosis specified) recruited in studies within the German research network for mental disorders for the Phenotypic, Diagnostic and Clinical Domain Assessment Network Germany (PD-CAN) were examined with a Mini-RDoC-Assessment including behavioral and self-report measures. The respective data was analyzed with confirmatory factor analysis (CFA) to delineate the underlying latent RDoC-structure. A revised four-factor model reflecting the core domains positive and negative valence systems as well as cognitive systems and social processes showed a good fit across this sample and showed significantly better fit compared to a one factor solution. The connections between the domains PVS, NVS and SP could be substantiated, indicating a universal latent structure spanning across known nosological entities. This study is the first to give an impression on the latent structure and intercorrelations between four core Research Domain Criteria in a transnosological sample. We emphasize the possibility of using already existing and well validated self-report and behavioral measurements to capture aspects of the latent structure informed by the RDoC matrix.

Social and Nonsocial Autism Symptom Domains in Children and Adolescents with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder: Insights into Their Symptomatological Interplay.

INTRODUCTION: Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) share overlapping symptomatology, particularly with regard to social impairments (including peer relationship difficulties), and they frequently co-occur. However, the nature of their co-occurrence remains unclear. Therefore, the current study aimed to examine the nature of the transdiagnostic link between ASD and ADHD from a symptomatological point of view measured with the Autism Diagnostic Observation Schedule (ADOS Module 3) and the Autism Diagnostic Interview-Revised (ADI-R). METHODS: We analyzed the social and nonsocial ASD symptom domain scores from both diagnostic instruments in 4 clinically referred groups (i.e., ASD, ADHD, ASD + ADHD, and no psychiatric diagnosis) without other co-occurring mental disorders using a two-by-two full-factorial MANOVA design with the factors ASD (yes/no) and ADHD (yes/no). RESULTS: We found no ASD by ADHD interaction effects across all symptom domain scores of ADOS and ADI-R, except for ADOS imagination/creativity. There were only main effects of the factor ASD but no main effects of ADHD. Follow-up contrasts showed that exclusively, ASD had an impact on the measured symptomatology in case of co-occurring ASD + ADHD. CONCLUSION: Overall, the results support an additive model of the symptomatology across areas of communication, social interaction, and stereotyped behaviors and restricted interests in case of the co-occurrence of ASD and ADHD when assessed with ADOS/ADI-R. Thus, one can assume that the phenotypic overlap of ASD + ADHD may be less complicated than suspected - at least with regard to ASD symptomatology - and that in the presence of ADHD, ASD symptomatology is generally well measurable with best-practice diagnostic instruments.

Conceptualization of the latent structure of autism: further evidence and discussion of dimensional and hybrid models.

Autism spectrum disorder (ASD) might be conceptualized as an essentially dimensional, categorical, or hybrid model. Yet, current empirical studies are inconclusive and the latent structure of ASD has explicitly been examined only in a few studies. The aim of our study was to identify and discuss the latent model structure of behavioral symptoms related to ASD and to address the question of whether categories and/or dimensions best represent ASD symptoms. We included data of 2920 participants (1-72 years of age), evaluated with the Autism Diagnostic Observation Schedule (Modules 1-4). We applied latent class analysis, confirmatory factor analysis, and factor mixture modeling and evaluated the model fit by a combination of criteria. Based on the model selection criteria, the model fits, the interpretability as well as the clinical utility we conclude that the hybrid model serves best for conceptualization and assessment of ASD symptoms. It is both grounded in empirical evidence and in clinical usefulness, is in line with the current classification system (DSM-5) and has the potential of being more specific than the dimensional approach (decreasing false positive diagnoses).

[Pathological Demand Avoidance: Current State of Research and Critical Discussion]. / Pathological Demand Avoidance ­ aktueller Forschungsstand und kritische Diskussion.

Pathological Demand Avoidance: Current State of Research and Critical Discussion Abstract: Pathological demand avoidance (PDA) describes children who obsessively avoid any demand to a clinically relevant extent and is presently the subject of controversial discussion. Their behavior may be interpreted as an attempt to reduce anxiety by establishing security and predictability through rigid control of the environment as well as the demands and expectations of others. The symptoms are described in the context of autism spectrum disorder. This article reviews the current state of research and discusses the questionable validity of pathological demand avoidance as an independent diagnostic entity. It also addresses the impact of the behavior profile on development and treatment. This paper concludes that PDA is not a diagnostic entity nor a subtype of autism; rather, it is a behavior profile that can be associated with adverse illness progression and unfavorable outcomes. PDA is one feature in a complex model. We must consider not only the patient's characteristics but also those of the caregiver and their psychopathology. The reactions of the interaction partners as well as the treatment decisions play a key role play for the affected individuals. Substantial research is needed concerning the occurrence of the behavior profile PDA in diverse disorders, treatment options, and treatment responses.

A systematic review of risk and protective factors of mental health in unaccompanied minor refugees.

In recent years, there has been a rising interest in the mental health of unaccompanied minor refugees (UMR), who are a high-risk group for mental disorders. Especially the investigation of predictive factors of the mental health of young refugees has received increasing attention. However, there has been no review on this current issue for the specific group of UMR so far. We aimed to summarize and evaluate the existing findings of specific risk and protective factors to identify the most verified influences on the mental health of UMR. Therefore, we conducted a systematic literature search. Study designs were limited to quantitative cross-sectional and longitudinal designs. Eight databases were searched in four different languages and article reference lists of relevant papers were screened. 27 studies were included (N = 4753). Qualitative synthesis revealed the number of stressful life events to be the most evaluated and verified risk factor for mental health of UMR. A stable environment and social support, on the other hand, can protect UMR from developing poor mental health. Besides that, several other influencing factors could be pointed out, such as type of accommodation, family contact, gender and cultural competences. Because of the large heterogeneity of outcome measures, quantitative synthesis was not possible. This review helps to improve our understanding of determinants of UMRs mental health and thus to provide more targeted treatment. Furthermore, it provides information on how to prevent the development of mental health problems by specifying factors that can be modified by different health and immigration sectors in advance. Further research is needed focusing on the interaction between the various predictive factors.

Mental health in refugees and asylum seekers (MEHIRA): study design and methodology of a prospective multicentre randomized controlled trail investigating the effects of a stepped and collaborative care model.

The sudden arrival of culturally diverse asylum seekers and refugees into Germany has created a strong demand for recognizing and appropriately treating those suffering from mental health issues. Due to many systemic, organizational, cultural and socio-linguistic barriers, psychiatric treatment of refugees is posing a major challenge to Germany's mental health care system. Thus, there is a need for alternative models that allow for increased access to adequate, effective and efficient culturally sensitive mental health care services. Here, we describe the Mental Health in Refugees and Asylum Seekers (MEHIRA) project, a multicentre randomized controlled trial investigating a stepped collaborative care model (SCCM) for providing mental health treatment in this vulnerable population. The proposed SCCM aims to decrease the aforementioned barriers. Adult and adolescent participants will be screened for depressive symptoms and matched to appropriate psychological interventions, including group-level interventions (START intervention, Empowerment/Gender-sensitive/Peer to peer), and other innovative, digital treatment approaches (Smartphone application). The therapeutic effect of the SCCM will be compared to TAU (treatment-as-usual). All interventions have been designed to be culturally sensitive, and offered in two different languages: Arabic and Farsi. The outcome of this study may contribute significantly to future clinical and legal guidelines in developing parallel and efficient new structures of treatment. Collected data will inform primary and secondary mental health care providers with recommendations concerning the design and implementation of effective treatment models and programmes. Guidelines and recommendations may also potentially be adopted by other host countries, developing countries and also in humanitarian aid programmes.

[Autism spectrum disorder in childhood and adults: diagnosis and differential diagnoses]. / Autismus-Spektrum-Störungen im Kindes- und Erwachsenenalter: Diagnose und Differenzialdiagnosen.

Autistic disorders are summarized in DSM­5 under the term autism spectrum disorder (ASD) and are severe, lifelong, pervasive neurodevelopmental disorders. Core features manifested even in childhood are impairments in social interaction and communication as well as restricted and repetitive behavior. The intensity of symptoms, language and cognitive impairments vary but the majority of affected individuals have below average intelligence and 80% have at least one comorbid disorder. The diverse pathology and heterogeneity in phenotypes are caused by a complex genetic etiology, which is associated with a reduced synaptic plasticity of neural networks. The disorder is associated with a clearly reduced quality of life as well as a high familial burden. The differential diagnostics have a high relevance and the diagnosis should be carried out by specialized institutions. Behavioral therapeutic interventions are indicated.

[Blessing or curse? The World Wide Web as information source for autism and Asperger Syndrome]. / Segen oder Fluch? Das Internet als Informationsquelle über Autismus und Asperger-Syndrom.

Blessing or curse? The World Wide Web as information source for autism and Asperger Syndrome Abstract. Objective: The World Wide Web is today one of the most common methods used for obtaining health-related information, though the quality of the information is sometimes questionable. The present study addresses the quality of the information source internet and the resulting implications and discusses examples related to autism spectrum disorder. Method: We systematically evaluated 96 German websites, with the aim of estimating specific characteristic features, reliability of publications, presentation of information as well as overall website quality. We also analyzed the clinical implications of the presentations. Results: Only 39 % of the websites provided references to scientifically well-founded information, whereas advertisements were found on 53 % of websites. The greatest percentage of false information (17 %) was disseminated concerning therapy. 75 % of the websites provided incomplete information. Only 10 % of websites discussed the impairment or familial burden. The quality of information was insufficient on 30 %, poor on 41 %, and good on only 6 % of the websites. Conclusions: Similar to results available for English-language websites, the quality of German websites providing health-related information can be considered low. Implications concerning confirmation bias, stigma, overidentification, in-group/outgroup, contrast and snowball effects are discussed.

[Transition in autism spectrum disorders]. / Transition bei Autismus-Spektrum-Störungen.

Transition in autism spectrum disorders Abstract. Children and adolescents with autism spectrum disorder (ASD) are regularly seen by child and adolescent psychiatrists. Many diagnostic and therapeutic interventions are available for this age group. However, ASD is a rather unknown disorder in adult services, including psychiatry - despite the chronic course and the individual need for diagnosis, intervention, and support also in adulthood. Transition from childhood into adulthood is a rather complex topic that includes the challenge of mastering education and employment. This article presents these transition-related aspects and recommendations to improve healthcare in Germany.

Complementary and alternative medicine use in adults with autism spectrum disorder in Germany: results from a multi-center survey.

BACKGROUND: Complementary and Alternative Medicine (CAM) is widely used both in the general population and for the treatment of somatic and psychiatric disorders. Studies on CAM use among patients with autism spectrum disorder (ASD) have so far only focused on children and adolescents. The aim of this study was to investigate patterns of CAM use among adults with ASD. METHODS: A questionnaire survey concerning current and lifetime use of CAM was distributed to adults with ASD between November 2015 and June 2016. Participants diagnosed by experienced clinicians using the current diagnostic gold standard were recruited from four ASD outpatient clinics in Germany. Questionnaire data was then linked to supplementary clinical data. RESULTS: The final sample consisted of 192 adults (response: 26.8%) with a mean age of 31.5 years (80% male; diagnoses: Asperger's syndrome (58%), childhood autism (27%), atypical autism (12%)). 45% of the respondents stated that they were currently using or had used at least one CAM modality in their life. Among the participants with lifetime CAM use, almost half had used two or more different types of CAM. Alternative medical systems (e.g. homeopathy, acupuncture) were most frequently used, followed by mind-body interventions (e.g. yoga, biofeedback, animal assisted therapy). Overall, 20% of respondents stated that they would like to try at least one listed CAM modality in the future. CONCLUSIONS: This is the first study on CAM use in adults with ASD, demonstrating considerable CAM use in this population. Given the popularity of CAM, patients should be informed about the effectiveness and potentially dangerous side effects of CAM treatments, as evidence for the majority of CAM methods in ASD is still limited.

Treatment of child externalizing behavior problems: a comprehensive review and meta-meta-analysis on effects of parent-based interventions on parental characteristics.

This is the first meta-meta-analysis examining the effects of parent-based interventions for children with externalizing behavior problems on parental characteristics (parenting, parental perceptions, parental mental health, parental relationship quality). Parent training interventions are recognized as evidence-based interventions for the treatment of externalizing behavior problems, although meta-analytic effects are heterogeneous. The objective of the present study was to comprehensively combine meta-analytic results on parent training interventions to arrive at valid effect predictions. Electronic databases were searched (PsycINFO, Medline, PubMed). In total, 11 meta-analyses were included that mainly comprised parents of children under the age of 13 years. Analyses were based on random effects models. Effect estimates were transformed to standardized mean differences (SMD) and corrected for primary study overlap. Results revealed a significant moderate overall effect for parenting (SMD 0.53) as well as for parents' report of parenting (SMD 0.60) and parental perceptions (SMD 0.52). Effects remained stable to follow-up. Results for observational data, parental mental health and parental relationship quality were small and only partially significant. Considerable heterogeneity within results was revealed. Overall, parent training interventions proved to be effective in improving parental characteristics for parents of children with externalizing behavior problems. Effectiveness was stronger regarding characteristics explicitly targeted by interventions. The findings should encourage health-care providers to apply evidence-based parent training interventions.

Disruptive Behaviors across Different Disorders: Evaluation of a Clinical Sample Using the Eyberg Child Behavior Inventory.

OBJECTIVE: The study reports the prevalence of disruptive behaviors in a help-seeking sample of young children across a diverse range of clinical diagnoses (based on ICD-10). METHOD: The Eyberg Child Behavior Inventory (ECBI), a parent rating scale of disruptive behaviors, was completed on 310 children (2-11 years) at three child and adolescent psychiatry clinics in three German states (Bavaria, Hesse, Lower Saxony); the majority of children were outpatients. RESULTS: Mean intensity scores of disruptive behaviors differed significantly by diagnostic group, with the lowest ratings within a community sample, and increasingly higher scores in children with a diagnosis from the internalizing spectrum, those with pervasive developmental disorders, and finally, those with externalizing disorders (e. g. hyperkinetic disorder, conduct disorders). Seventy percent of the clinical sample, compared to only 17 % of the community sample, exceeded the normative cut-off score of 111, indicating that disruptive behaviors are common in young German children seeking help for different mental health problems. CONCLUSIONS: These findings support the Research Domain Criteria approach by showing that disruptive behaviors cross our current diagnostic labels and may need to be assessed and conceptualized in treatment planning, even in children without a primary diagnosis from the externalizing spectrum.

[The diagnostics of autism spectrum disorder in children, adolescents and adults: Overview of the key questions and main results of the first part of the German AWMF-S3 - clinical guideline]. / Diagnostik von Autismus- Spektrum-Störungen im Kindes-, Jugend- und Erwachsenenalter: Überblick zu den wesentlichen Fragestellungen und Ergebnissen des ersten Teils der S3-Leitlinie.

The diagnostics of autism spectrum disorder in children, adolescents and adults: Overview of the key questions and main results of the first part of the German AWMF-S3 - clinical guideline Abstract. Background: Autism spectrum disorders (ASD) include ICD-10 diagnoses of childhood autism, Asperger syndrome, and atypical autism; there is a lifetime prevalence of ~1 %. The aim of the evidence-based clinical guideline (AWMF-S3-Guideline) is to summarize the current evidence concerning diagnostic and therapeutic processes for professionals working in healthcare and social welfare and to provide consensus on clinical recommendations. The present study summarizes the most important results of the diagnostic part of this guideline. Method: The guideline group comprised 14 clinical and scientific expert associations from the German healthcare system, in addition to representatives of relatives and patients. Recommendations were based on results of a systematic literature search, data extraction, the evaluation of study quality, and, if possible, meta-analytic aggregation of included data in combination with the clinical expertise of the respective representatives. Consensus-based recommendations were determined via nominal group technique. Results: The AWMF-S3-Clinical Guideline, Diagnostic Part, summarizes current research on this topic. The main focus is put on the question of obligatory versus redundant diagnostic procedures. After a general introduction to the clinical picture of ASD, essential aspects like obtaining the medical history, the effective use of screening and diagnostic instruments, medical examination, the full diagnostic work-up as well as communicating the diagnostic results to relatives and patients are described in detail. We also conducted a meta-analysis on the stability of early diagnosis. Conclusion: This first part of the ASD guideline offers users the opportunity to inform themselves about the background of ASD as well as evidence-based and broadly consented information on the correct diagnostic process of ASD from infancy to adulthood.

Study protocol of the ASD-Net, the German research consortium for the study of Autism Spectrum Disorder across the lifespan: from a better etiological understanding, through valid diagnosis, to more effective health care.

BACKGROUND: Autism Spectrum Disorder (ASD) is a severe, lifelong neurodevelopmental disorder with early onset that places a heavy burden on affected individuals and their families. Due to the need for highly specialized health, educational and vocational services, ASD is a cost-intensive disorder, and strain on health care systems increases with increasing age of the affected individual. METHODS: The ASD-Net will study Germany's largest cohort of patients with ASD over the lifespan. By combining methodological expertise from all levels of clinical research, the ASD-Net will follow a translational approach necessary to identify neurobiological pathways of different phenotypes and their appropriate identification and treatment. The work of the ASD-Net will be organized into three clusters concentrating on diagnostics, therapy and health economics. In the diagnostic cluster, data from a large, well-characterized sample (N = 2568) will be analyzed to improve the efficiency of diagnostic procedures. Pattern classification methods (machine learning) will be used to identify algorithms for screening purposes. In a second step, the developed algorithm will be tested in an independent sample. In the therapy cluster, we will unravel how an ASD-specific social skills training with concomitant oxytocin administration can modulate behavior through neurobiological pathways. For the first time, we will characterize long-term effects of a social skills training combined with oxytocin treatment on behavioral and neurobiological phenotypes. Also acute effects of oxytocin will be investigated to delineate general and specific effects of additional oxytocin treatment in order to develop biologically plausible models for symptoms and successful therapeutic interventions in ASD. Finally, in the health economics cluster, we will assess service utilization and ASD-related costs in order to identify potential needs and cost savings specifically tailored to Germany. The ASD-Net has been established as part of the German Research Network for Mental Disorders, funded by the BMBF (German Federal Ministry of Education and Research). DISCUSSION: The highly integrated structure of the ASD-Net guarantees sustained collaboration of clinicians and researchers to alleviate individual distress, harm, and social disability of patients with ASD and reduce costs to the German health care system. TRIAL REGISTRATION: Both clinical trials of the ASD-Net are registered in the German Clinical Trials Register: DRKS00008952 (registered on August 4, 2015) and DRKS00010053 (registered on April 8, 2016).

[Diagnostic accuracy of the ADOS-2 taking account of gender effects]. / Zur Validität der deutschen Fassung der ADOS-2 unter Berücksichtigung von Geschlechtseffekten.

Objectives: The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) is a revision of the standardized assessment for individuals with suspected autism spectrum disorders (ASD). The study examines the diagnostic accuracy of the original and revised algorithms for Modules 1 through 3. Methods: In a large clinical sample of children and adolescents (N = 1080, age 1.7 to 20.5), the differentiation of ASD from relevant differential diagnoses was investigated. As studies on the diagnostic accuracy for girls are sparse, comparisons concerning the diagnostic accuracy for gender subgroups were undertaken. Results: The revised algorithms exhibit an improvement in sensitivity (84.9 %) and a slight reduction in specificity (85.7 %). The improvements in the ADOS-2 pertain especially to cases with core autism and girls. Including the repetitive behavior domain in the algorithm contributes to a correct clinical ASD classification in modules 2 and 3. This was not found for younger children examined with module 1. Results also suggest less effective diagnostic differentiation for children and adolescents with internalizing disorders and conduct disorder. Conclusions: Good diagnostic accuracy was found for children in the average range of cognitive abilities. Results suggest good diagnostic utility for the ADOS-2 in clinical settings, provided that thorough diagnostics are given by experienced examiners.