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Sample BOSA Clinical Summaries

The following examples are provided for guidance on writing a clinical summary for the BOSA to
include in diagnostic reports. Written descriptions can be modeled after an ADOS-2 summary and
should make clear that ADOS-2 items were used to interpret symptom presence. Note that each of
the following is just one example; edit as necessary for your clinical needs and include
individualized descriptions of symptoms, strengths, and weaknesses. Examples are included for: (1)
individuals who demonstrate clinically significant symptoms across domains, (2) individuals who
do not meet full crtieria based on the BOSA and need information supplemented by parent report
(e.g., ADI-R), and (3) individuals who do not meet criteria for autism. Be sure to change wording to
specify the administrator: The writing samples for MV and F2 give examples of observations
completed with a parent; PSYF and F1 give examples of observations completed with an examiner
(e.g., therapist).
Please keep in mind that there will be a subset of children for which the BOSA is not sufficient to
confirm or rule out a diagnosis of autism; a sample diagnostic impressions section is provided at the
end of this document for these cases (see Deferring a Diagnosis).
Clinical Summary Write-Up: Introduction to the BOSA
Due to the current COVID-19 pandemic, a valid Autism Diagnostic Observation Schedule – Second
Edition (ADOS-2) could not be administered. Instead, the Brief Observation of Symptoms of Autism
(BOSA) was administered with XXX and his/her mother/father/therapist in the clinic/home setting
and observed by the clinician through an observation window/recorded video/telehealth session.
The BOSA - MV version was used for this evaluation, which is appropriate for individuals who are
minimally verbal (i.e., nonverbal, single words, or only rote phrases) and includes sets of free play
toys and bubbles. / The BOSA - PSYF version was used for this evaluation, which is appropriate for
individuals of any age who use phrase speech or verbally fluent children under the age of 8 and
includes sets of free play toys, a dollhouse with figurines, and bubbles. / The BOSA - F1 version
was used for this evaluation, which is appropriate for verbally fluent children ages 6 through 10 and
consists of games and conversational topics, including questions about emotions and/or social
relationships. / The BOSA - F2 version was used for this evaluation, which is appropriate for
verbally fluent children age 11 through adults and consists of games and conversational topics,
including questions about emotions, social relationships, and/or responsibility.
The BOSA was created by Dr. Catherine Lord, co-developer of the ADOS-2, and uses activities
adapted from the ADOS-2 and Brief Observation of Social Communication Change (BOSCC). It
provides opportunities for a parent or therapist to engage in social interactions with an individual
through semi-structured activities, creating a context in which to observe symptoms of autism.
Existing ADOS-2 data was used to create binary scores based on distributions of scores for children
and adults with and without autism; however, empirically derived cut-offs are not yet available.
Therefore, the BOSA should be considered to provide a standardized observation that must be
interpreted with clinical judgment due to risk of reduced specificity. For this evaluation, BOSA
scores were interpreted within the DSM-5 diagnostic framework for autism spectrum disorder and
supplemented with a developmental history, medical background, and the Autism Diagnostic
Interview – Revised (ADI-R), a standardized, semi-structed parent interview for autism symptoms /
parent report of symptoms. The following provides a summary of the clinical observations:
The following are provided as examples of each version:
BOSA - MV (Toddler Module or M1 Scoring) Summary. Example of a child who
demonstrates symptoms across diagnostic categories:
XXX’s speech consisted of a few single words, such as “baby” and “bubbles,” which he used when
labeling objects. He also produced undirected vocalizations at times, which were sometimes of an
atypical tone. While XXX clapped during the observation, he did not use any other gestures or
pointing.
Socially, XXX made direct eye contact with his mother on occasion, but this was not integrated
with other forms of communication or with social intent. He did not demonstrate clear shared
enjoyment with her. He gave a baby doll for the purpose of sharing, but did not request. He showed
a limited range of facial expressions (i.e., smiles only). Overall, XXX’s level of engagement was
appropriate, but he made few clear social initiations toward his mother. While he showed a few
instances of positive social overtures, such as sharing the baby doll, he also made some unclear and
unusual social overtures, such as bringing objects to her and dropping them in her lap. XXX also
had a limited and inconsistent pattern of social responses, as he often ignored his mother’s
comments and social approaches.
Regarding his play skills, XXX played with a ball, blocks, and cause-and-effect toys (e.g., Poppin
Pals). He did not demonstrate any pretend play and did not imitate his mother’s actions when she
pretended that a block was a car and fed the baby doll.
Regarding repetitive behaviors, XXX displayed atypical sensory interests by licking objects (e.g.,
the bubble gun wand, textured block). He exhibited possible hand posturing during bubble play, as
well as one instance of arm flapping and complex body mannerisms (i.e., running in place). He did
not show any self-injury, anxiety, fussiness, overactivity, or aggression.
BOSA - PSYF (M2 or M3 Scoring) Summary. Example of a child who demonstrates some
symptoms, with additional information needed from the ADI-R:
Regarding communication, XXX primarily used phrase speech that typically consisted of three or
more words per utterance. However, the rate and rhythm of his speech were atypical, and were
halting, dysfluent, and marked by breaks between words. The tone of his speech was also somewhat
flat and atypical. XXX did not use repetitive or echolalic language. His responses to the examiner’s
prompts were generally limited to single-word responses. His parents also reported on the ADI-R
that he is unable to carry on a back and forth conversation that is appropriate for his expressive
language level. Nonverbally, XXX used spontaneous descriptive, instrumental and conventional
gestures (i.e. proximal pointing, shrugging, and nodding). His parents reported that he only waves
when prompted and does not consistently point to objects at a distance.
Socially, XXX’s eye contact was inconsistent and he had trouble coordinating eye contact with
speech and gestures; parents also reported limited coordinated eye contact. Although he directed
some facial expressions to convey his emotions, they were limited in range (e.g., smile and brief
furrowed brow). XXX made some social overtures to the examiner, but his overtures were
somewhat limited and generally related to his own interests or needs. These included short
verbalizations (i.e., “house,” “car”), one example of showing an interesting toy, and asking
questions about toys. He did appear to share enjoyment with the examiner throughout several
different activities, and frequently made attempts to gain and maintain the examiner’s attention
during the observation.
Regarding his play skills, XXX spontaneously demonstrated functional play with cause-and-effect
toys as well as the construction truck and blocks. He also displayed some spontaneous imaginative
play. For example, he fed the baby doll and pretended an action figure was sitting and eating dinner.
His parents reported that he plays chase with peers at school, but does not yet engage in pretend
play with other children.
XXX did not demonstrate restricted or stereotyped interests, repetitive actions with objects,
compulsions, hand or body mannerisms, or unusual sensory interests during the BOSA. However,
his parents reported several clinically significant symptoms related to restricted and repetitive
behaviors on the ADI-R including a restricted interest in trains, unusual sensory interests and
responses (e.g., frequent visual inspection of wheels, hyperresponsivity to loud noises), repetitive
use of objects (e.g., opening and shutting doors on toy cars), and hand mannerisms (e.g., flapping
hands when excited).
Behaviorally, he remained seated when expected to do so; however, he was often fidgeting in his
chair. XXX did not engage in any disruptive behaviors and did not show signs of anxiety.
BOSA – F1 (M3 Scoring) Summary. Example of child who does not demonstrate clinically
significant symptoms across domains (but scores on some items):
XXX’s language consisted of fluent speech with no recurrent grammatical errors. The volume,
rhythm and rate of his speech were appropriate. He did not exhibit any echolalia or stereotyped or
idiosyncratic use of words or phrases. He was able to carry on back-and-forth conversations with
the examiner, and frequently offered information and recalled life events (e.g., when talking to the
examiner about a previous vacation). XXX also responded appropriately to the examiner’s
comments and inquired about them in order to maintain dialogue and facilitate a back-and-forth
exchange. He used spontaneous descriptive gestures when explaining his ideas; he also used
instrumental gestures (e.g., pointing, shrugging and nodding).
Socially, XXX displayed appropriate eye contact for the majority of the observation, and directed
subtle and appropriate facial expressions toward the examiner to convey his emotions. His
vocalizations were consistently accompanied by the use of appropriate and expressive gestures,
gaze, and facial expressions. He appeared to show pleasure with the examiner throughout the
observation during many different conversational topics and activities. XXX also initiated effective
social overtures and frequently attempted to get and maintain the examiner’s attention. The quality
of his social response and amount of reciprocal social communication were appropriate. Regarding
his play, XXX played appropriately with the presented games, but did not demonstrate imagination
and creativity in the activities.
Regarding his social and emotional insight, XXX seemed to have insight into typical social
relationships (e.g., a friend is “someone you like to hang out with at recess and see on the
weekends”), though he did not demonstrate insight into his own role in those relationships. He gave
an appropriate example of feeling scared, noting that he does not like when his brother jumps out
when he is not expecting it; he had difficulty generating examples for additional emotional
experiences.
XXX had a strong interest in videogames, often referencing them during conversations. He did not
exhibit any unusual sensory interests during the evaluation. At times, he used unusual emphatic
hand gestures, but did not demonstrate repetitive or stereotyped movements. He did not display any
self-injurious behaviors. Behaviorally, XXX appeared to have no difficulty sitting in his chair. He
did not display any overt anxiety or negative behaviors.
BOSA – F2 (M3 or M4 Scoring) Example Summary. Example of an individual who
demonstrates symptoms across diagnostic categories:
XXX’s language consisted of fluent speech with no observed grammatical errors. He did not exhibit
any echolalia but occasionally used stereotyped and idiosyncratic words and phrases. He was able to
carry on a back-and-forth conversation with his father, but his conversations were less frequent and
less reciprocal than would be expected for his expressive language level. However, XXX was able
to spontaneously offer information and recall previous life experiences (e.g., an argument he had
with a peer) while talking with his father. He also responded appropriately to his father’s comments,
but did not inquire about them or build on his statements in a way that contributed to ongoing
dialogue. Regarding nonverbal gestures, XXX used spontaneous descriptive gestures when
explaining his ideas. He also used instrumental gestures (e.g., pointing), but did not use emphatic or
other conventional gestures while talking.
Socially, XXX displayed limited eye contact throughout the observation. He directed some facial
expressions (i.e., brief smiles) toward his father, but his expressions were limited in range. XXX
showed enjoyment in his interaction at times during conversations, but this was not consistent
throughout. XXX initiated slightly unusual social overtures that were usually restricted to his own
interests. He was socially responsive to most of his father’s social overtures, but his responses were
odd. As a result, the amount of reciprocal social communication was less than expected.
Regarding social and emotional insight, XXX described a time he felt angry when he had an
argument with his peer, but his insight into his peer’s perspective was limited. XXX discussed
future career aspirations, but showed little indication that he understood the steps it would take to
obtain those goals. He stated that the only reason he has his current job is because his parents got it
for him.
Behaviorally, XXX did not display any unusual sensory interests during the observation. He
exhibited a brief unusual hand mannerism; he did not demonstrate any self-injurious behaviors. He
made unusually repetitive comments about some topics, and was extremely detailed and precise in
his telling of events and describing the rules for the games; however, this behavior did not appear to
be clearly compulsive in quality. XXX appeared to have no difficulty sitting in his chair. He did not
display any negative behaviors and did not appear anxious at any point during the observation.
Deferring a Diagnosis
Please keep in mind that there will be a subset of individuals for which the BOSA is not sufficient to
confirm or rule out autism, even when additional information from parent report is considered. In
these situations, a diagnosis should be deferred until in-person testing can take place. The following
provides an example from a diagnostic impressions / summary section of a report when diagnosis
needs to be deferred:
“Due to the brief duration and limited scope of this “socially distanced” evaluation, sufficient
evidence is not available at this time to confirm or rule out autism spectrum disorder. Clinically
significant symptoms in two broad areas, deficits in social interaction and social communication
and the presence of restricted and/or repetitive behaviors or interests, are required across contexts
for a diagnosis. While XXX exhibited clinically significant deficits in social communication and
social interaction (e.g., limited use of nonverbal communication, inconsistent social response,
unusual social overtures, reduced shared enjoyment), evidence for restricted and/or repetitive
behaviors (RRBs) is limited based on this brief evaluation and does not meet diagnostic criteria.
Symptoms in one subdomain of RRBs (i.e., unusual response to sensory stimuli) were reported by
parents on the ADI-R (e.g., covering ears to the sound of the coffee grinder; occasionally walking on
tiptoes); no RRBs were observed during the BOSA behavioral observation. Due to the presence of
clinically significant symptoms across domains with insufficient evidence to meet diagnostic
criteria for autism spectrum disorder, a follow-up in-person evaluation using the Autism Diagnostic
Observation Scale, Second Edition (ADOS-2) is recommended.”

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