Brief Observation of Symptoms of Autism - Version 7-28-20

Brief Observation of Symptoms
of Autism (BOSA)
Version: 7-28-2020
Catherine Lord, Alison Holbrook, Deanna Dow, Katherine Byrne,

Rebecca Grzadzinski, Kyle Sterrett, Christina Toolan, & So Hyun Kim
Select ADOS-2 and BOSCC content adapted and/or referenced within the work now known as BOSA is used under
written permission from WPS. No additional use, including and not limited to adaptation or translation, is permitted. 1
ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved (rights@wpspublish.com).
Table of Contents
Who Can Administer the BOSA? ........................................................................................... 4
Choosing the Appropriate Version of the BOSA ..................................................................... 4
BOSA – MV .......................................................................................................................... 6
Clinical Guidelines........................................................................................................................6
Caregiver Instructions ................................................................................................................ 10
Materials Needed ........................................................................................................................ 11
DSM-5 Checklist for Module 1 ................................................................................................... 12
Additional Items for Module 1 .................................................................................................... 13
DSM-5 Checklist for Toddler Module ......................................................................................... 14
Additional Items for Toddler Module ......................................................................................... 15
BOSA – PSYF ..................................................................................................................... 16
Clinical Guidelines...................................................................................................................... 16
BOSA – F1 .......................................................................................................................... 27
Question Cards ........................................................................................................................... 33
BOSA – F2 .......................................................................................................................... 36
Question Cards – Examiner ........................................................................................................ 42
Question Cards – Participant...................................................................................................... 43
Materials to Purchase for the BOSA .................................................................................... 47
Completed DSM-5 Checklist Example .................................................................................. 48
Who Can Administer the BOSA?
Clinicians with sufficient training and experience using the ADOS-2 can administer the BOSA.
Since the BOSA relies on ADOS-2 codes, it is essential that BOSA users possess the same clinical
skill and judgment required when administering and scoring the ADOS-2. For more information
on user qualification and learning to use the ADOS-2, please refer to the ADOS-2 manual on
page 22.
Choosing the Appropriate Version of the BOSA

Use the following guidelines based on the individual’s age and language level to decide which
version is most appropriate:
The BOSA-MV is appropriate for individuals of any age who are minimally verbal (i.e.,
nonverbal or use only single words/rote phrases) and includes sets of free play toys and
bubbles.
The BOSA-PSYF is appropriate for individuals of any age who use flexible phrase speech or
verbally fluent children under the age of 6-8* and includes sets of free play toys, a dollhouse
with figurines, and bubbles.
The BOSA-F1 and BOSA-F2 are very similar versions that differ due age appropriate materials
and questions.
The BOSA-F1 is appropriate for verbally fluent children ages 6-8* through 10 and includes
games and conversational topics, including questions about emotions and/or social relationships.
The BOSA-F2 is appropriate for verbally fluent children ages 11 and up through adults and
includes games and conversational topics, including questions about emotions, social
relationships, and/or responsibility. The BOSA-F2 requires the participant to read aloud. If the
participant is unable to read, the BOSA-F1 may be more appropriate, but the BOSA-F2 materials
may still be used.
The guidelines listed above should be combined with clinical judgment to determine which
version and materials are most developmentally appropriate for a participant. Therefore,
developmental age and ability should be considered when selecting the version. For example, if
using the BOSA with a 12-year-old with intellectual disability, it may be appropriate to use the
BOSA-F1 protocol with the BOSA-F2 materials.
* If the participant is between 6:0 and 7:11 years, you may select either the BOSA-PSYF or
BOSA-F1. When selecting between the BOSA-PSYF or BOSA-F1, please consider the purpose of
the assessment, the verbal ability, and attention span of the participant. For example, if the BOSA
is being used for research, it may be important to have consistency across children. The BOSA-
PSYF is primarily free play based, which often makes it easier for participants to engage with the
materials and examiner during the assessment. The BOSA-F1 is game and conversation based, so
often times younger participants may have a difficult time taking turns during the game and
answering the questions. Due the exclusion of ADOS-2 related questions in the BOSA-PSYF, it
may be more challenging to make a judgment for some ADOS-2 codes (e.g., A7. Reporting of
Events and B6. Insight into Typical Social Situations and Relationships) and easier to code
others (e.g., C1. Imagination/Creativity). Clinical judgment should be used to determine the most
appropriate version for verbally fluent participants between the ages of 6:0 and 7:11 years.
BOSA – MV
Clinical Guidelines
Introduction
The Autism Diagnostic Observation Schedule (ADOS-2) provides a way for clinicians to observe
the social communicative behavior and play/imagination of a participant in a relatively natural
context and to place these observations within a framework of standardized codes. However, the
ADOS-2 is not appropriate to administer via telehealth nor when the parties involved are wearing
face masks. Thus, the Brief Observation of Symptoms of Autism (BOSA) provides a context of
activities that can be presented by an examiner (e.g., a caregiver, therapist) within a 12-14-
minute observation to help fill the gap left by not being able to carry out a valid ADOS.
Clinicians familiar with the ADOS-2 can observe the BOSA live, through telehealth, or on
recorded video and complete many of the ADOS-2 codes. The ADOS–2 codes will then be used
to denote evidence of symptoms of autism and recorded within a DSM-5 checklist. In the event
the BOSA observation did not provide evidence of the presence of particular autism symptoms,
additional evidence should be sought through alternative methods (e.g., Autism Diagnostic
Interview-Revised; parent report) before it is concluded that it doesn’t exist.
Preparation Guidelines
As the clinician, your role will be to assist the examiner (e.g., caregiver or therapist) during their
interaction with the participant. Before bringing the participant and examiner into a room, you
should ensure the room is properly set up. You will need Toy Set 1, Toy Set 2, and a bubble gun.
Each toy set should be in a clearly labeled container to help ensure the examiner is easily able to
transition from one activity to the next.
1. Go over the instruction sheet with the examiner.

a. Show the examiner the materials for each activity.
b. Discuss what they should do with the participant during each activity.
c. Inform the examiner to look through the materials and select toys that the
participant most typically plays with and enjoys.
d. Give the instruction sheet to the examiner and let them know they are allowed to
reference it throughout the interaction.
2. Tell the examiner where they should sit, where the participant should sit, and where the
toy containers should be placed while they are interacting.
a. The examiner should sit across from the participant, leaving room between them
to play with toys. The examiner should select a few toys to play with and place
them between him/herself and the participant, then move the toy container with
the remaining toys off to the side and out of reach from the participant. See
graphic for suggested placement of materials, camera, and people. The materials
for the remaining activities should be on a separate table or shelf off to the side.
Assessment Room
Camera/ Observation
Clinician
Participant
Window
Bubbles
Toys
Set 2
Toys
Set 1
Examiner
Table/shelf
3. Let the examiner know where you will be observing from. This is important so they know
not to block your view of the interaction to help ensure everything can be seen as well as
possible for coding purposes.
4. Tell the examiner you will let them know when to move from one activity to the next.
You can do this using a timer in the room, providing a verbal prompt via Zoom or
microphone, or a knock on the observation window. Ensure the examiner knows which
method you plan to use to inform them when to move to the next activity.
5. Before the examiner begins, be sure to answer any questions they may have regarding the
play interaction.
Administration Guidelines
The BOSA-MV is appropriate for individuals of any age who are minimally verbal (i.e.,
nonverbal or use only single words/rote phrases). The overall interaction should be 12 minutes of
the examiner and participant playing together. Encourage the examiner to play naturally with the
child throughout the activities.
Toy Set 1
Instruct the examiner to begin with the materials labeled Toy Set 1. The examiner should look
through the materials and take out a few toys that are most typical of what the child plays with
and enjoys. The remaining toys should be placed off to the side and out of reach from the
participant. The examiner can bring out more toys as needed during the interaction to help the
participant engage. During this activity, the examiner should play naturally with the participant.
Make sure the examiner encourages the participant to play with at least 2 toys in the set. If the
examiner struggles to come up with play ideas, remind them of the suggestions provided on the
instruction sheet. Toy Set 1 should be used during the first 4 minutes of the interaction. With 30
seconds remaining (3:30 minutes into the interaction), instruct the examiner to clean up the
materials and begin to transition to the bubble activity. Clean up should not take longer than
about 30 seconds. Therefore, the examiner should not be expected to thoroughly clean up each
toy after the activity (e.g., toys do not need to neatly be put back in bags or boxes), but rather let
them know they should try to transition as quickly as possible. If the participant gets upset during
the transition, instruct the examiner to tell the participant they will be playing with more toys
next.
Bubbles*
The bubbles activity should be 2 minutes long. Instruct the examiner to move around the room
and play naturally with the participant. Tell the examiner to have the participant stand to play
with the bubbles; this allows for observations of hand and body mannerisms during this activity.
With 15 seconds remaining (5:45 minutes into the overall interaction), instruct the examiner to
put the bubbles away and transition to Toy Set 2.
*Foam rockets or disc launcher can be used in place of the bubbles.
Toy Set 2
As with Toy Set 1, this activity should be 4 minutes long. With 30 seconds remaining (9:30
minutes into the interaction), instruct the examiner to clean up the materials and begin to
transition to the bubble activity for the second time.
Bubbles*
Allow the examiner and participant to interact with the bubbles for the remaining 2 minutes.
After the full 12-minute interaction is complete, let the examiner know that they are done.
Coding Procedures
To code, use the ADOS-2 protocol for the appropriate module based on the participant’s age and
language level (e.g., for BOSA-F2, a Module 3 or Module 4 should be used). Use the protocol for
notetaking during the observation and then score the codes to the best of your ability based on
which behaviors you observed. Each BOSA version also includes several additional items from
other ADOS modules that should be scored alongside the selected ADOS protocol. Be sure to
also code these additional items provided on the extra codesheet for the module you used, when
possible (e.g., see Additional Items for Module 1 on page 12 and Additional Items for the
Toddler Module on page 14).
Caregivers and therapists vary widely in their interaction style and the level of support they
provide for their child/individual; therefore, it is important to keep in mind when coding that this
is different than in an ADOS-2 administration where the clinician intentionally sits back and
adds support at different times. Consider how much support the caregiver or therapist is giving
the child/individual in their interactions, as caregivers often accommodate to the level that is
needed to allow their child to be successful. That said, there will be variability in caregivers
regardless of the child’s abilities; do your best to code objectively on the individual’s skills using
your clinical judgment.
Do not score items if you do not have enough information to make an accurate judgment
regarding the presence or absence of a particular symptom. Some ADOS-2 codes are based on
symptoms intentionally elicited through certain activities on the ADOS-2. For example, the
demonstration task gives a standardized context that prompts the individual to use gestures and
describe a routine event. These items are then coded based on behaviors the individual
demonstrates during the activity, as well as any other behaviors observed throughout the ADOS-
2. Because the BOSA is a more naturalistic interaction than the ADOS-2, there may not be
sufficient opportunity for the individual to show the coded behaviors, in which case an 8 code
should be used. Codes that should be given particular attention in regard to considering an 8 code
are marked on the DSM-5 Checklists with a ❖. However, if opportunities arise for the individual
to demonstrate the skills being assessed during the BOSA, a 0-3 code should be assigned.
Finally, transfer your ADOS-2 codes to the BOSA DSM-5 checklist and convert them to binary
BOSA scores to indicate presence or absence for each symptom. Indicate unscored ADOS-2
codes on the checklist using “N/A.” There is also space on each form to score and note additional
evidence collected from parent report or other observations to aid in determining whether the
participant meets diagnostic criteria across domains.
Clinical Considerations and Limitations
While the BOSA provides a standardized context to observe behaviors consistent with autism
spectrum disorder, this measure is not meant to replace the ADOS-2. We acknowledge that
clinicians and researchers who are accustomed to using the ADOS-2 may feel limited in their
ability to confidently assess symptom presence in certain subdomains (e.g., restricted interests)
based on this behavioral observation alone, while some symptoms may be more readily
observable (e.g., limited use of nonverbal communication). We also do not expect severity of
symptoms to be accurately measured in this context, which is why we have used a binary coding
system to judge presence versus absence of symptoms only, in place of the 0-3 coding system
from the ADOS-2.
You may have noticed there are many different items on the ADOS-2 that are linked to autism
but are not necessarily specific to autism, leading to a potentially high risk of “false positives”
(i.e., an individual scoring on many items when they do not have autism). There is also risk for
“false negatives” (i.e., ruling out autism when the person does have autism) because the
observation is so brief and limited in scope. Please note that scores will be lower than you are
accustomed to when using the ADOS-2, as 0-3 codes were condensed into binary 0 vs. 1 codes;
be cautious to not mistakenly rule out autism due to an apparent “low score” on the BOSA. While
we are working on developing algorithms to improve psychometrics of the measure, this may
take a while and may also be limited by what we can do during the pandemic. For these reasons,
we encourage clinicians to rely heavily on a thorough developmental history, medical
background, and parent report of symptoms, ideally using the Autism Diagnostic Interview-
Revised (ADI-R). Information across contexts should be interpreted by someone with clinical
expertise in autism spectrum disorder to determine whether the individual meets DSM-5
diagnostic criteria.
BOSA – MV
Caregiver Instructions
Today you will play with your child for 12 minutes. You will use two sets of toys and bubbles.
We will let you know when to clean up each activity and move on to the next. The session will
consist of:
Toy Set 1 Bubbles Toy Set 2 Bubbles

4 mins 2 mins 4 mins 2 mins
1. INTRODUCTION
First, describe to your child what you are going to do. For example, say “We are going to
play with toys and bubbles!”
2. PLAY WITH TOY SET 1

Start by looking through the toys. Then take out a few toys that your child may typically
4 mins play with and enjoy. Play naturally with your child. Encourage them to play with at least
2 toys. You can follow what your child is doing (imitate their play), comment, and show
excitement. Please try to limit the number of prompts, instructions, and questions you use
while playing with your child. Here are a few play ideas:
• Put the shapes in the shape sorter
• Drive the cars and/or fly the rocket
• Take turns on the pop-up
If your child gets upset when you clean up, remind them that you will be playing with
more toys next.
3. PLAY WITH BUBBLES

Encourage your child to stand when you bring out the bubble gun. You may move around
2 mins the room and play naturally with your child.

Tell your child that you have more toys! Look through the toys and then take a few out
4 mins that you think your child may typically play with and enjoy. Play together until it is time
to clean up. Here are a few play ideas:
• Build a tower with the blocks
• Roll the ball back and forth
• Use the tools to fix the dump trick

Just like the first time, play with the bubbles while standing up!
2 mins
BOSA – MV
BOSA Activity BOSA Grouping Materials Needed ADOS-2 Activity
Materials Needed
Family dolls* (at least 2 figures)
Furniture
Group 1 Dog Make-Believe Play
Hologram disk
Toy rocket
Toy Set 1 Cars
Group 2
Small balls
Toy purse and miniature objects inside

Group 3 Free Play
Plastic ring & cylindircal tube
Telephone
Shape sorter
No bag needed
Pop-up
Bubble
Bubbles Bubble gun/foam rocket/disc launcher* Play/Anticipation of
Routine with Objects
Action figures* (at least 2)
Dinosaur
Group 4 Minature toy tools & brush Make-Believe Play
Small teapot/measuring cup
Metal lid
Toy Set 2 Letter Blocks
Group 5 Toy tools
Dump truck
Free Play
Baby doll*
Plates and utensils
Group 6
Textured block
Cup Birthday Party
Medium ball
No bag needed Jack-in-the-box Free Play
Music box
Bubble
Bubbles Bubble gun/foam rocket/disc launcher* Play/Anticipation of
Routine with Objects
* Note: Figures and doll for Toy Set 1 & 2 may need to be purchased separately if the ADOS toys cannot easily be cleaned; disc
launcher needs to be purchased separately but is not required.
Module 1 DSM-5 Checklist | ID: _____________________ Date: ____________________ Age: ___________________ Examiner: ☐ Parent/Caregiver ☐ Therapist
ecklist for Module 1
Language Level: A1. Overall Level of Nonechoed Spoken Language: _________
BOSA Version: MV
A. Impairment in Social Communication & Social Interaction B. Restricted and Repetitive Behaviors
ADOS Recode BOSA Parent Other ADOS Recode BOSA Parent Other
1. Deficits in Social-Emotional Reciprocity 1. Repetitive and Stereotyped Behavior
Score Rule Score Report Info Score Rule Score Report Info
0-1→0 0→0
*A2. Frequency of Spontaneous Vocalization Directed to Others *A3. Intonation of Vocalizations or Verbalizations
2-3→1 1-2→1
0→0 0→0
*B5. Shared Enjoyment in Interaction A4. Immediate Echolalia
1-3→1 1-3→1
0→0 0→0
B7. Requesting *A5. Stereotyped/Idiosyncratic Use of Words or Phrases
1-3→1 1-3→1
0-1→0 0→0
vB8. Giving *D2. Hand and Finger and Other Complex Mannerisms
2→1 1-3→1
0-1→0 0→0
*B9. Showing D3. Self injurious behavior
2→1 1-2→1
0-1→0
v*B10. Spontaneous Initiation of Joint Attention Other (Specify):_______________
2→1
0→0
(B11 from M2). Amount of Reciprocal Social Communication 2. Excessive Adherence to Routines and Ritualistic Behavior
1-3→1
0-1→0 0→0
*B12. Quality of Social Overtures (D5 from M3). Compulsions/Rituals
2-3→1 1-2→1
0-1→0
B13a or B13b. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
2-3→1
0-1→0
B14. Quality of Social Response 3. Restricted, Fixated Interests
2-3→1
0-1→0
Other (Specify):_______________ *D4. Unusually Repetitive Interests or Stereotyped Behaviors
2-3→1
2. Deficits in Nonverbal Communication used for Social Interaction Other (Specify):_______________
0→0
A6. Use of Another's Body 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
1-2→1
0→0 0→0
*B1. Unusual Eye Contact *D1. Unusual Sensory Interest in Play Material/Person
2→1 1-3→1
0-1→0
*B3. Facial Expressions Directed to Others Other (Specify):_______________
2→1
0-1→0
*B4. Integration of Gaze and Other Behaviors During Social Overtures Other Behaviors (E Codes)
2-3→1
ADOS Recode BOSA Parent Other
Other (Specify):_______________
Score Rule Score Report Info
0→0
3. Deficits in relationships E1. Overactivity
1-3→1
0-1→0 0→0
B15. Level of Engagement E2. Tantrums, Aggression, Negative or Disruptive Behavior
2-3→1 1-3→1
0-1→0 0→0
C1. Functional Play With Objects E3. Anxiety
2-3→1 1-2→1
0-1→0 Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9
C2. Imagination/Creativity
2-3→1 should be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview;
Other Info: P if symptom present based on additional gathered or observed information.
Other (Specify):_______________
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3
Clinical Notes on Observations or Outside Information:
Select codes from ADOS-2 reprinted by author C. Lord, for authorized use within the work now known as BOSA, under written permission from WPS. No
additional use, including and not limited to adaptation or translation, is permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved
12
(rights@wpspublish.com).
Additional Items for Module 1
(Module 2)
(Module 3)
Select codes from ADOS-2 reprinted by author C. Lord, for authorized use within the work now known as
BOSA, under written permission from WPS. No additional use, including and not limited to adaptation or 13
translation, is permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved
Toddler Module DSM-5 Checklist | ID: ___________________ Date: __________________ Age: _________________ Examiner: ☐ Parent/Caregiver ☐ Therapist
BOSA Version: MV
DSM-5 Checklist
A. Impairmentfor Toddler
in Social Module
Communication & Social Interaction B. Restricted and Repetitive Behaviors
0-1→0 0→0
*A2. Frequency of Spontaneous Vocalization Directed to Others *A3. Intonation of Vocalizations or Verbalizations
2-3→1 1-3→1
0→0 0-1→0
1-3→1 2-3→1
0→0 0→0
*B9. Requesting A5. Stereotyped/Idiosyncratic Use of Words or Phrases
1-3→1 1-3→1
0-1→0 0-1→0
vB11. Giving A9. Frequency of Undirected Vocalization
2-3→1 2-3→1
0-1→0 0-1→0
*B12. Showing *D2. Hand and Finger Movements/Posturing
2-3→1 2-3→1
0→0 0→0
v*B13. Spontaneous Initiation of Joint Attention D3. Other Complex Mannerisms
1-3→1 1-3→1
0→0 0→0
*B15. Quality of Social Overtures D4. Self Injurious Behavior
1-3→1 1-3→1
0-1→0
B16a or *B16b. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
2-3→1
Other (Specify):_______________ 2. Excessive Adherence to Routines and Ritualistic Behavior
0→0
2. Deficits in Nonverbal Communication used for Social Interaction (D5 from M3). Compulsions/Rituals
1-2→1
0-1→0
A6. Use of Another's Body Other (Specify):_______________
2-3→1
0-1→0
*B1. Unusual Eye Contact 3. Restricted, Fixated Interests
2-3→1
0-1→0 0-1→0
*B4. Facial Expressions Directed to Others *D5. Unusually Repetitive Interests or Stereotyped Behaviors
2-3→1 2-3→1
0-1→0
*B5. Integration of Gaze and Other Behaviors During Social Overtures Other (Specify):_______________
2-3→1
Other (Specify):_______________ 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
0→0
3. Deficits in relationships *D1. Unusual Sensory Interest in Play Material/Person
1-3→1
0-1→0
B17. Level of Engagement Other (Specify):_______________
2-3→1
0-1→0
C1. Functional Play With Objects Other Behaviors (E Codes)
2-3→1
0-1→0 ADOS Recode BOSA Parent Other
vC2. Imagination/Creativity
2-3→1 Score Rule Score Report Info
0→0
Other (Specify):_______________ E1. Overactivity
1-3→1
0-1→0
E2. Fussiness/Irritability
Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9 should 2-3→1
be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if 0→0
E3. Aggressive and Disruptive Behavior
symptom present based on additional gathered or observed information. 1-3→1
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3 0-1→0
E4. Anxiety
2-3→1
additional use, including and not limited to adaptation or translation, is permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved 14
Additional Items for Toddler Module
(Module 3)
BOSA – PSYF
Clinical Guidelines
Introduction
The Autism Diagnostic Observation Schedule (ADOS-2) provides a way for clinicians to observe the
social communicative behavior and play/imagination of a participant in a relatively natural context and to
place these observations within a framework of standardized codes. However, the ADOS-2 is not
appropriate to administer via telehealth nor when the parties involved are wearing face masks. Thus, the
Brief Observation of Symptoms of Autism (BOSA) provides a context of activities that can be presented by
an examiner (e.g., a caregiver, therapist) within a 12-14-minute observation to help fill the gap left by not
being able to carry out a valid ADOS-2. Clinicians familiar with the ADOS-2 can observe the BOSA live,
virtually through telehealth, or on recorded video and complete many of the ADOS-2 codes. The ADOS-2
codes will then be used to denote evidence of symptoms of autism and recorded within the BOSA DSM-5
checklist. In the event the BOSA observation did not provide evidence of the presence of particular autism
symptoms, additional evidence should be sought through alternative methods (e.g., Autism Diagnostic
Interview-Revised; parent report) before it is concluded that it doesn’t exist.
interaction with the participant. Before bringing in the participant and examiner into a room, you should
ensure the room is properly set up. You will need Toy Set 1, Toy Set 2, the Melissa & Doug dollhouse,
and a bubble gun. Each toy set should be in a clearly labeled container to help ensure the examiner is
easily able to transition from one activity to the next.

c. Inform the examiner to look through the materials and select toys that the participant most
typically plays with and enjoys.
d. Give the instruction sheet to the examiner and let them know they are allowed to reference
it throughout the interaction.
2. Tell the examiner where they should sit, where the participant should sit, and where the toy
containers should be placed while they are interacting.
a. The examiner should sit across from the participant, leaving room between them to play
with toys. The toy container should be placed between the participant and examiner, so
they both have access, but slightly off to the side that is away from the observer or camera.
See graphic for suggested placement of materials, camera, and people. The materials for
the remaining activities should be on a separate table or shelf off to the side.
Assessment Room
Camera/ Observation
Clinicia
n Clien
Window
t
Toys
Set 1
Toys
Set 2
Bubbles
Dollhouse
Examiner
Table/shelf
Select ADOS-2 and BOSCC content adapted and/or referenced within the work now known as BOSA is used under written
permission from WPS. No additional use, including and not limited to adaptation or translation, is permitted. ADOS-2, BOSCC 16
and BOSA are copyrighted by WPS. All rights reserved (rights@wpspublish.com).
3. Let the examiner know where you will be observing from. This is important so they know not to
block your view of the interaction to help ensure everything can be seen as well as possible for
coding purposes.
4. Tell the examiner you will let them know when to move from one activity to the next. You can do
this using a timer in the room, providing a verbal prompt via Zoom or microphone, or a knock on
the observation window. Ensure the examiner knows which method you plan to use to inform
them when to move to the next activity.
5. Before the examiner begins, be sure to answer any questions they may have regarding the play
interaction.
The BOSA-PSYF is appropriate for individuals of any age who use phrase speech or verbally fluent
children under 6-8* years old. (*If the participant is between 6:0-7:11 years old, you may select either
BOSA-PSYF or BOSA-F1. See page 4, “Choosing the Appropriate Version of the BOSA” for more
details.) The overall interaction should be 14 minutes of the examiner and participant playing together.
Encourage the examiner to play naturally with the participant throughout the activities.
Toy Set 1
Instruct the examiner to begin with the materials labeled Toy Set 1. The examiner should look through the
materials and take out a few toys that are most typical of what the child plays with and enjoys. The
remaining toys should be placed off to the side and out of reach from the participant. The examiner can
bring out more toys as needed during the interaction to help the participant engage. During this activity,
the examiner should play naturally with the participant. Make sure the examiner encourages the
participant to play with at least 2 toys in the set. If the examiner struggles to come up with play ideas,
remind them of the suggestions provided on the instruction sheet. Toy Set 1 should be used during the
first 4 minutes of the interaction. With 30 seconds remaining (3:30 minutes into the interaction), instruct
the examiner to clean up the materials and begin to transition to the dollhouse activity. Clean up should
not take longer than about 30 seconds. Therefore, the examiner should not be expected to thoroughly
clean up each toy after the activity (e.g., toys do not need to neatly be put back in bags or boxes), but
rather let them know they should try to transition as quickly as possible. If the participant gets upset
during the transition, instruct the examiner to tell the participant they will be playing with more toys next.
Dollhouse*
Instruct the examiner to play with the participant and dollhouse for 2 minutes. Give the examiner
suggestions on how to engage with the dollhouse and the participant, such as telling them to encourage
the participant to figure out which keys open the doors, commenting on the decorations on the house, and
playing with the toys inside the house. Instruct the examiner to encourage conversation by making open
ended comments such as, “I like this...” or “Look, this house has a cat…” Let the examiner know the
doors are numbered with corresponding keys. If the participant gets stuck trying to unlock the doors and it
prevents them from engaging with the examiner, then the examiner should offer help or unluck the doors
for the participant so that conversation about the activity can continue. Tell them to try to limit direct
questions to no more than five. With 15 seconds remaining (5:45 minutes into the overall interaction),
instruct the examiner to put the dollhouse aside and transition to bubbles.
*The Melissa and Doug Mailbox toy can be used in place of the dollhouse. If you plan to use the Melissa
and Doug Mailbox, you should place four envelopes inside the mailbox before the assessment begins.
Address two envelopes to the participant and two to the examiner. Hide a small prize toy (e.g., stickers,
slap bracelets, or animal erasers) inside each envelope that the participant can keep after the assessment is
completed. The objective of the mailbox activity is the same as that of the dollhouse activity – to
encourage conversation between the participant and examiner around a joint activity.
Bubbles*
The bubbles activity should be 2 minutes long. Instruct the examiner to move around the room and play
naturally with the participant. Tell the examiner to have the participant stand to play with the bubbles.
This allows for observations of hand and body mannerisms during this activity. With 15 seconds
remaining (7:45 minutes into the overall interaction), instruct the examiner to put the bubbles away and
transition to Toy Set 2.
Toy Set 2
As with Toy Set 1, this activity should be 4 minutes long. With 30 seconds remaining (11:30 minutes into
the interaction), you will instruct the examiner to clean up the materials and begin to transition to the
dollhouse activity for the second time.
Dollhouse*
Instruct the examiner to play with the participant and dollhouse for the remaining 2 minutes. Remind the
examiner to encourage conversation during their play.
*The Melissa and Doug Mailbox toy can be used in place of the dollhouse.
Coding Procedures
To code, use the ADOS-2 protocol for the appropriate module based on the participant’s age and language
level (e.g., for BOSA-F2, a Module 3 or Module 4 should be used). Use the protocol for notetaking during
the observation and then score the codes to the best of your ability based on which behaviors you
observed. Each BOSA version also includes several additional items from other ADOS modules that
should be scored alongside the selected ADOS protocol. Be sure to also code these additional items
provided on the extra codesheet for the module you used, when possible (e.g., see Additional Items for
Module 2 on pages 22-23 and Additional Items for Module 3 on page 25).
Caregivers and therapists vary widely in their interaction style and the level of support they provide for
their child/individual; therefore, it is important to keep in mind when coding that this is different than in
an ADOS-2 administration where the clinician intentionally sits back and adds support at different times.
Consider how much support the caregiver or therapist is giving the child/individual in their interactions,
as caregivers often accommodate to the level that is needed to allow their child to be successful. That said,
there will be variability in caregivers regardless of the child’s abilities; do your best to code objectively on
the individual’s skills using your clinical judgment.
Do not score items if you do not have enough information to make an accurate judgment regarding the
presence or absence of a particular symptom. Some ADOS-2 codes are based on symptoms intentionally
elicited through certain activities on the ADOS-2. For example, the demonstration task gives a
standardized context that prompts the individual to use gestures and describe a routine event. These items
are then coded based on behaviors the individual demonstrates during the activity, as well as any other
behaviors observed throughout the ADOS-2. Because the BOSA is a more naturalistic interaction than the
ADOS-2, there may not be sufficient opportunity for the individual to show the coded behaviors, in which
case an 8 code should be used. Codes that should be given particular attention in regard to considering an
8 code are marked on the DSM-5 Checklists with a ❖. However, if opportunities arise for the individual
to demonstrate the skills being assessed during the BOSA, a 0-3 code should be assigned. Additionally,
you may assign a 0-2 code for Language Production and Linked Nonverbal Communication (B3 on
Modules 3 and 4), even if you coded Unusual Eye Contact as a 2 (B1).
Finally, transfer your ADOS-2 codes to the BOSA DSM-5 checklist and convert them to binary BOSA
scores to indicate presence or absence for each symptom. Indicate unscored ADOS-2 codes on the
checklist using “N/A.” There is also space on each form to score and note additional evidence collected
from parent report or other observations to aid in determining whether the participant meets diagnostic
criteria across domains.

While the BOSA provides a standardized context to observe behaviors consistent with autism spectrum
disorder, this measure is not meant to replace the ADOS-2. We acknowledge that clinicians and
researchers who are accustomed to using the ADOS-2 may feel limited in their ability to confidently
assess symptom presence in certain subdomains (e.g., restricted interests) based on this behavioral
observation alone, while some symptoms may be more readily observable (e.g., limited use of nonverbal
communication). We also do not expect severity of symptoms to be accurately measured in this context,
which is why we have used a binary coding system to judge presence versus absence of symptoms only,
in place of the 0-3 coding system from the ADOS-2.
You may have noticed there are many different items on the ADOS-2 that are linked to autism but are not
necessarily specific to autism, leading to a potentially high risk of “false positives” (i.e., an individual
scoring on many items when they do not have autism). There is also risk for “false negatives” (i.e., ruling
out autism when the person does have autism) because the observation is so brief and limited in scope.
Please note that scores will be lower than you are accustomed to when using the ADOS-2, as 0-3 codes
were condensed into binary 0 vs. 1 codes; be cautious to not mistakenly rule out autism due to an apparent
“low score” on the BOSA. While we are working on developing algorithms to improve psychometrics of
the measure, this may take a while and may also be limited by what we can do during the pandemic. For
these reasons, we encourage clinicians to rely heavily on a thorough developmental history, medical
background, and parent report of symptoms, ideally using the Autism Diagnostic Interview-Revised (ADI-
R). Information across contexts should be interpreted by someone with clinical expertise in autism
spectrum disorder to determine whether the individual meets DSM-5 diagnostic criteria.
BOSA – PSYF
Today you will play with your child for 14 minutes. You will use two sets of toys, a dollhouse, and
bubbles. We will let you know when to clean up each activity and move on to the next. The session will
consist of:
Toy Set 1 Dollhouse Bubbles Toy Set 2 Dollhouse

4 mins 2 mins 2 mins 4 mins 2 mins
1. INTRODUCTION
First, describe to your child what you are going to do. For example, say “We are going to play
with toys and talk!” If your child gets out of the chair and moves while playing with toys or during
the dollhouse activity, encourage them to sit back in the chair and continue playing. Your child is
encouraged to stand and move around the room during bubbles.

Start by looking through the toys. Then take out a few toys that your child may typically play with
and enjoy. Play naturally with your child. Encourage them to play with at least 2 toys. You can
follow what your child is doing (imitate their play), comment, and show excitement. Please try to
4 mins limit the number of prompts, instructions, and questions you use while playing with your child.
Here are a few play ideas:
• Use the toy telephone to call a family member
• Have the family feed their pet dog
• Look inside the purse and play with miniature objects
3. PLAY WITH DOLLHOUSE

Encourage your child to play with the house by figuring out which keys open the doors,
2 mins commenting on the decorations on the house, and playing with the toys inside the house. If your
child has trouble opening the doors, help them with the keys which are numbered to match the
doors. Try to encourage conversation about the house (or a related topic) by making open ended
comments such as, “I like this...” or “Look, this house has a cat…” If you ask direct questions
during this activity, try to limit them to no more than five.

Encourage your child to stand when you bring out the bubble gun. You may move around the
2 mins
room and play naturally with your child.

Tell your child that you have more toys! Look through the toys and then take a few out that you
think your child may typically play with and enjoy. Play together until it is time to clean up. Here
4 mins are a few play ideas:
• Have the action figures play soccer with the small ball
• Use the toy tools to fix the truck
• Take turns playing pin ball
6. PLAY WITH DOLLHOUSE

Play with the dollhouse just like the first time. Remember to engage your child in back and forth
2 mins conversation about the house as much as possible and try to limit the number of direct questions
you ask.
BOSA – PSYF
ADOS-2
BOSA
Materials Activity
Needed BOSA Grouping Materials Needed
Activity
Family dolls* (at least 2 figures)
Furniture
Dog Make-Believe
Group 1
Hologram disk Play
Minature plates, utensils, & food
Toy rocket
Toy Set 1
Cars
Group 2
Small balls
Toy purse and miniature objects inside
Group 3 Plastic ring & cylindircal tube Free Play
Telephone
Shape sorter
No bag needed Pop-up
Markers and Paper Break
Melissa & Doug Dollhouse + plastic figures for inside the house or Melissa &
Dollhouse or Mailbox
Doug Mailbox + objects to put in the envelopes*
Bubble
Play/Anticipation
Bubbles Bubble gun/foam rocket/disc launcher*
of Routine with
Objects
Action figures* (at least 2)
Props for figures & small soccer ball
Dinosaur Make-Believe
Group 4
Minature toy tools & brush Play
Small teapot/measuring cup
Toy Set 2
Metal lid
Letter Blocks
Group 5 Toy tools
Dump truck
Free Play
Baby doll*
Plates and utensils
Group 6
Textured block
Cup Birthday Party
Medium ball
Jack-in-the-box Free Play
No bag needed
Music box
Pinball Break
Melissa & Doug Dollhouse + plastic figures for inside the house or Melissa &
Dollhouse or Mailbox
Doug Mailbox + objects to put in the envelopes*
* Note: Figures and doll for Toy Set 1 & 2 may need to be purchased separately if the ADOS toys cannot easily be cleaned; disc
launcher needs to be purchased separately but is not required.
BOSA Version: PSYF
DSM-5 Checklist for Module 2
0-1→0 0→0
A5. Conversation A2. Speech Abnormalities Associated with Autism
2-3→1 1-2→1
0→0 0-1→0
1-3→1 2-3→1
0→0 0→0
*B5. Showing *A4. Stereotyped/Idiosyncratic Use of Words or Phrases
1-2→1 1-3→1
0→0 0→0
v*B6. Spontaneous Initiation of Joint Attention *D2. Hand and Finger and Other Complex Mannerisms
1-2→1 1-3→1
0→0 0→0
1-3→1 1-2→1
0→0
B9b. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
1-3→1
0-1→0
B10. Quality of Social Response 2. Excessive Adherence to Routines and Ritualistic Behavior
2-3→1
0→0 0→0
*B11. Amount of Reciprocal Social Communication (D5 from M3). Compulsions/Rituals
1-3→1 1-2→1
0→0
v(A5 from M3). Offers Information Other (Specify):_______________
1-2→1
0-1→0
v(A6 from M3). Asks for Information 3. Restricted, Fixated Interests
2-3→1
0-1→0
Other (Specify):_______________ *D4. Unusually Repetitive Interests or Stereotyped Behaviors
2-3→1
0→0
*B1. Unusual Eye Contact 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
2→1
0→0 0→0
*B2. Facial Expressions Directed to Others *D1. Unusual Sensory Interest in Play Material/Person
1-2→1 1-3→1
0→0
(B3 from M3). Language Production & Linked Nonverbal Communication Other (Specify):_______________
1-2→1
Other (Specify):_______________ Other Behaviors (E Codes)
3. Deficits in relationships
0-1→0 0→0
(B15 from M1). Level of Engagement E1. Overactivity
2-3→1 1-3→1
0→0 0→0
C1. Functional Play With Objects E2. Tantrums, Aggression, Negative or Disruptive Behavior
1-3→1 1-3→1
0-1→0 0→0
vC2. Imagination/Creativity E3. Anxiety
2-3→1 1-2→1
Other (Specify):_______________
Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9 should be
converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if symptom present
based on additional gathered or observed information.
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence or language too limited to code 0-3
22
(Module 3) (Module 3)
Additional Items for Module 2 Continued
(Module 1)
(Module 3)
(Module 3)
BOSA Version (please circle one): PSYF F1 F2

0→0 0→0
vA5. Offers Information A2. Speech Abnormalities Associated with Autism
1-2→1 1-2→1
0-1→0 0→0
vA6. Asks for Information A3. Immediate Echolalia
2-3→1 1-3→1
0-1→0 0→0
*A8. Conversation *A4. Stereotyped/Idiosyncratic Use of Words or Phrases
2-3→1 1-3→1
0→0 0→0
*B4. Shared Enjoyment *D2. Hand and Finger and Other Complex Mannerisms
1-3→1 1-3→1
0→0 0→0
1-3→1 1-2→1
0→0
B8. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
1-3→1
0-1→0
*B9. Quality of Social Response 2. Excessive Adherence to Routines and Ritualistic Behavior
2-3→1
0→0 0→0
*B10. Amount of Reciprocal Social Communication D5. Compulsions/Rituals
1-3→1 1-2→1
0→0
(B5 from M4). Communication of Own Affect Other (Specify):_______________
1-3→1
Other (Specify):_______________ 3. Restricted, Fixated Interests
0→0
2. Deficits in Nonverbal Communication used for Social Interaction *D4. Excessive Interest or Repetitive Behaviors
1-3→1
0→0
v*A9. Descriptive, Conventional, Instrumental, or Informational Gestures Other (Specify):_______________
1-3→1
0→0
(A10 from M4). Emphatic or Emotional Gestures 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
1-3→1
0→0 0→0
2→1 1-3→1
0→0
1-2→1
0→0
B3. Language Production and Linked Nonverbal Communication Other Behaviors (E Codes)
1-2→1
Other (Specify):_______________
0-1→0
2-3→1
0-1→0 0→0
(B15 from M1). Level of Engagement E2. Tantrums, Aggression, Negative or Disruptive Behavior
2-3→1 1-3→1
0-1→0 0→0
v*A7. Reporting of Events E3. Anxiety
2-3→1 1-2→1
0-1→0 Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9 should
vB5. Comments on Others' Emotions/Empathy
2→1 be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if
0-1→0 symptom present based on additional gathered or observed information.
vB6. Insight into Typical Social Situations and Relationships
2-3→1 *Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3
0-1→0 Clinical Notes on Observations or Outside Information:
2-3→1
0-1→0
v(B8 from M4). Responsibility
2→1
Other (Specify):_______________
(Module 4)
(Module 4)
BOSA – F1
Clinical Guidelines
Introduction
activities that can be presented by an adult (e.g., a parent, therapist) within a 12-14-minute
observation to help fill the gap left by not being able to carry out a valid ADOS. Clinicians
familiar with the ADOS-2 can observe the BOSA live, virtually through telehealth, or on recorded
video and complete many of the ADOS-2 codes. The ADOS-2 codes will then be used to denote
evidence of symptoms of autism and recorded within a DSM-5 checklist. In the event the BOSA
observation did not provide evidence of the presence of particular autism symptoms, additional
evidence should be sought through alternative methods (e.g., Autism Diagnostic Interview-
Revised; parent report) before it is concluded that it doesn’t exist.
interaction with the participant. Before bringing the participant and examiner into a room, you
should ensure the room is properly set up. You will need a tabletop basketball toy, the game Pop
the Pig, the game Pop Up Pirate, and two sets of precut conversation-starting question cards.
The games for BOSA-F2 (i.e., Slap Jack, the game Jenga, and/or the game Suspend) may be used
in place of basketball, Pop the Pig, and/or Pop Up Pirate if deemed developmentally appropriate
by you as the clinician. As the clinician, you should speed up the games during setup to help
make sure the exciting event (the pig/pirate popping) occurs within the four minutes of play. In
order to speed up Pop the Pig, the you should press the pig’s head 10 times before having the
examiner and participant play the game. To speed up Pop Up Pirate, you should pre-load the
barrel with 5 swords before having the examiner and participant play the game.

c. Give the instruction sheet to the examiner and let them know they are allowed to
a. The adult should sit across or kitty-corner from the participant. See graphic for
suggested placement of materials, camera, and people. The materials for the
remaining activities should be on a separate table or shelf off to the side.
Assessment Room
Camera/ Observation
Participant
Pop the Pig
Window
Clinician
Examiner Pop Up Pirate
Table/shelf
Select ADOS-2 and BOSCC content adapted and/or referenced within the work now known as BOSA is used
under written permission from WPS. No additional use, including and not limited to adaptation or translation, is 27
permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved
play interaction.
The BOSA-F1 is appropriate for verbally fluent children ages 6-8* through 10. (*If the
participant is between 6:0-7:11 years old, you may select either BOSA-PSYF or BOSA-F1. See
page 4, “Choosing the Appropriate Version of the BOSA” for more details.) The overall
interaction should be 14 minutes of the examiner and participant playing games and talking
together.
Basketball
Instruct the examiner to begin with the basketball activity for 2 minutes. The objective is to have
the examiner and participant briefly engage in a fun, turn-taking game. With 15 seconds
remaining (1:45 minutes into the interaction), instruct the examiner to clean up the materials and
begin transitioning to the Pop the Pig game. Let the examiner know the game does not need to
be neatly put away, as this will be done at the end after all activities have been completed. It is
recommended to have a box that the games can be easily put into after each activity is complete.
Pop the Pig*

Instruct the examiner to play Pop the Pig with the question cards for 4 minutes. The examiner
should have control of all the hamburgers to maintain control of the game. After the participant
feeds a hamburger to the pig and presses its head down the number of times written on the
hamburger, the examiner should read a conversation-starting question to the participant. Game 1
question cards should be used during this first game activity. The questions are numbered and
should be asked in order. After the participant answers the question, the examiner should also
provide an answer to the same question. For example, the examiner will ask “What’s your
favorite color?” The participant responds, “Blue!” Then the examiner answers, “Mine is purple.”
They should continue taking turns until it is time to move to the next activity. The examiner is
not required to make it through all of the question cards during the activity. However, if the
examiner does finish all the cards before the activity is over, they should continue to play the
Pop the Pig without the questions. With 30 seconds remaining (5:30 minutes into the overall
interaction), instruct the examiner to quickly put the game aside. Clean up should not take longer
than about 30 seconds. Therefore, the examiner should not be expected to thoroughly clean up
the game (e.g., toys do not need to neatly be put back in bags or boxes), but rather let them know
they should try to transition as quickly as possible.
*If Pop the Pig does not interest the participant, then the examiner and participant can play Pop
Up Pirate or the games from BOSA-F2 (i.e., the games Jenga or Suspend). While any of the
games mentioned can be played during this activity, it is important that the BOSA-F1 Game 1
question cards be used during this activity.
Conversation
The examiner and participant should chat for 2 minutes with no games or materials on the table.
Instruct the examiner to engage the participant in a natural back-and-forth conversation. Give the
examiner possible topics they can discuss with the participant (e.g., pets, siblings, food, movies,
or video games). Remind the examiner to ask no more than 5 questions about different topics
during this time. It is fine for the examiner to ask follow-up questions on a topic they are already
discussing with the participant; follow-up questions would not count toward the aforementioned
5 questions.
Pop Up Pirate*
As with Pop the Pig, this activity should be 4 minutes long. The game should be carried out
exactly as it was done with Pop the Pig. Game 2 question cards should be used during this
second game activity. The questions are numbered and should be asked in order. With 30
seconds remaining (11:30 minutes into the interaction), instruct the examiner to clean up the
game and clear the table.
*If Pop Up Pirate does not interest the participant, then the examiner and participant can play
Pop the Pig again, or the games from BOSA-F2 (i.e., the games Jenga or Suspend). While any of
the games mentioned can be played during this activity, it is important that the BOSA-F1 Game 2
question cards be used during this activity.
Conversation
Instruct the examiner to have one more conversation with the participant. Again, remind the
examiner to ask no more than 5 questions about different topics during this time.
Coding Procedures
possible (e.g., see Additional Items for Module 3 on page 34).
Additionally, you may assign a 0-2 code for Language Production and Linked Nonverbal
Communication (B3 on Modules 3 and 4), even if you coded Unusual Eye Contact as a 2 (B1).

from the ADOS-2.
BOSA – F1
Today you will play some games and talk with your child for 14 minutes. We will let you know when to
clean up each activity and move on to the next. The session will consist of:
Basketball Pop the Pig Conversation Pop Up Pirate Conversation

1. INTRODUCTION
First, describe to your child what you are going to do. For example, say “We are going to play
some games, answer some questions, and talk!” If your child gets out of the chair and moves
around, encourage them to sit back in the chair and continue with the play or conversation
activity.
2. PLAY BASKETBALL
Play basketball with your child. Have fun and see who can score the most points!
2 mins
3. PLAY POP THE PIG
To begin Pop the Pig you will have control of all the hamburgers. Ask your child which color
4 mins hamburger they would like to feed the pig. After you give them a hamburger, they feed the pig,
and press down on the top of its head the number of times written on the hamburger, you will
then read a question card aloud to your child. After you ask your child the question and they
answer, you should answer the same question. For example, you will ask “What’s your favorite
color?” Your child responds, “Blue!” Then you answer, “Mine is purple.” Once you have both
answered the question, it will be your turn to pick a hamburger to feed the pig. Continue the game
by allowing your child to feed the pig, followed by a question card, and then you take a turn
feeding the pig. You do not need to ask all the question cards. However, if you do make it
through all the cards, continue playing Pop the Pig without asking questions. We will let you
know when it is time to clean up the game.
4. CHAT WITHOUT GAMES

With the games removed, try to engage your child in a natural back-and-forth conversation.
2 mins Encourage your child to talk about fun and exciting things. Here are a few topics you can chat
about:
• Pets • Favorite foods
• Siblings and family • T.V. shows, movies, and games
During your conversation, try to limit the number of questions you ask about a new topic to no
more than 5.
5. PLAY POP UP PIRATE

Play Pop Up Pirate just like Pop the Pig. To begin, you will have control of all the swords. Ask
4 mins your child which color sword they would like to put in the barrel. After you give them a sword
and they put it in the barrel, you will read a question to your child. Continue just as you did with
the first game. We will let you know when it is time to clean up the game.
6. CHAT WITHOUT TOYS

Just like the first chat (with the games removed), try to engage in back-and-forth conversation
2 mins with your child. Try to limit the number of questions you ask during your conversation to no
more than 5.
BOSA – F1/F2
Materials Needed
BOSA Activity
F1 F2
Table top basketball Waterproof cards to play Slap
Jack
Warm-up Game
Pop the Pig Jenga
Game 1 with question cards

(see additional page for
questions)
Conversation No materials needed

Pop Up Pirate Melissa & Doug Suspend

questions)

Note: All materials will need to be purchased separately from the ADOS.
BOSA – F1
Question Cards
Game 1 Game 2
Game 1 Game 2
1. What makes you happy? Pick someone in

1. What frightens you?
your family. What makes him/her happy?
Game 1 Game 2
2. Do you ever get lonely? What do you do to

2. What makes you sad? help yourself feel better? Do you think other
kids/people ever feel lonely?
Game 1 Game 2
3. Where do you want to live when you get
3. Do you have some friends? Tell me about
older? What kind of place (apartment, condo,
them. How do you know someone is your
house)? Who would you like to live there with
friend?
you?
Game 1 Game 2
4. What’s your favorite game? Tell me how to 4. What do you like doing with your friends or
play it. family?
Game 1 Game 2
5. If you could be anyone in the world

5. What is your favorite place to go on
(including characters like Spiderman), who
vacation?
would you like to be?
Game 1 Game 2
6. Would you rather have a giant pet cat or a

6. If you had two wishes, what would they be?
tiny pet elephant?
Game 1 Game 2
7. Would you rather be invisible or be able to 7. Would you rather live in a cave or a
fly? treehouse?

0→0 0→0
1-2→1 1-2→1
0-1→0 0→0
2-3→1 1-3→1
0-1→0 0→0
2-3→1 1-3→1
0→0 0→0
1-3→1 1-3→1
0→0 0→0
1-3→1 1-2→1
0→0
1-3→1
0-1→0
2-3→1
0→0 0→0
1-3→1 1-2→1
0→0
1-3→1
0→0
1-3→1
0→0
1-3→1
0→0
1-3→1
0→0 0→0
2→1 1-3→1
0→0
1-2→1
0→0
1-2→1
Other (Specify):_______________
0-1→0
2-3→1
0-1→0 0→0
2-3→1 1-3→1
0-1→0 0→0
2-3→1 1-2→1
2-3→1
0-1→0
2→1
Other (Specify):_______________
34
(Module 4)
(Module 4)
BOSA – F2
Clinical Guidelines
Introduction
activities that can be presented by an examiner (e.g., a caregiver, therapist) within a 12-14-
minute observation to help fill the gap left by not being able to carry out a valid ADOS.
Clinicians familiar with the ADOS-2 can observe the BOSA either live, virtually through
telehealth, or on recorded video and complete many of the ADOS-2 codes. The ADOS-2 codes
will then be used to denote evidence of symptoms of autism and recorded within a DSM-5
checklist. In the event the BOSA observation did not provide evidence of the presence of
particular autism symptoms, additional evidence should be sought through alternative methods
(e.g., Autism Diagnostic Interview-Revised; parent report) before it is concluded that it doesn’t
exist.
As the clinician your role will be to assist the examiner (e.g., caregiver or therapist) during their
interaction with their participant. Before bringing the participant and examiner into a room, you
should ensure the room is properly set up. You will need a deck of cleanable cards, the game
Jenga, the game Suspend, and precut conversation starter questions. You should increase the
number of jacks (e.g., use 8 jacks) to make Slap Jack more exciting.

c. Give the instruction sheet to the examiner and let them know they are allowed to
a. The examiner should sit across or kitty-corner from the participant. See graphic
for suggested placement of materials, camera, and people. The materials for the
remaining activities should be on a separate table or shelf off to the side.
Assessment Room
Clien
Camera/ Observation
t
Clinicia Examiner
n
Window
Cards
Suspend
Jenga
Table/shelf
play interaction.
The BOSA-F2 is appropriate for verbally fluent children aged 11 through adults. The overall
interaction should be 14 minutes of the examiner and participant playing games and talking
together.
Slap Jack*
Instruct the examiner to begin by playing Slap Jack for 2 minutes. The objective is to have the
examiner and participant briefly engage in a fun, turn-taking game. With 15 seconds remaining
(1:45 minutes into the interaction), instruct the examiner to clean up the materials and begin to
transition to the next game. Let the examiner know the game does not need to be neatly put
away, as this will be done at the end after all activities have been completed. It is recommended
to have a box the games can be easily put into after each activity is complete.
*If Slap Jack does not interest the participant, then the examiner and participant can play
basketball (from the BOSA-F1).
Jenga*
Instruct the examiner to play Jenga with the question cards for 4 minutes. After each turn, each
player should read a question card to the other person. After the other player answers the
question, the player reading the card should also answer the question. For example, the examiner
will ask “What’s your favorite color?” The participant responds, “Blue!” Then the examiner
answers, “Mine is purple.” The question cards need to be put in the correct order and given to the
correct person. The examiner and participant will each have their own stack of question cards to
draw from. They should continue taking turns until it is time to move to the next activity. The
participant and examiner are not required to make it through all of the question cards during the
activity. However, if they do finish all the cards before the activity is over, they should continue
playing Jenga without the questions. With 30 seconds remaining (5:30 minutes into the overall
interaction), instruct the examiner to quickly put the game aside. Clean up should not take longer
than about 30 seconds. Therefore, the examiner should not be expected to thoroughly clean up
the game (e.g., toys do not need to neatly be put back in bags or boxes), but rather let them know
they should try to transition as quickly as possible.
*If Jenga does not interest the participant, then the examiner and participant can play the game
Suspend. If Suspend is played, then the question cards should still be asked in the same manner
described above for Jenga.
Conversation
The examiner and participant should chat for 2 minutes with no games or materials on the table.
Instruct the examiner to engage the participant in a natural back-and-forth conversation. Give the
examiner possible topics they can discuss with the participant (e.g., pets, siblings, food, movies,
or video games). Remind the examiner to ask no more than 5 questions about different topics
during this time. It is fine for the examiner to ask follow-up questions on a topic they are already
discussing with the participant.
Suspend*
As with Jenga, this activity should be 4 minutes long. The game should be carried out exactly as
it was done with Jenga. With 30 seconds remaining (11:30 minutes into the interaction), instruct
the examiner to clean up the game and clear the table.
*If Suspend does not interest the participant, then the examiner and participant can play Jenga
again.
Conversation
Instruct the examiner to have one more conversation with the participant. Again, remind the
examiner to ask no more than 5 questions about different topics during this time.
Coding Procedures
possible (e.g., see Additional Items for Module 3 on pages 44).
Additionally, you may assign a 0-2 code for Language Production and Linked Nonverbal
Communication (B3 on Modules 3 and 4), even if you coded Unusual Eye Contact as a 2 (B1).

from the ADOS-2.
BOSA – F2
Today you will play some games and talk with the participant for 14 minutes. We will let you know when
to clean up each activity and move on to the next. The session will consist of:
Slap Jack Jenga Conversation Suspend Conversation
1. INTRODUCTION
First, describe to the participant what you are going to do. For example, say “We are going to
play some games, answer some questions, and talk!”
2. PLAY SLAP JACK

Read the following instructions aloud to the participant: “This is a game where we each try to win
2 mins as many cards as possible by being the first person to slap the jacks as they are played. We will
each have a pile of cards that are face down. We will take turns lifting one card at a time from our
piles and placing it face up in the center of the table. When the card played to the center is a jack,
we will both try to slap the card. The first player to slap their hand down on the jack wins it, as
well as all the cards beneath it. Let’s play!”
3. PLAY JENGA
Read the following instructions aloud to the participant: “We will now play Jenga with a twist.
4 mins Just like in the regular version of Jenga, we will each remove a piece and place it on top of the
tower. However, after we remove a Jenga piece and put it on top, we will need to read a card
from our pile of questions to the other player. The other player will then answer the question.
Once they have answered it, we will give our own answer to the same question. We will continue
the game by taking turns removing a Jenga piece, putting it on top, and then reading a card. We
do not need to ask all the question cards. However, if we finish the cards, we can continue
playing Jenga normally.”

With the games removed, try to engage the participant in a natural back-and-forth conversation.
2 mins Encourage the participant to talk about fun and exciting things. Here are a few topics you can chat
about:
• Pets • T.V. shows, movies, and games
• Siblings and family • Vacations (past or future)
• Favorite foods
5. PLAY SUSPEND
Suspend will be played just like Jenga. Read the following instructions aloud to the participant:
4 mins “We will now play Suspend by taking turns putting a rod on to create a tower that doesn’t fall
over. After we put a rod on top, we will read a card from our pile of questions to the other player.
The other player will then answer the question. Once they have answered it, we will give our own
answer to the same question. We will continue the game by taking turns putting rods on the
Suspend tower, and then reading a card. We do not need to ask all the question cards. However, if
we finish the cards, we can continue playing the game normally.”

Just like the first chat (with the games removed), try to engage in back-and-forth conversation
2 mins with the participant. Try to limit the number of questions you ask during your conversation to no
more than 5.
BOSA – F1/F2
Materials Needed
BOSA Activity
F1 F2
Table top basketball Waterproof cards to play Slap
Jack
Warm-up Game
Pop the Pig Jenga

questions)

Pop Up Pirate Melissa & Doug Suspend

questions)

Note: All materials will need to be purchased separately from the ADOS.
BOSA – F2
Question Cards – Examiner
Game 1 Game 2
Game 2
Game 1
1. Do you have an idea of a job that you’d like

1. What makes you sad? Pick someone in your to have some day? What would you have to do
family. What makes him/her sad? to get it?
Game 1 Game 2
2. Have you ever saved your money to buy

something or do something special? Tell me 2. What makes you angry?
about it.
Game 1 Game 2
3. Where do you want to live when you get

older? What kind of place (apartment, condo,
3. How do you know someone is your friend?
house)? Who would you like to live with when
you get older?
Game 1 Game 2
4. Do you ever feel lonely? What are things 4. If you could go anywhere in the world,
you do to help yourself feel better? where would you choose and why?
Game 1 Game 2
5. Would you rather be able to move things 5. If you were stuck on a desert island, what is
with your mind or have the ability to read other the one thing you would bring and why?
peoples’ minds?
BOSA – F2
Question Cards – Participant
Game 1 Game 2
Game 1 Game 2
1. What makes you happy? 1. What frightens you?
Game 1 Game 2
2. What do you like doing with your friends or 2. Do you like to be surprised? When was the
family? last time someone surprised you?
Game 1 Game 2
3. Are there things that other people do that

irritate or annoy you? What about things you 3. Would you rather be completely invisible for
do that annoy other people? Have you ever one day or be able to fly for one day?
tried to change these things?
Game 1 Game 2
4. Would you rather live in a cave or 4. If you could time travel, would you rather go
treehouse? back in time or to the future?
Game 1 Game 2
5. If you won the lottery, what would be the 5. If you could only eat one food for the rest of
first thing you would buy? your life, what would it be and why?

0→0 0→0
1-2→1 1-2→1
0-1→0 0→0
2-3→1 1-3→1
0-1→0 0→0
2-3→1 1-3→1
0→0 0→0
1-3→1 1-3→1
0→0 0→0
1-3→1 1-2→1
0→0
1-3→1
0-1→0
2-3→1
0→0 0→0
1-3→1 1-2→1
0→0
1-3→1
0→0
1-3→1
0→0
1-3→1
0→0
1-3→1
0→0 0→0
2→1 1-3→1
0→0
1-2→1
0→0
1-2→1
Other (Specify):_______________
0-1→0
2-3→1
0-1→0 0→0
2-3→1 1-3→1
0-1→0 0→0
2-3→1 1-2→1
2-3→1
0-1→0
2→1
Other (Specify):_______________
(Module 4)
(Module 4)
(Module 4)
(Module 1)
Module 4 DSM-5 Checklist | ID: _____________________ Date: ____________________ Age: ___________________ Examiner: ☐ Parent/Caregiver ☐ Therapist ☐ Other
BOSA Version: F2
DSM-5 Checklist forCommunication
A. Impairment in Social Module& 4Social Interaction B. Restricted and Repetitive Behaviors
0→0 0→0
A5. Offers Information *A2. Speech Abnormalities Associated with Autism
1-2→1 1-2→1
0-1→0 0→0
A6. Asks for Information A3. Immediate Echolalia
2-3→1 1-3→1
0-1→0 0→0
2-3→1 1-3→1
0→0 0→0
B4. Shared Enjoyment *D2. Hand and Finger and Other Complex Mannerisms
1-3→1 1-3→1
0→0 0→0
*B5. Communication of Own Affect D3. Self Injurious Behavior
1-3→1 1-2→1
0→0
*B9. Quality of Social Overtures Other (Specify):_______________
1-3→1
0→0
B10. Amount of Social Overtures/Maintenance of Attention 2. Excessive Adherence to Routines and Ritualistic Behavior
1-3→1
0-1→0 0→0
*B11. Quality of Social Response D5. Compulsions/Rituals
2-3→1 1-2→1
0→0
*B12. Amount of Reciprocal Social Communication Other (Specify):_______________
1-3→1
0→0
1-3→1
0→0
*B1. Unusual Eye Contact Other (Specify):_______________
2→1
0-1→0
*B2. Facial Expressions Directed to Others 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
2→1
0-1→0 0→0
B3. Language Production and Linked Nonverbal Communication *D1. Unusual Sensory Interest in Play Material/Person
2→1 1-3→1
0→0
*A10. Emphatic or Emotional Gestures Other (Specify):_______________
1-3→1
Other (Specify):_______________ Other Behaviors (E Codes)
3. Deficits in relationships
0→0 0→0
vA7. Reporting of Events E1. Overactivity
1-3→1 1-3→1
0-1→0 0→0
vB6. Comments on Others' Emotions/Empathy E2. Tantrums, Aggression, Negative or Disruptive Behavior
2→1 1-3→1
0-1→0 0→0
v*B7. Insight into Typical Social Situations and Relationships E3. Anxiety
2-3→1 1-2→1
0-1→0
vB8. Responsibility
2→1 Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9
0-1→0 should be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other
2-3→1 Info: P if symptom present based on additional gathered or observed information.
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3.
Other (Specify):_______________
Materials to Purchase for the BOSA
Replace a cloth baby doll Replace family dolls Disc launcher can be
BOSA-MV with an all plastic doll with cloth clothes/ used in place of
(Most of the MV
toys are from the felt hair with all bubbles or foam
ADOS- we only platic family figures rockets
recommend
replacing toys that
are difficult to clean-
see examples to the
right)
Possible replacement Melissa & Doug Melissa & Doug

options for ADOS toys that Dollhouse Mailbox
are difficult to clean:
Plastic baby doll
BOSA-PSYF Plastic toys for Small prize toys to

Plastic family dolls inside the house hide inside
envelopes (for the
child to keep)
Disc launcher
(not required)
Table-top basketball Pop the Pig Pop Up Pirate
BOSA-F1
Waterproof cards to play Plastic Neon Jenga Melissa & Doug

Slap Suspend
Jack
BOSA-F2
Module 1 DSM-5 Checklist | Date: 6/24/20 Examiner: Deanna Dow Age: 2:8 ID: XXX
Language Level: A1. Overall Level of Nonechoed Spoken Language: 3
BOSA Version: MV
A. Impairment
Completed DSM-5 in Social Communication Example
Checklist & Social Interaction B. Restricted and Repetitive Behaviors
0-1→0 0→0
*A2. Frequency of Spontaneous Vocalization Directed to Others 2 1 *A3. Intonation of Vocalizations or Verbalizations 1 1
2-3→1 1-2→1
0→0 0→0
*B5. Shared Enjoyment in Interaction 1 1 A4. Immediate Echolalia 0 0 P
1-3→1 1-3→1
0→0 0→0
B7. Requesting 2 1 P *A5. Stereotyped/Idiosyncratic Use of Words or Phrases 8 N/A
1-3→1 1-3→1
0-1→0 0→0
B8. Giving 2 1 *D2. Hand and Finger and Other Complex Mannerisms 2 1 P P
2→1 1-3→1
0-1→0 0→0
*B9. Showing 2 1 P D3. Self injurious behavior 0 0
2→1 1-2→1
0-1→0
*B10. Spontaneous Initiation of Joint Attention 2 1 Other (Specify):_______________
2→1
0→0
(B11 from M2). Amount of Reciprocal Social Communication 8 N/A P 2. Excessive Adherence to Routines and Ritualistic Behavior
1-3→1
0-1→0 0→0
*B12. Quality of Social Overtures 2 1 (D5 from M3). Compulsions/Rituals 0 0
2-3→1 1-2→1
0-1→0
B13a or B13b. Amount of Social Overtures/Maintenance of Attention 2 1 Other (Specify):_______________
2-3→1
0-1→0
B14. Quality of Social Response 2 1 3. Restricted, Fixated Interests
2-3→1
0-1→0
Other (Specify):_______________ *D4. Unusually Repetitive Interests or Stereotyped Behaviors 3 1 P
2-3→1
0→0
A6. Use of Another's Body 0 0 P 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
1-2→1
0→0 0→0
*B1. Unusual Eye Contact 2 1 P *D1. Unusual Sensory Interest in Play Material/Person 1 1 P P
2→1 1-3→1
0-1→0
*B3. Facial Expressions Directed to Others 1 0 Other (Specify):_______________
2→1
0-1→0
*B4. Integration of Gaze and Other Behaviors During Social Overtures 2 1 Other Behaviors (E Codes)
2-3→1
Other (Specify):_______________
0→0
3. Deficits in relationships E1. Overactivity 0 0
1-3→1
0-1→0 0→0
B15. Level of Engagement 0 1 E2. Tantrums, Aggression, Negative or Disruptive Behavior 0 0
2-3→1 1-3→1
0-1→0 0→0
C1. Functional Play With Objects 3 1 E3. Anxiety 0 0
2-3→1 1-2→1
C2. Imagination/Creativity 3 1 P
2-3→1 be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if
symptom present based on additional gathered or observed information.
Other (Specify): No interest in other children P
*Indicates ADOS-2 algorithm items.
Visual inspection with toy train - observed outside of assessment
Use of mom's hand as tool when requesting to leave (placed her hand on doorknob)
Toe walking in hallway
48

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Brief Observation of Symptoms

Catherine Lord, Alison Holbrook, Deanna Dow, Katherine Byrne,

Choosing the Appropriate Version of the BOSA

1. Go over the instruction sheet with the examiner.

Toy Set 1 Bubbles Toy Set 2 Bubbles

2. PLAY WITH TOY SET 1

3. PLAY WITH BUBBLES

4. PLAY WITH TOY SET 2

5. PLAY WITH BUBBLES

Toy purse and miniature objects inside

1. Go over the instruction sheet with the examiner.

Clinical Considerations and Limitations

Toy Set 1 Dollhouse Bubbles Toy Set 2 Dollhouse

2. PLAY WITH TOY SET 1

3. PLAY WITH DOLLHOUSE

4. PLAY WITH BUBBLES

5. PLAY WITH TOY SET 2

6. PLAY WITH DOLLHOUSE

BOSA Version (please circle one): PSYF F1 F2

1. Go over the instruction sheet with the examiner.

Pop the Pig*

Clinical Considerations and Limitations

Basketball Pop the Pig Conversation Pop Up Pirate Conversation

4. CHAT WITHOUT GAMES

5. PLAY POP UP PIRATE

6. CHAT WITHOUT TOYS

Pop the Pig Jenga

Game 1 with question cards

Conversation No materials needed

Game 2 with question cards

Conversation No materials needed

1. What makes you happy? Pick someone in

2. Do you ever get lonely? What do you do to

5. If you could be anyone in the world

6. Would you rather have a giant pet cat or a

BOSA Version (please circle one): PSYF F1 F2

1. Go over the instruction sheet with the examiner.

Clinical Considerations and Limitations

2. PLAY SLAP JACK

4. CHAT WITHOUT GAMES

6. CHAT WITHOUT GAMES

Pop the Pig Jenga

Game 1 with question cards

Conversation No materials needed

Game 2 with question cards

Conversation No materials needed

1. Do you have an idea of a job that you’d like

2. Have you ever saved your money to buy

3. Where do you want to live when you get

1. What makes you happy? 1. What frightens you?

3. Are there things that other people do that

BOSA Version (please circle one): PSYF F1 F2

Possible replacement Melissa & Doug Melissa & Doug

Plastic baby doll

BOSA-PSYF Plastic toys for Small prize toys to

Table-top basketball Pop the Pig Pop Up Pirate

Waterproof cards to play Plastic Neon Jenga Melissa & Doug

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