CHILDHOOD AUTISM RATING SCALE (CARS)

developed by Eric Schopler, Robert Reichier and Barbara Rochen Renner

BACKGROUND/ HISTORY OF TESTING

Autism Spectrum Disorders (ASD) are neurodevelopmental disorders characterized by impaired social
interactions, deficits in verbal and nonverbal communication, and repetitive behaviours or unusual or
severely limited interests (American Psychiatric Association 2000). The conceptualization of autism as a
spectrum disorder suggests that the disorder exists on a continuum of impairment, with autistic disorder
representing the most severe presentation of the disorder. Pervasive developmental disorder, not otherwise
specified (PDD-NOS) is often thought to represent the less severe end of a spectrum of autism severity
and is sometimes loosely interchanged with the label of high functioning autism to denote a milder version
of autism

One widely used rating scale for the detection and diagnosis of autism is the childhood autism rating scale.
The CARS was initially developed 20 years ago by staff of the Treatment and Education of Autistic and
related Communication-handicapped Children program, or TEACCH, and was published in 1980. Over a
period of fifteen years, TEACCH staff used a database of a sample of about 1,606 children (approximately
three quarters of whom were male, 67% percent of the sample was white, 30% African American, and 3%
was of other racial descent), to develop this comprehensive autism diagnostic tool. Clinicians and other
professionals with minimal autism experience can easily administer this test. The scale includes all the
features of autism as mentioned by Leo Kanner, as well as the characteristics as described by Creak. It was
developed originally by the Child Research Project at the University of NC at Chapel Hill. It was
originally titled as ‘Childhood Psychosis Rating Scale’.

DESCRIPTION OF THE TEST

The CARS consists of 14 domains assessing behaviours associated with autism, with a 15th domain
rating general impression of autism.

1. Relationship to people -This is a rating of how the child behaves in a variety of situations
involving interaction with other people

2. Imitation- This rating is based on how the child imitates both verbal and nonverbal acts.
Behaviour to be imitated should clearly be within the child’s abilities

3. Emotional response - This is a rating of how the child reacts to both pleasant and unpleasant
situations. It involves a determination of whether the child’s emotions or feelings seem
appropriate to the situation. This item is concerned with the appropriateness of both the type of
response and the intensity of the response

4. Body use -This area represents a rating of both coordination and appropriateness of body
movements. It includes such deviations as posturing, spinning, tapping, rocking, toe-walking,
and self-directed aggression.
5. Object use - This is a rating of both the child’s interest in toys or other objects, and his or her
uses of them.

6. Adaptation to change - This item concerns difficulties in changing established routines or

patterns and in changing from one activity to another. These difficulties are often related to the
repetitive behaviours and patterns rated on previous items.

7. Visual response - This is a rating of unusual visual attention patterns found in many individuals
on the autism spectrum. This rating includes the child’s response when he or she is required to
look at objects or material.

8. Listening response - This is a rating of unusual listening behaviour or unusual responses to

sounds. It involves the child’s reaction to both human voices and other types of sound. This item
is also concerned with the child’s interest in various sounds.

9. Taste-smell-touch response and use - This is a rating of the child’s response to stimulation of the
taste, smell, and touch senses (including pain). It is also a rating of whether the child makes
appropriate use of these sense modalities.

10. Fear and nervousness - This is a rating of unusual or unexplainable fears. However, it also
includes rating the absence of fear under conditions where a typically developing child at the
same developmental level would be likely to show fear or nervousness.

11. Verbal communication - This is a rating of all facets of the child’s use of speech and language.

12. Non-verbal communication - This is a rating of the child’s nonverbal communication through the
use of facial expression, posture, gesture, and body movement. It also includes the child’s
response to the nonverbal communication of others. If the child has reasonably good verbal
communication skills, there may be less nonverbal communication; however, a child with
impairments of verbal communication may or may not have developed a nonverbal means of
communication

13. Activity level - This rating refers to how much the child moves about in both restricted and
unrestricted situations. Either overactivity or lethargy are part of this rating.

14. Level and consistency of intellectual response - This rating is concerned both with the child’s
general level of intellectual functioning and with the consistency or evenness of functioning from
one type of skill to another. Some fluctuations in mental functioning occur in many typical
children or in those with other problems besides autism. However, this area is intended to
identify extremely unusual or “peak” skills.

15. General impressions - This is intended to be an overall rating of autism based on your subjective
impression of the degree to which the child has autism as defined by the other 14 items. This
rating should be made without recourse to averaging the other ratings. In making this rating, you
should take into account all available information concerning the child, including information
from such sources as the case history, parent interviews, or past records.
The CARS2 includes three forms:

1. Standard Version Rating Booklet (ST)

Equivalent to the original CARS; for use with individuals younger than 6 years of age and
those with communication difficulties or below-average estimated IQs

2. High-Functioning Version Rating Booklet (HF)

An alternative for assessing verbally fluent individuals, 6 years of age and older, with IQ scores
above 80

3. Questionnaire for Parents or Caregivers (QPC)

An unscored scale that gathers information for use in making ST and HF ratings

The Standard and High Functioning Forms each include 15 items addressing the following functional
areas:

PSYCHOMETRIC PROPERTIES

● The psychometric properties of the CARS2-ST and CARS2-HF have been investigated based on
ratings for over 3,600 individuals.
● CARS2-ST and CARS2- HF Total scores are associated with interrater reliability
estimates of .71 and .96, respectively.
● Internal consistency reliability is estimated at .93 for the CARS2-ST and .96 for the
CARS2-HF.
● Validity research examined the use of the forms in a variety of settings, with groups of
individuals with and without an autism diagnosis, and evaluated CARS2-ST and CARS2-HF
results in relation to results of other screening and diagnostic instruments.
● Results support the use of each form as accurate quantitative measures of behavioural problems
that are specific to the presence of autism in a given case.
 ● The forms appear to be both sensitive and specific to behavioural problems associated with
autism. In addition, over the decades that the CARS has been in use, its psychometric properties
have been investigated by numerous researchers.

SCORING

The Childhood Autism Rating Scale categories are scored on a scale of one to four, with half points
awarded for those that are between those steps. For instance, a score of 1.5 can be given for a behaviour
that falls between the criteria for a score of one or two. Scoring standards are as follows:

1- within the normal range for child's age

2- mildly abnormal
3- moderately abnormal
4-severely abnormal

● CARS scores range from 15 to 60, and the cut-off point for an autism diagnosis is a score of 30
or above.
● Scores falling within the range for a diagnosis of autism are broken down further to reflect the
degree in which symptoms are present. According to the scoring standards of CARS, scores
between 30 and 37 indicate mild to moderate autism and scores between 38 and 60 are
characterised as severe autism.
● However, The CARS-2 does not provide a diagnosis on its own. To obtain a diagnosis other
factors including (but not limited to) developmental history, medical symptoms and other
unique characteristics need to be evaluated by professionals who are experts in autism, are
trained to make differential diagnoses and are authorised to make clinical diagnoses.

UTILITY

● CARS distinguishes individuals with AD from other developmental disorders or cognitive

defects.
● It is also well versed in distinguishing between mild to moderate levels of ASD.
● The recently used version of it, CARS-2, expands the test’s clinical value, making it more
responsive to individuals on the “high functioning” end of autism spectrum disorders.
● Apart from diagnosing the levels of Autism, CARS-2 is also adaptive in dealing with
Asperger’s Syndrome in addition.
● According to the NY State Department of Health there is evidence to support CARS as a
useful part of the assessment of children with possible autism in a variety of settings: early
intervention programs, preschool developmental programs, and developmental diagnostic
centres.
● CARS possesses an acceptable combination of practicality and research support, despite the
limited research on its use in children under 3 years of age.
● Little training is required for administering CARS.
● CARS can be administered over a wide age range of population.
LIMITATIONS

Although it is highly sensitive, CARS appears to over-diagnosis young children as having autism. Lord
(1995) found that the CARS consistently classified non-autistic intellectually disabled children as having
autism in a sample of 2-year-olds referred for possible autism. Lord (1995) reported that a CARS cutoff
score of 30 correctly classified 61.5% of the non-autistic children and 93.7% of the children with autism;
however, increasing the CARS autism cutoff to 32 improved classification and accurately classified 84.6%
of the non-autistic children, while still correctly classifying 93.7% of the children with autism.

In addition to a relative lack of empirical testing of the cut-off of 30 for autistic disorder in toddlers and
preschool children, another limitation of the CARS is the lack of an empirically based ASD cutoff.
Although significant group differences on CARS total scores have been reported among clinical groups
(Perry et al. 2005) the CARS is not designed to distinguish PDD-NOS from autistic disorder, or the ASD
spectrum from non-spectrum (Perry et al. 2005). The lack of an ASD cutoff on the instrument reduces the
diagnostic agreement among the CARS, other autism diagnostic instruments, and clinical judgement
(Chlebowski et al. 2008).

When determining optimal cutoff scores for ASD on the CARS, levels of sensitivity and specificity will
vary depending on how the instrument is being used (e.g., for screening or diagnosis). When screening for
autism, the goal is to identify as many children with an ASD as possible and sensitivity should be high so
that the measure misses few cases and does not falsely reassure parents that their children are not at risk
(Charman and Baron-Cohen 2006). High sensitivity results in lower specificity since screening is erring on
the side of producing more “false positives” than “false negatives.” However, when using an instrument for
diagnosis, specificity needs to increase in order to avoid inaccurately diagnosing children, unnecessarily
worrying parents, and providing unnecessary referrals for costly intervention services. Filipek et al. (1999)
recommend that instruments used in the diagnosis of ASD should have moderate sensitivity and good
specificity for autism.