J Autism Dev Disord (2016) 46:3361–3368
DOI 10.1007/s10803-016-2860-z
BRIEF REPORT
The Relationship Between the Childhood Autism Rating Scale:
Second Edition and Clinical Diagnosis Utilizing the DSM-IV-TR
and the DSM-5
Tamara Dawkins1 • Allison T. Meyer2 • Mary E. Van Bourgondien1
Published online: 15 July 2016
Ó Springer Science+Business Media New York 2016
Abstract The Childhood Autism Rating Scale, Second
Edition (CARS2; 2010) includes two rating scales; the
CARS2-Standard Version (CARS2-ST) and the newly
developed CARS2-High Functioning Version (CARS2-
HF). To assess the diagnostic agreement between the
CARS2 and DSM-IV-TR versus DSM-5 criteria for Autism
Spectrum Disorder (ASD), clinicians at community based
centers of the University of North Carolina TEACCH
Autism Program rated participants seen for a diagnostic
evaluation on symptoms of autism using both the DSM-IV-
TR and DSM-5 criteria and either the CARS2-HF or the
CARS2-ST. Findings suggest that overall, the diagnostic
agreement of the CARS2 remains high across DSM-IV and
DSM-5 criteria for autism.
Keywords Autism Spectrum Disorder
Diagnosis

CARS2
DSM-IV-TR
DSM-5
Introduction
The Childhood Autism Rating Scale (CARS; Schopler
et al. 1988, 2010) is one of the most widely researched
rating scales for evaluating clinical behaviors of autism that
has been used around the world (Lord and Corsello 2005).
The CARS-original version (CARS; Schopler et al. 1988)
& Tamara Dawkins
Tamara_dawkins@med.unc.edu
1 the sensitivity (i.e., the ability of a measure to correctly
TEACCH Autism Program, Department of Psychiatry,
University of North Carolina – Chapel Hill, CB 7180,
Chapel Hill, NC 27599-7180, USA
2
Department of Psychology, University of North Carolina –
Chapel Hill, CB 7180, Chapel Hill, NC 27599, USA
is now referred to as the CARS2-Standard Version
(CARS2-ST) and includes updated field trial data. The
CARS2-ST continues to be used with children under the
age of 6 and individuals of any age with less developed
verbal skills and IQ scores less than 80. The CARS2-High
Functioning Version (CARS2-HF) was added to assess
individuals with estimated overall IQ scores of 80 or higher
who are verbally fluent and 6 years of age or older.
In the three decades since the first edition of the CARS,
there have been several changes in the diagnostic criteria
for Autism Spectrum Disorder (ASD) as outlined by the
Diagnostic and Statistical Manual of Mental Disorders
(DSM). During all of these revisions in the diagnostic
system, the CARS has consistently been shown to have
good diagnostic agreement with the DSM-III-R (Nordin
et al. 1998; Sevin et al. 1991; Sponheim 1996; Van
Bourgondien et al. 1992) and DSM-IV (Perry et al. 2005;
Rellini et al. 2004). The purpose of the present study is to
examine the diagnostic agreement of the CARS2 with the
DSM-5 criteria for ASD.
With the publication of the DSM-IV, concerns were
raised around consistent diagnostic classification and dif-
ferentiation of individuals with Autistic Disorder versus
Asperger’s Syndrome versus Pervasive Developmental
Disorder-Not Otherwise Specified (PDD-NOS) when using
the CARS. The CARS exhibited strong agreement with the
DSM-IV, although this agreement varied depending on the
inclusion or exclusion of those diagnosed with PDD-NOS.
When the CARS scores were compared for toddlers with
Autistic disorder without including those with PDD-NOS,
identify individuals with a disorder) went up from .889 to
.963 but the specificity (i.e., the ability of a measure to
correctly exclude cases without a disorder) went down
from 1.00 to .667 (Ventola et al. 2006). The CARS and the
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DSM-IV have inconsistently agreed on diagnostic classi-
fication for those with Asperger’s Syndrome diagnoses. In
a study of children 18 months to 11 years of age, Rellini
et al. (2004) found that the CARS was a useful tool for
picking up individuals diagnosed with autistic disorder by
DSM-IV criteria (100 %). However, 5 individuals with
Asperger’s Syndrome and 4 individuals with PDD-NOS
did not meet the clinical cut-off score for autism.
In a more recent study, Chlebowski et al. (2010)
assessed the sensitivity and specificity of CARS in rela-
tionship to DSM-IV with samples of 2 and 4 year olds. In
the 2 year old sample, utilizing the standard CARS cut off
of 30 yielded a sensitivity of .93, and specificity of .49 for
autistic disorder. The low specificity according to the
authors was due to incorrectly diagnosing 52 PDD-NOS
children as in fact meeting criteria of autism. For the 4 year
old sample, the traditional 30 point cut-off resulted in good
sensitivity (.86) and specificity (.80) when compared to the
DSM-IV. In order to establish a means for capturing the
PDD-NOS on a rating scale, Chlebowski et al. recom-
mended a cut off of 25.5 on the CARS for toddlers and
preschoolers. For distinguishing between autism and PDD-
NOS, they recommend a cut off of 32. To date, several
studies have been published assessing diagnostic agree-
ment between the CARS and DSM-5. For example, Mayes
et al. (2014) found 84 % agreement between the CARS and
DSM-5 in a sample of individuals between the ages of 1
and 18. The authors reported that diagnostic agreement
improved to 94 % when the number of DSM-5 symptoms
within the category of social communication and interac-
tion was reduced from 3 to 2.
A significant development in the CARS2-HF is the use
of a lower clinical cut-off score (28) compared to the
CARS2-ST (30). Perry et al. (2005) found that young
children ages 2–6 years with a diagnosis of PDD-NOS had
an average CARS2-ST score of 28 compared to 36 for
those with Autistic Disorder suggesting that a lower cut-off
score may better capture individuals with PDD-NOS or
individuals with autism who are higher functioning. In a
comparison study of the same individuals tested before age
10 with the CARS and then retested as teenagers, Van
Bourgondien and Mesibov (1989) also showed that a lower
cut-off score of 28 better captured the group with autism as
they got older. However, others have reported that an even
lower cut-off score of 25.5 may best distinguish between
children with high functioning autism or Asperger syn-
drome and children who are better characterized by another
diagnosis such as ADHD (Mayes et al. 2011).
With the publication of the DSM-5 (American Psychi-
atric Association 2013), Autism Spectrum Disorder (ASD)
replaced PDD as the broader category. In addition, there
are no longer separate subtypes within ASD such as
Asperger’s Syndrome or PDD-NOS. The objective of the
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J Autism Dev Disord (2016) 46:3361–3368
current study was to evaluate the effectiveness of using the
CARS2-ST and the more recently developed CARS2-HF in
a community referred sample to identify individuals with
an Autism Spectrum Disorder according to both DSM-IV-
TR and DSM-5 criteria. An additional aim of the present
study was to examine the effectiveness of the CARS2 for
identifying individuals across the lifespan in a clinic-based
sample referred for an evaluation for autism.
Method
Participants
Participants for this study included 183 individuals that
were seen at one of the TEACCH Autism Program
(TEACCH) Centers in North Carolina for a diagnostic
evaluation of ASD from 2012 to 2014. Participants ranged
in age from 1 to 62 years (M = 9.02 years;
SD = 8.12 years). 78.6 % of individuals were male and
racial and ethnic composition was comparable to the gen-
eral population of North Carolina (61.2 % Caucasian,
20.9 % African American, 7.7 % Hispanic, 5.1 % more
than one race, 2 % Asian, 1 % American Indian, 2 %
unknown or not reported).
Procedure
Participants in this study were referred to one of five
TEACCH Autism Centers in North Carolina for a clinical
evaluation of ASD. The TEACCH Autism Program is a
University of North Carolina at Chapel Hill (UNC-CH)
program that has been serving the North Carolina (NC)
autism population since the 1970s and currently has 7
community clinics around the state. Five of these com-
munity clinics located in Chapel Hill, Greenville, Fayet-
teville, Wilmington, and Charlotte, NC participated in this
study. Clinics serve populations in urban (e.g. Charlotte)
and rural (e.g. Greenville) areas of NC.
The evaluation team consisted of a Clinical Psycholo-
gist, Autism Specialists with experience assessing and
treating individuals with ASD, and/or supervised trainees
in relevant fields. The evaluation included an in-person
assessment of the individual using the CARS2, informal
assessments and records review of previous testing. In
addition, the ADOS-2 was administered to all individuals
rated using the CARS2-HF. For the CARS2-ST, 75 indi-
viduals were assessed using the ADOS-2, 22 were assessed
using the Psychoeducational Profile 3rd Edition (PEP-3),
and 1 was assessed using the TEACCH Transition
Assessment Profile (TTAP). If cognitive testing was not
conducted at the TEACCH center, cognitive scores were
obtained from records review. In addition, caregivers or
J Autism Dev Disord (2016) 46:3361–3368
another individual familiar with the participant were
interviewed about the participant’s current and past
behavior related to ASD symptoms and adaptive
functioning.
The psychologist used a rating form to indicate which
criteria were met on both the DSM-IV-TR and DSM-5 on
the basis of results from the assessments, interviews, and
clinical judgment on the day of the evaluation. For DSM-
IV, an ASD diagnosis included those meeting criteria for
Autistic Disorder, Asperger’s Disorder, or PDD-NOS.
When the study began, clinicians used the proposed DSM-
5 criteria for ASD when rating individuals during assess-
ments. The DSM-5 was released in the middle of data
collection and the published criteria were largely consistent
with the proposed criteria with only minor wording
differences.
Measures
The Childhood Autism Rating Scale-Second Edition
(CARS2; Schopler et al. 2010) is a clinician-rated scale for
autism symptomatology. The CARS2 includes 15 items
rated on a 7-point scale (with a range of 1–4) with higher
scores indicating greater severity. The clinical cut-off for
ASD is a score of 30 for children 12 years and younger and
a score of 28 for children 13 years and older on the
CARS2-ST. The clinical cut-off for ASD is 28 for the
CARS2-HF. Individuals with average or above average
intelligence and were 6 years of age or older received the
CARS2-HF. In one instance, a 5-year-old was administered
the CARS2-HF. Clinician report indicated that this indi-
vidual scored in the average range of intelligence with
strong verbal ability. Individuals with below average
intelligence or intellectual disability and/or were 5 years of
age or younger received the CARS2-ST. The CARS2-ST
was completed using direct observation of the individual’s
behavior during the assessment. The CARS2-HF was
completed using both direct observations of the individ-
ual’s behavior as well as collateral information from a
caregiver or informant (e.g. a spouse) that had knowledge
of the individual’s behavior across different environments.
The Autism Diagnostic Observation Schedule-2
(ADOS-2; Lord et al. 2012) is a semi-structured assessment
of social interaction, communication, repetitive behaviors
and restricted interests, and imaginative or symbolic play
administered to individuals who may have ASD. The
ADOS-2 has 5 modules. Clinicians select a module based
on the individuals’ expressive language and chronological
age.
The Psychoeducational Profile—Third edition (PEP-3;
Schopler et al. 2005) and TEACCH Transition Assessment
Profile—Second Edition (TTAP; Mesibov et al. 2007) are
assessment tools developed at the TEACCH Autism
3363
Program. The PEP-3 is designed to assess skills in children
with autism and communication difficulties between the
ages of 6 months to 7 years. Similar to the ADOS-2, sev-
eral subtests of the PEP-3 assess skills in the area social
communication including shared enjoyment, asking for
help, commenting, and directing attention. The TTAP, is
used to assess skills in older children and adolescents with
autism for the purpose of educational and transition
planning.
Results
Descriptive Statistics
Table 1 depicts the demographic information for partici-
pants assessed on the basis of CARS2-ST and CARS2-HF.
The sample of participants was divided into two groups. Of
the 183 participants, 98 were assessed using the CARS2-
ST form while 85 were assessed using the CARS2-HF
form.
ASD Classification Based on DSM and CARS2
Criteria
Within the sample of 183 individuals seen for a diagnostic
evaluation, 127 (69 %) met criteria for Autistic Disorder, 9
(5 %) met criteria for Asperger’s Disorder, and 6 (3 %)
met criteria for PDD-NOS. The remaining 41 (22 %)
individuals did not meet criteria for diagnosis under the
category of DSM-IV-TR Pervasive Developmental Disor-
der. When the DSM-5 was used as the classification tool,
134 (73 %) cases met criteria for ASD and 49 (27 %) did
not meet criteria for ASD. For the participants assessed
using the CAR2-ST, 70 (71 %) participants had scores at or
above the autism cut-off while 61 (72 %) of participants
assessed using the CARS2-HF met clinical cut-off for
autism. Typically, participants who met CARS2 but not
DSM5 were individuals with a language based learning
disability coupled with Attention Deficit Hyperactivity
Disorder possibly with a mood disorder. However, these
individuals did not have sufficient social-communication
impairments or restricted and repetitive behaviors to meet
criteria for ASD according to DSM-5.
CARS2-ST Diagnostic Outcome Compared to DSM-
IV-TR and DSM-5 Criteria
The diagnostic sensitivity and specificity of the CARS2-ST
in the present sample, when compared to diagnostic out-
come on the basis of DSM-IV-TR and DSM-5 was asses-
sed (see Table 2). Within this sample the CARS2-ST had a
sensitivity of .81 and .84 for the DSM-IV-TR and DSM-5
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Table 1 Demographics
CARS2 CARS2-ST CARS2-HF
n = 183 n = 98 n = 85

Age (years)
Mean (SD) 9.02 (8.12) 4.9 (2.8) 13.8 (9.5)
Range 1.09-62.01 1.09-18.0 5.03-62.01
Gender
Male (%) 79 76 84
Female (%) 21 25 17
CARS2 total score
Mean (SD) 31.6 (5.7) 32.8 (6.0) 30.3 (5.0)
Range 18.5-45.5 18.5-45.5 18.5-41
Clinician diagnosis of Autism (%) 78 88 66

Table 2 Sensitivity and

DSM-IV DSM-5
Specificity of the CARS2-ST
with DSM-IV-TR and DSM-5 PDD (n) No PDD (n) ASD (n) No ASD (n)

CARS2-ST (score C clinical cut-off) 70 0 70 0

CARS2-ST (score \ clinical cut-off) 16 12 13 15
Sensitivity 81 % 84 %
Specificity 100 % 100 %
Clinical cut-off = 30, 28 for ages 13?

respectively, and showed 1.00 specificity with the DSM-
IV-TR and DSM-5.
Of the 98 participants who were assessed using the
CARS2-ST, 16 individuals met DSM-IV-TR criteria for a
PDD but had CARS2-ST scores below the clinical cut-off.
When the group of individuals who met DSM-IV-TR but not
CARS2-STcriteria for a PDD was compared to the group of
individuals for whom there was diagnostic agreement
between the CARS2-ST and DSM-IV-TR, no difference was
observed on the basis of age t(96) = .6, gender, v2(1,
n = 98) = .52, p = .47, or IQ t(52) = .01, p = .9 (See
Table 3). Among the 16 participants who met DSM-IV-TR
criteria for a PDD but did not meet CARS2-ST cut-off for
autism, 3 received a diagnosis of PDD-NOS and the remaining
participants received a diagnosis of Autistic Disorder.
A similar analysis was conducted in order to investigate
differences between the 13 participants who did not meet
CARS2-ST clinical cut-off for autism but met the DSM-5
criteria for ASD and the 86 individuals for whom there was
agreement between the CARS2-ST and the DSM-5. No
significant differences between groups in age,
t(96) = 1.27, p = .26, gender, v2(1, n = 98) = .92,
p = .35, or IQ, t(52) = .41, p = .52, was found among the
group who did not meet CARS2-ST cut-off for autism but
met DSM-5 criteria for ASD in comparison to individuals
for whom diagnostic agreement between the two measures
was observed (see Table 3). All 13 participants received a
clinical diagnosis of ASD.
An additional analysis was conducted to determine
whether CARS2-ST scores differed as a result of the
observational tool used for scoring (e.g., ADOS2 vs. PEP-3
vs. TTAP). Given that only 1 participant was assessed
using the TTAP, their data was removed from the analysis.
For the 97 remaining participants, a significant difference,
F(1,95) = 4.80, p = .03, in CARS2-ST scores was
observed between the group assessed using the ADOS2
(M = 32.0) who had lower CARS2-ST scores than the
group assessed using the PEP-3 (M = 35.1). Further
analysis revealed that the groups did not differ on the basis
of age, F(1,95) = .15, p = .70. The intelligence quotient
(IQ) data was available for only 54 of the 97 participants
assessed using either the ADOS2 or PEP-3. Within this
group, CARS2-ST scores did not differ on the basis of IQ,
F(1,95) = .47, p = .50. Of note, a significant difference in
CARS2-ST score was observed, F(1,95) = 5.99, p = .02,
between the group of individuals for whom IQ data was
available (M = 31.4) and those for whom IQ data was not
available (M = 34.3).
CARS2-HF Diagnostic Outcome Compared
to DSM-IV-TR and DSM-5 Criteria
Within the present sample, the CARS2-HF had a sensitivity
of 1.0 across both versions of the DSM, and showed a
specificity of .83 and .71 for the DSM-IV-TR and DSM-5
respectively (see Table 4).

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Table 3 Agreement and

CARS2-ST & DSM-IV-TR CARS2-ST & DSM-5
Disagreement with CARS2-ST
and DSMs Agree Disagree Agree Disagree
n = 81 n = 17 n = 84 n = 14

Age (years)
Mean (SD) 5.0 (2.9) 4.5 (2.2) 5.0 (2.9) 4.3 (1.8)
Gender
Male (%) 74 82 86 74
Female (%) 26 18 14 26
CARS2 total mean (SD) 33.9 (6.1) 27.5 (1.7) 33.7 (6.1) 27.4 (1.7)

n = 44 n = 10 n = 46 n=8

IQ
Mean (SD) 73.6 (18.1) 81.8 (16.8) 73.9 (17.8) 82.1 (18.9)
CARS2 total mean (SD) 32.4 (5.9) 27.1 (1.8) 32.2 (5.9) 27.2 (1.9)

The group of individuals who met CARS2-HF cut-off
for autism but not DSM-IV-TR criteria (n = 5) was com-
pared to the group of individuals for whom there was
diagnostic agreement between the two measures (n = 80).
No significant difference in age, t(83) = -.53, p = .81, or
gender, v 2(1, n = 85) = 2.13, p = .14 was found between
groups. However, a higher IQ, t(63) = .77, p \ .05 was
found among the group for whom there was diagnostic
agreement between the two measures in comparison to the
group who met CARS2-HF cut-off for autism but did not
meet DSM-IV-TR criteria for a PDD (see Table 4). Within
this group of 5 individuals, diagnostic outcomes included
Attention Deficit Hyperactivity Disorder (ADHD), Dis-
ruptive Behavior Disorder-NOS, Mixed Receptive-Ex-
pressive Language Disorder and Cognitive Disorder-NOS.
While the national field trials indicated that a cut-off of 28
yielded the best clinical sensitivity and specificity (Scho-
pler et al. 2010). An analysis was conducted to explore
outcomes if the cut-off is raised to 30 (see Table 4).
Although this adjustment increased the specificity and
lowered the sensitivity within an acceptable range, 4 of the
9 individuals who met criteria for Asperger’s Disorder on
DSM-IV-TR and ASD on DSM-5 no longer met criteria on
the CARS2-HF with the raised cut-off. In addition, 6
individuals who met criteria for Autistic Disorder on the
basis of DSM-IV-TR and ASD on the basis of DSM-5, no
longer met clinical cut-off on the CARS2-HF (Table 5).
The group of individuals who met CARS2-HF cut-off
for autism but not DSM-5 (n = 10) criteria for ASD was
compared to the group of individuals for whom there was
diagnostic agreement between the two measures (n = 75).
A comparison of the groups revealed no significant dif-
ference in age, t(83) = -.61, p = .67, gender, v 2 (1,
n = 85) = 1.51, p = .22, or IQ, t(63) = 1.04, p = .22.
Among the group in which diagnostic disagreement was
observed, 3 participants received diagnoses of PDD-NOS
while the others received diagnoses including ADHD,
Disruptive Behavior Disorder-NOS, Mixed Receptive-Ex-
pressive Language Disorder, Anxiety Disorder-NOS and
Cognitive Disorder-NOS.
Discussion
The purpose of this study was to evaluate the appropri-
ateness of using the CARS2 to identify individuals with
ASD according to both the DSM-IV-TR and DSM-5.
Overall, results from the present study indicate that the

Table 4 Sensitivity and

DSM-IV DSM-5
Specificity of the CARS2-HF
with DSM-IV-TR and DSM-5 PDD (n) No PDD (n) ASD (n) No ASD (n)

CARS2-HF (score C 28.0) 56 5 51 10

CARS2-HF (score \ 28.0) 0 24 0 24
Sensitivity 100 100
Specificity 83 71
CARS2-HF (score C 30.0) 45 2 41 6
CARS2-HF (score \ 30.0) 11 27 10 28
Sensitivity 80.4 80.4
Specificity 93.1 82.3

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Table 5 Agreement and

CARS2-HF & DSM-IV-TR CARS2-HF & DSM-5
Disagreement with CARS2-HF
and DSMs Agree Disagree Agree Disagree
n = 80 n=5 n = 75 n = 10

Age (years)
Mean (SD) 13.7 (9.5) 16.0 (10.4) 13.6 (9.6) 15.5 (9.4)
Gender
Male (%) 60 85 85 70
Female (%) 40 15 15 30
CARS2 total mean (SD) 30.3 (5.2) 29.7 (1.8) 30.3 (5.3) 30.6 (1.7)

n = 61 n=4 n = 56 n=9

IQ
Mean (SD) 103.2 (14.8) 96.8 (31.4) 103.6 (14.9) 97.7 (21.3)
CARS2 total mean (SD) 30.0 (5.5) 29.8 (2.0) 29.9 (5.7) 30.7 (1.8)

CARS2 continues to be an appropriate diagnostic tool for
individuals referred for an ASD evaluation across the
lifespan when using the DSM-5 criteria. In the present
sample there were high levels of sensitivity (range
81–100 %) and specificity (range 70–100 %) for both
versions of the CARS2 when using DSM-IV-TR or DSM-5
criteria. It is interesting to note that the CARS2-ST was
very high in specificity while the CARS2-HF was very high
in sensitivity.
This study used the cut-offs determined by previous
research with the original CARS and subsequently sup-
ported by the CARS2 field trials (Schopler et al. 2010).
While the cut-off for the CARS2-HF (28) led to excellent
sensitivity compared to both the DSM-IV-TR and DSM-5,
the CARS2-ST with its differing cut-off scores (30, 28 for
ages 13?) had a slightly lower sensitivity. Future studies
may continue to examine alternate cut-off scores for the
CARS2-ST to increase its sensitivity without jeopardizing
its specificity with the DSM-5. In conducting these future
studies of the CARS2-ST, it would be helpful to have a
large enough sample of different ages in order to determine
if there may be a different cut-off for individuals who are
over 6 and have intellectual disabilities versus children
under 6 years of age. Intelligence data was not available
for all the participants in the present study. Many of these
younger children were given the Psychoeducational Pro-
file-Third Edition (PEP-3) as a measure of both the child’s
developmental level as well as symptoms of autism. These
children were typically of lower developmental levels who
presented with difficultly performing on more language
based tests of intelligence. The clinical staff using the PEP-
3 reported that they chose this tool over the ADOS and
other tests of intelligence in order to develop more mean-
ingful programming ideas for these children who appeared
to be functioning at a lower developmental level. In
previous studies using the original CARS (now CARS2-
ST), children with lower cognitive ability received higher
scores on the CARS (Pilowsky et al. 1998; Rellini et al.
2004). This may explain why higher CARS2-ST scores
were found among individuals assessed using the PEP-3 as
the basis for observational ratings and why higher CARS2-
ST scores were observed among those for whom no IQ data
was available than those for whom IQ data was available.
On the CARS2-HF, the few individuals that met the
criteria for autism on the CARS2-HF but did not meet DSM-
IV-TR criteria were typically individuals with lower IQs and
met criteria for another neurodevelopmental disorder. While
the possibility of a higher cut-off (30) on the CARS2-HF
was notable for increased specificity in the present study, the
accompanying decrease in sensitivity resulted in nearly half
of the individuals who met criteria for Asperger’s Disorder
no longer meeting the autism cut-off on the CARS2-HF,
thus reducing the tool’s utility for identifying individuals on
the spectrum who are higher functioning. Therefore, the
CARS2-HF successfully identifies individuals with ASD
who are high functioning with the established cut-off of 28,
but the tool should be included as part of a comprehensive
diagnostic evaluation in order to enhance its utility for
excluding cases that do not meet criteria for ASD.
The present study had a very wide age range
(1–62 years) making it difficult to examine age-related
differences in CARS2 sensitivity and specificity. Future
studies can examine narrower age ranges with in the
CARS2. More specifically, it is important to better deter-
mine when children are better assessed using the CARS2-
HF compared to the CARS2-ST. The clinicians conducting
the study wondered whether some higher functioning
4–6 year olds may have been better identified by the
CARS2-HF. Studies may examine children ages 3–8 years
to determine the most appropriate tool for this age range.

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This study had several limitations that should be noted.
First, the CARS2 ratings and clinical diagnoses were not
independent. Clinicians identified the specific DSM-IV-TR
and DSM-5 criteria each participant met in order to ensure
diagnosis was based on the diagnostic criteria. However, the
observed estimates of sensitivity and specificity may be
overestimates of agreement given that the CARS2 and
diagnostic criteria ratings were given by the same clinician.
Second, the basis for behavioral observation on the CARS2-
ST was not consistent across all participants resulting in
higher CARS2-ST scores among individuals assessed using
the PEP-3 than the ADOS2. When asked, some clinicians in
this study reported that they were more likely administer the
PEP-3 when the individual’s symptoms of autism were not
as subtle, appeared to have a lower developmental level, and
needed the degree of structure offered by the PEP-3 in order
to generate programming recommendations. In future stud-
ies, the use of similar observational tools across participants
may yield improved estimates of diagnostic agreement.
Finally, the sample in the present study consisted of clients
referred due to suspected autism. Therefore, a high propor-
tion of the sample did in fact meet criteria for an autism
diagnosis. The goal of the present study was to assess the
effectiveness of the CARS2 in a clinic-based sample.
Although the terms sensitivity and specificity were used
throughout the paper as a test of the effectiveness of the
measure, caution should be used when interpreting the
observed estimates given that a true test of the psychometric
properties of the CARS2 was beyond the scope of this study
and would have required a larger sample with a higher
proportion of individuals not meeting criteria for autism.
The CARS2 is a well-validated measure that can be used
in community clinics as part of the diagnostic process for
individuals with ASD. The CARS2 can be used as part of a
broader evaluation that encompasses multiple sources of
information such as caregiver report and other diagnostic,
behavioral, or cognitive measures.
Acknowledgments The authors would like to thank Joyce Lum,
Janette Wellman, John Dougherty, Laura Grofer Klinger, and Mark
Klinger for their contributions to this research.
Author Contributions TD participated in the conception and coor-
dination of the study, drafting of the manuscript, and the design and
interpretation of the data. MVB participated in the conception and
design of the study and the drafting of the manuscript. ATM partic-
ipated in drafting the manuscript and editing. All authors read and
approved the final manuscript.
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