Introduction

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by a unique

combination of social communication challenges, repetitive behaviors, and highly restricted interests.

Emerging in early childhood, ASD presents a diverse range of manifestations and intensities, which has

led to the term "spectrum." The disorder affects individuals differently, with some exhibiting profound

impairments that necessitate substantial support, while others may possess exceptional skills and require

minimal assistance. This heterogeneity underscores the importance of personalized approaches to

diagnosis, intervention, and support.

The prevalence of autism has been steadily increasing, with current global estimates suggesting that just

under 1% of the population is affected. However, the rates are notably higher in high-income countries,

where greater awareness, improved diagnostic practices, and potentially environmental factors contribute

to the rising numbers. The growing prevalence emphasizes the need for comprehensive public health

strategies and resources to support individuals with autism and their families.

Despite extensive research, the precise causes of autism remain elusive. It is widely recognized that ASD

arises from a complex interplay of genetic and environmental factors. Initial hopes that accurate

measurement of behavioral phenotypes would lead to the identification of specific genetic subtypes have

not been fully realized. Instead, genetic studies have revealed that autism is associated with a

heterogeneous array of genetic variations, many of which are not unique to the disorder. This genetic

diversity poses significant challenges for developing targeted treatments and interventions.

Neurobiological research has provided insights into the subtle anatomical and functional differences in the

brains of individuals with autism. While gross brain pathology is not characteristic of ASD, studies using

post-mortem analysis, neuroimaging, and electrophysiology have identified variations in brain structure

and activity. These findings contribute to our understanding of the neural underpinnings of autism and

highlight the importance of continued investigation into brain development and function in individuals

with ASD.
Families play a crucial role in supporting individuals with autism throughout their lives. The demands

placed on families can be substantial, and their perspectives, along with those of autistic individuals, must

be central to both research and practice. Recognizing the vital contributions of families and ensuring their

inclusion in the development of support strategies is essential for improving the independence and quality

of life of individuals with autism. autism spectrum disorder is a multifaceted condition with a broad range

of presentations and challenges. Understanding its complexities requires a multidisciplinary approach,

encompassing genetics, neurobiology, psychology, and social sciences. As research progresses, it is

imperative to prioritize individualized interventions, support systems, and the voices of those directly

affected by autism to foster an inclusive and supportive environment for all.

The Childhood Autism Rating Scale (CARS) evaluates behavior across 14 domains commonly affected

by severe autism-related problems, plus one general category that captures overall impressions of autism.

This scale aims to distinguish children with autism from those with other developmental disorders. The 15

items assessed in CARS are Relating to people, Imitative behavior, Emotional response, Body use, Object

use, Adaptation to change, Visual response, Listening response, Perceptive response, Fear or anxiety,

Verbal communication, Non-verbal communication, Activity level, Level and consistency of intellectual

response, and General impressions. CARS has demonstrated good sensitivity and specificity, which are

critical aspects of any diagnostic tool. Sensitivity refers to the scale's ability to correctly identify

individuals who have autism, while specificity pertains to correctly excluding those who do not. High

sensitivity and specificity reduce the likelihood of false positives and false negatives, enhancing the

overall diagnostic accuracy of the scale.

Each item is rated on a scale from 1 to 4, where 1 signifies behavior appropriate for the child's age and 4

indicates severe deviance from typical age-appropriate behavior. The scores for each item are summed to

create a total score, which classifies the child as not autistic (below 30), mildly to moderately autistic

(30–36.5), or severely autistic (above 36.5).

For diagnosing severe autism, further guidelines provided by Schopler et al. (1980) recommend counting

the number of items where the child scores 3 or higher. A diagnosis of severe autism is appropriate if the

child scores 3 or higher on at least 5 items.

The Childhood Autism Rating Scale (CARS) has demonstrated strong inter-rater reliability (ICC=0.74)

and test-retest reliability (ICC=0.81). In addition to having adequate face and content validity, CARS

shows good internal consistency, with a Cronbach's alpha of 0.79, and strong item-total correlation. It has

moderate convergent validity with the Binet-Kamat Test of Intelligence or Gessell's Developmental

Schedule (r=0.42; P=0.01) and divergent validity with the ADD-H Comprehensive Teacher Rating Scale

(r=-0.18; P=0.4). Furthermore, CARS has a high concordance rate (82.52%; Cohen's kappa=0.40,

P=0.001) with the reference standard ICD-10 diagnosis for classifying autism. The scale's 5-factor

structure accounts for 65.34% of the variance.