The Childhood Autism

Rating Scale (CARS)

Jennifer Connelly
Caldwell College
 CARS Described
 Childhood Autism Rating Scale
 15-item behavior rating scale to identify and
differentiate children with autism from typical
or other developmentally disabled individuals
 Distinguishes placement on spectrum
 Each of 15 items based on five major
diagnostic systems (Kanner, Creak, Rutter,
NSAC, and DSM-IV)
 Can be used to evaluate across ages
 CARS Development, History, and
Relationship to Other Scales
 Developed 20 years ago
 Includes Kanner’s autism features,
characteristics described by Creak
 Original developed by Child Research Project
at the University of NC at Chapel Hill
 Originally titled “Childhood Psychosis Rating
Scale”
 Used initially to evaluate children referred to
state-side TEACCH program
 Behavioral Items Assessed
 Relating to People
 Imitation
 Emotional Response
 Body Use
 Object Use
 Adaption to Change
 Visual Response
 Listening Response
 Taste, Smell, and Touch Response and Use
 Fear or Nervousness
 Verbal Communication
 Nonverbal Communication
 Activity Level
 Level and Consistency of Intellectual Response
 General Impressions
 How to Observe and Rate
 Psychological testing, classroom participation,
parent reports, history records
 Ratings should not be made until after data
collection is complete
 Child’s behavior should be compared to that of a
typical child of the same age
 Anecdotal data should be recorded on peculiarity,
frequency, intensity, and duration of behaviors
observed
 Familiar with definitions/descriptions
 Rating of 1-4 (with midpoints)
 Interpretation of Scores
 Total score by summing the 15 individual
ratings (range from 15-60)
 Scores place individuals within a
diagnostic categorization system
(NonAutistic, Mild/Moderate Autism,
Severe Autism)
 Practice: Object Use (Timmy)
Definition: The child’s
interest in toys/other
objects and how he/she
uses them
Keep in mind…
1.Unstructured times
2.Use after given a model
3.Level of interest (lack of or
excessive)
4.Use of toys in
appropriate/inappropriate
ways
Practice: Object Use (Matty)
 Practice: Imitation (Timmy)
Definition: How the child
imitates verbal and
nonverbal acts
Keep in mind…
1. Behavior to be imitated
should be within child’s
abilities
2. Sounds, words, motor
movements, written
model
3. Unwilling or unable to
imitate?
4. Latency in responding
Practice: Imitation (Matty)
Practice: Visual Response (Timmy)
Definition: Rating of unusual
visual attention patterns
when required to look at
objects/people
Keep in mind…
1. Avoiding eye contact or
making through corners
of eyes
2. How often must child be
prompted to make eye
contact
3. How intrusive must those
prompts get to achieve
eye contact
Practice: Visual Response (Matty)
Evaluation of CARS: Reliability and
Validity
 Internal consistency
 Inter-rater agreement
 Test-retest stability

 Criterion-related validity
 Validity under alternate conditions
 Perry, A., Condillac, R. A., Freeman N. L., Dunn-
Geier, J., & Belair J. (2005)

 Participants:
Sample of 274 preschool children
diagnosed with AD, PDD-NOS, MR,
Delayed, and Other
 Objectives:
1. CARS scores vs. DSM-IV clinical
diagnosis
2. CARS scores between different
diagnostic groups
 Perry, A., Condillac, R. A., Freeman N. L., Dunn-
Geier, J., & Belair J. (2005)

 Findings:
1. High degree of concordance between CARS
and clinical diagnoses (DSM-IV)
2. Negative correlation using CARS between
autism severity and cognitive level
3. Clinically defined groups differed in scores in
significant/sensible ways, however autistic
disorder vs. PDD-NOS still some overlap
 Rellini, E., Tortolani, D., Trillo, S., Carbone, S., &
Montecchi, F. (2004)

 Participants:
65 children (18 months – 11 years)
diagnosed with autism
 Objectives:
1. CARS and ABC correspondence with
diagnosis made with DSM-IV criteria
 Rellini, E., Tortolani, D., Trillo, S., Carbone, S., &
Montecchi, F. (2004)

 Findings:
1. CARS distinguishes individuals with AD
from other developmental disorders
2. CARS does not clearly differentiate
individuals with other ASDs
 NYS Dept of Health: Evidence to
Support
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 centers.
 CARS possesses an acceptable combination of practicality and
research support, despite the limited research on its use in
children under 3 years of age.
 NYS Dept of Health: No Evidence
to Support
According to the NY State Department of Health there is no
evidence to support:

 That the CARS may be useful for periodic monitoring of children

with autism or for assessing long-term outcomes.
 That professionals using the CARS have experience in assessing
children with autism or have adequate training in administering
and interpreting the CARS.
 That the instrument (CARS) is practical, is supported by research,
or is useful for collecting information to assist with estimating the
prevalence of autism or assessing functional outcomes.
 CARS: Pros and Cons
PROS CONS
 Agreement with DSM-IV  Does not include peer
diagnoses of AD relationships, joint attention, or
symbolic play
 Easy to train
 Does not differentiate between
 Can be done quickly individuals with other ASDs
 Useful with wide age  Dated (terminology)
range  Somewhat subjective
 Summary
 Arguments for and against the use of
CARS as a diagnostic tool
 Some level of subjectivity is involved
 Other measures have been developed as
the field advances (ADOS)
 References
 Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J.
(2005). Mulit-site study of the Childhood Autism Rating Scale (CARS) in
five clinical groups of young children. Journal of Autism and
Developmental Disorders, 35, 625-634.
 Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004).
Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist
correspondence and conflicts with DSM-IV criteria in diagnosis of autism.
Journal of Autism and Developmental Disorders, 34, 703-708.
 Stella, J., Mundy, P., & Tuchman R. (1999). Social and nonsocial factors in
the Childhood Autism Rating Scale. Journal of Autism and
Developmental Disorders, 29, 307-317.
 New York State Department of Health. (1999). Autism/Pervasive
Developmental Disorders. Clinical practice guideline technical report.
New York: Author.