The Childhood Autism The Childhood Autism Rating Scale (CARS)Rating Scale (CARS)

Jennifer ConnellyJennifer Connelly

Caldwell CollegeCaldwell College

CARS DescribedCARS Described

Childhood Autism Rating ScaleChildhood Autism Rating Scale 15-item behavior rating scale to identify and 15-item behavior rating scale to identify and

differentiate children with autism from typical differentiate children with autism from typical or other developmentally disabled or other developmentally disabled individualsindividuals

Distinguishes placement on spectrumDistinguishes placement on spectrum Each of 15 items based on five major Each of 15 items based on five major

diagnostic systems (Kanner, Creak, Rutter, diagnostic systems (Kanner, Creak, Rutter, NSAC, and DSM-IV) NSAC, and DSM-IV)

Can be used to evaluate across agesCan be used to evaluate across ages

CARS Development, History, and CARS Development, History, and Relationship to Other ScalesRelationship to Other Scales

Developed 20 years agoDeveloped 20 years ago Includes Kanner’s autism features, Includes Kanner’s autism features,

characteristics described by Creakcharacteristics described by Creak Original developed by Child Research Project Original developed by Child Research Project

at the University of NC at Chapel Hillat the University of NC at Chapel Hill Originally titled “Childhood Psychosis Rating Originally titled “Childhood Psychosis Rating

Scale” Scale” Used initially to evaluate children referred to Used initially to evaluate children referred to

state-side TEACCH programstate-side TEACCH program

Behavioral Items AssessedBehavioral Items Assessed Relating to PeopleRelating to People ImitationImitation Emotional ResponseEmotional Response Body UseBody Use Object UseObject Use Adaption to ChangeAdaption to Change Visual ResponseVisual Response Listening ResponseListening Response Taste, Smell, and Touch Response and UseTaste, Smell, and Touch Response and Use Fear or NervousnessFear or Nervousness Verbal CommunicationVerbal Communication Nonverbal CommunicationNonverbal Communication Activity LevelActivity Level Level and Consistency of Intellectual ResponseLevel and Consistency of Intellectual Response General ImpressionsGeneral Impressions

How to Observe and RateHow to Observe and Rate Psychological testing, classroom participation, Psychological testing, classroom participation,

parent reports, history recordsparent reports, history records Ratings should not be made until after data Ratings should not be made until after data

collection is completecollection is complete Child’s behavior should be compared to that of a Child’s behavior should be compared to that of a

typical child of the same agetypical child of the same age Anecdotal data should be recorded on peculiarity, Anecdotal data should be recorded on peculiarity,

frequency, intensity, and duration of behaviors frequency, intensity, and duration of behaviors observedobserved

Familiar with definitions/descriptionsFamiliar with definitions/descriptions Rating of 1-4 (with midpoints)Rating of 1-4 (with midpoints)

Interpretation of ScoresInterpretation of Scores

Total score by summing the 15 individual Total score by summing the 15 individual ratings (range from 15-60)ratings (range from 15-60)

Scores place individuals within a Scores place individuals within a diagnostic categorization system diagnostic categorization system (NonAutistic, Mild/Moderate Autism, (NonAutistic, Mild/Moderate Autism, Severe Autism) Severe Autism)

Practice: Object Use (Timmy)Practice: Object Use (Timmy)

Definition: The child’s Definition: The child’s interest in toys/other interest in toys/other objects and how he/she objects and how he/she uses themuses them

Keep in mind…Keep in mind…1.Unstructured times1.Unstructured times2.Use after given a model2.Use after given a model3.Level of interest (lack of or 3.Level of interest (lack of or

excessive)excessive)4.Use of toys in 4.Use of toys in

appropriate/inappropriate appropriate/inappropriate waysways

Practice: Object Use (Matty)Practice: Object Use (Matty)

Practice: Imitation (Timmy)Practice: Imitation (Timmy)

Definition: How the child Definition: How the child imitates verbal and imitates verbal and nonverbal actsnonverbal acts

Keep in mind…Keep in mind…1. Behavior to be imitated 1. Behavior to be imitated

should be within child’s should be within child’s abilitiesabilities

2. Sounds, words, motor 2. Sounds, words, motor movements, written movements, written modelmodel

3. Unwilling or unable to 3. Unwilling or unable to imitate?imitate?

4. Latency in responding4. Latency in responding

Practice: Imitation (Matty)Practice: Imitation (Matty)

Practice: Visual Response (Timmy)Practice: Visual Response (Timmy)

Definition: Rating of unusual Definition: Rating of unusual visual attention patterns visual attention patterns when required to look at when required to look at objects/peopleobjects/people

Keep in mind…Keep in mind…1. Avoiding eye contact or 1. Avoiding eye contact or

making through corners making through corners of eyesof eyes

2. How often must child be 2. How often must child be prompted to make eye prompted to make eye contactcontact

3. How intrusive must those 3. How intrusive must those prompts get to achieve prompts get to achieve eye contacteye contact

Practice: Visual Response (Matty)Practice: Visual Response (Matty)

Evaluation of CARS: Reliability and Evaluation of CARS: Reliability and ValidityValidity

Internal consistency Internal consistency Inter-rater agreementInter-rater agreement Test-retest stabilityTest-retest stability

Criterion-related validityCriterion-related validity Validity under alternate conditionsValidity under alternate conditions

Perry, A., Condillac, R. A., Freeman N. L., Dunn-Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J. (2005)Geier, J., & Belair J. (2005)

Participants: Participants: Sample of 274 preschool children Sample of 274 preschool children diagnosed with AD, PDD-NOS, MR, diagnosed with AD, PDD-NOS, MR, Delayed, and OtherDelayed, and Other

Objectives: Objectives: 1. CARS scores vs. DSM-IV clinical 1. CARS scores vs. DSM-IV clinical

diagnosisdiagnosis2. CARS scores between different 2. CARS scores between different

diagnostic groupsdiagnostic groups

Perry, A., Condillac, R. A., Freeman N. L., Dunn-Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J. (2005) Geier, J., & Belair J. (2005)

Findings:Findings:

1.1. High degree of concordance between CARS High degree of concordance between CARS and clinical diagnoses (DSM-IV)and clinical diagnoses (DSM-IV)

2.2. Negative correlation using CARS between Negative correlation using CARS between autism severity and cognitive levelautism severity and cognitive level

3.3. Clinically defined groups differed in scores in Clinically defined groups differed in scores in significant/sensible ways, however autistic significant/sensible ways, however autistic disorder vs. PDD-NOS still some overlapdisorder vs. PDD-NOS still some overlap

Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004)Montecchi, F. (2004)

Participants:Participants:

65 children (18 months – 11 years) 65 children (18 months – 11 years) diagnosed with autismdiagnosed with autism

Objectives:Objectives:

1. CARS and ABC correspondence with 1. CARS and ABC correspondence with diagnosis made with DSM-IV criteriadiagnosis made with DSM-IV criteria

Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004)Montecchi, F. (2004)

Findings:Findings:

1.1. CARS distinguishes individuals with AD CARS distinguishes individuals with AD from other developmental disordersfrom other developmental disorders

2.2. CARS does not clearly differentiate CARS does not clearly differentiate individuals with other ASDs individuals with other ASDs

NYS Dept of Health: Evidence to NYS Dept of Health: Evidence to SupportSupport

According to the NY State Department of Health there According to the NY State Department of Health there isis evidence evidence to support:to support:

CARS as a useful part of the assessment of children with possible CARS as a useful part of the assessment of children with possible autism in a variety of settings: early intervention programs, autism in a variety of settings: early intervention programs, preschool developmental programs, and developmental preschool developmental programs, and developmental diagnostic centers. diagnostic centers.

CARS possesses an acceptable combination of practicality and CARS possesses an acceptable combination of practicality and research support, despite the limited research on its use in research support, despite the limited research on its use in children under 3 years of age. children under 3 years of age.

NYS Dept of Health: No Evidence NYS Dept of Health: No Evidence to Supportto Support

According to the NY State Department of Health there is According to the NY State Department of Health there is nono evidence to support:evidence to support:

That the CARS may be useful for periodic monitoring of children That the CARS may be useful for periodic monitoring of children with autism or for assessing long-term outcomes.with autism or for assessing long-term outcomes.

That professionals using the CARS have experience in assessing That professionals using the CARS have experience in assessing children with autism or have adequate training in administering children with autism or have adequate training in administering and interpreting the CARS. and interpreting the CARS.

That the instrument (CARS) is practical, is supported by research, That the instrument (CARS) is practical, is supported by research, or is useful for collecting information to assist with estimating the or is useful for collecting information to assist with estimating the prevalence of autism or assessing functional outcomes.prevalence of autism or assessing functional outcomes.

CARS: Pros and ConsCARS: Pros and Cons

PROSPROS Agreement with DSM-IV Agreement with DSM-IV

diagnoses of ADdiagnoses of AD Easy to trainEasy to train Can be done quicklyCan be done quickly Useful with wide age Useful with wide age

rangerange

CONSCONS Does not include peer Does not include peer

relationships, joint attention, or relationships, joint attention, or symbolic playsymbolic play

Does not differentiate between Does not differentiate between individuals with other ASDs individuals with other ASDs

Dated (terminology)Dated (terminology) Somewhat subjective Somewhat subjective

SummarySummary

Arguments for and against the use of Arguments for and against the use of CARS as a diagnostic toolCARS as a diagnostic tool

Some level of subjectivity is involvedSome level of subjectivity is involved Other measures have been developed as Other measures have been developed as

the field advances (ADOS)the field advances (ADOS)

ReferencesReferences Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J. Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J.

(2005). Mulit-site study of the Childhood Autism Rating Scale (CARS) (2005). Mulit-site study of the Childhood Autism Rating Scale (CARS) in in five clinical groups of young children. five clinical groups of young children. Journal of Autism and Journal of Autism and Developmental DisordersDevelopmental Disorders, 35, 625-634. , 35, 625-634.

Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004). Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004). Childhood Autism Rating Scale (CARS) and Autism Behavior Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist Checklist correspondence and conflicts with DSM-IV criteria in correspondence and conflicts with DSM-IV criteria in diagnosis of autism. diagnosis of autism. Journal of Autism and Developmental DisordersJournal of Autism and Developmental Disorders, , 34, 703-708. 34, 703-708.

Stella, J., Mundy, P., & Tuchman R. (1999). Social and nonsocial factors in Stella, J., Mundy, P., & Tuchman R. (1999). Social and nonsocial factors in the Childhood Autism Rating Scale. the Childhood Autism Rating Scale. Journal of Autism and Journal of Autism and

Developmental DisordersDevelopmental Disorders, 29, 307-317. , 29, 307-317. New York State Department of Health. (1999). New York State Department of Health. (1999). Autism/Pervasive Autism/Pervasive

Developmental Disorders. Clinical practice guideline technical report.Developmental Disorders. Clinical practice guideline technical report. New York: Author. New York: Author.