what is CARS(childhood autism rating scale)?

Autism

Autism is a neurodevelopmental disorder characterized by impaired social interaction, impaired verbal and non-verbal communication, and restricted and repetitive behavior. Parents usually notice signs in the first two years of their child's life. These signs often develop gradually, though some children with autism reach their developmental milestones at a normal pace and then regress.

The Childhood Rating Scale (CARS)                                                               

Introduction

The Childhood Autism Rating Scale (CARS) is a 15 item behavioral rating scale developed to identify children with autism, and to distinguish them from developmentally handicapped children without autism syndrome. The CARS is especially effective in discriminating between autistic children and trainable mentally retarded children (Morgan,1998: Teal & Wiebe, 1986) It further distinguishes children with autism in the mild to moderate to severe range. It was first constructed more than 15 years ago (Riechler and Scopler,1971)to enable clinicians to obtain a more objective diagnosis of autism in a more readily usable form. The 15 CARS items incorporate (a) Kanner’s primary autism features, (b) other characteristics noted by Creak, which are found in many, but not all, children who may be considered autistic, and (c) additional scales useful in tapping the symptoms characteristic of the younger child.

Development of the CARS Method

The 1988 edition of the CARS is the result of a process of use, evaluation, and modification which has spanned approximately 15 years and involved more than 1500 cases. The scale was first developed as a research instrument in response to the limitations of the diagnostic classifications instruments available at that time. This original rating scale, developed by the Child Research Project at the University of the North Carolina at Chapel Hill was based primarily on consensual diagnostic criteria for autism as reported by the British Working PARTY (Creak, 1964). It was referred to as the Childhood psychosis rating scale (CPRS) (Reichler,Schopler, 1971) to minimize confusion with Kanners’s (1943) narrower classic definition of autism. Now, however since the definition of autism has been expanded and is no longer restricted to Kanner’s early use of the term.

The original scale was revised in order to evaluate children referred to our statewide North Carolina program for the Treatment and Education of Autistic and related Communication handicapped Children (Division TEACCH). It was started in 1966.Most of the research is centered at the University of the North Carolina in Chapel Hill, where the CARS was developed. As is typical of developmentally disabled populations, approximately 75% are male. The age distributions are similar for the two sexes with approximately 57% below age 6 years at time of entry into the program, 32% from age 6 to age 10, and 11% at age 10 or above. Most of our sample show intellectual deficits as measured by standardized tests such as WISC. Approximately 71% have IQ’S below 70, with only 17% having IQ’S from 70 through 84, and 13% at or above 85.

Relationship to other diagnostic criteria and scales

Five important systems for diagnosing autism have been extensively used. They include the Kanner (1943) criteria, the Creak (1961) points, the definition of Rutter(1978), that of the National Society for Autistic Children (NSAC 1978), and the DSM IV (1994) Although  widely used for clinical diagnosis and research, none of these five systems has been connected to a rating scale or checklist. While these five overlap on major features of autism, they also represent significant differences. The design of the CARS scales incorporate all five these diagnostic systems. In the scale rationale section each item is marked according to its consistency with these five systems.

A number of other schemes for rating autism have been published. These include the rating instrument developed by Ruttenberg et al. (1966). A behavior observation scale (BOS) for autism was developed by Freeman et al. (1978), an Autism screening instrument for Education planning was reported by Krung et al.(1979), and a checklist, the E-2 was proposed by Rimland (1964).

Advantages of the CARS

The emphasis of the CARS on behavioral and empirical data rather than on clinical intuition makes it possible to move the diagnosis from the private domain of the clinically initiated to the less restricted domain of appropriately informed persons from different professions. The ratings are extremely useful for identification of behavioral symptoms, for research purposes or for classification purposes.

The CARS offers several significant advantages over other instruments:

1.      The inclusion of items representing varied diagnostic criteria and reflecting the broadened data based definition of the autism syndrome which has evolved as a result of continued empirical research.

2.      Scale development and refinement based on over a decade of use with more than 1500 children.

3.      Applicability to children of all ages, including preschoolers.

4.      Replacement of subjective or esoteric clinical judgments with objective and quantifiable ratings based on direct behavioral observation.

Rationale for 15 Scale Items

Each of the 5 items of the scale is listed below along with its rationale for inclusion (Schopler, Riecher, DeVellis & Daly, 1980). The relationship between each item and the five major diagnostic systems discussed is marked, with an indication of whether the item is primary, secondary, or not included for each of these five diagnostic systems.

I.            Relating to people.

Impairment in this area is considered one of the primary features of autism in virtually every description of the disorder found in the literature, and is for the five systems represented in this instrument. Kanner, Creak,  Rutter,NASC, DSM-IV (Primary)

II.            Imitation

This item was included because of the finding that many children with severe language difficulties also had problems with both verbal and non-verbal and motor imitation. The ability to imitate has long been considered an important basis for developing speech. Imitation is also a skill that is highly relevant to the treatment and education of younger children. Therefore while this impairment in this area is not considered primary feature of autism, this item is included in the CARS: DSM IV (Primary) Creak, NSAC(Not include) Kanner, Rutter(secondary)

III.            Emotional Response

Autism was first considered a disturbance in affective contact; moreover abnormal and inappropriate emotional responses have widely been considered a feature of this disorder. DSM –IV, Kanner, Rutter (primary) Creak,NSAC (Secondarry)

IV.            Body Use

Peculiar body movements and especially stereotypes like hand flapping, tapping, and spinning have been widely reported by both clinicians and researchers. Such body use movements were included in all diagnostic systems. Creak, DSM IV,Rutter (primary) NSAC, Kaner ( secondary)

V.            Object Use

Inappropriate use of objects such as toys and other materials is closely related to inappropriate relations with other people. Such behaviors appears frequently in clinical descriptions and are placed as. Creak (secondary) DSM-IV, Kanner, Rutter, NSAC (Primary)

VI.            Adaption to Change

Difficulty in this area is another primary autism features first identified by Kanner, supported by subsequent data of research and maintained in most definitions of autism: Kanner, Creak, Rutter, NASC, DSM-IV (Primary).

VII.            Visual Response

Avoidance of eye contact during personal interactions was widely reported for autistic children. Whether such avoidance of eye contact extended equally to visual avoidance of toys and other materials been a research question. Kanner, Creak, NASC, DSM-IV (Primary) Rutter (secondary).

VIII.            Listening Response

This scale refers to the avoidance of auditory distance receptors. Learning functions assessed by this scale have clear implications for the teaching of speech alternative communication skills: Creak, NSAC (primary), DSM-IV (not included) Kanner, Rutter (secondary).

IX.            Taste, Smell and Touch Response and Use

This item was included to assess the frequently reported preoccupation with mouthing, licking, smelling and rubbing of objects plus the peculiar reactions to pain sometimes observed in autistic individuals. Creak, NSAC (primary), DSM-IV( not included) Kanner, Rutter (secondary).

X.             Fear or Nervousness

Unusual or unexplainable fears are not a primary characteristic of autism. However such behavior occurs frequently to warrant inclusion: Creak, (primary), DSM-IV (not included) Kanner, Rutter, NSAC (secondary).

XI.            Verbal Communication

 This item evaluates the degree autistic language ranging from muteness to the use of bizzare, meaningless language. Most of the definitions autism consider the autistic communication behavior rated the item to be primary feature of the disorder: Kanner, Creak, Rutter, NASC, DSM-IV (Primary

XII.            Nonverbal Communication

This item assesses the child’s use of or response to gestures and other non-verbal types of communication. It is particularly useful in assessing the communicative ability of the nonverbal child. Rutter, NASC, DSM-IV (Primary), Creak, Kanner (secondary)

XIII.            Activity Level

While abnormal activity level generally is not considered a primary feature of autism it is frequently observed in autistic children and plays an important role in child’s learning environment: Creak, DSM-IV, Kanner, Rutter (not included) and NSAC (Secondary)

XIV.            Level of Consistency of Intellectual Response

This item represents an expansion of one of Kanner’s primary autism features to include assessment both of retardation and unevenness in intellectual functioning: Creak, Kanner (primary) DSM-IV, NSAC, Rutter (secondary).

XV.            General Impressions

This is global rating of the degree of autism observed in the child during the observation period, including both quantitative and qualitative judgments of all behaviors observed and rated during the diagnostic session. The rating is made prior to the summing up of scores from the previous 14 items

Psychometric properties

Reliability

Internal consistency reliability: in order to assess the internal consistency of the CARS, Coefficient alpha was computed. The alpha obtained was .94, indicating a high degree of internal consistency.

Interrater reliability: In order to assess the interrater reliability individual item scores from two independent trained raters were correlated for 280 cases. An average interrater reliability of .71 was obtained, indicating good agreement between the raters.

Test –Retest Reliability: In order to assess the test retest reliability of the CARS total scores from two separate test occasions approximately one year apart was compared for 91 cases. The resulting correlation is an indication of the scales stability overtime. The result correlation was .88(p is less than .01).

Validity

Criterion related validity: Criterion validity of the CARS was determined though a comparison of total scores to clinical settings obtained during the same diagnostic sessions. The resulting correlation, r= .84 (p less than .001) indicates that CARS scores have high validity when compared with the clinical ratings.

Intended users and uses of the CARS

In addition to evaluating CARS used in different settings we also assessed its validity as a screening tool when used by a variety of well-informed individuals who are not psych diagnosticians. Trials in division TEACCH indicate that professionals such as physicians, special educators, school psychologist, speech pathologists and audiologists who had only minimal exposure to or training about autism can be trained through brief written or videotaped instructions to administer CARS.

How to make observations and ratings?

            The CARS ratings can be made from such different sources of observations as during psychological testing or classroom participation, from parent reports and history records. These sources can be used as long as they include the required information for rating all scales. Brief notes concerning relevant behaviors should be made in the space provided for each of the 15 items on CARS rating sheet. Actual ratings should not be made before completing the data collection. The rater should be familiar with descriptions and scoring criteria of all 15 items before making observations.

            In making observations child behavior should be compared with that of normal child of the same age. When observed behaviors are not normal for child of same age then the peculiarity, frequency, intensity and duration of these behaviors should be considered. The purpose of the scale is to rate behavior without resource to casual explanations. Some behaviors resulting from childhood autism are similar to behaviors caused by other childhood disorders so, it is important to rate the degree to which the child’s behavior deviate from normal without making  judgment that behavior is due to brain damage, mental retardation or another childhood disorder. The total score and pattern of impairment will distinguish an autistic child from other developmental disorder.

            After completing the observations the rater should use worksheet notes to make actual ratings on rating sheet. To score the CARS, each of the 15 items is given a rating from 1 to 4. A rating of 1 indicated that a child’s behavior is coherent with child of same age. A 2 means that child’s behavior is mildly abnormal compared to child of same age. A 3 indicates that child behavior is moderately abnormal of that age. A 4 shows that behavior is severely abnormal for that age. The mid points between these scores (1.5, 2.5, 3.5) are to be used when behavior fall between two categories. For example for a behavior of mildly to moderate is should be rated 2.5. Thus seven allowable ratings can be as follows;

1          Within normal limits for that age

1.5       Very mildly abnormal for that age

2          Mildly abnormal for that age

2.5       Mildly to moderately abnormal for that age

3          Moderately abnormal for that age

3.5       Moderately to severely abnormal for that age

4          Severely abnormal for that age

            To determine the degree of abnormality it is necessary to consider child chronological age, peculiarity, frequency, intensity and duration of child behavior. The greater the degree of difference from child of same age the greater the abnormal behavior and higher the score would be assigned. Definition, consideration and scoring of each 15 items is given below:

(I) Relating to People

            Definition. This is the rating of how the child behaves in a variety of situations involving interaction with other people.

            Considerations. Consider both structured and unstructured situations where the child has a chance to interact with an adult, sibling or peer. Also consider how the child reacts to a behavior ranging from persistent, intensive attempts at making child respond, to the allowance of complete freedom. In particular, note how persistent or forceful the adult must be to get the child’s attention. Note the child’s reaction to physical contact, to physical signs of affection, such as hugging or stroking, and also in response to praise and criticism or punishment. Consider the degree to which child clings to parents or others. Note weather or not child initiates interactions with others. Also consider responsiveness, aloofness, shyness and awareness of strangers.

Scoring

1.      No evidence of difficulty or abnormality in relating to people. The child’s behavior is appropriate for his age. Some shyness, fussiness annoyance at being told what to do may be observed but not to greater degree than is typical for children of the same age.

2.      Mildly abnormal relationships. The child may avoid looking the adult in the eye, may avoid the adult or become fussy if interaction is forced, may be excessively shy, may not be as responsive to the adult as a typical child of the same age, or may cling to parents somewhat more than most children of the same age.

3.      Moderately abnormal relationships. The child shows aloofness at times. Persistent and forceful attempts are necessary to get the child’s attention at times. Minimal contact is initiated by the child and contact may have an impersonal quality.

4.      Severely abnormal relationships. The child is consistently aloof or unaware of what the adult is doing. He or she almost never responds to the adult or initiates contact with the adult. Only the most persistent attempts to get the child’s attention have any effect.

(II) Imitation

            Definition. This rating is based on how the child imitates both verbal and nonverbal acts. Behavior to be imitated should clearly be within the child abilities. Remember that this scale is intended to be an assessment of ability to imitate, not ability to perform specific tasks or behaviors. Often it is advantageous to request imitation of behaviors to skills the child has already demonstrated spontaneously.

            Considerations. Verbal imitation might involve repeating simple sounds, or repeating long sentences. Physical imitation might involve imitating hand movements or movements of whole body, cutting with scissors, copying shapes with pencil, or playing with toys. Make sure the child understand that he or she is supposed to imitate as part of a game. For example, note how the child returns a bye-bye wave, imitates clapping pat a cake, or copies nursery rhymes or songs. Notice how the child imitates both simple and complex sounds and movements. Try to recognize whether the child is unwilling to imitate, or unable to make the sound, say the word or do the movement that would be necessary to imitate the adult. Try to note a wide range of situations where the child is asked to imitate. In particular, notice whether the imitation occurs fairly immediately or whether it occurs after a considerable delay.

Scoring

1-      Appropriate imitation. The child can imitate sounds, word and movements which are appropriate for his or her skill level.

2-      Mildly abnormal imitation. The child imitates simple behaviors such as clapping or single verbal sounds most of the time. Occasionally, he or she may imitate only after prodding or after a delay.

3-      Moderately abnormal imitation. The child imitates only part of the time and requires a great deal of persistence and help from the adult. He or she may frequently imitate only after a delay.

4-      Severely abnormal imitation. The child rarely or never imitates sounds, words, or movements even with prodding and assistance from the adult.

(III) Emotional response

            Definition. This is the rating of how the child reacts to both pleasant and unpleasant situations. It involves a determination of whether or not 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.

            Considerations. Evaluate how the child responds to pleasant stimuli such as a show affection or praise, a mild tickle, a favorite toy or food, a pleasant game of roughhouse. Also evaluate how the child responds to unpleasant stimuli such as scolding or criticism, the removal of a favorite food or toy, difficult work demands, punishment or painful procedures. Inappropriate type of response may include such things as laughing when spanked or shifting mood unpredictably, without apparent reason. Inappropriate degree of response may include showing lack of emotion in situations where normal children of the same age would show some form of emotion, overreacting by tantrum, or becoming highly agitated and excited in response to a minor event.

Scoring

1-      Age appropriate and environment appropriate emotional responses. The child shows the appropriate type and degree of emotional response as indicated by a change in facial expression, posture and manner.

2-      Mildly abnormal emotional responses. The child occasionally displays a somewhat inappropriate type or degree of emotional reactions. Reactions are sometimes unrelated to the objects or events surrounding them.

3-      Moderately abnormal emotional responses. The shows definite signs of inappropriate type and or degree of emotional response. Reactions may be quite inhibited or quite excessive and may be unrelated to the situation. The child may grimace, laugh, or become rigid even though no apparent emotion producing object or events are present.

4-      Severely abnormal emotional responses. Responses are seldom appropriate to the situation; once the child gets in a certain mood, it is very difficult to change the mood even though activities may be changed. Conversely, the child may show wildly different emotions during a short period of time when nothing has changed.

(IV) Body Use

            Definition. This scale represents a rating of both coordination and appropriateness of body movements. It includes such deviations as posturing, spinning, tapping, and rocking, toe walking and self- directed aggression.     

            Considerations. Consider such activities as cutting with scissors, drawing or putting together puzzles in addition to active physical games. Evaluate the frequency and intensity of bizarre body use. Reactions to attempts by the examiner to prohibit bizarre body use should be observed in order to determine the persistence of these behaviors.

Scoring

1-      Age appropriate body use. The child moves with the same ease, agility and coordination of a normal child of the same age.

2-      Mildly abnormal body use. Some minor peculiarities may be present, such as clumsiness, repetitive movements, poor coordination or the rare appearance of the more unusual movements.

3-      Moderately abnormal body use. Behaviors that are clearly strange or unusual for a child of this age are noted. These may include strange finger movements, peculiar finger and body posturing, staring or picking at the body, self-directed aggression, rocking, spinning, finger-wiggling or toe walking.

4-      Severely abnormal body use. Intense or frequent movements of the type listed in 3 are signs of severely abnormal body use. These behaviors may be persistent despite attempts to discourage them or involve the child in other activities.

(V) Object use

            Definition. This is rating of both of the child’s interest in toys or other objects and his uses of them.

            Considerations. Consider how the child interacts with toys and other objects particularly in unstructured activities with a large variety of items available. These items should be appropriate to the child’s skills and interests. Note the level of interest child displays. Pay particular attention to the child’s use of toys with parts that dangle or spin. For instance, note excessive preoccupation with spinning the wheels on a toy truck or car instead of rolling toy. Note over repetitious use of toys such as blocks. For instance, repeatedly lining up blocks in a row, rather than using them to build a variety of structures or patterns. Consider excessive interest in things which normally are of no interest to a child with similar skills. For example does the child spend excessive time flushing and re-flushing the toilet and watching water run in the sink? Does the child seem preoccupied with something such as a phone-book, which has list but no pictures? Finally, consider whether or not the child will use toys or objects in a more appropriate way or usual manner being shown how.

Scoring                                       

1.      Appropriate use of, and interest in, toys and other objects. The child shows normal interest in toys and other objects appropriate for his skill level and uses these toys in an appropriate manner.

2.      Mildly inappropriate interest in, toys and other objects. The child may show less than the typical amount of interest in a toy or may play with it in an inappropriately childish way, such as banging or sucking on the toy or object, past the age where these behaviors are normal.

3.      Moderately inappropriate interest in, toys and other objects. The child may show very little interest in toys or other objects, or he or she may be preoccupied with using an object or toy in some strange way. He or she may focus attention on some insignificant part of a toy, become fascinated with light reflecting off the object, repetitively move some part of the object, or play with one object to the exclusion of all others. This behavior may be at least partially or temporarily modifiable.

4.      Severely inappropriate interest in, toys and other objects. The child may engage in the same behaviors as in 3, above but with greater frequency and intensity. The child is most difficult to distract when engaged in these inappropriate activities, and it is extremely difficult to modify the child’s inappropriate use of the object.

(VI) Adaptation to Change

            Definition. This scale concerns difficulties in changing established routines or patterns and difficulties in changing from one activity to another. These activities are often related to the repetitive behaviors and patterns rated on previous scales.

            Considerations. Note to child’s reaction to changing from one activity to another, particularly if the child was actively involved in the previous activity. Note the child’s reaction to attempts at modifying patterned responses or behaviors. For example, if left alone the child my repeatedly stack blocks in a particular pattern. Note the child’s reaction to adult attempts at changing the patterns. Consider how the child reacts to change in routine. For example does the child show signs of distress when guests arrived unexpectedly causes a change in routine when driven to school by a different route, when furniture is rearranged, when a substitute teacher a new child is introduced in in the classroom? Does the child established elaborate rituals around specific activities such as eating or going to bed? Does he or she insist on arranging certain objects “just so”, or eating or drinking only with a specific utensil?

Scoring

1.      Age appropriate response to change. While the child may notice or comment on change sin routine, he or she accept these changes with undo the stress

2.      Mildly abnormal adaptation to change. When an adult tries to change task the child might continue to do the same activity or use the same material, but the child can easily be distracted or shifted. For example, the child may initially fuss if taken to a different grocery store, or if driven to school by a new route, but is easily calmed.

3.      Moderately abnormal adaptation to change. The child actively changes in routine. When a change of activities attempted, the child tries to continue the old activities and is difficult to distract. For example, he or she may insist on trying to replace furniture that has been moved. He or she may become angry and unhappy when an established routine is altered.

4.      Severely abnormal adaptation to change. When changes occur, the child shows severe reaction which are difficult to eliminate. If a change is forced on the child, he or she may become extremely angry and uncooperative, and perhaps respond with tantrums.

(VII) Visual Response

            Definition. This is a rating of unusual visual attention pattern found in many autistic children. This rating includes the child response when he is required to look at objects and materials.

            Considerations. Consider whether the child uses his or her eyes normally when looking at objects or interacting with people. For example, does he or she look only out of the corners of his or her eyes? When engaged in a social interaction does the child look the other person in the eye or does he avoid the eye contact? How often must the child be told when to look while working on the task? Must the adult turn the child head to obtain his or her attention? Rating of unusual visual response also includes observation of peculiar behaviors such as the child’s gazing at his wiggling fingers or becoming absorbed in watching reflections or movements.

Scoring                                       

1.      Age appropriate visual response. The child’s visual behavior is normal and appropriate for a child of that age. Vision is used together with other senses, such as hearing or touch, as a way to explore a new object.

2.      Mildly abnormal visual response. The child must be reminded, from time to time, to look at objects. The child may be more interested in looking t the mirrors or lighting than most children of the same age, or he may occasionally stare off into space. The child may also avoid looking people in the eye.

3.      Moderately abnormal visual response. The child must be reminded frequently to look at what he or she is doing. He or she may stare into space, avoid looking people in the eye, look at objects very close to the eyes even though he or she can see them normally.

4.      Severely abnormal visual response. The child consistently avoids looking at people or certain objects and may show extreme forms of other visual peculiarities described above.

(V111) Listening Response

             Definition. This is rating of unusual listening behavior or unusual responses to sound. It involves the child’s reaction to both human voices and other types of sound. This item os also concerned with the child’s interest in various sounds.

             Considerations. Consider unusual preferences for, or fear of, certain everybody sounds such as those made by vacuum cleaners, washing machines, or passing trucks. Note whether the child reacts inappropriately to the loudness of the sounds. For example, the child may appear not to hear very loud sounds such as sirens, while reacting to very soft sounds such as whispers. The child may even overreact to normal sounds, which others do not mind, by wincing or by placing his or her hands over his or her ears. Some children may appear to hear sounds only while unoccupied. While others may attend to unrelated sounds to the point of becoming distracted from their primary activity. Remember to consider the child’s interest in sounds and to be sure that the child’s response is to the sound rather than to the sight of the object producing the sound.

Scoring

1.      Age appropriate listening response. The child’s listening behavior is normal and is appropriate for children of the child’s age. Listening is used together with other senses, such as seeing or touching.

2.      Mildly abnormal listening response. There may be some lack of response to certain sounds, or mild overreaction to certain sounds. At times, responses to sounds may be delayed, and sounds may occasionally need repetition to catch the attention of child. The child may, at times, be distracted by extraneous sounds.

3.      Moderately abnormal listening response. The child’s responses to sounds may vary. The child often ignores a sound the first few times it is made. The child may also be startled by some everyday sounds or cover his or her ears when these are heard.

4.      Severely abnormal listening response. The child overreacts and/or underreacts to sounds to an extremely marked degree, regardless of the type of the sound.

(IX) Taste, Smell, and Touch Response and Use

            Definition. This is a rating of child’s response to stimulation of taste, smell and touch senses (including pain). It is also a rating of whether or not the child makes appropriate use of these sense modalities. In contrast to the “distance” sense of audition and vision rated in the previous two scales, this is the rating of the “near” senses.

            Considerations. Consider whether the child shows either excessive avoidance of or excessive interest in certain odors, foods, tastes, or textures. Is child preoccupied with certain surface such as the table top, or texture such as fur or sandpaper? Does the child smell the ordinary objects such as toy blocks or puzzle pieces? Does he or she try to eat inedible things such as dirt, leaves or wood? Distinguish the ordinary, exploratory, infantile mouthing and touching in a younger child from the more frequent, peculiar, or intense type of behavior which appears to be unrelated to the specific objects. Does the child have unusual reactions to pain? Does he or she overreact or underreact to pain?

Scoring

1.      Normal use of, and response to, taste, smell, and touch. The child explore new objects in an age appropriate manner, generally by feeling them and looking at them. Taste or smell may be used when appropriate, such as when an object looks like it is supposed to be eaten. When reacting minor, everyday pain resulting from such things as a bump, fall, or pinch, the child expresses discomfort but does not overreacted.

2.      Mildly abnormal use of, and response to, taste, smell, and touch. The child may persist in putting objects, in his or her mouth even though most children of the same age have outgrown this. The child may taste or smell inedible objects from time to time. The child may ignore or overreact to a pinch or other mild pain that would be expressed as mild discomfort in a normal child.

3.      Moderately abnormal use of, and response to, taste, smell, and touch. The child may be moderately preoccupied with touching, smelling, or tasting objects or people. The child may show a moderately unusual reaction to pain, either by reacting too much or too little.

4.      Severely abnormal use of, and response to, taste, smell, and touch. The child is preoccupied with smelling, tasting or feeling objects more for the sensation than for the normal exploration or use of the objects. The child may completely ignore pain or react very strongly to something that is only slightly uncomfortable.

(X) Fear or Nervousness

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

            Considerations. Fearful behavior may include such things as crying, screaming, hiding or nervous giggling. When making this rating, consider the frequency, severity and duration of the child’s reaction. Do the fears appear reasonable or understandable? Also consider the pervasiveness of the response. It is confined to a single type or class of situation, or is it widespread over many or all situations? Would same aged normal children react this way in similar situation? The intensity of the response may be assessed by how difficult it is to calm the child. This type of reaction may occur upon separation from parents, in response to physical closeness, or upon being lifted off the ground in physical contact play. Unusual responses may occur to specific items such as rain, a doll, a puppet, play-doh, etc. Another type of unusual fear response is the failure to show appropriate fear for such things as heavy traffic or strange dogs, to which normal children react. Remember to consider unusual nervousness. Is the child particularly jumpy, startling easily in response to normal sound or movement?

Scoring

1.      Normal fear or nervousness. The child’s behavior is appropriate both to the situation and to his or her age.

2.      Mildly abnormal fear or nervousness. The child occasionally shows fear or nervousness that is slightly inappropriate either too much or too little, when compared to the reaction of a normal child of the same age in a similar situation.

3.      Moderately abnormal fear or nervousness. The child shows either quite a bit more or quite a bit less fear than is typical even for a younger child in a similar situation. It may be difficult to understand what is triggering the fear response, and it is difficult to comfort the child.

4.      Severely abnormal fear or nervousness. Fears persist even after repeated experience with harmless events or objects. In an evaluation session, the child may remain fearful without apparent reason throughout the entire session. It is extremely difficult to calm or comfort the child. The child may conversely fail to show appropriate regard for hazards such as strange dogs or heavy traffic, which other children of the same age avoid.

(XI) Verbal Communication

            Definition. This is a rating of all facets of the child’s use of speech and language. Assess not only the presence or absence of speech but also the peculiarity, bizarreness, or inappropriateness of all the elements of the child’s utterance when speech is present. Thus, when speech of any sort is present, assess the child’s vocabulary, sentence structure, the tonal quality, volume or loudness, and rhythm of utterances, and the situation appropriateness of the content of meaning of the child’s speech.

            Considerations. Consider the frequency, intensity, and extensiveness of peculiar, bizarre or inappropriate utterances. Note how the child speaks, answer questions, and repeats words or sounds when asked to do so. Problems in verbal communication include muteness or lack of speech, delay in learning to talk, use of speech characteristics of a younger child, or use of words in a peculiar or meaningless way. Three specific types of language peculiarities to note, if observed past the age when they typically occur, are pronoun reversal, echolalia, and the use of jargon. Examples of pronoun reversal include the child sayings, “you want a cookie”, when he or she means “I want a cookie”, or saying “I ate a cookie”, when he or she is referring to the fact you just ate a cookie. Echolalia refers to repeating or echoing what has just been said. For instance, a child may repeat questions rather than answering them. The child may even repeat, at inappropriate times, things heard in the past. This is referred to as delayed echolalia. Jargon refers to the use of strange or meaningless words with no intent to convey a message related to those words. For verbal children, remember to note the tonal quality, rhythm and volume or loudness of the voice. Also note excessive repetition past an age where this is common.

Scoring

1.      Normal verbal communication, age and situation appropriate

2.      Mildly abnormal verbal communication. Speech shows overall retardation. Most speech is meaningful; however, some echolalia or pronoun reversal may occur occasionally in a child past the age when this normally occurs. Some peculiar words or jargon may be used very occasionally.

3.      Moderately abnormal verbal communication. Speech may be absent. When present, verbal communication may be mixture of some meaningful speech or peculiar speech such as jargon, echolalia, or pronoun reversal. Some examples of peculiar speech may include speech mixed with phrases from television commercials, weather reports, baseball scores. When meaningful speech is used, peculiarities may include excessive questioning or preoccupation with particular topics.

4.      Severely abnormal verbal communication. Meaningful speech is not used; rather the child may make infantile squeals, weird or animal-like sounds, or complex noises approximating speech. The child may also show persistent, bizarre use of some recognizable words or phrases.

(XII) Nonverbal communication

         Definition. This is a rating of the child nonverbal communication through the use of facial expression, posture, gesture and body movement, it also include the child response to the nonverbal communication of others. If the child has reasonably good verbal communication skills, there may be less nonverbal communication however, those with Impairments of verbal communication may or may not have developed a nonverbal means of communication.

            Considerations. Consider particularly the child’s non-verbal communication at times when child has need or desire to communicate. Also note the child’s response to non-verbal communication of others. Does the child use gestures and facial expressions to indicate what he or she wants or where he or she wants to go? Does show extension of hands toward adults?

Scoring

1.      Normal use of nonverbal communication, age and situation and appropriate.

2.      Mildly abnormal use of nonverbal communication. The child’s use of nonverbal communication is immature. For instance, the child may only point vaguely, or reach for what he or she wants, in situations where a normal child of the same age may point or gesture more specifically to indicate what he or she wants

3.      Moderately abnormal use of nonverbal communication. The child is generally unable to express needs or desires nonverbally, and is generally unable to understand the non-verbal communication of others. He or she may take an adult’s hand to lead the adult to a desired object, but is unable to indicate this desire by gesturing or pointing.

4.      Severely abnormal use of nonverbal communication. The child only uses bizarre or peculiar gesture which have no apparent meaning, and he or she shows no awareness of the meanings associated with the gestures or facial expressions of others.

(XIII) Activity Level             

            Definition. This rating refers to how much the child moves about in both restricted and unrestricted situations. Either over activity or lethargy are part of this rating.

            Considerations. Consider both how much the child moves about in a free play situation and how he or she reacts when made to sit still. Consider the persistence of the child’s activity level. If lethargic, can the child be encouraged to move about more? If excessively active, can the child be encouraged or reminded to calm down or sit still? In making this rating, factors such as the child’s age, the distance he or she may have traveled to a testing site, the length of the testing situation, fatigue and boredom should be taken into account. Consider also the influence of medications which may affect activity level.

Scoring

1.      Normal activity level for age and circumstances. The child is neither more active nor less active than a normal child of the same age in a similar situation.

2.      Mildly abnormal activity level. The child may either be mildly restless or somewhat lazy and slow moving at times. The child’s activity level interferes slightly only with his performance. Generally it is possible to encourage the child to maintain the proper activity level.

3.      Moderately abnormal activity level. The child may be quite active and different to restrain. There may be a driven quality to the activity. He or she may appear to have boundless energy and may not go to sleep readily at night. Conversely the child may be quite lethargic and a great deal of prodding may be necessary to get him or her to move about. He or she may dislikes games requiring physical activity and may thought to be extremely lazy.

4.      Severely abnormal activity level. The child exhibits extremes of activity or inactivity and may even shift from one extreme to the other. It may be very difficult to manage the child. Hyperactivity, when present occurs in virtually every aspect of the child’s life and almost constant adult control is needed. If the child is lethargic it is extremely difficult to engage his or her motivation for any activity and adult encouragement is needed to initiate learning or task performance.

(XIV) Level and Consistency of Intellectual Response

            Definition. This rating is concerned both with the 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 normal or handicapped children. However this scale is intended to identify the extremely unusual or peak skills.

            Considerations. Consider not only the child’s use and understanding of language, numbers and concepts but also such things as how well the child remembers things he or she has seen or heard or how he or she explore the environment and figures out how things work. Particular attention should be paid to evaluating whether the child displays unusual skill in one or two areas relative to his or her general level of intellectual functioning. Does the child have special talent with numbers, rote memory or music for instance? Note concrete thinking or the tendency to take things literally past and age or functional level where this is appropriate.

Scoring

1.      Intelligence is normal and reasonably consistent across various areas. The child is an intelligent as typical children of his or her age and does not have any unusual intellectual skills or problems.

2.      Mildly abnormal intellectual functioning. The child is not as smart as typical children of the same age, and his or her skills appear fairly evenly retarded across all areas.

3.      Moderately abnormal intellectual functioning. In general the child is not as smart as typical children of the same age, however, the child may function nearly normally in one or more intellectual areas.

4.      Severely abnormal intellectual functioning. While the child generally is not as smart as the typical child of the same age, he or she function even better than the normal child of the same age in one or more areas. He or she may have certain skills which are particularly unusual for instance he or she may have special artistic or musical talent or particular facility with numbers.

(XV) General Impressions

            This is intended to be an overall rating of autism based on your subjective impression of the degree to which the child is autistic as defined by the other 14 items. This rating should be made without resource to averaging the other ratings. In making this rating all available information concerning the child should be taken into account including information from such sources as the case history, parent interviews, or past records.

Scoring

1.      No autism. The child shows none of the symptoms characteristics of autism.

2.      Mild autism. The child shows only a few symptoms or only a mild degree of autism.

3.      Moderate autism. The child shows a number of symptoms or a moderate degree of autism.

4.      Severe autism. The child shows many symptoms or an extreme degree of autism.

Interpretation of CARS Scores

After the child has been rated on each of the 15 items, a total score is computed by summing the 15 individual ratings. The child’s final classification is based on information from all 15 items. The total CARS scores may range from a low of 15, obtained when the child’s behavior is rated as falling within normal limits (1) on all 15 scales, a high of 60, obtained when the child’s behavior is rated as severely abnormal (4) on all 15 scales. A diagnostic categorization system, which aids in the interpretation of the total CARS scores, has been established based on the comparison of CARS scores with the corresponding expert clinical assessment of over 1500 children. The categorization system represents the adaptation of an earlier system in order to produce a simplified version for the use by professionals outside the field of autism. Using the categorization system, children with blow score 30, are categorized as non-autistic while those with scores of 30 and above are categorized as autistic. In addition, scores falling in the autistic range (30-60) can be divide into two categories which have been assigned descriptive labels indicating the severity of the autism. Scores ranging from 30 to 36.5 indicate mild to moderate autism while scores ranging from 37 to 60 indicate sever autism.

Total CARS Score	Diagnostic Category	Descriptive Level	% of TEACCH Population
15-29.5	Non-Autistic	Non- Autistic	46%
30-36.5	Autistic	Mild to Moderate Autism	27%
37-60.0	Autistic	Severe Autism	27%

            In our use of the CARS with over 15000 children referred to our state wide program, we have found that approximately 46% (702) fall in the non-autistic category while 54% (818) fall in the autistic category. Of the 54% who are classified as autistic, approximately half (405) are labeled mildly to moderately autistic, while the other half (413) are labeled as severely autistic using the categorization system.

The CARS was developed with the conception of autism as occurring along a continuum of disabilities. Accordingly, the CARS scores also represent a continuum. The lower the score, the fewer autistic behaviors child exhibits; the higher the score, the more autistic behaviors the child exhibit. Thus, breaking the continuum of scores to produce diagnostic categories or classification labels is somewhat arbitrary. The CARS was developed primarily to meet the needs of the TEACCCH program for both research and administrative classification of children. It was not intended to satisfy all diagnostic needs. As discussed above, the cutoffs were determined by comparing 1520 CARS scores with corresponding clinical classifications to determine the percent of agreement, false positives and false negatives. Using the autism cut off score of 30 we obtained an overall agreement rate of 87% with a false negative rate of 14.6% and a false positive rate of 10.7%. Using a severe autism cutoff score of 37 we obtained an overall agreement rate of 88.8% with a false negative rate of 14.4% and a false positive rate of 10.3%.

            These are not the only cutoff points possible for distinguishing these diagnostic groups. Just as there are valid differences in groupings according to diagnostic purpose so could other cutoff points be used for CARS? However for identifying autistic children in a large school system, the purpose for which CARS was originally designed the cutoff points previously described are optimal.

            It should be noted that it is possible for a child to obtain a CARS rating of 30 or higher and not qualify for a DSM-IV diagnosis of Autistic disorder. Likewise it is possible for a child to qualify for a DSM-IV diagnosis of Autistic Disorder and obtain a CARS score lower than 30. The DSM-IV criteria are categorical and diagnosis requires the presence of a disturbance prior to age 36 months in at least six specified areas, with at least two from the category of impaired social interaction and one each from the categories of impaired communication and restricted, repetitive and stereotyped patterns of behavior. When the DSM-IV diagnostic criteria for Autistic Disorder are not met for a child who’s CARS score is 30 or higher, consider a DSM-IV diagnosis of Rett’s disorder, Childhood Disintegrative disorder, Asperger’s disorder, or Pervasive Developmental Disorder Not Otherwise Specified. When DSM-IV criteria for Autistic disorder are met for a child who’s CARS score are under 30, the use of mild or moderate severity specifies may be appropriate.

            Finally we should like to emphasize the classification using the CARS is not intended as an endpoint in assessment. Instead, it is intended in the first step in diagnosis and grouping and should serve as the beginning point of a process to point the way for individualized assessment needed for understanding other aspects of the child’s problem, be they in language, behavior or biological functioning.

Use of the CARS with Adolescents and Adults

            A child diagnosed as autistic frequently retains the diagnosis throughout his or her life. Sometimes, however, it is necessary to evaluate adolescents or adults who have never received a diagnosis of autism. The CARS can be used for this purpose.

            The CARS scores are tended to decrease over time. This decrease in scores may reflect effects of intervention or developmental changes. When using the CARS for evaluating adolescents and adults a cutoff score of 28 is recommended as the criterion for the presence of autism, and a cutoff score of 35 is recommended as the criterion for distinguishing between moderate and severe autism. As with children, the diagnosis of autism for adolescents and adults using the CARS should mark the beginning of an individualized assessment process.