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

1. CARS scores vs. DSM-IV clinical diagnosis 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 Perry, A., Condillac, R. A., Freeman N. L., Dunn-Geier, J., & Belair J. (2005) Findings: High degree of concordance between CARS and clinical diagnoses (DSM-IV) Negative correlation using CARS between autism severity and cognitive level Clinically defined groups differed in scores in significant/sensible ways, however autistic disorder vs. PDD-NOS still some overlap

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

CARS does not clearly differentiate individuals with other ASDs Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F. (2004) Findings: CARS distinguishes individuals with AD from other developmental disorders 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 diagnoses of AD Easy to train Can be done quickly Useful with wide age range Does not include peer relationships, joint attention, or symbolic play Does not differentiate between individuals with other ASDs Dated (terminology) 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.