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Childhood autism rating scale (CARS)

Psychodiagnostics Lab- II

Kanikha. k

2339423

2MPCLB
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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 potential

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
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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 Related 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
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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.
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Report

Demographics:

Name: IA

Age: 6 years 8 months

Gender: Male

Date of Birth: 11-11-2018

Education: Class II, CBSE board

Languages Known: English, Tamil

Address: Bangalore

Religion: Hindu

Informant: Mother

Purpose of Testing

This assessment was administered for academic purposes to train in administering and

scoring the CARS 2 as a part of the Master’s program in Clinical Psychology

Assessment Procedure

Basic demographic information about the child, including their name, age, and gender, is

collected along with additional relevant details. Informed consent is obtained from the parents,

and the child's assent is also secured. A rapport is established with the child, and the instructions

for the questionnaire are explained using simple language. Any questions from the child are

addressed.The CARS assessment procedure is followed, encompassing various domains to

evaluate different aspects such as general impression, communication, behavior, and the child's

responses. Clear instructions are provided before each assessment, and any questions from the
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participant are answered. The participant is given pencil and paper as needed. The scores for

each section are recorded.

Brief History

Child A is a 7-year-old in the second grade, from an upper-middle-class family. His

mother is a homemaker, and his father is a manager. He has a keen interest in sports, particularly

football, and participates in extracurricular activities daily. Although there are some concerns

about his hyperactivity and inattention, they are not severe enough to require significant

intervention. There are no notable academic challenges reported, but his parents do mention that

they need to encourage him to complete his homework and attend online tutoring.

Upon observation, the child appears to be very active and can engage in conversations with

strangers. However, his speech is rapid and often inappropriate. He frequently talks without

showing respect to his elders, which is a concern for his parents.

Behavioural Observations

A is a well-groomed boy with healthy hair and nails. His weight and height are typical for

his age group, and his speech abilities are also on par with children of the same age. A notable

observation about A is his tendency to be constantly on the move. It was challenging for him to

stay seated in one spot, and he frequently climbed the furniture in his home. He did not respond

to his mother’s repeated requests for him to sit down. A also speaks rapidly and has a lot to say,

articulating his thoughts clearly. He shows a particular interest in physical play and maintains a

high energy level even after a day at school and football coaching. Although he may appear shy

around strangers, he generally gets along well with others.

Results:

Relating to People: With a score of 1, IA's social interactions are generally

age-appropriate, but he does exhibit some minor challenges. He may occasionally find it difficult

to start or continue interactions with peers and adults. In unfamiliar settings, He can interact

quite well with people he knows well. To further enhance his social skills and peer interactions,

implementing strategies like structured playdates and using social stories could be helpful.

Imitation: This rating is based on how the child imitates other verbal and nonverbal acts. The

behavior to be imitated should clearly be within the child's abilities. Remember that this area is

intended to be an assessment of the ability to imitate, not the ability to perform specific tasks or

behaviors. The child's scored 1 in this which indicates words, and movements that are

appropriate for his skill level.

Emotional Response: This score indicates that IA emotional responses are typical for his age. He

likely exhibits appropriate emotional reactions to different situations, such as displaying

happiness, sadness, or frustration in ways similar to his peers. This suggests good emotional

regulation and understanding, which are positive indicators of his emotional development.

Boody Use: A score of 1 indicates that IA's body use is typical for his age. He exhibits normal

physical movements and coordination, participating in activities such as running, jumping, and

playing without any major issues. This suggests that his motor skills are well-developed, and

there is no need for additional intervention.

Object Use: This score suggests that IA engages with objects in a manner appropriate for his age.

He likely plays with toys, tools, and other items as they are meant to be used, participating in
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common play activities like building with blocks, playing with action figures, or using art

supplies. This indicates strong fine motor skills and suitable cognitive development in terms of

object usage.

Adaptation to Change:A score of 1 indicates that IA responds to changes in routines or

transitions in an age-appropriate manner. He typically handles unexpected changes with minimal

discomfort or resistance, showing flexibility in adjusting to new situations. This suggests that IA

adapts well and does not require significant support to manage changes in his environment.

Consistent routines and preparing him for changes can still be beneficial to maintain his

adaptability and comfort.

Visual Response:.A score of 1 indicates that IA responds to visual stimuli in a typical manner for

his age. He generally follows visual instructions and notices details in his environment without

significant difficulty. This suggests that his visual processing skills are developing well, and he

uses visual cues effectively.

Listening Response With a score of 1, IA demonstrates normal listening behavior and responses

to auditory information for his age. He processes verbal instructions adequately, even in slightly

noisy or distracting environments. His listening skills are on par with his peers, and he responds

appropriately to both human voices and other sounds in his surroundings.

Taste, Smell, and Touch Response and Use - This score reflects that IA has typical sensory

responses in terms of taste, smell, and touch. He generally does not show significant sensitivities

in these areas and can navigate a range of sensory experiences comfortably. This indicates a

well-developed sensory processing system for these modalities.

Fear or Nervousness -A score of 1 implies that IA exhibits a typical level of fear or nervousness

for his age. He likely manages stressful or anxiety-provoking situations in a manner similar to his

peers, demonstrating appropriate caution without excessive fear. This points to strong emotional

resilience and coping skills

Verbal Communication - This score indicates that IA’s verbal communication skills are typical

for his age. He likely communicates effectively through speech, using a good vocabulary and

articulating his needs, thoughts, and feelings clearly. This is a strong area for IA, reflecting good

language development.

Non-Verbal Communication - A score of 1 suggests that IA’s non-verbal communication skills

are typical. He likely utilizes gestures, facial expressions, and body language effectively to

enhance his verbal communication. This signifies good social communication skills, which are

crucial for engaging with others.

Activity Level - This score indicates a slightly higher-than-average activity level. IA may be a bit

more energetic or restless compared to his peers, showing a preference for physical activities and

possibly finding it challenging to sit still for extended periods. This can be managed by

integrating regular physical breaks and activities into his routine to positively channel his energy.

Level and Consistency of Intellectual Response -A score of 1 suggests that IA demonstrates a

typical level and consistency in intellectual responses. He likely excels in cognitive tasks,

exhibiting good problem-solving skills and consistent intellectual abilities that are appropriate

for his age. This indicates a solid cognitive foundation.

General Impression: This is intended to be an overall rating of autism based on your subjective

impression of the degree to which the child has autism as defined by the other 14 items. No

autism spectrum disorder. The child shows none of the symptoms characteristic of autism.

Table: CARS

Category Ratings

Relating to People 1

Imitation 1

Emotional Response 1

Boody Use 1

Object Use 1

Adaptation to Change 1

Visual Response 1

Listening Response 1

Taste, Smell, and Touch Response and Use 1

Fear of Nervousness 1
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Impression

Based on the scores provided, IA exhibits typical behaviors and abilities across a wide

range of developmental domains. His scores indicate that he relates to people, imitates, and

responds emotionally in ways that are appropriate for his age. His physical movements, object

use, adaptability to change, visual and listening responses, sensory processing, and

communication skills are all within normal ranges for his developmental stage.

The slightly elevated score in activity level suggests that IA may be a bit more energetic

or restless compared to his peers, but this is not considered atypical. Overall, IA displays no

symptoms of autism, indicating typical development across the assessed areas.

Recommendation

Given IA's overall typical developmental scores, it is recommended to support his

slightly elevated activity level by incorporating regular physical activities and breaks throughout

his day. This will help him channel his energy positively and maintain focus during quieter times.

Maintaining a structured environment with clear expectations will continue to support his

adaptability and ease any potential anxiety during transitions. Encouraging participation in group

activities and playdates can further enhance his social skills and interactions with peers.

Additionally, fostering his verbal and non-verbal communication through regular conversations,

shared reading, and opportunities for self-expression will support his communication

development. To keep his cognitive abilities engaged, providing age-appropriate puzzles, games,

and educational activities is advisable. Lastly, ongoing communication with parents and

caregivers is essential to ensure IA’s needs are met and any concerns are promptly addressed.

These strategies will support IA’s continued growth and well-being across various developmental

domains.

These recommendations are aimed at supporting IA’s overall development and ensuring he

continues to thrive in his environment.

References
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Chu, J. H., Bian, F., Yan, R. Y., Li, Y. L., Cui, Y. H., Li, X. W., ... & Lu, C. M. (2022).

Comparison of diagnostic validity of two autism rating scales for suspected autism in a large

Chinese sample. World Journal of Clinical Pediatrics, 11(2), 47-55.

Jurek, L., Baltazar, M., Gulati, S., Novakovic, N., Zhu, Z., & Rahbar, M. H. (2022). Response

(minimum clinically relevant change) in ASD symptoms after an intervention according to

CARS-2: Consensus from an expert elicitation procedure. European Child & Adolescent

Psychiatry, 31(6), 895-907.

Chakraborty, S., Bhatia, T., Antony, N., Roy, A., Shriharsh, V. R., Madaan, P., & Deshpande, S.

N. (2022). Comparing the Indian Autism Screening Questionnaire (IASQ) and the Indian Scale

for Assessment of Autism (ISAA) with the Childhood Autism Rating Scale–Second Edition

(CARS-2). PLOS ONE, 17(9), e0273780.

Hemedan, N., & Maharmeh, L. (2022). The psychometric properties of the Jordanian version of

the Childhood Autism Rating Scale–Second Edition (CARS2-HF). Dirasat: Human and Social

Sciences, 49(3), 358-366.

Sanchez, M. J., & Constantino, J. N. (2020). Expediting clinician assessment in the diagnosis of

autism spectrum disorder. Developmental Medicine & Child Neurology, 62(12), 1432-1437

Appendix
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