The childhood autism rating scale

Childhood Autism Rating Scale

C.A.R.S. - Evaluation Sheet

Instructions

For each category, use the space provided below each scale to take
notes related to the relevant behaviors for each scale. After having
After observing the child, evaluate the relevant behaviors for each item on the scale.
For each item, circle the number that corresponds to the statement that
better describe the child. You can indicate that the child is between two descriptions
using intermediate ratings of 1.5, 2.5, or 3.5. For each scale, some are presented.
abbreviated assessment criteria. See Chapter 2 of the manual for the criteria
detailed.

I. Relationship with people

There is no evidence of difficulty or abnormality concerning people.

the child's behavior is appropriate for their age. Some shyness may be observed,
nervousness or annoyance when told what to do, but not to an extent
atypical.
1.5
2. Slightly abnormal relationships. The child may avoid looking at the adult.
eyes, avoid adult or get nervous if the interaction is forced, be excessively
shy, not being as sensitive to adults as is typical, depending on parents more than the
most children of his age.
2.5
3. Moderately abnormal relationships. The child shows coldness (seems
indifferent to the adult) to voices. Strong and persistent efforts are needed to attract the
Child attention, sometimes. The child may initiate minimal contacts.
3.5
4. Deeply abnormal relationships. The child is continually cold or
indifferent to what the adult is doing. He or she almost never responds or
Establish contact with the adult. Only the most persistent attempts to attract attention.
the child's effects.

Observations:

II. Imitation
1. Appropriate imitation. The child can imitate sounds, words, and movements.
appropriate to their skill level.
1.5
2. Slightly abnormal imitation. The child imitates simple behaviors such as
applaud or simple verbal sounds most of the time; occasionally imitates only
after elbowing him, pushing him, or after a delay.
2.5
3. Moderately abnormal imitation. The child only imitates part of the time and
requires a great deal of persistence and adult help; often imitates
only after a delay.
3.5
4. Deeply abnormal imitation. The child never or rarely imitates sounds.
words or movements even pushing it not even with the help of an adult.

Observations

III. Emotional response

1. Appropriate emotional responses to both the situation and age. E1 child

shows both the degree and the appropriate type of emotional response as it
indicates through the change in facial expression, posture, and manner.
1.5
2. Slightly abnormal emotional responses. The child occasionally
in a certain way shows an inappropriate type or degree of emotional reactions. The
Reactions sometimes have no relationship with objects or events
that surround them.
2.5
3. Moderately abnormal emotional responses. The child shows signs
clear types and/or degrees of inappropriate emotional responses. Reactions can
be quite inhibited or exaggerated and have no relation to the situation, they can
make faces, laugh or stiffen even if they are not present
apparently objects or events that evoke emotion.
3.5
4. Deeply abnormal emotional responses. The responses are
rarely appropriate to the situation; once the child is in a mood
determined, it is very difficult to change it. Conversely, the child can show emotions
highly different when nothing has changed.

Observations:

IV. Use of the body

1. Use of the body appropriate to the age. The child moves with the same ease,
agility and coordination of a normal child of their age.
2. Use of the body slightly abnormal. Some may be present.
minor peculiarities, such as clumsiness, repetitive movements, coordination
poor, or rare appearance of more unusual movements.
3. Use of the body moderately abnormal Behaviors that are clearly rare
unusual for a child of his age may include strange finger movements,
peculiar postures of both fingers and body, staring fixedly or scratching oneself
body, self-directed aggression, swinging, spinning, move quickly
to walk on tiptoes.
4. Use of the body deeply abnormal. Intense and frequent movements.
of the type indicated above are signs of a profoundly abnormal use of the body. These
Behaviors may persist despite attempts to discourage them or involve the child.
in other activities.

Observations:

V. Use of the object

1. Appropriate use and interest in toys and other objects. The child shows an interest.
normal in toys and other objects appropriate to their skill level and uses those objects
appropriately.
2.Slightly abnormal interest, or slightly abnormal use of toys and others
Objects. A child may show an atypical interest in a toy or play with it in a
inappropriately childish way (for example by hitting it or sucking it)
3. Interest and moderately inappropriate use of toys and other objects.
a child may show little interest in toys and other objects, or may be
worried about using an object or toys in a strange way. He or she may
to focus on some insignificant part of a toy, to become fascinated by it
light that reflects from an object, repeatedly moving some part of the object, or playing
exclusively with an object.
4. Interest and deeply inappropriate use of toys or other objects.
A child can become entangled in behaviors like those shown above, with
a greater frequency and intensity. The child is difficult to distract when he is completely
involved in these inappropriate activities.

Observations:

VI. Adaptation to change

1. Age-appropriate response to change. While the child may realize or

Comment on the changes in the routine, accept these changes without undue distress.
2. Adaptation to slightly abnormal change. When an adult tries to change
The child can continue the same activity or use the same materials.
3. Moderately abnormal adaptation to change. The child resists in a way
activate the changes in routines, try to continue with their activity, and it is difficult to
to distract. They can become angry and unhappy when a established routine is disrupted.
4. Deeply abnormal adaptation to change. The child shows reactions
deeply affected by change. If change is forced, it may get very angry or not cooperate and
respond with tantrums.

Observations:

VII. Visual Response

1. Age-appropriate visual response. The child's visual behavior is normal.

appropriate to its ~d The vision is used together with other senses as a way of
explore the new object.
2. Slightly abnormal visual response. The child should be reminded occasionally.
looking at objects. The child may be more interested in looking at mirrors or at
the lighting systems that ~to their colleagues, can be distracted by voices or can
also avoid looking people in the eyes.
3. Moderately abnormal visual response. The child should be reminded.
frequently look at what is being done. It can be distracting, avoid looking at people.
the eyes, looking at objects from a strange angle or holding objects very close to them
eyes.
4. Deeply abnormal visual response. The child consistently avoids.
looking at people in the eyes or certain objects can show in an extreme way
visual response forms as described above.

Observations:

VIII. Auditory response

1. Appropriate auditory response for their age. The child's auditory behavior is
normal and appropriate for their age. The ear is used along with other senses.
2. Slightly abnormal auditory response. There may be a lack of response or
slightly extreme reaction to certain sounds. The responses to the sounds can
to be delayed, and the sounds may need to be repeated to attract the attention of
child. The child can be distracted by strange sounds.
3. Moderately abnormal auditory response. The child's responses to the
sounds may vary; often ignore a sound the first few times it is made:
he may get scared or cover his ears if he hears familiar sounds.
4. Deeply abnormal auditory response. The child may react to
extreme way or not reacting to sounds emitted very loudly,
regardless of the type of sound.

Observations:

IX. Use and response of taste, smell, and touch

1. Normal use and response of taste, smell, and touch. The child explores new
objects in an age-appropriate manner, generally by touching and looking. The taste
and the sense of smell can be used appropriately. When it reacts to a daily pain
The little boy expresses displeasure but does not react in a strange way.
2. Slightly normal use and response. The child may persist in putting the
objects in its mouth, can smell or touch objects that are not edible, can ignore
or react extremely to mild pains to which a normal child
would express discomfort.
3. Moderately abnormal use and response. The child may be
moderately concerned with the touch, smell, or taste of objects or people. The
The boy can either react a lot or very little.
4. Deeply abnormal use and response. The child is concerned about the
smell, taste or touch of objects more by sensation than by normal exploration
or the use of objects. The child may completely ignore the pain or react to it.
extreme way in response to a slight discomfort.

Observations:

X. Fear or Nervousness

1. Normal fear or nervousness. The child's behavior is appropriate to both

situation like at his/her age.
2. Slightly abnormal fear or nervousness. The child occasionally shows
too much or too little fear or nervousness compared to a child's reaction
normal for the same age in a similar situation.
3. Moderately abnormal fear or nervousness. The child shows either a
a little more or rather a little less fear than what is typical even for a child more
small in similar situations.
4. Deeply abnormal fear or nervousness. The fear persists even
after a repeated experience with innocuous events and objects. It is
extremely difficult to calm or comfort the child. The child may, on the contrary, not
show the appropriate caution against risks that other children of the same age avoid.

Observations:
XI. Verbal communication

1. Normal and appropriate verbal communication for both age and situation.
2. Slightly abnormal verbal communication. E1's speech shows a delay in
general. Most of what they express makes sense, however, there may be
repetition or inversion of pronoun. Occasionally, it may say strange words or
nonsense.
3. Moderately abnormal verbal communication. May not speak. When it
verbal communication can be a blend of language with full meaning and
peculiar language with nonsense, repetitions or pronoun inversion. The
peculiarities in language with meaning include excessive questions or concern
about specific topics.
4. Deeply abnormal verbal communication. There is no meaningful language.
A child can produce childish squeals, strange sounds, or sounds like animals.
complex noises that resemble speech, or it may show a persistent and rare use
of some recognizable words or phrases.

Observations:

XII. Non-verbal communication

1. Normal use of age-appropriate nonverbal communication for the situation.

2. Slightly abnormal use of non-verbal communication. The immature use of
non-verbal communication; it can point vaguely or serve for what it wants, in
situations where children of the same age can point or gesture more
specifically to indicate what they want.
3. Moderately abnormal use of nonverbal communication. The child is
generally unable to express needs or desires non-verbally, and not
can understand the non-verbal communication of others.
4. Deeply abnormal use of non-verbal communication. The child only uses
strange or peculiar gestures that make no apparent sense, and do not show knowledge of the
meaning associated with the gestures or facial expressions of others.

Observations:

Level of activity

1. Normal activity level for his age and circumstances. The child is either more
more active or less active than a normal child of the same age in a similar situation.
2. Slightly abnormal activity level. The child may either be slightly
moved or in some way 'lazy' and sometimes slow-moving. The level of
the child's activity is only slightly interfered with in its execution.
3. Moderately abnormal activity level. The child can be quite active.
difficult to stop. It can have unlimited energy and it may not sleep well.
night. On the contrary, the child may be quite lethargic and need quite
I pushed to make him move.
4. Level of profoundly abnormal activity. The child shows extremes of
activity or inactivity and can even range from one extreme to the other.

Observations:

XIV. Level and consistency of intellectual response

1. Normal intelligence and reasonably consistent in various areas. The child is

as smart as any child of his age and has no skills
rare intellectuals nor problems.
2. Slightly abnormal intellectual functioning. The child is not that bright.
Like children of their age, the skills are quite delayed in various areas.
areas.
3. Moderately abnormal intellectual functioning. In general, the child is not
as bright as children of their age; however, it can function almost
normally in one or more intellectual areas.
4. Deeply abnormal intellectual functioning. Although generally cl
the child is not as bright as those of his age, he can even function better than a
normal child of his same age in one or more areas.

Observations:

XV. General impressions

1. No autism. The child shows no characteristic symptoms 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. Profound autism. The child shows many symptoms or an extreme degree of
autism

Observations:

Childhood Autism Rating Scale

Eric Schopler PhD, Robert J. Reichler MD, and Barbara Rochen Renner PhD.
Introduction

The Child Autism Scale is a behavioral assessment scale consisting of 15 items.

designed to identify children with autism, and to distinguish them from those with delays
mental without autism syndrome. It also distinguishes from children with autism.
moderate to children with profound autism. It was originally built in
more than 15 years (Reichler & Schopler, 1971) in order to train clinicians to
that they had a more objective diagnosis of autism through a more detailed questionnaire
useful. The scale of the 15 items incorporates (a) the primary traits of autism
Kanner, (b) other characteristics noted by Creak, which are found in many,
but not in all, the children who can be considered autistic, and (c) additional scales
useful in the treatment of the characteristic symptoms of younger children.

Development of the CARS method

The 1988 edition of CARS is the result of a process of use, evaluation, and
modification over approximately 15 years and involving more than 1500 cases. The
the scale was primarily developed as a research tool in response
to the limitations of the classification instruments available at that time. The
original scale, developed by CHILD RESEARCH PROJECT at the university of
North Carolina in Chapel Hill was primarily based on certain criteria of
consensus diagnoses for autism as reported by the British Working Party
It was referred to as the Childhood Psychosis Scale (CPRS)
(Reichle & Schopler, 1971) to minimize confusion with the more reduced
definition of Kanner's autism. Now, however, since the definition of
autism has been broadened and no longer refers to the restrictive definition that Kanner made in a
First, we call our instrument CARS (The Childhood Autism Rating)
Scale).
The original scale was revised in order to assess children within a
program for the entire state of North Carolina. The program was for the
treatment and education of the autistic and children with communication problems
(TEACCH Division). TEACCH started in 1966 as the first program at a national level
of state for the autistic and similarly for children and adults with intellectual disabilities, designed
to provide extensive services, research, and training. It is especially abundant
in three major areas of the child's life: home, school, and community. Five
Regional centers provide a diagnostic assessment and advice to parents to improve.
the adaptation of the family and the home. Special education is provided in about 40 classes located
in public schools, and under the charge of trained and supervised teachers by the
TEACCH staff. The relationships between the community and special needs.
the child's behavior is moderated through parent groups related to each class and
center. Although each center is located in a branch of the university system of
state, most of our research focuses on the University of Carolina of
North, in Chapel Hill, where the CARS was developed.
As is typical of the population with developmental problems, 75%
Approximately our cases are male. The age distribution is similar.
for both sexes, with approximately 57% having less than 6 years in the
moment of entering the program, a 32% between 6 and 10, and an 11% of ten or more. E1
economic status of our clients, as measured by the two factors of
Hollingshead-Redlich (1958), (profession and education), in the index it is IV, the second
lower than five categories. Approximately 67% of our population is white,
30% is black and 3% is from other races. This reflects the existing racial distribution.
in the public schools of North Carolina. Most of our sample reflects
intellectual deficit, as measured by standardized tests such as the WISC,
Merrill-Palmer, Bayley, and Leiter International Performance Scale. Approximately
71% have an IQ below 70, with only approximately a
17% with an intelligence quotient between 70 and 84, and 13% with 85 or higher. (table I)

Relationships with other criteria of diagnosis and scales

Five important systems for the diagnosis of autism have been widely
used. These include Kanner's criteria (1943), Creak's points (1961), the
definition of Rutter (1978), that of the National Society for Autistic Children (NSAC,
1978), and the DSM-III-R (1987). Although widely used for clinical diagnosis and the
research, none of these five systems have had a relationship with a scale of
measurement or verification. Although these five coincide in the general traits of
autism, they also have notable differences.
When we first developed our diagnosis appraisal 14 years ago
(Reichler & Schopler, 1971) Kanner's (1943) definition was the basic system for
the diagnosis of autism. It was followed by the 9 points of Creak (1961) which had
as a mission to extend it to a broader definition that could also include the
childhood schizophrenia. These nine points from Creak were among the first
criteria based on the observation of behavior rather than on theory. However,
they were difficult to use for research because they were never quantified. The lack
from a development perspective, they made it particularly difficult to use with children
small. Although Creak's points include autism and schizophrenia, De Myer and
others (1971) concluded that Creak's nine points for childhood schizophrenia
corresponded more specifically to autism than to schizophrenia, as it was
Used by Rimland (1964). It is important to keep in mind that the research of
Kolvin (1971) who demonstrated the distinction between autism and childhood schizophrenia.
it had not yet been published.

TABLA l (información demográfica) -- N: 1.606 casos

I.Gender Women Men

371 160
24.3% 75.7%
Race Blacks Whites Others
450 996 43
30.2% 66.9% 2.9%
III. Social class
(Hoilinqshead) I II III IV V
 128 131 317 466 371
9.1% 9.3% 22.4%
IV.Ageatstart0-5 6-10 11+
847 480 171
56.4% 32.0% 11.4%
V. Coc. intellect. 0 - 6 9 70-8485+
841 197 153
70.6% 16.5% 12.8%

C.A.R.S. - AUTISM RATING SCALE

CHILDISH
Eric Schopler, Ph.D., Robert J. Reichler, M.D. and Barbara Rochen Renner, Ph.D.
Published by WPS (Los Angeles, California)

NAME: ..............................................................

..........................

...............................................

TEST DATE:

Year

DATE OF BIRTH:

Year

CHRONOLOGICAL AGE:
............................

EVALUATOR: ............................................................................................................

..

Rating score of the categories

I II III IV V VI VII VIII IX X XI XII XIII XIV XV T

TOTAL

Total score
15 18 21 24 27 30 No Autism
33 36 Mild or moderate autism
39 42 45 48 51 54 57 60 Deep Autism

The following three diagnosis systems were of more recent origin. There are
some differences between the three systems that reflect the different intentions for
which were produced. Rutter's definition (1978) was based on the most thorough
evaluation of the empirical research published since Kanner's publications
Creak. The definition of NSAC (1978), developed by the Advisory Cabinet
Professional (NSAC) under the direction of Ritvo, aimed for use in the
formation of a social policy, in legislation and for public knowledge.
DSM-III-R represents the classification system formulated by the American Association
of Psychiatry. All three of these systems coincide on three basic traits of autism:

1) Early onset age (before 30 months)

2) Continual lack of response to other people
3) Deterioration of verbal and cognitive functions.

Both Rutter's criteria and DSM-III-R consider traits as

primary the rare interest or the attachments to objects and the resistance to change of
routines. The definition of NSAC states response disturbances to stimuli
sensorial, which is considered more idiosyncratic in Rutter's definitions and
DSM-III-R. These diagnostic differences are discussed further (Schopler and Rutter,
1978). However, the design of the CARS scale incorporates all five of these.
systems. In the Rational Scale section (below), each item is marked accordingly
its consistency with these five systems. Interested user can estimate the
scope within which a child is considered autistic according to the five
definitions already described, and thus resolve some of the confusion of diagnosis that still
remains in their community.
A number of other schemes for the evaluation of autism have been published.
These include the measuring instruments developed by Ruttenberg and others.
(1966). This measurement scale of eight (BRIAAC) has been used to evaluate the
effects of the treatment, but not the diagnosis of the children. A Scale of
Behavior Observation Scale (BOS) for autism was developed by Freeman and
others (1978), an Observation Instrument for Autism Planning
Educational (ASIEP), by Krug and others (1979), and a check, the E-2, was proposed by
Rimland (1964). However, in a recent critique of diagnostic systems,
Parks (1983) clearly shows that in none of the studies that mention
of these three instruments, children with conduct disorder were included. Therefore
Thus, the distinguishing validity has not been established, nor has it yet been demonstrated
used for the individual diagnosis of children, a use for which this scale (CARS) was created
specifically designed.