The Childhood Autism Rating Scale, Second Edition (CARS2), authored by Eric Schopler, PhD, Mary E. Van Bourgondien, PhD, Glenna Janette Wellman, PhD, and Steven R. Love, PhD, stands as a cornerstone in autism assessment. Since its inception, CARS has become a widely recognized and empirically validated tool, particularly effective in differentiating autism from intellectual disability and in distinguishing between varying severities of autism spectrum disorder (ASD).
The CARS2 represents an evolution of the original assessment, expanding its utility to better serve individuals across the autism spectrum, including those who are “high-functioning.” This revised edition is more sensitive to the nuances of autism in individuals with average or above-average IQs, stronger verbal abilities, and subtler social and behavioral challenges. While maintaining the original test’s simplicity, conciseness, and clarity, CARS2 introduces new forms and features designed to enhance diagnostic precision, evaluate functional skills, provide insightful feedback to parents, and guide the development of targeted interventions.
Exploring the Three Forms of CARS2
CARS2 is structured into three distinct forms to cater to diverse needs and age groups:
1. Standard Version Rating Booklet (CARS2-ST): This form is the direct equivalent of the original CARS and is designed for use with younger children (under 6 years) and individuals who may have communication limitations or estimated IQs below average. It provides a foundational assessment for those who may present with more overt autism symptoms.
2. High-Functioning Version Rating Booklet (CARS2-HF): This alternative form is tailored for verbally fluent individuals aged 6 years and older with IQ scores exceeding 80. CARS2-HF is designed to capture the more subtle manifestations of autism in individuals with higher cognitive and verbal abilities, addressing the specific challenges in diagnosing “high-functioning” autism.
3. Questionnaire for Parents or Caregivers (CARS2-QPC): This unscored questionnaire serves as a valuable information-gathering tool. It is completed by parents or caregivers and provides supplementary data to inform the ratings on both the CARS2-ST and CARS2-HF forms. The QPC enhances the comprehensiveness of the assessment process by incorporating caregiver insights.
Delving into the Standard and High-Functioning Forms: CARS2-ST and CARS2-HF
Both the CARS2-ST and CARS2-HF forms consist of 15 items that evaluate functional behaviors across key domains. These domains are crucial for understanding an individual’s adaptive functioning and autism-related characteristics:
Functional Areas Assessed:
- Relating to People: Evaluates the quality of social interaction and engagement with others.
- Imitation (ST) / Social-Emotional Understanding (HF): Assesses the ability to imitate actions (ST) or understand social and emotional cues (HF).
- Emotional Response (ST) / Emotional Expression and Regulation of Emotions (HF): Examines the appropriateness of emotional reactions (ST) and the ability to express and manage emotions (HF).
- Body Use: Observes atypical body movements, postures, or mannerisms.
- Object Use (ST) / Object Use in Play (HF): Assesses how objects are manipulated and used, particularly in play scenarios (HF).
- Adaptation to Change (ST) / Adaptation to Change/Restricted Interests (HF): Evaluates responses to changes in routines or environments (ST) and the presence of restricted interests (HF).
- Visual Response: Observes visual attention, tracking, and unusual visual behaviors.
- Listening Response: Assesses auditory processing and responses to sounds.
- Taste, Smell, and Touch Response and Use: Examines sensory sensitivities or unusual sensory interests related to taste, smell, and touch.
- Fear or Nervousness (ST) / Fear or Anxiety (HF): Evaluates levels of fear or anxiety in different situations.
- Verbal Communication: Assesses the use and understanding of spoken language.
- Nonverbal Communication: Observes nonverbal cues such as gestures, facial expressions, and body language.
- Activity Level (ST) / Thinking/Cognitive Integration Skills (HF): Evaluates general activity levels (ST) and cognitive processing skills (HF).
- Level and Consistency of Intellectual Response: Assesses the consistency and level of intellectual responses in various contexts.
- General Impressions: Provides an overall clinical judgment based on observed behaviors.
While the CARS2-ST items mirror those in the original CARS, the CARS2-HF items have been updated to reflect contemporary research on the characteristics of high-functioning autism and Asperger’s Syndrome. This distinction ensures that the assessment remains relevant and sensitive to the evolving understanding of ASD.
Clinicians utilize a 4-point rating scale for each item, considering not only the frequency of a behavior but also its intensity, peculiarity, and duration. This nuanced approach allows for a more comprehensive integration of diagnostic information, while still yielding quantifiable results.
The Rating Booklets for both versions are designed for practical clinical use. They offer space for note-taking and documentation, brief descriptions of each rated area to aid in recall of rating criteria, and a framework for communicating results to parents. Crucially, they include cutoff values to quickly determine if further evaluation is indicated.
Total Raw Scores are calculated by summing the ratings across all items. Each form includes a graph to facilitate the conversion of Total Raw Scores into standard scores or percentile ranks, based on a clinical sample of 1,034 individuals with autism spectrum disorders. The accompanying Manual provides detailed guidance on score interpretation, intervention suggestions, and illustrative case examples.
The Role of the Questionnaire for Parents or Caregivers (CARS2-QPC)
The CARS2-QPC is an essential component of the CARS2 assessment process. This unscored questionnaire is completed by the individual’s parent or caregiver, providing valuable background information to inform the CARS2-ST or CARS2-HF ratings. Often, the QPC serves as a basis for a follow-up interview, allowing clinicians to clarify and delve deeper into the responses provided.
Areas Covered in the CARS2-QPC:
- Early Developmental Milestones
- Social Skills
- Emotional Skills
- Communication Abilities
- Repetitive Behaviors and Interests
- Play and Routines
- Unusual Sensory Interests
By gathering comprehensive information from parents and caregivers, the CARS2-QPC ensures a more holistic and informed assessment.
CARS2: A Leading Tool for Autism Diagnosis and Support
The CARS2 stands out as an invaluable tool for identifying autism symptoms due to several key strengths:
- Comprehensive Spectrum Coverage: CARS2 effectively assesses the entire autism spectrum, aligning with current empirical research definitions of ASD.
- Extensive Empirical Foundation: It is built upon decades of use with thousands of individuals referred for autism assessment, ensuring a robust evidence base.
- Broad Age and Functional Level Applicability: CARS2 is suitable for individuals across a wide age range and varying functional abilities.
- Objective and Quantifiable Ratings: It provides concise, objective, and quantifiable ratings grounded in direct behavioral observation.
- Strong Diagnostic Validity: Scores from CARS2 demonstrate a consistent, strong, positive, and specific correlation with an autism diagnosis.
- Reliable and Consistent: Ratings are reliable across different time points, settings, information sources, and raters, enhancing the consistency of assessment outcomes.
With the addition of the High-Functioning form, a structured method for incorporating caregiver information, and guidelines linking scores to intervention strategies, the CARS2 remains a premier autism assessment tool. Its continued evolution ensures it remains at the forefront of autism diagnosis and support.
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