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Childhood Autism Rating Scale,

Second Edition
(CARS2)

MANUAL

Eric Schopler, Ph.D., Mary E. Van Bourgondien, Ph.D.,

G. Janette Wellman, Ph.D., and Steven R. Love, Ph.D.
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Copyright 2010 by Western Psychological Services. All rights reserved.

Not to be reproduced, adapted, and/or translated in whole or in part without
prior written permission of WPS (rights@wpspublish.com).
Second edition published 2010
Sixth printing: April 2015
18 17 16 15 6789
Printed in the United States of America

WPS and Test with Confidence are registered trademarks and CARS is a trademark of
Western Psychological Services. Names of other companies, products, or services
mentioned herein may be trademarks, registered trademarks, or service marks of
their respective mark owners.

Related products from WPS

Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)
Developmental Profile 3 (DP-3)
Monteiro Interview Guidelines for Diagnosing Aspergers Syndrome (MIGDAS)
Sensory Processing Measure (SPM)
Social Responsiveness Scale, Second Edition (SRS-2)
Adaptive Behavior Assessment System, Third Edition (ABAS-3)

For more information about these and other products from WPS, please contact
WPS Customer Service at 800-648-8857 or customerservice@wpspublish.com,
or visit our website at www.wpspublish.com.

Reference citation
In citing this manual, please use the following:
Schopler, E., Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism
Rating Scale, Second Edition [Manual]. Torrance, CA: Western Psychological Services.

10 9 8 7 6 5 4
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Dedication

This publication is dedicated to our mentor, Dr. Eric Schopler,

whose vision created the TEACCH program and the first edition
of the Childhood Autism Rating Scale, both of which have
withstood the test of time. His insight into the past, the present,
and especially the future was invaluable as we worked together
with him to develop a new version of the scale, the CARS2-HF.
Thank you, Eric. We miss you.

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CONTENTS

List of Figures ............................................................................................................................................. viii

List of Tables .............................................................................................................................................. viii

Preface ........................................................................................................................................................... xi

Acknowledgments ...................................................................................................................................... xiii

Part I: Administration, Scoring, Interpretation, and Intervention Guide

Chapter 1. Introduction .............................................................................................................................. 3

General Description .................................................................................................................. 4
Advantages of the CARS2 ....................................................................................................... 5
Intended Users and Uses of the CARS2-ST and CARS2-HF ................................................. 5

Chapter 2. Administration and Scoring of the CARS2-ST ........................................................................ 7

General Considerations for Making CARS2-ST Ratings ....................................................... 7
How to Make CARS2-ST Observations and Ratings .............................................................. 8
Item 1. Relating to People .............................................................................................. 8
Item 2. Imitation .............................................................................................................. 9
Item 3. Emotional Response ........................................................................................... 9
Item 4. Body Use ............................................................................................................ 9
Item 5. Object Use ........................................................................................................ 10
Item 6. Adaptation to Change ....................................................................................... 10
Item 7. Visual Response ............................................................................................... 10
Item 8. Listening Response .......................................................................................... 11
Item 9. Taste, Smell, and Touch Response and Use .................................................... 11
Item 10. Fear or Nervousness ....................................................................................... 12
Item 11. Verbal Communication .................................................................................. 12
Item 12. Nonverbal Communication ............................................................................ 13
Item 13. Activity Level ................................................................................................. 13
Item 14. Level and Consistency of Intellectual Response ........................................... 13
Item 15. General Impressions ....................................................................................... 14
Using the CARS2-QPC to Inform CARS2-ST Ratings ........................................................ 14
Case Example: Michaels CARS2-ST Ratings ...................................................................... 15
Scoring the CARS2-ST Rating Booklet ................................................................................ 16

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Chapter 3. Administration and Scoring of the CARS2-HF ..................................................................... 23

General Considerations for Making CARS2-HF Ratings ..................................................... 23
How to Make CARS2-HF Observations and Ratings ........................................................... 24
Item 1. Social-Emotional Understanding ..................................................................... 24
Item 2. Emotional Expression and Regulation of Emotions ....................................... 25
Item 3. Relating to People ............................................................................................ 25
Item 4. Body Use .......................................................................................................... 26
Item 5. Object Use in Play............................................................................................. 26
Item 6. Adaptation to Change/Restricted Interests ...................................................... 26
Item 7. Visual Response ............................................................................................... 27
Item 8. Listening Response .......................................................................................... 27
Item 9. Taste, Smell, and Touch Response and Use .................................................... 28
Item 10. Fear or Anxiety ............................................................................................... 28
Item 11. Verbal Communication .................................................................................. 29
Item 12. Nonverbal Communication ............................................................................ 29
Item 13. Thinking/Cognitive Integration Skills ........................................................... 30
Item 14. Level and Consistency of Intellectual Response ........................................... 30
Item 15. General Impressions ....................................................................................... 31
Using the CARS2-QPC to Inform CARS2-HF Ratings ........................................................ 31
Case Example: Daniels CARS2-HF Ratings ........................................................................ 32
Scoring the CARS2-HF Rating Booklet ................................................................................ 33

Chapter 4. Interpretation and Feedback ................................................................................................... 43

Interpretation of CARS2-ST and CARS2-HF Scores ........................................................... 43
General Considerations ................................................................................................. 43
Case Example: Michaels Diagnosis ..................................................................................... 49
Case Example: Daniels Diagnosis ........................................................................................ 49
Bridging the Gap: Providing Diagnostic Feedback to Parents .............................................. 50
When the Diagnosis Is an Autism Spectrum Disorder ................................................ 51
When the Diagnosis Is Not an Autism Spectrum Disorder ......................................... 54

Chapter 5. Intervention Planning and Resources .................................................................................... 57

Structured Teaching as a Foundation for Understanding and Intervention .......................... 57
Addressing the Social Interaction Domain .................................................................. 59
Addressing the Communication Domain ..................................................................... 60
Addressing Restricted Interests and Patterns of Behavior............................................ 61
Addressing the Sensory World and Associated Features ............................................ 61
Addressing Thinking Style and Cognitive Issues ........................................................ 62
Case Example: Intervention Planning for Michael ............................................................... 63
Case Example: Intervention Planning for Daniel .................................................................. 63

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Part II: Technical Guide

Chapter 6. Development of the CARS Method ....................................................................................... 67

Relationship of the CARS to Diagnostic Criteria and Scales ............................................... 67
Rationale for the 15 CARS Rating Items ............................................................................... 68
Development of the CARS2-HF and Its Relationship to the CARS ..................................... 69
Relationship of the CARS2-HF to Diagnostic Criteria and Research .................................. 69
Social and Emotional Impairment ................................................................................ 70
Restricted and Repetitive Patterns of Behavior ........................................................... 71
Communication Impairment ......................................................................................... 71
Cognitive Features ........................................................................................................ 72
Other Associated Features ............................................................................................ 72

Chapter 7. Psychometric Properties ......................................................................................................... 73

Development of the Original CARS and CARS2-HF ........................................................... 73
Development Sample for the Original CARS .............................................................. 73
CARS2-ST Verification Sample ................................................................................... 74
CARS2-HF Development Sample ................................................................................ 76
Reliability ............................................................................................................................... 76
Internal Consistency Reliability ................................................................................... 76
Interrater Reliability ......................................................................................................78
Stability of Ratings Over Time ..................................................................................... 80
Standard Error of Measurement ................................................................................... 80
Validity .................................................................................................................................... 81
Internal Structure of CARS2-ST and CARS2-HF Item Ratings ................................. 81
Relationship of Clinical Diagnosis to CARS2-ST and
CARS2-HF Total Scores ............................................................................................... 85
Relationship of Total Scores on the Original CARS and CARS2-HF to
Other Measures of Autism ............................................................................................ 87
Relationship of Scores on the Original CARS to Age ................................................. 89
CARS2-ST and CARS2-HF Item Rating Patterns Related to Diagnosis,
Cognitive Functioning, and Age ................................................................................... 89
Research Uses of the CARS ................................................................................................... 93
Summary ................................................................................................................................. 93

References .................................................................................................................................................. 103

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Figures

1. Completed CARS2-ST Rating Booklet for Michael ........................................................................... 17

2. Completed CARS2-HF Rating Booklet for Daniel ............................................................................. 34

3. Dimensions of Autism Symptoms ....................................................................................................... 53

Tables

1. Items Rated on the CARS2-ST and the CARS2-HF ............................................................................. 4

2. Interpretive Categories Associated With CARS2-ST Total Raw Score Ranges ................................ 44

3. Interpretive Categories Associated With CARS2-HF Total Raw Score Ranges ................................ 44

4. Interpretive Categories Associated With CARS2-ST or CARS2-HF T-Score Ranges ...................... 45

5. CARS2-ST Items Most and Least Likely to Receive High Item Ratings for
Individuals With Autism ...................................................................................................................... 46

6. CARS2-ST Items Most and Least Likely to Receive High Item Ratings for
Younger and Older Individuals With Autism ...................................................................................... 47

7. CARS2-HF Items Most and Least Likely to Receive High Item Ratings for
Individuals With High Functioning Autism or Aspergers Disorder .................................................. 47

8. CARS2-HF Items Most and Least Likely to Receive High Item Ratings for
Individuals With High Functioning Autism or PDD-NOS ................................................................. 47

9. CARS2-HF Items Most and Least Likely to Receive High Item Ratings for
Individuals With High Functioning Autism or ADD .......................................................................... 48

10. CARS2-HF Items Most and Least Likely to Receive High Item Ratings for
Individuals With High Functioning Autism or LD ............................................................................. 48

11. CARS2-HF Items Most and Least Likely to Receive High Item Ratings for
Individuals With High Functioning Autism or Other Clinical Diagnoses ......................................... 48

12. CARS2-ST Items Related to Areas of Intervention ............................................................................ 58

13. CARS2-HF Items Related to Areas of Intervention ........................................................................... 58

14. Demographic Characteristics of the Development Sample for the Original CARS .......................... 74

15. Demographic Characteristics of the CARS2-ST Verification Sample ............................................... 75

16. Demographic Characteristics of the CARS2-HF Development Sample ............................................ 77

17. Corrected Item-to-Total Correlations for CARS2-ST Item Ratings

in the CARS2-ST Verification Sample ................................................................................................ 78

18. Corrected Item-to-Total Correlations for CARS2-HF Item Ratings

in the CARS2-HF Development Sample ............................................................................................. 78

19. Interrater Reliability for Item Ratings on the Original CARS ............................................................ 79

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20. Item Rating Reliability for CARS2-HF Items .................................................................................... 79

21. Correlations Between Item Ratings on the CARS2-ST for Individuals

in the CARS2-ST Verification Sample ................................................................................................ 82

22. Correlations Between Item Ratings on the CARS2-HF for Individuals

in the CARS2-HF Development Sample ............................................................................................. 82

23. Factor Analytic Results for Item Ratings in the CARS2-ST Verification Sample ............................ 83

24. Factor Analytic Results for Item Ratings of Individuals With an Autism Spectrum Disorder
in the CARS2-HF Development Sample ............................................................................................. 84

25. Factor Analytic Results for Item Ratings of Individuals Without an Autism Spectrum Disorder
in the CARS2-HF Development Sample ............................................................................................. 84

26. Relationship Between Total Score Categories and Autism Diagnosis

in the Development Sample for the Original CARS ........................................................................... 85

27. Average CARS2-HF Scores for Various Clinical Groups .................................................................. 87

28. Average Ratings for CARS2-HF Items ............................................................................................... 88

29. Relationship Between CARS2-HF Total Score Categories and Autism Diagnosis
in the CARS2-HF Development Sample ............................................................................................. 88

30. Relationship Between CARS2-ST Item Ratings and Total Score for Individuals
in the CARS2-ST Verification Sample ................................................................................................ 90

31. Relationship of CARS2-ST Item Ratings and Total Score for Individuals
With Low or High Cognitive Functioning and a Diagnosis of Autism .............................................. 92

32. Relationship of CARS2-ST Item Ratings and Total Score for Younger and
Older Individuals in the CARS2-ST Verification Sample ................................................................... 94

33. Relationship of CARS2-ST Item Ratings and Total Score for Individuals
With Low Cognitive Functioning and a Diagnosis of Autism or PDD-NOS ..................................... 95

34. Relationship of CARS2-ST Item Ratings With Total Score and CARS2-HF Item Ratings
With Total Score for Individuals With a Diagnosis of Autism ........................................................... 96

35. Relationship of CARS2-HF Item Ratings With Total Score for Individuals
With a Diagnosis of Autism or Aspergers Disorder .......................................................................... 97

36. Relationship of CARS2-HF Item Ratings With Total Score for Individuals
With a Diagnosis of Autism or PDD-NOS .......................................................................................... 98

37. Relationship of CARS2-HF Item Ratings With Total Score for Individuals
With a Diagnosis of Autism or ADHD ................................................................................................ 99

38. Relationship of CARS2-HF Item Ratings With Total Score for Individuals
With a Diagnosis of Autism or a Learning Disorder ........................................................................ 100

39. Relationship of CARS2-HF Item Ratings With Total Score for Individuals
With an Autism or a Non-Autism-Related Clinical Diagnosis ......................................................... 101

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Preface

The Childhood Autism Rating Scale (CARS) has been in use since 1971 in
the form published as an appendix to Schopler, Reichler, DeVellis, and Daly
(1980). The 1988 edition allowed for continuity of use from the first version. It
also included additional data analysis, resulting in new and broader use of the
scales. In particular, the changes in the 1988 edition allowed for use by a greater
variety of professionals trained in different disciplines, with the observation data
gathered from a greater variety of sources and incorporating differences existing
in diagnostic systems. In addition to observations during formal testing sessions,
the scales could also be rated from relevant medical records, classroom
observations, and parent reports.
The early working edition of the CARS was used primarily by trained
diagnosticians in making observations and ratings while observing specific
psychological test sessions. Its applications were expanded in the 1988 edition. A
number of other professionals, including medical students, pediatric residents,
special educators, school psychologists, speech pathologists, and audiologists
were thus enabled to make reliable use of this instrument. In the 1988 edition, the
15 scale items were identified according to their consistency with the major
diagnostic systems then extant for identifying the presence of autism. This
enabled users to evaluate CARS ratings according to any one of those five
diagnostic systems. The features of the CARS included in the 1988 edition
allowed for broader clinical and research use, while maintaining continuity with
existing systems.
This Second Edition of the CARS has added new features to further extend
the utility of the instrument. A new formthe CARS2 High-Functioning Version
(CARS2-HF)has been added for evaluating high-functioning individuals in
whom the presence of autism, Aspergers Disorder, or PDD-NOS is suspected.
The items from the original CARS form are presented in a redesigned format
the CARS2 Standard Version (CARS2-ST) formthat is even easier to use and
includes new features. Support for the use of the CARS2-ST and CARS2-HF
provided in the Second Edition includes the availability of standard scores based
on a mixed clinical sample of individuals with developmental problems and an
updated literature review. Guidance for obtaining information from and
discussing results with parents is offered. Recommendations are made of helpful
resources for designing interventions in each area evaluated by the CARS2-ST
and CARS2-HF. Researchers engaged in longitudinal research wherein the
original CARS has been used should note that the content of CARS2-ST items
and the recommended clinical cutoff values have not been changed from the
original version.
The psychometric support presented in this Second Edition manual is based
on data collected at a number of sites around the country, including North
Carolinas Division TEACCH. Clinicians interested in further verifying the
generalizability of the CARS to other regions of the country, and to other
countries, are referred to Campbell and Palij (1985), Eaves and Milner (1993),
Garfin, McCallon, and Cox (1988), Kurita, Miyake, and Katsuno (1989), Sevin,
Matson, Coe, Fee, and Sevin (1991), Sturmey, Matson, and Sevin (1992), and
Teal and Wiebe (1986).

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Acknowledgments
1988 Edition
This instrument has been in the making for more than 15 years. It has had
the thoughtful attention of more colleagues than can be recalled at this time.
However, the authors wish to acknowledge the invaluable contribution of
Alexandra Adams and Susan Rosenthal in collecting the data for the expanded
use of the CARS. Margaret D. Lansing patiently collected clinical examples of
ratings. Robert DeVellis and Ken Daly provided the data and analysis of the first
CARS edition, and Bob McConnaughey contributed the admirable computer
program and analysis of the expanded sample for this edition. Sue Ellis and her
mastery of the word processor enabled us to review several drafts. The development
of this edition of the CARS was supported in part by the U.S. Department of
Education Contract #330-80-0841.

Second Edition
The CARS2-HF represents the work of our clinical directors and psycho-
educational therapists at the nine TEACCH Centers located around the state of
North Carolina. Their efforts and the contributions of research site coordinators
and their clients across the country have been essential to the development and
evaluation of this extension of the original CARS. We value the participation of
all who have contributed their time and attention to the renewal of this important
instrument for the purpose of helping those with autism and their families in the
coming decades.

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Part I

Administration, Scoring, Interpretation,

and Intervention Guide
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1
INTRODUCTION
The Childhood Autism Rating Scale, Second Edition
(CARS2) includes three forms and this updated manual. The
three forms are the two Rating BookletsChildhood Autism
Rating Scale, Second EditionStandard Version (CARS2-ST;
formerly titled CARS) and the Childhood Autism Rating
Scale, Second EditionHigh-Functioning Version (CARS2-
HF)and the Questionnaire for Parents or Caregivers
(CARS2-QPC). The CARS2-ST and CARS2-HF are not
intended as screeners for use in the general population. Their
primary value lies in their providing brief, quantitatively
specific and reliable yet comprehensively based summary
information that can be used to help develop diagnostic
hypotheses among referred individuals of all ages and func-
tional levels. CARS2-ST and CARS2-HF ratings are made
based not only on the frequency of behaviors, but also on their
intensity, peculiarity, and duration. This allows for great
flexibility in integrating comprehensive information about a
case, and at the same time yields consistent quantitative
results. Professionals can also use CARS2 results to help in
giving diagnostic feedback to parents, characterizing func-
tional profiles, and guiding intervention planning.
Each of the two rating forms asks about 15 areas of
behavior defined by a unique rating system developed to
assist in identifying individuals with autism spectrum
disorders (ASDs) and distinguishing them from individuals
with other diagnoses. The CARS form from the 1988 edition
has been renamed the CARS2-ST. It includes the same rating
areas that comprised the original CARS form, and it is
designed to be even easier to use than its predecessor, with
ample room for clinical note taking and documentation. Each
booklet now includes a Summary section where a Raw Score
table allows the Total score to be easily converted to a
standard score based on a clinical sample of those with ASDs.
The standard scores are intended to reflect a continuum of the
behavioral problems that are related to autism and are useful
when the goal of a clinician or researcher is to make
comparative judgments regarding the level of autism-related
behaviors present in a given individual or group, or to evaluate
changes in the level of such behaviors, independent of
diagnostic status. In the context of diagnosis, the ability to
make interpretations based on relative score elevations is
likely to be of use. As always, practitioners should be mindful
3
of the limitations described in chapter 4. Researchers engaged
in longitudinal research wherein the original CARS has been
used should note that the content of CARS2-ST items and the
recommended clinical cutoff values have not been changed
from the original version. The new Questionnaire for Parents
or Caregivers (CARS2-QPC) is an unscored questionnaire
provided for acquiring information from parents or caregivers
for subsequent use by professionals making CARS2-ST or
CARS2-HF ratings.
This updated manual includes the following: detailed
instructions about how to make CARS2-ST and CARS2-HF
ratings, including a discussion about using the CARS2-QPC
(chapters 2 and 3); guidance for interpreting the CARS2-ST
and CARS2-HF and for providing feedback to parents, and
case examples (chapter 4); guidance for using obtained
ratings in combination with other resources to plan
interventions (chapter 5); detailed information about
CARS2-ST and CARS2-HF development (chapter 6); and a
description of validity work that supports the use of both
forms and includes a review of work that has appeared in the
professional literature since the 1988 edition of the CARS
was published (chapter 7).
Since its original publication, the CARS has become one
of the most widely used and empirically validated instruments
advancing the field of autism diagnosis. The instrument
continues to be a very important measure contributing to the
diagnosis of children with autism. The CARS2-ST is
especially effective in discriminating between children with
autism and children with severe cognitive deficits (Morgan,
1988; Teal & Wiebe, 1986). It further distinguishes children
with autism in the mild-to-moderate range from children with
autism in the moderate-to-severe range. However, since the
original publication of the CARS, the autism spectrum has
been expanded to include more individuals who have near-
average or better IQ scores, better verbal skills, and more
subtle social and behavioral deficits.
The CARS2-HF was developed as an alternative to the
original CARS in helping to identify high functioning
individuals with autism or Aspergers Disorder. Thus, the
CARS2-HF does not replace the original CARS. Instead, it
provides another option for practitioners and researchers
who are working with verbally fluent individuals 6 years of
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4 Administration, Scoring, Interpretation, and Intervention Guide
age and older with IQs greater than 80. The original CARS,
now titled the CARS2-ST, is still appropriate for children
under age 6 or individuals 6 and older who have less than
average intelligence or notable communication difficulties.
The CARS2-HF preserves the basic structure of the
original CARS. It includes 15 rating areas, each with a 4-
point rating system. The items have been amended to reflect
the current research on the diagnostic characteristics of
individuals with at least near-average intelligence (with an
estimated overall IQ of at least 80) and autism or Aspergers
Disorder. More detailed information about the development
of the CARS2-HF is provided in chapter 6.
General Description
The CARS2-ST and CARS2-HF each include 15 items
that ask respondents to rate an individual on a scale from 1
to 4 in key areas related to autism diagnosis. A list of the
rating items included on each form is provided in Table 1.
Samples of the complete Rating Booklets and detailed
instructions for their use are provided in chapters 2 and 3. In
each booklet, comprehensive descriptions are provided of
each of the 15 functional areas to be rated. Detailed item-
specific rating anchors are provided that give specific
examples of the kinds of behavior represented at each rating
level. The rating values given for the 15 areas are summed to
produce a Total score. For each form, Total score cutoff
values are provided that help to determine whether further
comprehensive evaluation for the presence of autism is
warranted. Total scores can also be converted to standard
Table 1
Items Rated on the CARS2-ST and the CARS2-HF
CARS2-ST items
For rating referred individuals under
age 6, or over age 6 and with an
estimated overall IQ of 79 or lower or
with notably impaired communication
1. Relating to People
2. Imitation
3. Emotional Response
4. Body Use
5. Object Use
6. Adaptation to Change
7. Visual Response
8. Listening Response
9. Taste, Smell, and Touch Response and Use
10. Fear or Nervousness
11. Verbal Communication
12. Nonverbal Communication
13. Activity Level
14. Level and Consistency of Intellectual Response
15. General Impressions
scores based on a sample of 1,034 individuals with autism
spectrum diagnoses. Information is provided in chapter 4
and chapter 7 of this manual about CARS2-ST and CARS2-
HF Total score results obtained for those in other diagnostic
groups as well.
The psychometric properties of the CARS2-ST and
CARS2-HF have been investigated based on ratings for over
3,600 individuals. The information in this manual describes
both the original CARS development sample of 1,606
individuals referred for autism evaluations and current
samples comprising 1,999 additional individuals from
clinical and nonclinical settings. CARS2-ST and CARS2-
HF Total scores are associated with interrater reliability
estimates of .71 and .96, respectively. Internal consistency
reliability is estimated at .93 for the CARS2-ST and .96 for
the CARS2-HF. Validity research examined the use of the
forms in a variety of settings, with groups of individuals
with and without an autism diagnosis, and evaluated
CARS2-ST and CARS2-HF results in relation to results of
other screening and diagnostic instruments. Results support
the use of each form as accurate quantitative measures of
behavioral problems that are specific to the presence of
autism in a given case. The forms appear to be both sensitive
and specific to behavioral problems associated with autism.
In addition, over the decades that the CARS has been in use,
its psychometric properties have been investigated by
numerous researchers. Detailed information about research
directly examining CARS2-ST and CARS2-HF reliability
and validity during their development and with updated
samples is presented in chapter 6 and chapter 7 of this
CARS2-HF items
For rating referred individuals
aged 6 and older, with an estimated
overall IQ of 80 or higher, with
fluent communication
1. Social-Emotional Understanding
2. Emotional Expression and Regulation of Emotions
3. Relating to People
4. Body Use
5. Object Use in Play
6. Adaptation to Change/Restricted Interests
7. Visual Response
8. Listening Response
9. Taste, Smell, and Touch Response and Use
10. Fear or Anxiety
11. Verbal Communication
12. Nonverbal Communication
13. Thinking/Cognitive Integration Skills
14. Level and Consistency of Intellectual Response
15. General Impressions
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Chapter 1 Introduction
manual. Summaries of key studies that have appeared in the
professional literature about the CARS2-ST form are
included in chapter 6.
Advantages of the CARS2
The emphasis of the CARS2 on behavioral and empirical
data makes it suitable for use by appropriately informed
persons from various professions. Both the CARS2-ST and
CARS2-HF were based on current research regarding the
central features of autism. The CARS2-ST was based on the
early findings by Kanner (1943) and Creak (1961) and over
time has been shown to also capture the basic symptoms ad-
dressed in all editions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM; American Psychiatric
Association, 1952, 1968, 1980, 1987, 1994, 2000). The
CARS2-HF is based on the original CARS but has been
adapted based on current research literature for use in identi-
fying the behavioral characteristics of higher functioning
individuals with autism or Aspergers Disorder. Thus, ratings
on both forms are extremely useful for identifying the
presence of behavioral symptoms of autism to support the
diagnostic process and also for research and classification
purposes. The CARS2-ST and CARS2-HF offer several other
significant advantages over other instruments:
1. The forms include items that ask about a broad range
of diagnostic criteria and reflect the broadened, data-
based definition of the autism syndrome that has
evolved as a result of continued empirical research.
2. The development of the scale, refinement of its
application, and support for its use are based on
decades of use with thousands of referred individuals.
3. The items are presented in such a way that they can
be rated for individuals across most, if not all, ages
and functional levels.
4. The CARS2-ST and CARS2-HF provide concise
objective and quantifiable ratings based on direct
behavioral observation while at the same time
offering comprehensive coverage and clinical
documentation across a wide variety of autism signs
and symptoms. Item ratings can be used to inform
intervention planning. Guidance for how to use
CARS2 ratings and other resources in the process of
planning interventions is provided in chapter 5.
5. The CARS2 instruments are particularly helpful as
points of departure for giving diagnostic feedback to
parents. The forms describe the breadth and intensity
of symptoms associated with an ASD. This helps
parents feel confident that the particular behaviors of
their child have been adequately considered in the
course of a comprehensive evaluation. They can
easily discern how the single-score result represents a
synthesis of comprehensive observational, interview,
and archival information. Guidance for using the
CARS2 forms in the context of providing feedback to
parents is provided in chapter 4.
5
In the past, clinical practice has been hampered by
inconsistent use of diagnostic criteria and confusion in the
diagnosis of autism. However, over the years there has been
increased empirical research regarding appropriate
systematic diagnostic criteria and widespread acceptance of
the behavioral criteria exemplified in the CARS2-ST and
CARS2-HF. Although some differences among professionals
persist, the trend toward empiricism has greatly increased the
diagnostic consensus about autism.
Intended Users and Uses of the
CARS2-ST and CARS2-HF
The CARS2 instruments are appropriate for use in a
variety of settings, including schools, clinics, and
intervention programs. Details regarding research
examining their use across settings and raters are provided
in chapter 6 of this manual. To summarize, the use of ratings
made by a variety of well-informed professionals who are
not necessarily psychodiagnosticians to help identify the
presence of autism has been examined and such use is
generally supported. Professionals such as physicians,
special educators, school psychologists, speech pathologists,
and audiologists, who have had exposure to and training
about autism, can acquirethrough relatively brief
trainingthe ability to make valid ratings. These uses must
remain within each users scope of practice, however. For
example, a school psychologist might use results to
determine educational placement, but not a medical
diagnosis; a teacher might use results to inform the creation
of a curriculum plan; and similarly, speech and hearing
specialists and occupational therapists could design
treatment regimens in their practice.
It should be noted in this context that although CARS2-
ST and CARS2-HF ratings can be made during diverse
conditions, such as a parent interview, a classroom
observation, or a case history review, it is important to keep
in mind that these instruments by themselves do not produce
a diagnosis. To obtain a diagnosis, other factors, including
the individuals developmental history, medical symptoms,
and other unique characteristics of each case, must be
evaluated by experienced professionals who are experts in
autism, trained in the process of differential diagnosis, and
authorized to make clinical diagnoses.
One difference between the CARS2-ST and the
CARS2-HF is that in order to complete ratings on the
CARS2-HF one must have information from multiple
sources. For example, to complete the CARS2-HF it is
necessary to have information from a direct observation of
the person being rated as well as an interview with someone
who knows of that persons behavior in different settings.
The CARS2-ST, on the other hand, can be completed based
on information from a single source, such as a parent
interview or a direct observation session. Although
information from multiple sources is needed to make the
diagnosis of autism, care should be taken when basing
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6 Administration, Scoring, Interpretation, and Intervention Guide
CARS2-ST ratings on information from multiple sources.
Direct observations should generally be given more weight
than the reports of others. When including information from
the reports of others, the professional should include
specific examples to help determine if the person giving the
report is in fact talking about the type of behavior addressed
in a given rating area.
The CARS2-HF is intended to assist in determining
whether a high functioning individual has sufficient
symptoms to be considered for a diagnosis of autism or
Aspergers Disorder. With an increasing number of high
functioning children being referred for evaluations,
convergent evidence from multiple sources is even more
critical than usual in the differential diagnostic process.
Ratings on the CARS2-HF require that consideration be given
to behavioral presentations encountered in multiple settings.
This makes it particularly suitable to support identification of
high functioning individuals with autism in the varied school-
based or clinical situations where such children are often
evaluated. However, this means that the information needed to
complete this form must come from a variety of sources,
including direct observations and interactions with the
individual in question, as well as his or her parents, teachers,
or other sources. Thus, the professional completing the
CARS2-HF must be in a position to gather sufficient data
from a variety of sources to make his or her ratings.
It is important to note that parents should not be asked
to complete the CARS2-ST or the CARS2-HF. Information
from parents should be obtained using the CARS2-QPC and
a direct interview.
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2
ADMINISTRATION AND SCORING
OF THE CARS2-ST
This chapter presents detailed guidance for making
CARS2-ST ratings. Guidance for making CARS2-HF
ratings is presented in chapter 3. Much of the material in this
chapter is taken directly from the 1988 edition of the CARS
Manual, with only relatively minor updating. The general
principles underlying the process remain unchanged. Thus
the ratings section will be familiar to those already experi-
enced with the 1988 edition. That section is followed by a
discussion of how to use the CARS2-QPC when making
CARS2-ST ratings. A case is then described to demonstrate
the assignment of individual CARS2-ST item ratings based
on direct observation. The final section of this chapter
describes the process of converting CARS2-ST ratings to a
Total score and a Total standard score. Guidance for inter-
preting scores and providing feedback to parents is provided
in chapter 4. Suggestions on how to use CARS2-ST ratings
and other resources to support intervention planning are
offered in chapter 5. Researchers engaged in longitudinal
research wherein the original CARS has been used should
note that the content of CARS2-ST items and the recom-
mended clinical cutoff values have not been changed from
the original version.
The CARS2-ST Rating Booklet (WPS Product No.
W-472A) should be used for assessing individuals with
estimated overall IQs of 79 or lower, who have notably
impaired communication, or who are younger than 6 years
of age regardless of their estimated IQ. Individuals in the
samples on which CARS2-ST scoring is based were age 2 or
older. However, clinicians do sometimes use the CARS2-ST
informally to evaluate younger children. When the CARS2-ST
is used informally as a way to collect and organize
information about children younger than 2, it is particularly
important to include multiple sources of information and
formulate clinical hypotheses in light of all available data. To
assess individuals with IQs of 80 or higher who have
relatively good verbal skills and who are aged 6 or older, use
the CARS2-HF Rating Booklet (WPS Product No. W-472B),
described in chapter 3.
Condensed versions of the guidelines in this chapter for
making ratings appear in the CARS2-ST booklet.
Abbreviated guidance for obtaining raw and standard scores
is also included there. The CARS2-ST booklet has been
7
redesigned to accommodate detailed note taking regarding
behavioral observations, information from diverse sources,
or unique information that may be of use in interpreting
score results, planning interventions, or delivering feedback
to parents. Familiarity with the criteria for making ratings
on the CARS2-ST should be gained to achieve the best
understanding of the foundation for making ratings. Raters
should be familiar with all of the information presented in
this manual. Mere review of the abbreviated information in
the Rating Booklet is insufficient preparation to administer
the CARS2-ST. It is important to note that parents should
not be asked to complete the CARS2-ST or the CARS2-HF.
Information from parents should be obtained using the
CARS2-QPC and a direct interview.
General Considerations for
Making CARS2-ST Ratings
In making ratings, you should compare the individuals
behavior with that of a typically developing individual of the
same age. When behaviors are observed that are not typical
for an individual of the same age, the peculiarity, frequency,
intensity, and duration of these behaviors should be
considered. All behavior should be rated without recourse to
causal explanations. Although some of the behaviors
resulting from autism are similar to behaviors caused by
other disorders, it is important simply to rate the degree to
which the individuals behavior deviates from typical
development without making judgments about whether the
behavior may be explained away as being caused by other
medical, psychiatric, or cognitive disorders. The appropriate
rating values thus made and the pattern of the impairments
will help to distinguish individuals with autism from those
with other disorders.
Once the collection of information has been completed,
use the notes recorded in the Observations section for each
item to assist in making the CARS2-ST rating. Before
deciding on a rating value, you may find it helpful to reread
all of the behavior descriptions for that item. Rating values
for each of the 15 CARS2-ST items range from 1 to 4.
Generally, a rating value of 1 indicates that an individuals
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8 Administration, Scoring, Interpretation, and Intervention Guide
behavior is within normal limits for an individual of that
age. A value of 2 means that the individuals behavior is
mildly abnormal compared with a person of the same age. A
value of 3 indicates that the individuals behavior is
moderately abnormal for that age. A value of 4 indicates that
the individuals behavior is severely abnormal for someone
of that age. In addition to these four ratings, the midpoints
between them (1.5, 2.5, and 3.5) should be used when the
behavior appears to fall between two categories. For
example, if a behavior is mildly-to-moderately abnormal, it
should be rated 2.5. Thus the seven allowable ratings for
each item are 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
Remember that in determining the degree of abnormality,
you must take into consideration not only the individuals
chronological age, but also the peculiarity, frequency,
intensity, and duration of his or her behavior. Peculiarity
encompasses the extent to which a behavior is unusual or
odd in general, as opposed to whether it is delayed or like
the behavior of a younger child. Frequency refers to how
often a behavior happens. Intensity refers to how extreme a
behavior is when it happens and how resistant to change it
is. Duration refers to how long a behavior lasts. The greater
the degree to which an individual differs along these
dimensions from a typically developing individual of the
same age, the more abnormal his or her behavior would be
and the higher the value that would be assigned. For most
items on the CARS2-ST, a rating of 4 indicates the presence
of a very unusual behavior that is persistent and extremely
difficult to reduce or modify.
How to Make CARS2-ST
Observations and Ratings
CARS2-ST ratings can be made from observations
made in various settings, such as psychological testing or
classroom participation, parent reports about their children,
comprehensive clinical records, or a combination of these
sources. As the rater, you should be familiar with the
descriptions and scoring criteria for all 15 items before
beginning the information collection process. Descriptions
provided in the CARS2-ST booklet are meant to serve only
as a cue and not as a substitute for careful study of the item
descriptions and rating criteria presented in this section. All
CARS2-ST areas must be rated to achieve a meaningful
Total score. Any single source of information can be used as
long as it can provide all of the information required for
rating all 15 areas. As you obtain the necessary information,
make brief notes concerning relevant behaviors in the
Observations section provided for each of the items. Actual
ratings should not be made until the collection of all relevant
information has been completed.
Each of the 15 CARS2-ST rating areas is defined over
the following pages. A description of the behavior that is
referenced by each item is offered and item-specific
considerations are discussed. These considerations are
followed by examples illustrating the basis on which each
rating value would be assigned.
Because the CARS2-ST is most frequently used with
young children, the item rating guidance appears as it was
first written, referring to children. This should not discourage
those who wish to rate the behaviors of adolescents or adults
from doing so. Sufficient information is available about
CARS2-ST ratings of adolescents and adults to support such
use of the instrument.
Item 1. Relating to People
Definition. This is a 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 behavior ranging from persistent,
intensive attempts at making the child respond to the
allowance of complete freedom. In particular, note how
persistent or forceful the adult must be to get the childs
attention. Note the childs reaction to physical contact; to
physical signs of affection, such as hugging or stroking; and
to praise or criticism. Consider the degree to which the child
clings to parents or others. Note whether the 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 childs behavior is appropriate for his
or her age. Some shyness, fussiness, or annoyance at
being told what to do may be observed, but not to a
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 be-
come 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 some-
what more than most children of the same age.
3 Moderately abnormal relationships. The child shows
aloofness (seems unaware of adult) at times. Persistent
and forceful attempts are necessary to get the childs
attention at times. Minimal contact is initiated by the
child; contact may have an impersonal quality.
4 Severely abnormal relationships. The child is consis-
tently 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 at-
tempts to get the childs attention have any effect.
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Chapter 2 Administration and Scoring of the CARS2-ST
Item 2. 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 childs abilities. Remember that
this area 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 or skills the
child has already demonstrated spontaneously.
Considerations. Verbal imitation might involve
repeating simple sounds or long sentences. Physical
imitation might involve imitating hand movements or
movements of the whole body, cutting with scissors, copying
shapes with a pencil, or playing with toys. Make sure the
child understands 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, unable to understand that the
adult wants him or her 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 imitation occurs fairly immediately or after a
considerable delay.
Scoring:
1 Appropriate imitation. The child can imitate sounds,
words, and movements that 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.
Item 3. Emotional Response
Definition. This is a rating of how the child reacts to
both pleasant and unpleasant situations. It involves a
determination of whether the childs 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 of affection or praise, a mild
tickle, a favorite toy or food, or a pleasant game of rough-
house. Also evaluate how the child responds to unpleasant
stimuli such as scolding or criticism, the removal of a favorite
toy or food, difficult work demands, discipline, or painful
procedures. Inappropriate type of response may include
9
such things as laughing when being disciplined 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 tantrumming,
or becoming highly agitated and excited in response to a
minor event.
Scoring:
1 Age-appropriate and situation-appropriate emotional
response. 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 response. The child occa-
sionally displays a somewhat inappropriate type or de-
gree of emotional reactions. Reactions are sometimes
unrelated to the objects or events surrounding them.
3 Moderately abnormal emotional response. The child
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 objects or events
are present.
4 Severely abnormal emotional response. 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 markedly different emotions during a
short period of time when nothing has changed.
Item 4. Body Use
Definition. This area represents a rating of both coordi-
nation and appropriateness of body movements. It includes
such deviations as posturing, spinning, tapping, rocking,
toe-walking, and self-directed aggression.
Considerations. Consider such activities as cutting
with scissors, drawing, or putting together puzzles in addi-
tion to active physical games. Evaluate the frequency and in-
tensity of bizarre body use. Reactions to attempts by the
examiner to prohibit bizarre body use should be observed 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 more unusual movements, as in category 3.
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 or body posturing, staring or picking at
the body, self-directed aggression, rocking, spinning,
finger-wiggling, or toe-walking.
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 10
10
4 Severely abnormal body use. Intense or frequent
movements of the type listed in category 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.
Item 5. Object Use
Definition. This is a rating of both the childs interest in
toys or other objects, and his or her 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 childs skills and interests. Note the level of
interest the child displays. Pay particular attention to the
childs use of toys with parts that dangle or spin; for instance,
an excessive preoccupation with spinning the wheels on a toy
truck or car instead of rolling the toy. Note overly 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
that normally are of no interest to a child with similar skills.
For example, does the child spend excessive time flushing and
reflushing the toilet or watching water run in the sink? Does
the child seem preoccupied with something such as a phone
book, which has lists but no pictures? Finally, consider
whether the child uses toys or objects in a more appropriate
way or usual manner after being shown how.
Scoring:
1 Appropriate interest in, or use of, toys and other
objects. The child shows normal interest in toys and
other objects appropriate for his or her skill level and
uses these toys in an appropriate manner.
2 Mildly inappropriate interest in, or use of, 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 when these
behaviors are normal.
3 Moderately inappropriate interest in, or use of, 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, or use of, toys or
other objects. The child may engage in the same
behaviors as in category 3, 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 childs inappropriate
use of the object.
Administration, Scoring, Interpretation, and Intervention Guide
Item 6. Adaptation to Change
Definition. This item concerns difficulties in changing
established routines or patterns and in changing from one
activity to another. These difficulties are often related to the
repetitive behaviors and patterns rated on previous items.
Considerations. Note the childs reaction to changing
from one activity to another, particularly if the child was
actively involved in the previous activity. Note the childs
reaction to attempts at modifying patterned responses or
behaviors. For example, if left alone the child may repeatedly
stack blocks in a particular pattern. Note the childs reaction
to adult attempts at changing the pattern. Consider how the
child reacts to a change in routine. For example, does the child
show signs of distress when guests arrive unexpectedly,
causing a change in routine, when driven to school by a
different route, when furniture is rearranged, when a
substitute teacher or new child is introduced in the classroom?
Does the child establish 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 changes in routine, he or she
accepts these changes without undue distress.
2 Mildly abnormal adaptation to change. When an adult
tries to change tasks, the child might continue to do the
same activity or use the same materials, 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 via a new route, but is easily calmed.
3 Moderately abnormal adaptation to change. The child
actively resists changes in routine. When a change of
activity is attempted, the child tries to continue the old
activity and is difficult to distract. For example, he or
she may insist on trying to replace furniture that has
been moved. Or 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 reactions that are
difficult to eliminate. If a change is forced on the child,
he or she may become extremely angry or uncoopera-
tive, and perhaps respond with tantrums.
Item 7. Visual Response
Definition. This is a rating of unusual visual attention
patterns found in many individuals on the autism spectrum.
This rating includes the childs response when he or she is
required to look at objects or material.
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 out only of
the corners of his or her eyes? When engaged in social
interaction, does the child look the other person in the eye or
does he or she avoid eye contact? How often must the child
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Chapter 2 Administration and Scoring of the CARS2-ST
be told to look when working on a task? Must the adult turn
the childs head to obtain his or her attention? Rating of
unusual visual response also includes observation of
peculiar behaviors, such as the childs gazing at his or her
wiggling fingers or becoming absorbed in watching
reflections or movement.
Scoring:
1 Age-appropriate visual response. The childs 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 at mirrors or
lighting than most children of the same age, or he or she
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 from an unusual angle,
or hold 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, as already described.
Item 8. Listening Response
Definition. This is a rating of unusual listening
behavior or unusual responses to sounds. It involves the
childs reaction to both human voices and other types of
sound. This item is also concerned with the childs interest
in various sounds.
Considerations. Consider unusual preferences for, or
fear of, certain everyday sounds such as those made by
vacuum cleaners, washing machines, or passing trucks. Note
whether the child reacts inappropriately to the loudness of
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 childs interest in sounds and be sure the
childs response is to the sound rather than to the sight of the
object producing the sound.
Scoring:
1 Age-appropriate listening response. The childs
listening behavior is normal and is appropriate for
children of the childs age. Listening is used together
with other senses, such as seeing or touching.
2 Mildly abnormal listening response. There may be
11
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 the child. The
child may, at times, be distracted by extraneous sounds.
3 Moderately abnormal listening response. The childs
responses to sounds may often 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 over-
reacts and/or underreacts to sounds to an extremely
marked degree, regardless of the type of sound.
Item 9. Taste, Smell, and Touch Response and Use
Definition. This is a rating of the childs response to
stimulation of the taste, smell, and touch senses (including
pain). It is also a rating of whether the child makes appro-
priate use of these sense modalities. In contrast to the dis-
tance senses of hearing and vision rated in the previous two
areas, this is a rating of the near senses.
Consideration. Consider whether the child shows either
excessive avoidance of or excessive interest in certain odors,
foods, tastes, or textures. Is the child preoccupied with feeling
certain surfaces such as the tabletop, or textures such as fur or
sandpaper? Does the child smell 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 occa-
sional, exploratory, infantile mouthing and touching in a
younger child from the more frequent, peculiar, or intense
type of behavior that 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 explores 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 to minor, everyday
pain resulting from such things as a bump, fall, or pinch,
the child expresses discomfort but does not overreact.
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 smell or taste
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,
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 12

12 Administration, Scoring, Interpretation, and Intervention Guide

and touch. The child is preoccupied with smelling, use of speech and language. Assess not only the presence or
tasting, or feeling objects more for the sensation than for absence of speech but also the peculiarity, bizarreness, or
the normal exploration or use of the objects. The child inappropriateness of all elements of the childs utterances
may completely ignore pain or react very strongly to when speech is present. Thus, when speech of any sort is
something that is only slightly uncomfortable. present, assess the childs vocabulary and sentence
Item 10. Fear or Nervousness structure; the tonal quality, volume or loudness, and rhythm
of utterances; and the situation appropriateness of the
Definition. This is a rating of unusual or unexplainable
content of meaning of the childs speech.
fears. However, it also includes rating the absence of fear
Considerations. Consider the frequency, intensity, and
under conditions where a typically developing child at the
extensiveness of peculiar, bizarre, or inappropriate utterances.
same developmental level would be likely to show fear or
Note how the child speaks, answers questions, and repeats
nervousness.
words or sounds when asked to do so. Problems in verbal
Considerations. Fearful behavior may include such
communication include muteness or lack of speech, delay in
things as crying, screaming, hiding, or nervous giggling.
learning to talk, use of speech characteristics of a younger
When making this rating, consider the frequency, severity,
child, or use of words in a peculiar or meaningless way. Three
and duration of the childs reaction. Do the fears appear
specific types of language peculiarities to note, if observed
reasonable or understandable? Also consider the
past the age when they typically occur, are pronoun reversal,
pervasiveness of the response. Is it confined to a single type
echolalia, and the use of jargon. Examples of pronoun reversal
or class of situation, or is it widespread over many or all
include the child saying You want a cookie when he or she
situations? Would same-aged, typically developing children
means I want a cookie, or saying I ate a cookie when he or
react this way in similar situations? The intensity of the
she is referring to the fact you just ate a cookie. Echolalia
response may be assessed by how difficult it is to calm the
refers to repeating or echoing what has just been said. For in-
child. This type of reaction may occur upon separation from
stance, a child may repeat questions rather than answering
parents, in response to physical closeness, or upon being
them. The child may even repeat, at inappropriate times,
lifted off the ground in physical contact play. Unusual
things heard in the past. This is referred to as delayed
responses may occur to specific items, such as rain, a doll, a
echolalia. Jargon refers to the use of strange or meaningless
puppet, Play-Doh, and so on. Another type of unusual fear
words with no intent to convey a message related to those
response is the failure to show appropriate fear for such
words. For verbal children, remember to note the tonal quali-
things as heavy traffic or strange dogs, to which typically
ty, rhythm, and volume or loudness of the voice. Also note ex-
developing children react. Remember to consider unusual
cessive repetition past an age where this is common.
nervousness. Is the child particularly jumpy, startling easily
in response to normal sound or movement? Scoring:
Scoring: 1 Normal verbal communication, age and situation
appropriate.
1 Normal fear or nervousness. The childs behavior is
appropriate both to the situation and to his or her age. 2 Mildly abnormal verbal communication. Speech
shows overall delay. Most speech is meaningful;
2 Mildly abnormal fear or nervousness. The child
however, some echolalia or pronoun reversal may occur
occasionally shows fear or nervousness that is slightly
occasionally in a child past the age when this typically
inappropriateeither too much or too littlewhen
occurs. Some peculiar words or jargon may be used very
compared to the reaction of a typically developing child
occasionally.
of the same age in a similar situation.
3 Moderately abnormal verbal communication. Speech
3 Moderately abnormal fear or nervousness. The child
may be absent. When present, verbal communication
shows either quite a bit more or quite a bit less fear than
may be a mixture of some meaningful speech and some
is typical even for a younger child in a similar situation.
peculiar speech such as jargon, echolalia, or pronoun
It may be difficult to understand what is triggering the
reversal. Some examples of peculiar speech may include
fear response, and it is difficult to comfort the child.
speech mixed with phrases from television
4 Severely abnormal fear or nervousness. Fears persist commercials, weather reports, and baseball scores.
even after repeated experience with harmless events or When meaningful speech is used, peculiarities may
objects. In an evaluation session, the child may remain include excessive questioning or a preoccupation with
fearful without apparent reason throughout the entire particular topics.
session. It is extremely difficult to calm or comfort the
4 Severely abnormal verbal communication. Meaningful
child. The child may, conversely, fail to show appropri-
speech is not used; rather, the child may make infantile
ate regard for hazards, such as strange dogs or heavy
squeals, odd noises or animal-like sounds, or complex
traffic, which other children of the same age avoid.
noises approximating speech. The child may also show
Item 11. Verbal Communication persistent, bizarre use of some recognizable words or
Definition. This is a rating of all facets of the childs phrases.
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 13
Chapter 2 Administration and Scoring of the CARS2-ST
Item 12. Nonverbal Communication
Definition. This is a rating of the childs nonverbal com-
munication through the use of facial expression, posture, ges-
ture, and body movement. It also includes the childs response
to the nonverbal communication of others. If the child has rea-
sonably good verbal communication skills, there may be less
nonverbal communication; however, a child with impairments
of verbal communication may or may not have developed a
nonverbal means of communication.
Considerations. Consider, particularly, the childs use
of nonverbal communication at times when the child has a
need or desire to communicate. Also note the childs
response to the nonverbal communication of others. Does
the child use gestures or facial expressions, for instance, to
indicate what he or she wants to eat or to play with, or does
he or she try to use an adults hand as an extension of his or
her own? Does the child use gestures to indicate where he or
she wants someone to go, or does he or she try to pull the
person to lead him or her there?
Scoring:
1 Normal use of nonverbal communication, age and
situation appropriate.
2 Mildly abnormal use of nonverbal communication.
The childs 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 typically developing child of the same age may
point or gesture more specifically to indicate what he or
she wants.
3 Moderately abnormal use of nonverbal communica-
tion. The child is generally unable to express needs or
desires nonverbally and is generally unable to under-
stand the nonverbal communication of others. He or she
may take an adults 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 uses only bizarre or peculiar gestures that
have no apparent meaning, and he or she shows no
awareness of the meanings associated with the gestures
or facial expressions of others.
Item 13. Activity Level
Definition. This rating refers to how much the child
moves about in both restricted and unrestricted situations.
Either overactivity 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 childs
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? For this
rating, factors such as the childs age, the distance he or she
may have traveled to the testing site, the length of the testing
situation, fatigue, and boredom should be taken into
13
account. Consider, also, the influence of medications that
may affect activity level.
Scoring:
1 Normal activity level for age and circumstances. The
child is neither more active nor less active than a
typically developing 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 childs activity level interferes only slightly
with his or her 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 difficult 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 dislike games
requiring physical activity and may be 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 childs 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.
Item 14. Level and Consistency of Intellectual Response
Definition. This rating is concerned both with the
childs 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 typical children or in those with other
problems besides autism. However, this area is intended to
identify extremely unusual or peak skills.
Considerations. Consider not only the childs 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 explores the environ-
ment and figures out how things work. Particular attention
should be paid to evaluating whether the child displays un-
usual 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 literal-
ly past an age or functional level where this is appropriate.
The purpose of this item is to document significant
variability within cognitive skills, and in particular whether
a child has unusual peak skills. Identifying learning
disabilities is not the focus of this item, so discrepancies
between cognitive functioning and achievement testing are
not intended to be included in this rating. The only exception
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 14
14
would be if the child has unusual, isolated strengths in
reading, letter, or number skills that may not be reflected in
achievement scores. Then the presence of the special skills
should be considered in making a rating. This item also does
not include adaptive functioning skills. To help guide
consistent use of this item, rating anchors are offered for the
intermediary half-point rating values as well.
Scoring:
1 Intelligence is normal and reasonably consistent
across various areas. The child is as intelligent as
typically developing children of his or her age and does
not have any unusual intellectual skills or problems.
1.5 The child has low intelligence (IQ between 71 and 85)
and does not have any unusual intellectual skills or
problems.
2 Mildly abnormal intellectual functioning. The child
has very low intelligence (IQ score 70 or lower), and his
or her skills appear fairly evenly delayed across all
areas.
2.5 The child has very low intelligence (IQ score 70 or
lower), and his or her skills appear to vary across areas,
but none is at or above the average range.
3 Moderately abnormal intellectual functioning. The
childs overall IQ is in the range from intellectually
disabled to average (IQ score less than 115), and there is
significant variability in skills. At least one skill is in the
average range.
3.5 The childs overall IQ is in the range from intellectual
disability to average (IQ score less than 115), and there
is significant variability in skills. At least one skill is in
the above-average range. Extreme savant skills are not
included here, but are rated in category 4.
4 Severely abnormal intellectual functioning. A rating
of 4 is given when extreme savant skills are present,
regardless of the overall level of intelligence.
Item 15. General Impressions
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. This rating
should be made without recourse to averaging the other
ratings. In making this rating, you should take into account
all available information concerning the child, including
information from such sources as the case history, parent
interviews, or past records.
Scoring:
1 No autism spectrum disorder . The child shows none of
the symptoms characteristic of autism.
2 Mild autism spectrum disorder. The child shows only a
few symptoms or only a mild degree of autism.
3 Moderate autism spectrum disorder. The child shows a
number of symptoms or a moderate degree of autism.
4 Severe autism spectrum disorder. The child shows
many symptoms or an extreme degree of autism.
Administration, Scoring, Interpretation, and Intervention Guide
Using the CARS2-QPC to
Inform CARS2-ST Ratings
It cannot be overemphasized that ratings from the
CARS2-ST should be used as only one piece of a multi-
faceted evaluation that includes developmental history;
review of prior evaluations; parent or caretaker interview;
results from intellectual, academic, vocational, adaptive, and
behavioral rating areas; and direct interaction with and
assessment of the individual being evaluated. Information of
all of the aforementioned types can potentially be used in
formulating ratings. The Questionnaire for Parents or
Caregivers (CARS2-QPC; WPS Product No. W-472C) is an
unscored form designed to assist in gathering information
from a parent or caregiver about behaviors related to autism.
Information from the CARS2-QPC can be integrated with
other evaluation information when making the final CARS2-
ST ratings.
The CARS2-QPC provides information relevant to each
of the 15 CARS2-ST rating areas. However, the form was
intentionally organized in a way that would be most
meaningful to caregivers. Categories thus do not map
directly onto the CARS2-ST Rating Booklet. Parent or
caregiver responses must be reviewed and summarized by a
professional familiar with autism in order to be effectively
integrated into CARS2-ST ratings. The most fruitful way to
facilitate this integration is to use the completed CARS2-
QPC as a framework for a follow-up interview to clarify
responses. Clarification and expansion of the parent or
caregiver responses through interview allows you to more
clearly interpret that persons perspective in relation to your
understanding of autism spectrum disorders (ASDs).
The areas assessed by the questionnaire and in a
thorough developmental interview include the individuals
social, emotional, and communication skills; repetitive
behaviors; play; and routines, as well as unusual sensory
interests. In both the questionnaire and follow-up interview,
gathering information about the individuals early
development as well as current functioning is essential.
There are four main considerations when interpreting
parent or caregiver responses on the CARS2-QPC. First, be
aware of the overall pattern of strengths and weaknesses that
is reported. Review the completed questionnaire and look
for discrepant patterns of skills or abilities. For example,
verbal communication skills and sensory preoccupations
may be indicated to occur often or to always be a problem,
while nonverbal communication, relating to others, and
showing emotions are not considered problems. Second,
review and evaluate any examples the parent or caregiver
may provide. A caregiver may endorse an item, but provide
a description of a behavior that is not of the same type
inquired about. Thus carefully consider whether the
examples are suggestive of the specific behaviors someone
with ASD might demonstrate. Consider, as an example, item
5.5: Has special interests or topics. Are the examples of
topics that have been provided highly unusual, such as
computer serial numbers or actuarial statistics? Are there
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 15
Chapter 2 Administration and Scoring of the CARS2-ST
multiple special interests listed, suggesting a variety of
interests rather than focused interests? Is the interest one that
is common to others in the individuals age group, such as
video games or computer use in general? Third, the
consistency of the information given by the caregiver with
regard to all other information obtained during the
assessment process should be taken into consideration.
When two sources offer discrepant reports, further inquiry
will help to clarify whether the individuals behavior differs
across settings and people or is only being reported
differently by different sources. Finally, since ASD is a
developmental disorder, these reports must indicate that the
symptoms of autism were present early in life, that is, prior
to the age of 4 or 5. Some other diagnostic conditions can
lead to social problems over time, but do not share the same
early history of social difficulties as ASD.
Case Example:
Michaels CARS2-ST Ratings
The chief purpose of the CARS2-ST is to assist in the
clinical diagnosis of an ASD. The case of Michael, a 4-year-
old boy, demonstrates how the CARS2-ST items are rated
based on direct observation. As has been previously noted,
the CARS2-ST may also be rated based on caretaker
interviews.
Michaels CARS2-ST ratings and related comments are
displayed in Figure 1. (The figure is provided at the end of
this chapter and is also used to illustrate the scoring process,
described in the final section.) The pattern of item scores
obtained for Michael on the CARS2-ST, and how his ratings
assisted in reaching a diagnostic decision, is discussed in
chapter 4. How Michaels item ratings contributed to
intervention planning is discussed in chapter 5.
It is important to keep in mind that an early develop-
mental history supportive of autism is an essential compo-
nent of the diagnostic decision tree, but such information is
not included in the rating of the CARS2-ST. CARS2-ST rat-
ings alone are not sufficient to diagnose an ASD. However,
CARS2-ST ratings can provide a significant component of a
comprehensive diagnostic evaluation.
Item 1. Relating to People 3.0
Getting Michaels attention can be hardhe will ignore
his name being called and does not always respond to
attempts by the evaluator to engage him in play (such as
peek-a-boo, rolling/throwing a ball).
Michael will at times initiate to get something he wants
(e.g., snack, favorite video), but he does not initiate to have
someone else come play with him or to show someone
something he has done.
He was responsive to the social initiations of others, but
sustaining a reciprocal interaction or initiating an interaction
was difficult for Michael.
Item 2. Imitation 3.0
Michael does not watch what others are doing; when
you have his attention and demonstrate something for him to
15
do, he will sometimes make an attempt to do what was
shown to him (e.g., he might not hold a kaleidoscope to his
eyes to look through, but will roll his Play-Doh like the
evaluator).
Item 3. Emotional Response 2.0
Michael did not demonstrate a wide range of emotions,
but did show pleasure through smiles during activities of
highest interest to him. Overall, he had little change in
emotion, as seen in his facial expressions. Once during
assessment he became quite upset and started crying, but it
was not clear what had upset him.
Item 4. Body Use 1.5
Michael is somewhat clumsy, but does not demonstrate
unusual body movements, rocking, or spinning.
Item 5. Object Use 3.5
During assessment Michael showed little interest in the
toys in the play area and did not explore when given free
play time. After being shown a small toy of a cartoon
character, he played with that toy in a repetitive way.
Item 6. Adaptation to Change 3.0
Michael actively resisted changes in materials, whining
and resisting placing finished materials off the table. If a
new material was placed on the table and his interest was
switched to the new item, taking away the item he was using
became easier.
Item 7. Visual Response 3.0
Michaels eye contact was inconsistent and often not
directed to the evaluator. During play with a ball, he was more
interested in looking at himself in the mirror than at the
evaluator to whom he was throwing the ball. He would look at
things very closely and often from the corner of his eye.
Item 8. Listening Response 2.0
Michael did not immediately respond or turn to a
person when his name was called. It often had to be called
several times before he responded. When unexpected noises
happened, he sometimes had no response at all, but at other
times he startled.
Item 9. Taste, Smell, and Touch Response
and Use 1.0
Nothing atypical noted.
Item 10. Fear or Nervousness 1.0
Nothing atypical noted.
Item 11. Verbal Communication 2.5
Michael used two- and three-word phrases meaningfully
and spontaneously to comment, label, refuse, and request.
He repeated lines from favorite cartoons and video movies
mixed with jargon. He has immediate echolalia, with some
jargon noted.
Item 12. Nonverbal Communication 3.0
Michael will use a close point in response to a question,
and occasionally he will use a spontaneous distal point if
there is something he is excited about seeing. He does not,
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 16
16
however, use descriptive or emphatic gestures, nor does he
look at a person when he is gesturing or seem to understand
the gestures of others.
Item 13. Activity Level 2.0
Michael was mildly restless during assessment, but it
was not interfering.
Item 14. Level and Consistency of
Intellectual Response 3.0
Michaels tested intellectual abilities are well below
average, but he can name all the alphabet letters, read the
names of favorite characters, count to 25, and receptively
identify basic shapes.
Item 15. General Impressions 3.0
Michael has many characteristics of autism, including
significant language delays with echolalia and video
dialoguing, restricted social interests and limited
engagement in socially reciprocal activities, repetitive play
patterns, resistance to change, and difficulty with imitation
and play with toys.
Scoring the CARS2-ST Rating Booklet
Scoring the CARS2-ST is a straightforward process. A
sample of a completed CARS2-ST Rating Booklet
(prepared for Michael, from the case example) is provided in
Figure 1. This sample will be used to illustrate the scoring
procedures described in this section. (The numbers in dark
circles in the following text correspond to those in the
figure.)
Administration, Scoring, Interpretation, and Intervention Guide
First, transfer the ratings for all 15 categories from the
inside pages of the booklet to the corresponding spaces
provided in the Summary section on the front page of the
booklet . Next, sum the ratings to obtain the Total raw
score. In Figure 1, a Total raw score of 36.5 has been
obtained and entered in the space provided . Indicate the
Severity Group that corresponds with the Total raw score by
making a check mark in the appropriate box. In the example,
a check mark has been made indicating that the Total raw
score is in the Mild-to-Moderate Symptoms range .
To obtain a standard score in the form of a T-score,
circle the value that corresponds to the Total raw score in the
Raw score table provided on the right side of the Summary
section . The number printed to the left of the value you
have circled is the T-score. In Figure 1, the Total raw score
of 36.5 corresponds to a T-score of 48T . The number
printed to the left of the T-score value is the percentile rank
that corresponds to the Total raw score. In the example, the
percentile rank for the obtained Total raw score is 42 .
The relationship between CARS2-ST raw scores and
standard scores is slightly but reliably different for younger
and older individuals with ASDs. Although the clinical
implications of the difference is minimal, score conversion
columns specific to younger and older age groups are
provided in the table in the CARS2-ST Summary section.
This allows score comparisons within a given age group to
be considered. In the sample case, the age-based standard
score of 48T is identical to the standard score derived based
on individuals of all ages. A discussion of the uses and
limitations of CARS2-ST standard scores is provided in
chapter 4.
007-022_Chap2_v2_001-004 chapter 01.qxd 8/13/10 2:43 PM Page 17

CARS2 -ST
Childhood Autism Rating Scale, Eric Schopler, Ph.D., Robert J. Reichler, M.D., Standard Version
Second Edition and Barbara Rochen Renner, Ph.D. Rating Booklet

Michael
Name: _________________________________________________________________________________________ Sample 1 8-12-2009
Case ID Number: ____________________________________ Test date: _______________________________

Male White
Gender: _____________________________ Ethnic background: ______________________________ Carol G.
Raters name: _______________________________________________ 4-8-2005
Date of birth: ____________________________

Observation during developmental assessment using PEP-3

Based on information from: __________________________________________________________________________________________________________________________ 4 years __________
Age: ___________ 4 months

DIRECTIONS: After rating the 15 items, transfer the ratings from the inside pages to the corresponding spaces below. Sum the ratings to obtain the Total raw score, and
indicate the corresponding Severity Group. Circle the Total raw score value in the table in the column labeled All ages and in the column that corresponds to the age of
the person who has been rated. The number printed to the left of each value you have circled is the T-score.

SUMMARY Symptom Level Compared to

Individuals With Autism Spectrum Diagnoses
CATEGORY RATINGS Percentile T-score All ages
Raw score
Ages 212 Ages 13 and older
3.0
1. Relating to People .............................................................. _________
median = 2.5 (3.0, 2.5) >70 >54 >54 >54
>97 70 54 54 54
3.0
2. Imitation ............................................................................ _________ 97 69 53.5 53.5 5253.5
median = 2.5 (2.5, 2.0) 68 5253 52.553 49.551.5
2.0
3. Emotional Response ........................................................... _________ 96 67 5151.5 51.552
median = 3.0 (3.0, 3.0) 95 66 5050.5 51
93 65 49.5 5050.5 49
1.5
4. Body Use ........................................................................... _________
92 64 49 49.5 47.548.5
median = 2.5 (2.5, 2.5)
90 63 4848.5 48.549 4647
3.5
5. Object Use ....................................................................... _________ 88 62 4747.5 47.548 4545.5
median = 2.5 (2.5, 2.0) 86 61 46.5 46.547 4444.5
3.0
6. Adaptation to Change ......................................................... _________ 84
82
60
59
45.546
44.545
46
4545.5 43.5
median = 2.5 (2.5, 2.5)
79 58 44 44.5 43
3.0
7. Visual Response ................................................................. _________ 76 57 43.5 44 42.5
median = 2.5 (2.5, 2.0) 72 56 42.543 4343.5 42
2.0
8. Listening Response ............................................................ _________ 69 55 42 4242.5 4141.5
65 54 4141.5 41.5 4040.5
median = 2.5 (2.5, 2.0)
62 53 4040.5 40.541 39.5
1.0
9. Taste, Smell, and Touch Response and Use ......................... _________ 58 52 3939.5 39.540 38.539
median = 2.0 (2.0, 2.0) 54 51 38.5 39 37.538
1.0
10. Fear or Nervousness ............................................................ _________ 50 50 37.538 3838.5 36.537

median = 2.5 (2.5, 2.5) 46 49 37 37.5 3536
42 48 3636.5 36.537 3434.5
2.5
11. Verbal Communication ........................................................ _________ 38 47 3535.5 35.536 33.5
median = 3.0 (3.0, 3.0) 35 46 3434.5 35 33
3.0
12. Nonverbal Communication .................................................. _________ 31 45 33.5 3434.5 32.5
median = 2.5 (2.5, 2.0) 28 44 33 33.5 3132
24 43 3232.5 32.533 3030.5
2.0
13. Activity Level ...................................................................... _________ 21 42 31.5 32 2929.5
median = 2.5 (2.5, 2.0) 19 41 30.531 31.5 27.528.5
3.0
14. Level and Consistency of Intellectual Response ................... _________ 16 40 30 30.531 26.527
median = 2.5 (2.5, 2.5) 14 39 28.529.5 30 26
3.0
15. General Impressions ........................................................... _________
12
10
38
37
27.528
2627
2929.5
2828.5
2525.5
23.524.5
median = 3.0 (3.0, 3.0) 8 36 25.5 2627.5 23
Note. The numbers in parentheses are medians for individuals aged 212 or 13+, respectively. 7 35 24.525 25.5 2122.5
6 34 24 24.525 20.5
5 33 2323.5 24

Total raw score = 36.5 4

3
32
31
22.5
21.522
23.5
23
Note. SEM = 0.68. 2 30 21 2222.5 20
29 20.5
1 28 21.5
SEVERITY GROUP <1 27 20 21
26 20.5
Minimal-to-No Symptoms of Autism Spectrum Disorder 25 20 19.5
(1529.5; 1527.5 for ages 13+) 24 19.5
23 19.5

Mild-to-Moderate Symptoms of Autism Spectrum Disorder

(3036.5; 2834.5 for ages 13+)
22
21
20 19 19
Severe Symptoms of Autism Spectrum Disorder <20 <19 <19 <19.5
(37 and higher; 35 and higher for ages 13+)
Note. SEM = 2.7T.

Additional copies of this form (W-472A) may be purchased from WPS. Please contact us at 800-648-8857, Fax 310-478-7838, or www.wpspublish.com.
W-472A Copyright 2010 by WESTERN PSYCHOLOGICAL SERVICES. Not to be reproduced in whole or in part without written permission. All rights reserved. Printed in U.S.A.

Figure 1
Completed CARS2-ST Rating Booklet for Michael

17
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1. Relating to People
DIRECTIONS
No evidence of difficulty or abnormality in relating to people.
For each category, use the space 1 The childs behavior is appropriate for his or her age. Some shyness, fussiness, or
provided in the Observations sec- annoyance at being told what to do may be observed, but not to an atypical degree.
1.5
tion for taking notes concerning Mildly abnormal relationships. The child may avoid looking the adult in the
the behaviors relevant to that 2 eye, avoid the adult or become fussy if interaction is forced, be excessively shy, not be
as responsive to the adult as is typical, or cling to parents somewhat more than most
item. After you have finished children of the same age.
2.5
observing the child, rate the
Moderately abnormal relationships. The child shows aloofness (seems
behaviors relevant to each item 3 unaware of adult) at times. Persistent and forceful attempts are necessary to get the
childs attention at times. Minimal contact is initiated by the child.
by circling the number that corre- 3.5
sponds to the statement that Severely abnormal relationships. The child is consistently aloof or unaware
4 of what the adult is doing. He or she almost never responds to or initiates contact with
best describes the child. You may the adult. Only the most persistent attempts to get the childs attention have any effect.
indicate that the childs behavior
Observations
falls between two descriptions by
circling ratings of 1.5, 2.5, or 3.5. Ignored his name being called
Abbreviated rating criteria are Doesnt always respond to attempts to engage
presented for each item. See (e.g., peek-a-boo, rolling/throwing ball)
chapter 2 of the Manual for Initiated to get snack, videonot to play or
detailed rating criteria. show something hes done
Responded to others social approach
Hard for him to sustain a reciprocal interaction
or initiate interaction

2. Imitation 3. Emotional Response

Appropriate imitation. The child can imitate sounds, words, and movements Age-appropriate and situation-appropriate emotional response.
1 that are appropriate for his or her skill level.
1 The child shows the appropriate type and degree of emotional response, as indicated
1.5 by a change in facial expression, posture, and manner.

Mildly abnormal imitation. The child imitates simple behaviors such as 1.5
2 clapping or single verbal sounds most of the time; occasionally, imitates only after Mildly abnormal emotional response. The child occasionally displays a
prodding or after a delay. 2 somewhat inappropriate type or degree of emotional reaction. Reactions are sometimes
2.5 unrelated to the objects or events surrounding him or her.

Moderately abnormal imitation. The child imitates only part of the time and 2.5
3 requires a great deal of persistence and help from the adult; frequently imitates only Moderately abnormal emotional response. The child shows definite signs
after a delay. 3 of inappropriate type and/or degree of emotional response. Reactions may be quite
3.5 inhibited or excessive and unrelated to the situation; child may grimace, laugh, or
become rigid even though no apparent emotion-producing objects or events are present.
Severely abnormal imitation. The child rarely or never imitates sounds, words,
4 or movements even with prodding and assistance from the adult.
3.5
Severely abnormal emotional response. Responses are seldom appropri-
Observations 4 ate to the situation; once the child gets in a certain mood, it is very difficult to change
the mood. Conversely, the child may show wildly different emotions when nothing has
Not watching others changed.

Could get attention and demonstrate things Observations

for him to dosometimes tried to do what Narrow range of emotions
was shown to himdidnt hold a kaleidoscope
to his eyes to look through, did imitate Showed pleasure during activities of highest
evaluator rolling Play-Doh interest to himsmiled. Overall, he had little
overall change in facial expressions
Once during assessment he became quite
upsetcryingreason unclear??

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4. Body Use 5. Object Use

Age-appropriate body use. The child moves with the same ease, agility, and Appropriate interest in, or use of, toys and other objects. The child
1 coordination as a normal child of the same age.
1 shows normal interest in toys and other objects appropriate for his or her skill level and
1.5 uses these toys in an appropriate manner.

Mildly abnormal body use. Some minor peculiarities may be present, such as
2 clumsiness, repetitive movements, poor coordination, or the rare appearance of more
unusual movements.
2.5
Moderately abnormal body use. Behaviors that are clearly strange or unusual
3 for a child of this age may include strange finger movements, peculiar finger or body
posturing, staring or picking at the body, self-directed aggression, rocking, spinning,
finger-wiggling, or toe-walking.
3.5
Severely abnormal body use. Intense or frequent movements of the type listed
4 above are signs of severely abnormal body use. These behaviors may persist despite
attempts to discourage them or involve the child in other activities.
Observations
1.5
Mildly inappropriate interest in, or use of, toys and other objects.
2 The child may show atypical interest in a toy or play with it in an inappropriately childish
way (e.g., banging or sucking on the toy).
2.5
Moderately inappropriate interest in, or use of, toys and other
3 objects. The child may show little interest in toys or other objects, or may be
preoccupied with using an object or toy in some strange way. He or she may focus 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 exclusively.
3.5
Severely inappropriate interest in, or use of, toys and other
4 objects. The child may engage in the same behaviors as above, with greater
frequency and intensity. The child is difficult to distract when engaged in these
inappropriate activities.

Clumsy
Observations
No unusual body movements, no
Not much interest in the toys in the play area
rocking/spinning
No exploration during free play time
Evaluator showed him a small toy of a cartoon
characterplayed with it in repetitive way

6. Adaptation to Change 7. Visual Response

Age-appropriate adaptation to change. While the child may notice or Age-appropriate visual response. The childs visual behavior is normal and
1 comment on changes in routine, he or she accepts these changes without undue distress.
1 appropriate for his or her age. Vision is used together with other senses as a way to
1.5 explore a new object.

Mildly abnormal adaptation to change. When an adult tries to change 1.5

2 tasks, the child may continue the same activity or use the same materials. Mildly abnormal visual response. The child must be occasionally reminded
2.5
2 to look at objects. The child may be more interested in looking at mirrors or lighting
than are his or her peers, may occasionally stare off into space, or may also avoid
Moderately abnormal adaptation to change. The child actively resists
3 changes in routine, tries to continue the old activity, and is difficult to distract. He or looking people in the eye.
she may become angry and unhappy when an established routine is altered.
2.5
3.5 Moderately abnormal visual response. The child must be reminded

Severely abnormal adaptation to change. The child shows severe reactions

3 frequently to look at what he or she is doing. He or she may stare into space, avoid
4 to change. If a change is forced, he or she may become extremely angry or uncooperative
looking people in the eye, look at objects from an unusual angle, or hold objects very

and respond with tantrums. close to the eyes.

3.5
Observations Severely abnormal visual response. The child consistently avoids looking
4 at people or certain objects and may show extreme forms of other visual peculiarities
Actively resisted changes in materials described above.

whining, resisted placing finished materials Observations

off table
Eye contact inconsistentoften not directed
Placing new material on table to switch his to the evaluator
interesteasier to take away other item
Distracted by looking at self in mirror during
he was using
play with ball
Looked at things very closelyoften looked
from the corner of his eye

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8. Listening Response 9. Taste, Smell, and Touch Response and Use

Age-appropriate listening response. The childs listening behavior is normal Normal use of, and response to, taste, smell, and touch. The child
1 and appropriate for his or her age. Listening is used together with other senses.
1 explores new objects in an age-appropriate manner, generally by feeling and looking.
1.5 Taste or smell may be used when appropriate. When reacting to minor everyday pain,

Mildly abnormal listening response. There may be some lack of response the child expresses discomfort but does not overreact.
2 or mild overreaction to certain sounds. Responses to sounds may be delayed, and
1.5
sounds may need repetition to catch the childs attention. The child may be distracted Mildly abnormal use of, and response to, taste, smell, and touch.
by extraneous sounds. 2 The child may persist in putting objects in his or her mouth; may smell or taste inedible
2.5 objects; may ignore or overreact to mild pain that a normal child would express as

Moderately abnormal listening response. The childs responses to sounds discomfort.

3 vary; often ignores a sound the first few times it is made; may be startled or cover ears
2.5
when hearing some everyday sounds. Moderately abnormal use of, and response to, taste, smell, and
3.5 3 touch. The child may be moderately preoccupied with touching, smelling, or tasting
objects or people. The child may either react too much or too little.
Severely abnormal listening response. The child overreacts and/or
4 underreacts to sounds to an extremely marked degree, regardless of the type of sound.
3.5
Severely abnormal use of, and response to, taste, smell, and touch.
Observations 4 The child is preoccupied with smelling, tasting, or feeling objects more for the sensation
than for normal exploration or use of the objects. The child may completely ignore pain
or react very strongly to slight discomfort.
No immediate response when his name was
called. Did not turn to face person calling Observations

Often had to be called several times before Nothing atypical noted

responding
Sometimes no response to unexpected
noisesat other times appeared startled
by them

10. Fear or Nervousness 11. Verbal Communication

Normal fear or nervousness. The childs behavior is appropriate both to the Normal verbal communication, age and situation appropriate.
1 situation and for his or her age.
1
1.5 1.5
Mildly abnormal fear or nervousness. The child occasionally shows too
2 much or too little fear or nervousness compared to the reaction of a normal child of the 2 Mildly abnormal verbal communication. Speech shows overall retardation.
Most speech is meaningful; however, some echolalia or pronoun reversal may occur.
same age in a similar situation.
Some peculiar words or jargon may be used occasionally.
2.5 2.5
Moderately abnormal fear or nervousness. The child shows either quite
3 a bit more or quite a bit less fear than is typical even for a younger child in a similar 3 Moderately abnormal verbal communication. Speech may be absent.
When present, verbal communication may be a mixture of some meaningful speech and
situation. some peculiar speech such as jargon, echolalia, or pronoun reversal. Peculiarities in
3.5 meaningful speech include excessive questioning or preoccupation with particular topics.
Severely abnormal fear or nervousness. Fear persists even after repeated 3.5
4 experience with harmless events or objects. It is extremely difficult to calm or comfort
Severely abnormal verbal communication. Meaningful speech is not used.
the child. The child may, conversely, fail to show appropriate regard for hazards that 4 The child may make infantile squeals, weird or animal-like sounds, or complex noises
other children of the same age avoid. approximating speech, or may show persistent, bizarre use of some recognizable words
or phrases.
Observations
Observations

Nothing atypical noted Used 2-word and 3-word phrasesmeaningful,

spontaneous comment, label, refusal
and requests
Repeated lines to cartoons or videos, but
mixed with jargon
Immediate echolalia with some jargon

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12. Nonverbal Communication 13. Activity Level

Normal use of nonverbal communication, age and situation Normal activity level for age and circumstances. The child is neither
1 appropriate. 1 more active nor less active than a normal child of the same age in a similar situation.
1.5 1.5
Mildly abnormal use of nonverbal communication. Immature use of Mildly abnormal activity level. The child may either be mildly restless or
2 nonverbal communication; may only point vaguely, or reach for what he or she wants, 2 somewhat lazy and slow moving at times. The childs activity level interferes only
in situations where a typically developing same-age child may point or gesture more slightly with his or her performance.
specifically to indicate what he or she wants. 2.5
2.5 Moderately abnormal activity level. The child may be quite active and
Moderately abnormal use of nonverbal communication. The child is 3 difficult to restrain. He or she may have boundless energy and may not go to sleep
3 generally unable to express needs or desires nonverbally and cannot understand the readily at night. Conversely, the child may be quite lethargic and need a great deal of
nonverbal communication of others. prodding to get him or her to move about.
3.5 3.5
Severely abnormal use of nonverbal communication. The child uses Severely abnormal activity level. The child exhibits extremes of activity or
4 only bizarre or peculiar gestures that have no apparent meaning and shows no
4 inactivity and may even shift from one extreme to the other.
awareness of the meanings associated with the gestures or facial expressions of others.
Observations
Observations
Points to things nearby to respond to Mildly restless during assessment
a question did not interfere with process

Occasionally spontaneously points to things at

a distance if excited about seeing something,
no descriptive or emphatic gestures
Does not look at a person when he is gesturing
Does not seem to understand the gestures
of others

14. Level and Consistency of Intellectual Response 15. General Impressions

To rate this item, it is essential to read the expanded definitions in the Manual. No autism spectrum disorder. The child shows none of the symptoms charac-
1 teristic of autism.
Intelligence is normal and reasonably consistent across various
1 areas. The child is as intelligent as typical children of the same age and does not have
1.5
Mild autism spectrum disorder. The child shows only a few symptoms or only
any unusual intellectual skills or problems. 2 a mild degree of autism.
The child has low intelligence (IQ score between 71 and 85) and does not have any unusual 2.5
1.5
intellectual skills or problems.
Moderate autism spectrum disorder. The child shows a number of symptoms
Mildly abnormal intellectual functioning. The child has very low intelligence 3
2 (IQ score is 70 or lower) and his or her skills appear fairly evenly delayed across all areas. 3.5
or a moderate degree of autism.

The child has very low intelligence (IQ score is 70 or lower) and skills appear to vary across Severe autism spectrum disorder. The child shows many symptoms or an
2.5 areas, but none is at or above average. 4 extreme degree of autism.
Moderately abnormal intellectual functioning. The childs overall
3 intelligence is in the range from intellectually disabled to average (IQ score less than Observations
115), and there is significant variability in skills. At least one skill is in average range.
The childs overall intelligence is in the range from intellectual disability to average (IQ
Many characteristics of autismsignificant
3.5 score less than 115), and there is significant variability in skills. At least one skill in above language delays, echolalia, video dialoguing,
average range. Extreme savant skills are not included here but are rated in category 4.

Severely abnormal intellectual functioning. A rating of 4 is given when

restricted social interest, limited engagement
4 extreme savant skills are present, regardless of overall level of intelligence. in socially reciprocal activities, repetitive
Observations play patterns, resists change, difficulty with
imitation and play with toys
Tested intellectual abilities are well below
average
Can name all alphabet letters, read names
of favorite characters, count to 25,
identify basic shapes (receptive)

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3
ADMINISTRATION AND SCORING
OF THE CARS2-HF
This chapter presents detailed guidance for making
CARS2-HF ratings. Much of the guidance is similar to that
for the CARS2-ST. However, some of the general principles
underlying the approach to making CARS2-HF ratings are
unique. As has been noted, the challenge of assessing
autism-related behavior in relatively high functioning
individuals makes it especially important that those making
CARS2-HF ratings gain a solid understanding of the criteria
for making ratings and be in a position to collect and
synthesize information from multiple sources about an
individual. The three sections at the end of this chapter are
similar to those at the end of chapter 2. The first discusses
how to use the CARS2-QPC when making CARS2-HF
ratings. The second provides a case example that
demonstrates the assignment of CARS2-HF ratings based
on multiple sources of information. The final section of this
chapter describes the process of converting CARS2-HF
ratings to a Total raw score and a Total standard score.
Guidance for interpreting scores and providing feedback to
parents is provided in chapter 4. Suggestions on how to use
CARS2-HF ratings and other resources to support
intervention planning are offered in chapter 5.
The CARS2-HF Rating Booklet (WPS Product No.
W-472B) is used to assess individuals with estimated overall
IQs of 80 or higher, who have relatively good verbal skills,
and who are aged 6 or older. To assess individuals with IQs of
79 or lower, who have notably impaired communication, or
who are younger than 6 years of age, use the CARS2-ST
Rating Booklet (WPS Product No. W-472A), described in
chapter 2. Condensed versions of the guidelines in this chap-
ter for making ratings appear in the CARS2-HF booklet.
Abbreviated guidance for obtaining raw and standard
scores is also included there. As with the CARS2-ST, the
CARS2-HF booklet is designed to accommodate detailed
note taking regarding behavioral observations, informa-
tion from diverse sources, or unique information that may
be of use in interpreting score results, planning interven-
tions, or delivering feedback to parents. As noted for the
CARS2-ST, familiarity with the criteria for making ratings
on the CARS2-HF should be gained to achieve the best un-
derstanding of the foundation for making ratings. Raters
should be familiar with all of the information presented in
23
this manual. Mere review of the abbreviated information in
the Rating Booklet is insufficient preparation to administer
the CARS2-HF. It is important to note that parents should
not be asked to complete the CARS2-ST or the CARS2-HF.
Information from parents should be obtained using the
CARS2-QPC and a direct interview.
General Considerations for
Making CARS2-HF Ratings
General considerations in making ratings for the
CARS2-HF are similar to those for the CARS2-ST. The
individuals behavior should be compared with that of a
typically developing individual of the same age. When
behaviors are observed that are not typical for an individual of
the same age, the peculiarity, frequency, intensity, and
duration of these behaviors should be considered. All
behavior should be rated without recourse to causal
explanations. Although some of the behaviors resulting from
autism are similar to behaviors caused by other disorders, it is
important simply to rate the degree to which the individuals
behavior deviates from typical development without making
judgments about whether the behavior may be explained
away as being caused by other medical, psychiatric, or
cognitive disorders. The appropriate rating values thus made
and the pattern of the impairments will help to distinguish
individuals with autism from those with other disorders.
Once the collection of information has been completed,
use the notes recorded in the Observations section for each
item to assist in making the CARS2-HF rating. Before
deciding on a rating value, you may find it helpful to reread
all of the behavior descriptions for that item. Rating values
for each of the 15 CARS2-HF items range from 1 to 4.
Generally, a rating value of 1 indicates that an individuals
behavior is within normal limits for an individual of that
age. A value of 2 means that the individuals behavior is
mildly abnormal compared with a person of the same age. A
value of 3 indicates that the individuals behavior is
moderately abnormal for that age. A value of 4 indicates that
the individuals behavior is severely abnormal for someone
of that age. In addition to these four ratings, the midpoints
between them (1.5, 2.5, and 3.5) should be used when the
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24
behavior appears to fall between two categories. For
example, if a behavior is mildly-to-moderately abnormal, it
should be rated 2.5. Thus the seven allowable ratings for
each item are 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
Remember that in determining the degree of abnormality,
you must take into consideration not only the individuals
chronological age, but also the peculiarity, frequency,
intensity, and duration of his or her behavior. Peculiarity
encompasses the extent to which a behavior is unusual or
odd in general, as opposed to whether it is delayed or like
the behavior of a younger child. Frequency refers to how
often a behavior happens. Intensity refers how extreme a
behavior is when it happens and how resistant to change it
is. Duration refers to how long a behavior lasts. The greater
the degree to which an individual differs along these
dimensions from a typically developing individual of the
same age, the more abnormal his or her behavior would be
and the higher the value that would be assigned. As is the
case for the CARS2-ST, for most items on the CARS2-HF a
rating of 4 indicates the presence of a very unusual behavior
that is persistent and extremely difficult to reduce or modify.
The CARS2-HF is more likely than the CARS2-ST to
be used with older individuals. The rating guidance is thus
written to be more general than the rating guidance for the
CARS2-ST with respect to the age of the person being rated.
How to Make CARS2-HF
Observations and Ratings
As with the CARS2-ST, the CARS2-HF is designed so
that ratings can be made from different sources of
observation, as during direct assessments or classroom
observations; observer reports, such as from parents or
spouses; or clinical records. Any of these sources can be used
as long as they include the information required for rating all
of the areas. On the CARS2-HF, however, to make ratings for
Items 2, 8, 9 and 10, you must have information about the
pervasiveness of symptoms across settings. So it is required to
have either the opportunity to observe the individual across
settings, an individual who can describe his or her own
behavior across settings, or access to someone such as a
parent, spouse, or teacher who has had the opportunity to
observe the persons behavior in other settings.
As with the CARS2-ST, in making observations you
should compare the childs or adults behavior to that of a
typically developing person of the same age. When atypical
behaviors are observed, the peculiarity, frequency, intensity,
Administration, Scoring, Interpretation, and Intervention Guide
pervasiveness, and duration of these behaviors should be
considered. It bears repeating that although some of the
behaviors resulting from autism are similar to behaviors
caused by other medical, cognitive, or psychiatric disorders,
it is important simply to rate the degree to which the indi-
viduals behaviors deviate from typical development with-
out making judgments about whether the behavior may be
explained away as being caused by such disorders as
Attention-Deficit/Hyperactivity Disorder or Obsessive-
Compulsive Disorder. In the context of a full diagnostic
evaluation, the Total score and the pattern of the impair-
ments will help to distinguish a person with an autism
spectrum disorder (ASD) from other types of disorders.
Note that on the CARS2-HF, behaviors that reflect the
moderate-to-severe degree of peculiarity seen in individuals
with classical autism, such as spinning or toe-walking, will
receive a rating of 3 or higher. Abnormal behaviors that are
frequent and pervasive such that they are obvious to
observers across multiple settings will also warrant high
scores. For most rating areas on the CARS2-HF, a rating of
4 indicates a very unusual behavior that is persistent and
extremely hard to modify or redirect.
Item 1. Social-Emotional Understanding
Definition. Social-emotional understanding addresses
an individuals cognitive understanding of others
communication, behaviors, and differing perspectives. The
dimensions of social understanding that are included in this
item are the ability to read the nonverbal cues of others and
the ability to take another persons perspective. This item
does not reflect whether someone has friends or is in a
relationship. Rather it deals with an individuals ability to
perceive and articulate how another person may feel or what
his or her perspective may be in a situation.
Considerations. This item is best assessed through a
direct interview with the individual. Presenting pictures of a
variety of social situations and asking the individual to tell
you what he or she thinks the people in the situation are
thinking and feeling is a helpful technique. Through the use
of either real-life experiences or these depicted situations,
the goal of the interview is to determine the degree to which
the individual understands and can articulate how others feel
and how others may have different perspectives of a social
situation. There are a number of theory of mind and social
perception tasks, such as the Roberts-2 (Roberts & Gruber,
2005), that also can be used to assess the individuals ability
to take anothers perspective. Again, this item reflects the
individuals cognitive understanding of others and not his or
her emotional empathy.
Scoring:
1 Age-appropriate social-emotional understanding.
Clearly understands the facial expressions, gestures,
tone of voice, and body language of others. The
individual is able to understand that others may have a
different perspective and what that perspective may be.
2 Mildly impaired social-emotional understanding. The
individual is responsive to most facial expressions,
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Chapter 3 Administration and Scoring of the CARS2-HF
expression of emotions in others, gestures, and body
language, but may need these to be slightly exaggerated,
excluding more subtle expressions such as mild sar-
casm, doubt, or ambiguity. The ability to take anothers
perspective is inconsistent.
3 Moderately impaired social-emotional understanding.
The individual shows an understanding of facial
expressions, tone of voice, and body language only
when they are exaggerated. He or she is likely to ignore
or misunderstand the expressions or perspectives of
others.
4 Severely impaired social-emotional understanding.
The individual demonstrates virtually no ability to
understand appropriate facial expressions, gestures, tone
of voice, or body language. He or she is unable to
recognize that the perspective, understanding, and
expression of others might differ from his or her own.
Item 2. Emotional Expression and Regulation
of Emotions
Definition. This rating is based on the individuals
ability to express and regulate his or her own emotions.
Considerations. This item is based on both direct
observation and the reports of others who have observed this
persons behavior in other settings. During a direct
interaction with the individual, engage in a discussion of
events that have happened to him or her that have been both
positive and negative. Note whether the individuals facial
expression and affect match the content of the discussion.
Does the person show the full range of emotions? Does he or
she have an exaggerated response to either positive or
negative events? Does the individual report having trouble
controlling his or her emotions or behaviors when stressed?
Do these emotional regulation problems happen in just one
or in more than one setting (e.g., home and work)? Parent
and observer reports are very important for this item, as
individuals who have problems controlling their emotions
across multiple settings get higher scores.
Scoring:
1 Age-appropriate and situation-appropriate emotional
response. The individual shows an appropriate type and
degree of emotional response, both by word and
behavior, including emotional variations such as happy,
sad, proud, angry, scared, anxious, and related internal
states.
2 Mildly abnormal emotional response. The individuals
emotional expressions are relatively flat, distorted, or
slightly exaggerated. Nonverbal expression of emotions
does not always match verbal content. The individual is
able to describe several emotions in him- or herself, but
this ability is limited compared to his or her develop-
mental level. The individual may have intermittent
emotional regulation problems.
3 Moderately abnormal emotional response. The
individuals expression of emotions is flat, excessive, or
frequently inconsistent with the situation or content of a
verbalized topic. The individual may display greater
25
emotion than expected about special interests or id-
iosyncratic concerns. Ability to describe or understand
emotional states in him- or herself is limited. He or she
has serious problems with emotional regulation that
occur frequently in at least one setting.
4 Severely abnormal emotional response. The individual
has extreme problems with emotional regulation that
occur in more than one setting. Responses are extreme
or seldom appropriate to the situation or content of dis-
cussion. Shows extreme mood shifts that are difficult to
change. Expresses only a few emotions in their exagger-
ated form or perseverates on a particular emotion with-
out understanding.
Item 3. Relating to People
Definition. This is a rating of how the individual behaves
in a variety of situations involving interaction with other
people. This item is related to the first two items, which also
rate aspects of social relationships. This item differs in that it
is confined to dimensions related to direct interpersonal
interactions, and the persons initiation of interactions and
reaction to another individual. The two dimensions that are
rated on this item are the individuals initiation of interactions
and the reciprocal nature of the interactions.
Considerations. Consider both structured and
unstructured situations where the individual has a chance to
interact with an adult, spouse, peer, sibling, or you (the rater).
Consider how the individual reacts to attempts by others to
engage him or her in an interaction. These attempts may range
from persistent, intensive attempts to get a response to the
allowance of complete freedom. Note whether the person
initiates interactions, and if yes, whether he or she does so
purely for social purposes or only to get specific needs met or
to discuss areas of intense special interest. Regardless of who
initiates the interaction, note if the individual engages in and
helps to maintain the interaction past the initial overtures.
Scoring:
1 No evidence of difficulty or abnormality in relating to
people. Age-appropriate initiation of interactions to get
help, to get needs met, and for purely social purposes.
Interactions with others are fluid and show a reciprocal,
back-and-forth pattern.
2 Mildly abnormal relationships. The individual initiates
interactions only to get obvious needs met or discuss
special interests. There is some give-and-take in interac-
tions, but it lacks consistency, fluidity, or appropriate-
ness. The individual is aware of children/adults of the
same age and interested in interactions, but may have
difficulty initiating or managing an interaction. Minimal
initiation for purely social purposes that does not
involve special interests.
3 Moderately abnormal relationships. The individual
initiates interactions almost totally around his or her
special interests, with little attempt to engage others in
these interests. He or she responds to overtures from
others, but the interaction lacks social give-and-take
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26
and/or his or her responses are unusual and not always
related to the overture from others. The individual is
unable to maintain an interaction past the initial
overture.
4 Severely abnormal relationships. The individual does
not initiate any directed interactions and shows minimal
response to overtures from others. Only the most
persistent attempts to get the individual to engage have
any effect.
Item 4. Body Use
Definition. This area represents both coordination and
appropriateness of body movements. Subtle forms of fine
and gross motor coordination are rated here, as well as
deviations such as posturing, spinning, tapping and rocking,
toe-walking, and self-directed aggression.
Considerations. Consider fine motor activities such as
handwriting, drawing, and tying shoes. Fine motor difficulties
are rated on this area, with higher ratings given for problems
that are so severe that the person actively resists certain tasks.
While this item can be scored using another persons report, it
should be scored based on current behaviors and directly
observed behaviors should be given more weight. Any current
obvious deviant behaviors, including posturing, spinning,
rocking, toe-walking, and self-directed aggression,
automatically earn a rating of 3 or more, depending on the
persistence of the behavior.
Scoring:
1 Age-appropriate body use. The individual moves with
the same ease, agility, and coordination of a typical
person of the same age.
2 Mildly abnormal body use. Some minor peculiarities
may be present, such as clumsiness, repetitive move-
ments, or poor coordination or balance. The individual
may have fine motor difficulties, such as problems with
handwriting or tying shoes, compared to others at the
same developmental level.
3 Moderately abnormal body use. The individual current-
ly displays an unusual body posture or stance, hand or
finger mannerism, flapping, self-directed aggression,
picking at body, rocking, spinning or toe-walking. Fine
motor or obvious handwriting difficulties are present,
which may result in resistance to writing tasks.
4 Severely abnormal body use. Intense or frequent
movements of the types listed in the other categories are
signs of severely abnormal body use.
Item 5. Object Use in Play
Definition. This rating includes the persons interest in
and use of toys or other objects. In addition to the traditional
issues related to repetitive play with parts of objects, the
focus of this item also includes the degree to which the
individual engages in imaginative symbolic play and the
degree to which toy figures are used as agents.
Considerations. Consider how the person interacts with
toys or other objects, particularly in unstructured activities
with a large variety of items available. For older individuals,
Administration, Scoring, Interpretation, and Intervention Guide
the rating may need to be based on a parent interview. Any
current obvious repetitive or inappropriate use of objects or
obvious interest in parts of objects, as opposed to the whole,
should be rated as a 3 or higher depending on the persistence.
Note the individuals imaginative or creative use of the
materials. Does the individual use an object as an agent of
action with the other toys? Does he or she engage in make-
believe play and use an object to represent something else?
Scoring:
1 Appropriate interest in, and creative use of, toys and
other objects. The individual is able to spontaneously
use toys in age-appropriate imaginative symbolic play
and is able to use objects to represent something else.
The individual shows interest in a variety of toys and
leisure materials.
2 Mildly inappropriate interest in, or use of, toys and
other objects. The individuals play themes tend to be
repetitive or appear to reflect things seen in movies or on
TV. Some use of toy people as agents of action (e.g., has
an action figure or doll use other play materials). Some
make-believe play or use of objects to represent
something else. The individual responds to attempts by
others to engage him or her in pretend play, but there is
limited spontaneous initiation of imaginative play. The
individuals interests may be unusual in intensity or
inappropriate for his or her age. No obvious repetitive
or inappropriate use of objects (twirling or spinning) or
interest in parts of objects at this level.
3 Moderately inappropriate interest in, or use of, toys
and other objects. Limited imaginative creative play
either spontaneous or in response to others. People
typically not used as agents of action, and limited use of
objects to represent other things. No original themes in
play. May show some repetitive inappropriate use of
objects or interest in parts of objects. Interest in play
materials is restricted to a few items that may be
inappropriate for his or her age or interest is of an
unusual intensity.
4 Severely inappropriate interest in, or use of, toys and
other objects. No creative play. Toys are used in
repetitive or inappropriate manner.
Item 6. Adaptation to Change/Restricted Interests
Definition. This area concerns difficulty in changing
established routines or patterns, difficulties in changing
from one activity to another, and restricted special interests.
Considerations. Note the individuals reaction to
changing from one activity to another, particularly if he or
she was actively involved in the previous activity. Note
whether the person has a particular activity or interest that
appears unusual either in its intensity or narrowness. If
engaged in this activity or a conversation about this interest,
how readily can the person switch to a different activity or
topic? Observe whether the individual is quick to establish
routines. Does the person have any unusual rituals around
going to bed at night or doing work at school or in the work
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Chapter 3 Administration and Scoring of the CARS2-HF
place? Does he or she insist on arranging certain objects
just so, or eating or drinking only with specific utensils?
For older individuals, interview them about changes in daily
activities and routines, and note their emotional reactions to
these events.
The rating for this item is based on the most severe level
of difficulty in any one of the following three areas: coping
with change, ritualistic behaviors, or restricted special
interests.
Scoring:
1 Age-appropriate response to change/variety of
interests. While the individual may notice or comment
on changes in routines, he or she accepts these changes
without undue stress. The individual shows a wide
variety of interests, with no one interest or theme
predominating.
2 Mildly abnormal adaptation to change/variety of
interests. Unusually quick to develop new routines. Or
when others try to change the task, the person may
continue the same activity or use the same materials,
though he or she can be directed to change if needed. Or
person shows preference for specific activities, toys, or
topics of conversation, though he or she can be directed
to other topics or activities.
3 Moderately abnormal adaptation to change/variety of
interests. The individual has definite special interests or
a preference for specific activities, toys, or topics. An
adult needs to actively work to engage the individual in
other topics or activities. The individual shows
displeasure and may resist change or try to maintain
routine. The individual may become distressed by
attempts to interrupt or change an activity or topic. He or
she may have rituals or routines that have to be done in a
particular way. The person may report subjective
feelings of distress about change and/or interruptions or
may become overly fixed on a schedule, checklist, or
timing of events.
4 Severely abnormal adaptation to change/variety of
interests. The individual has definite special interests or
preferences, or has severe reaction to change. Reacts
with extreme anxiety, anger, or resistance to attempts to
change an activity, topic, or routine.
Item 7. Visual Response
Definition. This item covers the use of vision in three
areas: visual fascinations, the ease with which the individual
can shift visual attention, and the degree to which the
individuals eye contact is integrated with actions and
communication.
Considerations. Consider whether the person uses his or
her eyes normally when looking at objects or interacting with
people. Does the individual look at the person to whom he or
she is talking? When interacting with more than one person,
does the person shift his or her visual attention to a new
speaker? Distractibility is not the focus of this item. Any
obviously unusual visual responsefor example, looking at
27
items or fingers out of the corners of the eyes or spinning
objectsreceives a rating of 3 or higher, depending on the
persistence of the behavior.
Scoring:
1 Age-appropriate visual response. The individuals
visual behavior is normal and appropriate for his or her
age. No evidence of visual fascinations or difficulty
shifting attention. Eye contact is good and integrated
with verbal and nonverbal communication skills. Easily
shifts visual attention.
2 Mildly abnormal visual response. The individual
may stare inappropriately at others. Eye contact is
not consistently integrated with verbalizations.
Included at this level is any inconsistency in eye
contact, regardless of the proportion of time the
individual makes eye contact. The individual may
show more interest in describing small details in a
room or in looking at specific objects (moving parts,
lights, mirrors) than is typical.
3 Moderately abnormal visual response. Eye contact is
not integrated with verbalizations. Obvious visual
fascination with objects, lights, mirrors, spinning toys,
and so on. May use peripheral vision to look at things.
Obvious difficulty in shifting visual attention from high-
interest items.
4 Severely abnormal visual response. Persistent avoid-
ance of eye contact. Excessive interest in looking at spe-
cific objects or looking at objects in a peculiar way.
Item 8. Listening Response
Definition. This rating is based on the persons unusual
responses to sounds and how the listening response is
coordinated with the use of other senses.
Considerations. In direct observation, note the
individuals reaction to both speech and other sounds. The
individuals ability to respond to his or her name by
orienting to the person speaking is scored on this item.
Unusual over- or underreactions to noise or sounds are more
salient indicators of difficulty than merely being distracted
by noises. For example, someone who remarks on the
distant sound of a train and comments on the type of engine
it must be and the number of cars, or where it is heading,
would be demonstrating a more salient behavior than
someone who merely turns his or her head toward a loud
noise. Older adolescents and adults should be directly asked
about their interest in or aversion to certain sounds. To
receive a rating of 3 or higher, unusual listening responses
must be apparent across more than one setting and they must
be directly observed or reported by the individual.
Scoring:
1 Age-appropriate listening response. The individuals
listening behavior is normal and appropriate for his or
her age. Listening is used together with other senses
(e.g., the individual looks toward the person who is
speaking). The individual responds to his or her name.
2 Mildly abnormal listening response. Some difficulty
responding to verbalizations when background noise is
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28
present. Responds to his or her name after repeated
attempts to get the individuals attention. There may be
some lack of response or mild overreaction to certain
sounds. Atypical listening responses are apparent either
in direct observation or by report from outside observer,
but not both.
3 Moderately abnormal listening response. The
individuals responses to sounds or verbalizations are
inconsistent. May show marked reaction to some
sounds, or complete disregard for others. Seldom
responds to his or her name when name is called to get
the individuals attention. Unusual responses are
obvious across settings, either based on direct report by
the individual or by combined observer report and direct
observation.
4 Severely abnormal listening response. The individual
overreacts and/or underreacts to sounds to an extremely
marked degree. He or she is noticeably less responsive
to verbalizations than to noises made by objects. The
individual does not respond to repeated attempts to get
his or her attention by calling his or her name.
Item 9. Taste, Smell, and Touch Response and Use
Definition. This item addresses the persons response
to stimulation of his or her taste, smell, and touch senses and
to pain. Subtler aspects of the unusual stimulation of these
senses include responses to the textures of clothing or food,
such that the individual wears a limited variety of fabrics or
eats a limited variety of foods.
Considerations. In individuals with the cognitive levels
specified for the CARS2-HF (IQ over 80, with fluent
language), direct observation of the more extreme examples
of sensory stimulation (e.g., rubbing objects against the
face) are unusual. Any obvious observation of these more
classic sensory behaviors warrants a rating of 3 or higher,
depending on the persistence of the behavior. For the more
subtle sensory behaviors of food or clothing preferences, the
degree to which they are pervasive across settings will be an
important determinant for which rating to give. Also, the
degree to which these unusual sensory reactions induce
stress, require environmental modifications, and are
resistant to change is an important consideration. Relatively
more pervasive difficulties and those more resistant to
change are given higher ratings. It is also important to keep
in mind that individuals of certain ages (e.g., adolescents)
often have strong food and clothing preferences. Look for
preferences that do not reflect societal trends or fads. To get
a rating of 3 or higher based on these types of behaviors, the
unusual clothing or food preferences must be obvious across
multiple settings and the individual self-reports these
difficulties or they are obvious on direct observation.
Scoring:
1 Normal use of, and response to, taste, smell, and
touch. The individual explores new objects in an age-
appropriate manner generally by looking and feeling.
Responds appropriately to pain or touch from others.
Administration, Scoring, Interpretation, and Intervention Guide
Reacts to minor pains or illnesses by showing appropri-
ate discomfort, but does not overreact. Wears a variety
of textures of clothing and eats a wide variety of foods.
2 Mildly abnormal use of, and response to, taste, smell,
and touch. The individual may occasionally explore
objects by subtle attempts to smell, taste, or rub them
against part of his or her face or body. The individual
may show a mild over- or underreaction to touch or
pain. The individual may have obvious clothing or food
preferences, but is easily encouraged to try new things.
Unusual sensory responses are apparent in direct
observation or by report from outside observer, but not
both.
2.5 (Use this rating when observers report obvious sensory
behaviors, such as clothing and food preferences that
are difficult to change or modify, but these issues are
not reported by the individual and not obvious during
the interview.)
3 Moderately abnormal use of, and response to, taste,
smell, and touch. The individual obviously explores
objects by smelling, tasting, or rubbing them against a
part of his or her face or body, or the individual over- or
underreacts or stiffens to a touch or pain to a moderate
degree. Or the individual has limited clothing he or she
will wear or food he or she will eat. Limitations in sen-
sory areas, such as clothing and/or food preferences, are
obvious across settings, and the individual self-reports
these difficulties or they are obvious on direct observa-
tion. Sensory issues are difficult to modify and create
stress or require adaptation in everyday environments.
4 Severely abnormal use of, and response to, taste, smell,
and touch. The individual places extreme limits on the
food he or she eats or clothing he or she wears. Or the
individual has extreme reactions or underreactions to a
touch or pain. Or he or she shows a persistent preoccu-
pation with smelling, touching, or tasting things. Near-
receptor issues are a source of extreme stress for the
individual, who puts stress on the environment to find
ways to cope with these difficulties.
Item 10. Fear or Anxiety
Definition. This item focuses on the degree to which
the person has unusual fears or anxiety compared to what is
appropriate for a situation or context.
Consideration. Fearful behavior may include crying,
screaming, or nervous giggling. Anxiety may be noted in the
persons rate of speech, body posture or tension, facial
expression, body movement, or frustration tolerance in
approaching tasks. Some individuals will be able to directly
express their fears or anxiety. They may perseverate on their
concern (e.g., their parents whereabouts, bees, or other items
of concern). Note the pervasiveness of these emotions. Is the
persons nervousness obvious during direct observation? Do
observers report this behavior in other settings? Note whether
the emotional reaction is proportionate to the stimulus. Can
the individual be reassured or calmed?
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Chapter 3 Administration and Scoring of the CARS2-HF
Scoring:
1 Normal fear or anxiety. The individuals behavior is
appropriate to both the situation and his or her age.
2 Mildly abnormal fear or anxiety. The individual
occasionally shows too much or too little fear or anxiety
compared to the reaction of a typical person of the same
age in a similar situation. The abnormal response is
evident in only one setting (e.g., either on direct
observation or based on report from observer in another
setting, but not both).
3 Moderately abnormal fear or anxiety. The individual
shows either quite a bit more or quite a bit less fear or
anxiety than is typical even for a younger person in a
similar situation. The abnormal response is apparent
across more than one setting, and the individual either
self-reports these difficulties or they are obvious on
direct observation.
4 Severely abnormal fear or anxiety. Fear and anxiety are
pervasive across all settings and persist even after
repeated explanations or experiences with harmless
events or objects. It is extremely difficult to calm or
comfort the individual. The person may, conversely,
show pervasive and persistent disregard for hazards that
others of the same age avoid.
Item 11. Verbal Communication
Definition. This is a rating of two facets of the individ-
uals speech and language skills. The two concepts rated are
verbal oddities, such as formal language, unusual tone or in-
flection, and repetitive or made-up phrases, and the ability
to carry on a reciprocal conversation.
Considerations. This item is best evaluated by a direct
interaction with the individual. Engage the individual in a dis-
cussion of either an immediate stimuli in the room (a game,
book, or picture) or a discussion of events that have happened
in the persons life or the world in general. Note the content of
the individuals language. Is the individual using vocabulary
that seems more sophisticated than is typical for his or her age
and developmental level? Or is he or she using words incor-
rectly or repetitively? Note the tonal quality, rhythm, and vol-
ume or loudness of the voice. As the conversation is pursued,
note whether the person engages in an ongoing sequence of
exchanges on the same general topic. Does the individual add
more information or make overtures to extend the discussion?
Or is the conversation merely a question-and-answer ex-
change? Can the individual carry on an extended conversation
only around high-interest topics? Or can he or she engage in
conversation about topics of interest to the other person?
Scoring:
1 Normal verbal communication, age and situation
appropriate. The individual is able to carry on an age-
appropriate conversation with another person; he or
she is able to respond to others overtures while also
adding additional information (at least a four-element
sequence). No evidence of unusual speech inflection,
volume, or tone. No evidence of made-up words or
repetitive or rote phrases.
29
2 Mildly abnormal verbal communication. Conversational
exchanges are more limited than would be expected for
someone his or her age. Occasional use of made-up
words or repetitive, rote phrases. At times may display
unusual vocal intonation or rate of speech. Ratings at
this level indicate that the individual has either prob-
lems with conversation or verbal oddities, but not both.
3 Moderately abnormal verbal communication. Minimal
initiation of conversation during direct interaction.
Verbalizations include overly formal language or
repetitive phrases. Little reciprocal conversation; may
speak on his or her own topic, but little sense of
interaction. Vocal intonation or rate of speech is often
unusual. Some use of unusual words or repetitive
speech. The individual has some apparent difficulties in
carrying on a reciprocal conversation and displays some
type of verbal oddity.
4 Severely abnormal verbal communication. The
individual is unable to have a conversation with another
person. May respond to specific questions, but does not
engage in a back-and-forth conversation. Does not
initiate communication. Language may be overly formal
or pedantic. Marked abnormal speech inflection or tone.
Frequently uses made-up words and/or repetitive
phrases. The individual has significant difficulties in
both areas of expressive communicationreciprocal
conversation and verbal oddities.
Item 12. Nonverbal Communication
Definition. This item rates all forms of nonverbal
communication, including the use of gaze to regulate and
understand interactions and the use of facial expressions and
gestures in combination with verbalizations for a variety of
communicative functions (instrumental, descriptive, and
emphatic). While the persons response to the nonverbal
communication of others is also considered, greater
emphasis should be placed on the use of these aforementioned
forms of communication.
Considerations. Consider particularly the individuals
use of nonverbal communication at times when the
individual has a need or desire to communicate. Also note
his or her response to the nonverbal communication of
others. Does the person use gestures to point to something of
interest or something he or she wants? When describing
events or visual stimuli (pictures or books), does the
individual use gestures to enhance the description or to
emphasize a point? Are the individuals gestures and gaze
used in coordination with his or her language to direct the
communication toward another person? Does the individual
use his or her gaze and gestures to draw another persons
attention to an object of interest?
Scoring:
1 Normal use of nonverbal communication, age and
situation appropriate. The individual uses a variety of
facial expressions and instrumental, descriptive, and
emphatic gestures that are well integrated with
verbalizations. The individual responds to facial
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30
expressions and gestures from others. The individuals
gaze is used to regulate interactions with others.
2 Mildly abnormal use of nonverbal communication.
The individual uses instrumental gestures (pointing,
reaching) to indicate what he or she wants. Descriptive
gestures are used infrequently and are not well
coordinated with verbalizations. The person responds to
very obvious facial expressions or gestures from others.
May show too little or exaggerated facial expressions at
times, though generally shows appropriate expressions.
The individual is inconsistent in the use of gaze to
regulate interactions with others.
3 Moderately abnormal use of nonverbal communica-
tion. Facial expressions are often flat or exaggerated.
The individual uses limited instrumental gestures, and
these gestures are not well integrated with verbaliza-
tions. The individual rarely uses descriptive or em-
phatic gestures. He or she shows limited response to
nonverbal communication from others. Joint attention
is rare, as the person seldom uses or responds to gaze
or gestures as a means of sharing attention to an object
or activity.
4 Severely abnormal use of nonverbal communication.
Facial expressions are either flat or exaggerated. The
individual does not use instrumental, descriptive, or
emphatic gestures and shows no awareness of nonverbal
communication from others. No evidence of using gaze
to regulate activities with others.
Item 13. Thinking/Cognitive Integration Skills
Definition. This is a rating of the individuals ability to
understand the meaning of larger concepts and to integrate
relevant details into a meaningful overview (central
coherence). Part of this process involves the persons ability
to discriminate between relevant and irrelevant details.
Considerations. To assess the individuals cognitive
integration skills, there are several types of activities that can
be helpful. For some individuals, present them with a short
reading exercise or a picture that has a lot of detail and ask
them to tell you what the main point or concept behind the
reading or the picture is. During a discussion of life events,
note the individuals ability to conceptualize the meaning of
events and not just report the numerous details. If the
individual does not immediately get the main concept, note
how he or she responds to your attempts to highlight
important information to help him or her see the main issue.
Scoring:
1 Age-appropriate thinking/cognitive integration skills.
The individual is able to understand the meaning of
information presented either pictorially, verbally, or in
writing. He or she demonstrates central coherence, that
is, the ability to attend to relevant versus irrelevant
details and to integrate this information into a meaning-
ful overview.
2 Mildly impaired in specific thinking/cognitive
integration skills. Delayed thinking compared to
Administration, Scoring, Interpretation, and Intervention Guide
individuals of the same age. Difficulties may be seen in
distinguishing relevant from irrelevant cues for
conceptualizing. Or the individual can verbalize an
overall understanding, but is unable to articulate how
meaning was derived. At times the supportive presence
of another person helps with comprehension.
3 Moderately impaired in specific thinking/cognitive
integration skills. The individual has notable difficulties
comprehending meaning and integrating information
into overall conceptualization, but shows great attention
to specific things and concrete details. Frequently
requires specific prompts from others to attend to
relevant details or grasp the larger conceptualization.
4 Severe delay in specific thinking/cognitive integration
skills. The individual shows repeated and consistent
difficulty distinguishing relevant from irrelevant details.
Even with the persistent efforts of another, he or she
may not be able to conceptualize the overall meaning of
information.
Item 14. Level and Consistency of Intellectual Response
Definition. This rating is concerned with both the
discrepancies in and consistency of the individuals skills as
well as his or her general level of intellectual functioning.
Some fluctuations in mental functioning occur in many
normal individuals. However, this item is intended to identify
extremely unusual or peak skills. Discrepancies between
academic performance and IQ test scores are not considered
in rating this category.
Considerations. By definition, this instrument is
appropriate only for an individual whose overall IQ score is
above 80, so the descriptors make this assumption. For
individuals of any age with an IQ less than 80, the CARS2-ST
is a more appropriate instrument. Anchor points for some of
the half-point ratings are included to provide greater
clarification in scoring. The IQ score ranges cited in the
ratings are rules of thumb only. As with most test scores,
expert discretion based on knowledge about the details of a
particular case and the instrument used to derive a given
score must be exercised when determining how to best
characterize the abilities of a person whose score falls on the
border of adjacent ranges. Best practice dictates that formal
intellectual assessment data should be included in diagnostic
considerations. However, when such formal data are not
available, clinical judgment based on a developmental
history and relevant observations should be used.
Unless the individual has a clearly identified savant skill
(this would be given a rating of 4), to get a score other than 1,
the individual should be delayed to some degree in his or her
adaptive functioning, especially in the area of social skills.
The assumption is that one would not be doing a diagnostic
evaluation of someone who had no problems in adaptation.
Scoring:
1 Intelligence is at least normal and reasonably consis-
tent across various areas. The individual has at least
near-average intellectual abilities and does not have
any unusual intellectual skills or problems. (IQ score is
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Chapter 3 Administration and Scoring of the CARS2-HF
85 or above, with limited variability.) Adaptive skills
are appropriate for age and intellectual abilities. Unless
the individual has a savant skill, which always
receives a rating of 4, all individuals whose adaptive
skills are appropriate for their age and intellectual
abilities should receive a rating of 1, regardless of
intellectual level or variability in skills.
1.5 IQ score is 90 or above, with limited variability
across areas. Adaptive skills are less than expected
for cognitive level.
2 Mildly abnormal intellectual functioning. The
individual is not as smart as a typical person of the same
age; skills appear evenly delayed across all areas. (IQ
score between 80 and 90, with limited variability.)
Adaptive skills are less than expected for level of
intelligence.
2.5 The individuals overall cognitive skills are near the
low-average range (IQ score between 80 and 90), but
there is significant variability in skills. Adaptive skills
are less than expected for level of intelligence.
3 Moderately abnormal intellectual functioning. In
general, the individuals overall functioning is within
the normal range (IQ score between 90 and 115), but he
or she shows significant variability in skills. Adaptive
skills are less than expected for level of intelligence.
3.5 The individuals overall intellectual functioning is
above average (IQ score greater than 115), and he or
she shows significant variability in skills. Adaptive skills
are less than expected for level of intelligence.
4 Severely abnormal intellectual functioning. Individual
has a skill that is significantly and extremely better than
expected for his or her level of intelligence and better
than that exhibited by typical peers (savant skill).
Cognitive functioning is at least near low-average
intelligence (IQ score is 80 or higher). Adaptive skills
are typically less than expected for level of intelligence,
though in rare instances may be appropriate for
cognitive level.
Item 15. General Impressions
This is intended to be an overall rating of autism based on
your subjective impression of the degree to which the
individual has an ASD, as defined by the other 14 items. This
rating should be made without recourse to averaging the other
ratings. As with the other items, this rating should be made
by taking into account all available data from such sources as
the individuals case history, test results, parent and individual
interviews, or past records.
Scoring:
1 No autism spectrum disorder. The individual shows
none of the symptoms characteristic of an autism
spectrum disorder.
2 Mild autism spectrum disorder. The individual shows
only a few symptoms or only a mild degree of an autism
spectrum disorder (mild interference with daily
functioning).
31
3 Moderate autism spectrum disorder. The individual
shows a number of symptoms or a moderate degree of
an autism spectrum disorder (moderate interference
with daily functioning).
4 Severe autism spectrum disorder. The individual shows
many symptoms or an extreme degree of an autism
spectrum disorder (extreme interference with daily
functioning).
Using the CARS2-QPC to
Inform CARS2-HF Ratings
The information in this section is substantially the same
as was presented in chapter 2 for the CARS2-ST. It is repeated
here for the convenience of readers who consistently use
either one form or the other, so that when referring to this
manual, it is not necessary to flip pages back and forth
between chapters.
As with the CARS2-ST, it cannot be overemphasized
that ratings from the CARS2-HF should be used as only one
piece of a multifaceted evaluation that includes developmen-
tal history; review of prior evaluations; parent or caretaker
interview; results from intellectual, academic, vocational,
adaptive, and behavioral rating areas; and direct interaction
with and assessment of the individual being evaluated.
Information of all of the aforementioned types can poten-
tially be used in formulating ratings. The Questionnaire
for Parents or Caregivers (CARS2-QPC; WPS Product No.
W-472C) is an unscored form designed to assist in gathering
information from a parent or caregiver about behaviors re-
lated to autism. Information from the CARS2-QPC can be
integrated with other evaluation information when making
the final CARS2-HF ratings.
The CARS2-QPC provides information relevant to each
of the 15 CARS2-HF rating areas. However, the form was
intentionally organized in a way that would be most mean-
ingful to caregivers. Categories thus do not map directly onto
the CARS2-HF Rating Booklet. Parent or caregiver responses
must be reviewed and summarized by a professional familiar
with autism in order to be effectively integrated into CARS2-
HF ratings. The most fruitful way to facilitate this integration
is to use the completed CARS2-QPC as a framework for a
follow-up interview to clarify responses. Clarification and
expansion of the parent or caregiver responses through
interview allows you to more clearly interpret the persons
perspective in relation to your understanding of ASDs.
The areas assessed by the questionnaire and in a
thorough developmental interview include the individuals
social, emotional, and communication skills; repetitive
behaviors; play; and routines, as well as unusual sensory
interests. In both the questionnaire and follow-up interview,
gathering information about the individuals early develop-
ment as well as current functioning is essential.
There are four main considerations when interpreting
parent or caregiver responses on the CARS2-QPC. First, be
aware of the overall pattern of strengths and weaknesses that
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 32
32
is reported. Review the completed questionnaire and look for
discrepant patterns of skills or abilities. For example, verbal
communication skills and sensory preoccupations may be
indicated to occur often or to always be a problem, while
nonverbal communication, relating to others, and showing
emotions are not considered problems. Second, review and
evaluate any examples the parent or caregiver may provide. A
caregiver may endorse an item, but provide a description of a
behavior that is not of the same type inquired about. Thus
carefully consider whether the examples are suggestive of the
specific behaviors someone with ASD might demonstrate.
Consider, as an example, item 5.5: Has special interests or
topics. Are the examples of topics that have been provided
highly unusual, such as computer serial numbers or actuarial
statistics? Are there multiple special interests listed,
suggesting a variety of interests rather than focused interests?
Is the interest one that is common to others in the individuals
age group, such as video games or computer use in general?
Third, the consistency of the information given by the
caregiver with regard to all other information obtained during
the assessment process should be taken into consideration.
When two sources offer discrepant reports, further inquiry
will help to clarify whether the individuals behavior differs
across settings and people or is only being reported differently
by different sources. Finally, since ASD is a developmental
disorder, these reports must indicate that the symptoms of
autism were present early in life, that is, prior to the age of 4
or 5. Some other diagnostic conditions can lead to social
problems over time, but do not share the same early history of
social difficulties as ASD.
Case Example:
Daniels CARS2-HF Ratings
The chief purpose of the CARS2-HF is to incorporate
multiple sources of information to help with the clinical
diagnosis of an ASD. The case of Daniel, an 8-year-old boy,
demonstrates how the CARS2-HF items are rated based on
multiple sources of information. A discussion of how
Daniels pattern of item ratings on the CARS2-HF assisted in
reaching a diagnostic decision is provided in chapter 4. A
demonstration of how Daniels CARS2-HF ratings helped to
shape intervention planning for him is provided in chapter 5.
As always, it is important to keep in mind that an early
developmental history supportive of autism is an essential
component of the diagnostic decision tree, but such infor-
mation is not included in the ratings of the CARS2-HF.
The information sources used for Daniels rating on
each item are indicated as follows:
(O) direct observation
(P) parent report
(T) teacher report
(R) record review
Item 1. Social-Emotional Understanding 3.0
Daniel will stand up for a child being bullied, and he
will report rule violations to his parents or teacher. On the
Administration, Scoring, Interpretation, and Intervention Guide
other hand, he can be quite naive and is sometimes a target
for children who try to get him to do something that will get
him into trouble. (P, T)
Daniel has significant delay in development of his
social understanding and ability to understand the
perspective of another person. (P, O)
Item 2. Emotional Expression and Regulation
of Emotions 2.5
Daniel has low affect. During assessment, he did not
show a range of facial expressions, which were limited to
neutral expressions or smiles; he did not consistently direct
any change in facial expression to others. (O)
Daniel was able to give descriptions of basic emotions,
such as happy, sad, or angry, but unable to describe or talk
about more complex emotions, such as jealousy, anxiety, or
pride. (O)
Daniel can easily become upset, and how he is
approached can set his emotional reaction for the day. (P) At
school, Daniel will shut down if he misses out on something
his classmates have a chance to do. Having his conduct
marker moved will also cause an upset for Daniel. (T)
Item 3. Relating to People 2.0
In preschool and kindergarten, Daniels teachers were
concerned about his social immaturity (R), and his current
teacher is concerned about his inability to appropriately
interact socially with peers. (T) He is described as not
understanding social boundaries and touching or getting into
others personal space. (P, T) He has always been reluctant
to participate in group activities in his classroom. (T)
Daniel shows an interest in other people, but his social
connectedness and his initiations are around his interests
and not reciprocal in nature. (O)
Daniels play with other children is one sided, with him
directing others as to what they should do. (P) During evalua-
tion, he used the examiner more as someone to fill a part
in his play, rather than engaging in a truly reciprocal play
interaction. (O)
Daniel will share things of interest with others and will
seek out others to share. (O)
Item 4. Body Use 3.0
Daniel was observed to engage in flapping his arms and
grimacing. (O) He has significant difficulty with handwrit-
ing and small fasteners on clothing. (O, P, T)
As a young child, Daniel toe-walked, spun in circles,
grimaced, and flapped his hands. (While this information is
not used in making the rating, it is important in establishing
a history of behavior supportive of an autism diagnosis.) (P)
Item 5. Object Use in Play 3.0
Daniel did not engage in pretend play in preschool. (R)
Daniel lacks varied and spontaneous make-believe play
appropriate to his developmental level; in play he did not use
action figures as agents. (O)
At home Daniel will play with race cars, but does not
play pretend with other children. (P)
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 33
Chapter 3 Administration and Scoring of the CARS2-HF
Item 6. Adaptation to Change/Restricted
Interests 2.0
Daniel has difficulty with changes to the daily school
routine. (T)
Daniel has a strong interest in trains and tools, and his
social initiations are around these interests. (P) When
opportunities were provided for him to demonstrate his
interest in trains and tools, he made more social initiations
around these interests, but he did not perseverate on these
topics and was easily directed to other topics. (O)
During assessment, he was flexible and easily made
transitions. (O)
Item 7. Visual Response 2.0
Inconsistent eye contact, with some looking at himself
in mirror. (O)
Item 8. Listening Response 1.0
Appropriately responds to his name being called and to
unexpected noises. (O)
Item 9. Taste, Smell, and Touch Response
and Use 2.0
Response to pain is inconsistentsometimes
nonexistent, but at other times he will overreact to
minor injuries. Labels on clothes bother him; he will
only wear loose clothing. (P)
Item 10. Fear or Anxiety 2.5
Daniel is anxious at school and shuts down when
corrected or disciplined. (T)
Daniel was mildly anxious during assessment,
repetitively questioning how long he would be there and
when lunch would be. (O)
Item 11. Verbal Communication 3.0
Difficulties with reciprocity were observed in Daniels
conversation; there was some reciprocity, but it was limited
in frequency and duration and occurred primarily around
things of interest to him. (O)
Speech is often very loud. (P) He has an unusual
intonation, with odd use of words and phrases. (O)
Item 12. Nonverbal Communication 2.0
Daniel used some instrumental gestures (points), but no
spontaneous emphatic or descriptive gestures. (O)
Facial expressions are appropriate, but limited in range;
inconsistent use of eye contact. (O)
Item 13. Thinking/Cognitive Integration Skills 3.0
Daniel is very detail focused in his thinking, yet has
difficulty integrating the details into conceptual meaning. (O)
He doesnt seem to understand abstract cause/effect
relationships (e.g., discipline doesnt seem to have the effect
of changing his behavior). (T, P)
33
Item 14. Level and Consistency of Intellectual
Response 3.0
He taught himself how to read by age 3 years. (P)
Intellectual ability testing shows that verbal and non-
verbal skills are in the average range, with working memory
low average and processing speed below average. (R)
Adaptive scores are clearly below the average range. (R)
Item 15. General Impressions 3.0
Daniel has many characteristics of higher functioning
autism, including difficulties with social-emotional
understanding and expression, emotional regulation, social-
communicative reciprocity, deficits in imagination, difficulty
with conceptual and abstract thinking, sensory sensitivities,
anxiety, fine motor difficulties, and a scattered skill profile,
with deficits in adaptive behavior.
Scoring the CARS2-HF Rating Booklet
Scoring the CARS2-HF is the same straightforward
process used to score the CARS2-ST. A sample of a com-
pleted CARS2-HF Rating Booklet (prepared for Daniel,
from the case example) is provided in Figure 2. This sample
will be used to illustrate the scoring procedures described in
this section. (The numbers in dark circles in the following
text correspond to those in the figure.)
First, transfer the ratings for all 15 categories from the
inside pages of the booklet to the corresponding spaces
provided in the Summary section on the front page of the
booklet . Next, sum the ratings to obtain the Total raw
score. In Figure 2, a Total raw score of 37 has been obtained
and entered in the space provided . Indicate the Severity
Group that corresponds with the Total raw score by making
a check mark in the appropriate box. In the example, a check
mark has been made indicating that the Total raw score is in
the Severe Symptoms range .
To obtain a standard score in the form of a T-score,
circle the value that corresponds to the Total raw score in the
Raw score table provided on the right side of the Summary
section . The number printed to the left of the value you
have circled is the T-score. In Figure 2, the Total raw score
of 37 corresponds to a T-score of 55T . The number
printed to the left of the T-score value is the percentile rank
that corresponds to the Total raw score. In the example, the
percentile rank for the obtained Total raw score is 69 .
Note that, unlike with the CARS2-ST Total raw scores,
the relationship between CARS2-HF Total raw scores and
standard scores is consistent across the life span. A
discussion of the uses and limitations of CARS2-HF
standard scores is provided in chapter 4.
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 34

CARS 2-HF
Childhood Autism Rating Scale, Eric Schopler, Ph.D., Mary E. Van Bourgondien, Ph.D.,
High-Functioning
Version
Second Edition G. Janette Wellman, Ph.D., and Steven R. Love, Ph.D.
Rating Booklet

Daniel
Name: _________________________________________________________________________________________ Sample 2 3-10-2009
Case ID Number: ____________________________________ Test date: _______________________________

Male African American

Gender: _____________________________ Ethnic background: ______________________________ Robert S.
Raters name: _______________________________________________ 10-4-2000
Date of birth: ____________________________

Direct interview of child, parent interview, previous psychological reports,

Based on information from: __________________________________________________________________________________________________________________________ 8 years __________
Age: ___________ 5 months
teacher report, CARS2-QPC
DIRECTIONS: After rating the 15 items, transfer the ratings from the inside pages to the corresponding spaces below. Sum the ratings to obtain the
Total raw score, and indicate the corresponding Severity Group. Circle the Total raw score value in the table. The number printed to the left of the value
you have circled is the T-score.

SUMMARY Symptom Level Compared to

Individuals With Autism Spectrum Diagnoses
CATEGORY RATINGS Percentile T-score
>70
Raw score
>47
1. 3.0
Social-Emotional Understanding ......................................... _________ >97 70 47
median = 2.5 97 69 46.5
2.5
2. Emotional Expression and Regulation of Emotions .............. _________ 68 46
median = 2.5 96 67 45.5
95 66 45
2.0
3. Relating to People .............................................................. _________ 93 65 4444.5
median = 2.5 92 64 43.5
3.0
4. Body Use............................................................................. _________ 90 63 42.543
median = 2.0 88 62 41.542
86 61 41
3.0
5. Object Use in Play ............................................................... _________ 84 60 40.5
median = 2.0 82 59 39.540
2.0
6. Adaptation to Change/Restricted Interests ......................... _________ 79 58 38.539
76 57 38
median = 2.5

72 56 37.5
2.0
7. Visual Response ................................................................. _________ 69 55 37
median = 2.0 65 54 3636.5
1.0
8. Listening Response ............................................................ _________
62 53 35.5
58 52 35
median = 2.0
54 51 3434.5
2.0
9. Taste, Smell, and Touch Response and Use ......................... _________ 50 50 3333.5
median = 2.0 46 49 32.5
2.5
10. Fear or Anxiety .................................................................... _________
42
38
48
47
32
31.5
median = 2.0 35 46 30.531
3.0
11. Verbal Communication ........................................................ _________ 31 45 30
median = 2.5 28 44 29.5
24 43 28.529
2.0
12. Nonverbal Communication .................................................. _________ 21 42 28
median = 2.0 19 41 27.5
3.0
13. Thinking/Cognitive Integration Skills ................................. _________ 16 40 27
median = 2.0 14 39 26.5
12 38 26
3.0
14. Level and Consistency of Intellectual Response ................... _________ 10 37 2525.5
median = 2.0 8 36 24.5
3.0
15. General Impressions ........................................................... _________ 7 35 24
median = 2.5 6 34 23.5
5 33 23
4 32 2222.5

3 31 21.5
2 30 21
Total raw score = 37 29 20.5
Note. SEM = 0.73.
1 28 20
<1 27 19.5
26 19
SEVERITY GROUP 25
24 18.5
Minimal-to-No Symptoms of Autism Spectrum Disorder
23
(1527.5)
22
21
Mild-to-Moderate Symptoms of Autism Spectrum Disorder
20 18
(2833.5)
<20 <18

Severe Symptoms of Autism Spectrum Disorder

(34 and higher)
Note. SEM = 2.8T.

Additional copies of this form (W-472B) may be purchased from WPS. Please contact us at 800-648-8857 or wpspublish.com.
W-472B Copyright 2010 by WESTERN PSYCHOLOGICAL SERVICES. Not to be reproduced in whole or in part without written permission. All rights reserved. Printed in U.S.A.

Figure 2
Completed CARS2-HF Rating Booklet for Daniel

34
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 35

DIRECTIONS
For each category, use the space provided in the Observations section for
taking notes concerning the behaviors relevant to that item. After you finish
the direct observation and have gathered information from an interview of a
parent or someone else who can give information about the persons early
development and current functioning across settings, rate the behaviors by
circling the statement that best describes the persons condition. You may
indicate that the individuals behavior falls between two descriptions by
using ratings of 1.5, 2.5, or 3.5. Abbreviated rating criteria are presented
for each item. See chapter 3 of the Manual for detailed rating criteria.

1. Social-Emotional Understanding 2. Emotional Expression and Regulation of Emotions

Social-emotional understanding addresses a persons cognitive under-
standing of others communication, behaviors, and differing perspectives.
The dimensions of social understanding that are included in this item are
the ability to read the nonverbal cues of others and the ability to take
another persons perspective. This item does not reflect whether someone
has friends or is in a relationship. Rather, it deals with a persons ability
to perceive and articulate how another person may feel or what his or her
perspective may be on a given situation.
1 Age-appropriate social-emotional understanding. Clearly understands
facial expressions, gestures, tone of voice, and body language of others. Able to under-
stand that others may have a different perspective and what that perspective may be.
1.5
Mildly impaired social-emotional understanding. Responsive to most
2 facial expressions and expressions of emotion in others gestures and body language,
but these cues may need to be slightly exaggerated. More subtle expressions such as
mild sarcasm, doubt, or ambiguity are sometimes not understood. The ability to take
anothers perspective is inconsistent.
2.5
Moderately impaired social-emotional understanding. Shows an under-
3 standing of facial expressions, tone of voice, and body language only when these cues are
exaggerated. Is likely to ignore or misunderstand expression or perspective of others.
3.5
Severely impaired social-emotional understanding. Demonstrates
4 virtually no ability to understand appropriate facial expressions, gestures, tone of voice,
or body language. Unable to recognize that the perspective, understanding, or expression
of others might differ.
Observations
Stands up for a child being bullied (P, T)
This item refers to the capacity to express feelings and regulate ones
emotions. This item is based on both direct observation and the reports
of others who have witnessed this persons behavior in other settings.
Age-appropriate and situation-appropriate emotional response.
1 Shows appropriate type and degree of emotional response, both by word and behavior,
including emotional variation such as happy, sad, proud, angry, scared, anxious, and
related internal states.
1.5
Mildly abnormal emotional response. Emotional expressions are relatively
2 flat, distorted, or slightly exaggerated. Nonverbal expression of emotions does not always
match verbal content. Able to describe several emotions in self but limited compared
to developmental level. May have intermittent emotional regulation problems.
2.5
3 Moderately abnormal emotional response. Expression of emotions is flat,
excessive, or frequently inconsistent with situation or content of verbalized topic. May
display greater emotion than expected about special interest or idiosyncratic concerns.
Ability to describe or understand emotional states in self is limited. Serious problems
with emotional regulation that occur frequently in at least one setting.
3.5
4 Severely abnormal emotional response. Extreme problems with emotional
regulation that occur in more than one setting. Responses are extreme or seldom appro-
priate to situation or content of discussion. Shows extreme mood shifts that are difficult
to change. Expresses only a few emotions in their exaggerated form, or perseverates on
a particular emotion without understanding.
Observations
Easily becomes upset (P)
How he is approached can set his emotional
reaction to the day (P)

Reports rule violations to his parents or Will shut down if he misses out on something his
teacher (P, T) classmates have a chance to do (T)
Having conduct marker moved causes an upset (T)
Can be naiveis sometimes a target for
other childrenthey try to get him to do Low affect (O)
things that will get him into trouble (P, T) Restricted range of facial expressions during
assessmentthey were limited to neutral or
Marked delay in development of social
smilesdid not consistently direct change in
understanding (P, O)
facial expression to others (O)
Marked delay in ability to understand the Able to describe basic emotions such as happy,
perspective of another person (P, O) sad, and angry (O)
Unable to describe or talk about more complex
emotions such as jealousy, anxiety, or pride (O)

Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel

35
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 36

3. Relating to People 4. Body Use

This item is related to the first two items, which also rate aspects of social This item represents grossly deviant body movements and also subtler
relationships. This item differs in that it is confined to dimensions related forms of fine motor and coordination problems. Any obvious current
to direct interpersonal interactions and the persons expression and deviant behaviorsincluding posturing, spinning, rocking, toe-walking,
reaction to another person. The two dimensions that are rated in this item and self-directed aggressionautomatically merit a rating of 3 or higher,
are the persons initiation of interactions and the reciprocal nature of the depending on the persistence of the behavior. Difficulties with handwrit-
interactions. ing and tying shoes are rated on this item, with higher ratings given for
problems that are so severe that the person actively resists these tasks.
No evidence of difficulty or abnormality in relating to people. Age-
1 appropriate initiation of interactions to get help, to have needs met, and for purely social
While this item can be scored using anothers report, it is best to base
purposes. Interactions with others are fluid and show a reciprocal, back-and-forth pattern.
your rating on current behavior. Directly observed behaviors should be
1.5 given more weight than those from anothers report.
Mildly abnormal relationships. Initiates interactions only to get obvious needs
2 met or around special interests. Some give-and-take noted in interactions, but lacks 1 Age-appropriate body use. Moves with the same ease, agility, and coordination
as a typical person of the same age.
consistency or fluidity or appropriateness. Aware of other people of same age and
interested in interactions, but may have difficulty initiating or managing interactions.
1.5
Mildly abnormal body use. Some minor peculiarities may be present, such as
2.5
Minimal initiation for purely social purposes that does not involve special interests.
2 clumsiness, repetitive movements, poor coordination, or poor balance. May have fine
motor difficulties, such as problems with handwriting or tying shoes, compared to others
Moderately abnormal relationships. Initiates interactions almost totally
3 around his or her special interests, with little attempt to engage others in these
at the same developmental level.
2.5
interests. Responds to overtures from others, but lacks social give-and-take or responds
Moderately abnormal body use. Currently displays any unusual body posture
in ways that are unusual and not always related to original overtures. Unable to maintain
an interaction beyond initial overtures.
3 or stance, hand or finger mannerism, flapping, self-directed aggression, picking at body,
3.5 rocking, spinning, or toe-walking. Fine motor difficulties or obvious handwriting
difficulties are present, which may result in resistance to writing tasks.
Severely abnormal relationships. Does not initiate any directed interactions
4 and shows minimal response to overtures from others. Only the most persistent
3.5
Severely abnormal body use. Intense or frequent movements of the type listed
attempts to get the person to engage have any effect.
4 above are signs of severely abnormal body use.
Observations
Observations
Preschool and kindergarten teachers
concerned about his social immaturity (R) Has much difficulty writing and with small
fasteners on clothing (P, T, O)
Doesnt understand social boundaries
touches or gets into others personal space Toe-walked as a young child, spun in
(P, T) circles, grimaced, and flapped his hands
(not used for rating, but important for
One-sided play with other childrendirects
diagnosis) (P)
others what they should do (P)
Observed flapping his arms and grimacing
Current teacher concerned about inability
(O)
to interact appropriately with peers
socially (T)
Has always hesitated to participate in
group activities in classroom (T)
Shows interest in other people (O)
Social connectedness and initiations around
his interestsnot reciprocal (O)
During evaluation he used the examiner as
someone to fill a part in his play, not
engaging in reciprocal play (O)
Shares things of interest with others
seeks others out to share (O)

Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel

36
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 37
5. Object Use in Play
This rating includes the persons interest in and use of objects. In addition
to the traditional issues related to repetitive play with parts of objects, the
focus of this item also includes the degree to which the person engages
in imaginative symbolic play and the degree to which toy figures are used
as agents. For older persons, the rating may need to be based on the
parent interview. Any obvious inappropriate or repetitive use of objects
or obvious interest in parts of objects as opposed to the whole should be
rated 3 or higher, depending on the persistence.
Appropriate interest in, and creative use of, toys and other objects.
1 Able to spontaneously use toys in age-appropriate imaginative symbolic play and able
to use objects to represent something else. He or she shows interest in a variety of toys
and leisure materials.
1.5
2 Mildly inappropriate interest in, or use of, toys and other objects.
Play or imaginative themes tend to be repetitive or appear to reflect things seen in
movies or on TV. Some use of toy people as agents, for example, has an action figure or
doll use other play materials. Some make-believe play or use of objects to represent
something else. Responds to others attempts to engage him or her in pretend play, but
limited spontaneous initiation of imaginative play. Interests may be unusual in intensity
or inappropriate for age. No obvious repetitive or inappropriate use of objects, such as
twirling or spinning, or interest in parts of objects at this level.
2.5
Moderately inappropriate interest in, or use of, toys and other
3 objects. Limited imaginative creative play, either spontaneously or in response to
others. People typically not used as agents, and limited use of objects to represent other
things. No original themes in play. May show some repetitive, inappropriate use of
objects or interest in parts of objects. Interest in play or novelty materials restricted to
a few items and may be inappropriate for age or of an unusual intensity.
3.5
Severely inappropriate interest in, or use of, toys and other objects.
4 No creative play. Toys or other novelty items are used in repetitive or inappropriate manner.
Observations
Did not engage in pretend play in
preschool (R)
At home plays with race cars, but
no pretend play with other children (P)
Little variety or spontaneity in
make-believe playdid not use action
figures as agents (O)
Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel
37
6. Adaptation to Change/Restricted Interests
This item includes difficulty coping with change, ritualistic behaviors, and
restricted special interests. The rating is based on the most severe level
of difficulty in any one specific area.
Age-appropriate response to change/variety of interests. May notice
1 or comment on changes in routines, but accepts these changes without undue stress.
Shows a wide variety of interests, with no single interest or theme predominating.
1.5
Mildly abnormal adaptation to change/variety of interests. Unusually
2 quick to develop new routine or, when others try to change task, the person may
continue the same activity or use the same materials, though he or she can be directed
to change if needed. OR, person shows preference for specific activities or toys or topics
of conversation, though can be directed to other topics.
2.5
Moderately abnormal adaptation to change/variety of interests. Has
3 definite special interests or preferences for specific activities, toys, objects, or topics.
Adult needs to actively work to engage him or her in other topics or activities. Shows
displeasure and may resist change or try to maintain routine. May become distressed by
attempts to interrupt or change topic or activity. May have rituals or routines that have to
be done in a particular way. May report subjective feelings of distress about change or
interruptions, or may become overly fixed on schedule, checklist, or timing of events.
3.5
Severely abnormal adaptation to change/variety of interests. Has
4 definite special interests or preferences, or has severe reaction to change. Reacts with
extreme anxiety, anger, or resistance to attempts to change activity or topic or routine.
Observations
Strong interest in trains/toolssocial
initiations are around these interests (P)
Difficulty with changes to the daily school
routine (T)
Opportunities provided to demonstrate his
interest in trains and toolshe made more
social initiations around these interests
didnt perseverateeasily directed to other
topics (O)
Flexibleeasily made transitions (O)
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 38
7. Visual Response
This item covers use of vision in three areas: visual fascinations, the ease
with which the person can shift visual attention, and the degree to which
the persons eye contact is integrated with actions and communication.
Age-appropriate visual response. Visual behavior is normal and appropriate
1 for his or her age. Eye contact is good and integrated with verbal and nonverbal
communication skills. Easily shifts visual attention.
1.5
Mildly abnormal visual response. May stare inappropriately at others. Eye
2 contact is not consistently integrated with verbalizations. Included at this level is any
inconsistency in eye contact, regardless of the proportion of time he or she makes eye
contact. May show more interest than is typical in describing small details in room or in
looking at specific objects, such as moving parts, lights, or mirrors.
2.5
Moderately abnormal visual response. Eye contact is not integrated with
3 verbalizations. Obvious visual fascination with objects, lights, mirrors, spinning toys,
and so on. May use peripheral vision to look at things. Obvious difficulty shifting visual
attention from high-interest items.
3.5
Severely abnormal visual response. Persistent avoidance of eye contact.
4 Excessive interest in looking at specific objects or in looking at objects in a peculiar way.
Observations
Inconsistent eye contact, some looking at
self in mirror (O)
Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel
38
8. Listening Response
This rating is based on the persons response to sounds and how the lis-
tening response is coordinated with the use of other senses. The persons
response to his or her own name is scored on this item. Emphasis is placed
on unusual over- or underinterest in sounds, as opposed to distractibility.
Older individuals should be asked directly about this item.
Age-appropriate listening response. Listening behavior is normal and
1 appropriate for his or her age. Listening is used together with other senses; for example,
1.5
child looks toward person who is speaking. Person responds to name.
Mildly abnormal listening response. Some difficulty responding to verbal-
2 izations when background noise present. Responds to name after repeated attempts to
get attention. There may be some lack of response or mild overreaction to certain
sounds. Atypical listening responses are apparent either in direct observation or by
2.5
report from outside witness, but not both.
Moderately abnormal listening response. Responses to sounds or verbal-
3 izations are inconsistent. May show marked reaction to some sounds or complete
disregard for others. Seldom responds to name as a means of getting attention. Unusual
responses are obvious across settings, based on some combination of direct report of
person, witness report, and direct observation.
3.5
Severely abnormal listening response. Overreacts or underreacts to sounds
4 to an extremely marked degree. Is noticeably less responsive to verbalizations than to
noises made by objects. Does not respond to repeated attempts to get his or her
attention by calling his or her name. Unusual responses are evident across settings.
Observations
Appropriately responds to name being
calledalso unexpected noises (O)
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 39

9. Taste, Smell, and Touch Response and Use 10. Fear or Anxiety

This item addresses the persons response to stimulation of the near
receptors of taste, smell, touch, and pain. Subtler aspects of the
stimulation of these senses include responses to the texture of clothing
or food such that the person wears a limited variety of clothes or eats a
limited variety of foods. Self-report of issues in this area should be
considered, especially for adults.
Normal use of, and response to, taste, smell, and touch. Explores new
1 objects in age-appropriate way, generally by looking and feeling. Responds appropri-
ately to pain or touch from others. Reacts to minor pains or illnesses by showing
appropriate discomfort, but does not overreact. Wears a variety of textures of clothing
1.5
and eats a wide variety of foods.
Mildly abnormal use of, and response to, taste, smell, and touch.
2 May occasionally explore things by subtle attempts to smell or taste the object, or rub
This item focuses on the degree to which the person has unusual fear or
anxiety compared to what is appropriate for the situation or context.
Normal fear or anxiety. Behavior is appropriate both to the situation and for his
1 or her age.
1.5
Mildly abnormal fear or anxiety. Occasionally shows too much or too little fear
2 or anxiety compared to the reaction of a typical person of the same age in a similar
situation. The abnormal response is only evident in one settingfor example, either on
direct observation or based on report from witness in another setting, but not both.
2.5
Moderately abnormal fear or anxiety. Shows either quite a bit more or quite
3 a bit less fear or anxiety than is typical even for a younger person in a similar situation.
The abnormal response is apparent across more than one setting, and the person either
3.5
reports these difficulties or they are obvious on direct observation.

the object against part of his or her face or body. May show a mild over- or underreaction
Severely abnormal fear or anxiety. Fear or anxiety is pervasive across all
to touch or pain. May have obvious clothing or food preferences, but is easily encouraged
to try new things. Unusual sensory responses are apparent in direct observation or by
4 settings and persists even after repeated explanations or experiences with harmless
report from outside witness, but not both. events or objects. It is extremely difficult to calm or comfort the person. Conversely, may
2.5 show persistent and pervasive disregard for hazards that others of same age avoid.

Moderately abnormal use of, and response to, taste, smell, and
3 touch. Obviously explores objects by smelling or tasting them, or rubbing the object Observations
against part of his or her face or body. Over- or underreacts or stiffens to touch or pain
to a moderate degree. OR, the person has limited clothing he or she will wear or food Anxious at school (T)
he or she will eat. Limitations in sensory areas such as clothing and/or food preferences
are obvious across settings, and the person reports these difficulties or they are obvious
on direct observation. Sensory issues are difficult to modify and create stress or require Shuts down when corrected or
adaptations in the everyday environment.
disciplined (T)
3.5
Severely abnormal use of, and response to, taste, smell, and touch.
4 Has extreme limits on the foods he or she eats or clothing he or she wears. OR, extreme
Mildly anxious during assessment (O)
reactions or underreactions to touch or pain. OR, he or she shows persistent preoccu-
pation with smelling, touching, or tasting things. Near-receptor issues are a source of Repetitive questioning about how long
extreme stress for person, who puts stress on the environment to find ways to cope with
these difficulties. Unusual responses are evident across settings. he would be there, when was lunch (O)
Observations

Response to pain inconsistent

sometimes nonexistentother times
overreacts to minor injuries; labels on
clothes bother him; wears only loose
clothing (P)

Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel

39
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 40
11. Verbal Communication
This is a rating of two facets of the persons speech and language skills,
and is best evaluated by a direct interaction with the person. This item
includes verbal odditiessuch as formal language, unusual tone or
inflection, and repetitive or made-up phrasesand the ability to carry on
a reciprocal conversation.
Normal verbal communication, age and situation appropriate. Able
1 to carry on an age-appropriate conversation with another person, he or she is able to
respond to others overtures while also adding additional information in at least a four-
element sequence. No evidence of unusual speech inflection, volume, or tone. No
evidence of made-up words or repetitive or rote phrases.
1.5
Mildly abnormal verbal communication. Conversation exchanges are more
2 limited than expected for this age. Occasional use of made-up words or repetitive, rote
phrases. At times may display unusual vocal intonation or rate of speech. Ratings at this
level indicate that the person has problems with conversation or verbal oddities, but
not both.
2.5
Moderately abnormal verbal communication. Minimal initiations of
3 conversation during direct interaction. Verbalizations include overly formal language or
repetitive phrases. Little reciprocal conversation; may talk on own topic but little sense
of interaction. Vocal intonation or rate of speech often unusual. Some use of unusual
words or repetitive speech. Some apparent difficulties in carrying on a reciprocal
conversation and displays some type of verbal oddity.
3.5
Severely abnormal verbal communication. Inability to have a conversation
4 with another person. May respond to specific questions, but does not engage in a to-
and-fro conversation. Does not initiate communication. Language may be overly formal
or pedantic. Marked abnormal speech inflection or tone. Frequently uses made-up words
or repetitive phrases. Significant difficulties in both areas of expressive communication
reciprocal conversation and verbal oddities.
Observations
Speech often very loud (P)
Difficulties with reciprocity observed in
conversationsome reciprocity, but
limited in frequency and duration
primarily around own interests (O)
Has unusual intonationodd use of
words and phrases (O)
Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel
40
12. Nonverbal Communication
This item rates all forms of nonverbal communication. While both use of
and response to nonverbal cues are considered, greater emphasis is
placed on their use. Attention is given to the use of gaze to regulate and
understand interactions and the use of facial expressions and gestures
in combination with verbalizations for a variety of communication
functionsinstrumental, descriptive, and emphatic.
Normal use of nonverbal communication, age and situation
1 appropriate. Uses a variety of facial expressions and instrumental, descriptive, and
emphatic gestures that are well integrated with verbalizations. Responds to facial
expressions and gestures from others. Gaze is used to regulate interactions with others.
1.5
2 Mildly abnormal use of nonverbal communication. Uses instrumental
gestures such as pointing or reaching to indicate wants. Descriptive gestures are used
infrequently and are not well coordinated with verbalizations. Responds to very obvious
facial expressions or gestures from others. May show too little or exaggerated facial
expressions at times, though generally shows appropriate expressions. Inconsistent in
use of gaze to regulate interaction with others.
2.5
Moderately abnormal use of nonverbal communication. Facial expres-
3 sions are often flat or exaggerated. Uses limited instrumental gestures, and these
gestures are not well integrated with verbalizations. Rarely uses descriptive or emphatic
gestures. Shows limited response to nonverbal communication from others. Joint atten-
tion is rare, as the person seldom uses or responds to gaze or gesture as a means of
sharing attention to an object or activity.
3.5
Severely abnormal use of nonverbal communication. Facial expressions
4 are either flat or exaggerated. Does not use instrumental, descriptive, or emphatic
gestures and shows no awareness of nonverbal communication from others. No evidence
of using gaze to regulate activities with others.
Observations
Used some pointingno emphatic or
descriptive gestures (O)
Facial expressions appropriate, limited
in range (O)
Use of eye contact inconsistent (O)
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 41
13. Thinking/Cognitive Integration Skills
This is a rating of the persons ability to understand the meaning of larger
concepts and the ability of the person to integrate relevant details into a
meaningful overview (central coherence). Part of this process involves the
persons ability to discriminate between relevant and irrelevant details.
Age-appropriate thinking/cognitive integration skills. Able to under-
1 stand meaning of information presented either pictorially, in writing, or verbally. He or
she demonstrates central coherence, that is, the ability to attend to relevant versus
irrelevant details and integrate this information into a meaningful overview.
1.5
Mildly impaired in specific thinking/cognitive integration skills.
2 Delayed thinking compared to persons of same age. Difficulties may be seen in
distinguishing relevant from irrelevant cues for conceptualizing or person can verbalize
an overall understanding but is unable to articulate how meaning was derived. At times
supportive presence of another person helps with comprehension.
2.5
Moderately impaired in specific thinking/cognitive integration
3 skills. Notable difficulties comprehending meaning and integrating information into
overall conceptualization, but shows great attention to specific things and concrete
details. Frequently requires specific prompts from others to attend to relevant details
or grasp the larger conceptualization.
3.5
Severe delay in specific thinking/cognitive integration skills. Shows
4 repeated and consistent difficulty distinguishing relevant from irrelevant details. Even
with persistent efforts from another, may not be able to conceptualize the overall
meaning of information.
Observations
Doesnt seem to understand abstract
cause/effect relationships (e.g.,
discipline doesnt seem to have the
effect of changing his behavior) (T, P)
Very detail focused, yet has difficulty
integrating details into meaning (O)
Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel
41
14. Level and Consistency of Intellectual Response
THE RATER MUST read the complete description in the Manual before
rating this item. This rating is concerned with the discrepancies in and
consistency of the individuals skills across different areas, as well as the
persons general level of intellectual functioning. By definition, this
instrument is appropriate only for individuals whose overall IQ score is
above 80, so the descriptors make this assumption. Unless the individual
has a savant skill, which always receives a rating of 4, all individuals whose
adaptive skills are appropriate for their age and intellectual abilities
should receive a rating of 1, regardless of intellectual level or variability
in skills.
Intelligence is at least normal and reasonably consistent across
1 various areas. Has at least average intellectual abilities and does not have any
unusual intellectual skills or problems. IQ score is average or higher (85) with limited
discrepancies. Adaptive skills are appropriate for age and intellectual abilities.
IQ score is 90 or above, with limited variability across areas. Adaptive skills are less than
1.5
expected for cognitive level.
Mildly abnormal intellectual functioning. Not as smart as typical person of
2 same age; skills appear evenly delayed across all areas. IQ score in the low-average
range (80 to 90) with limited discrepancies. Adaptive skills are less than expected for
level of intelligence.
2.5
The individuals overall cognitive skills are near the low-average range (IQ score between
80 and 90), but there is significant variability in skills. Adaptive skills are less than expected
for level of intelligence.
Moderately abnormal intellectual functioning. In general, overall function-
3 ing is within the normal range, but shows significant discrepancy across skill areas.
Adaptive skills are less than expected for level of intelligence.
The individuals overall intellectual functioning is above average (IQ score >115), and he
3.5 or she shows significant variability in skills. Adaptive skills are less than expected for level
of intelligence.
Severely abnormal intellectual functioning. Has a skill that is significantly
4 better than expected for his or her level of intelligence and better than that exhibited by
typical peers (savant skill). At least low-average intelligence (80). Adaptive skills are
typically less than expected for level of intelligence, but in rare instances may be
appropriate for cognitive level.
Observations
Intellectual ability testingverbal and
nonverbal skills in the average range,
working memory low average,
processing speed below average (R)
Adaptive scores are clearly below the
average range (R)
Taught self how to read by age
3 years (P)
023-042_Chap3_v4_040215_001-004 chapter 01.qxd 4/2/15 10:52 AM Page 42

15. General Impressions

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

impression of the degree to which the person has autism as defined by
the other 14 items. This rating should be made without recourse to
averaging the other ratings. As with the other items, this rating should be
made by taking into account all available data from such sources as the
case history, test results, parent and other interviews, or past records.

No autism spectrum disorder. Shows none of the symptoms characteristic of

1 an autism spectrum disorder.
1.5
Mild autism spectrum disorder. Shows only a few symptoms or only a mild
2 degree of an autism spectrum disordermild interference with daily functioning.
2.5
Moderate autism spectrum disorder. Shows a number of symptoms or a
3 moderate degree of an autism spectrum disordermoderate interference with daily
functioning.
3.5
Severe autism spectrum disorder. Shows many symptoms or an extreme
4 degree of an autism spectrum disorderextreme interference with daily functioning.

Observations

Daniel has many characteristics of

higher functioning autism, including
difficulties with social-emotional
understanding and expression, emotional
regulation, social-communicative
reciprocity, deficits in imagination,
difficulty with conceptual and abstract
thinking, sensory sensitivities, anxiety,
fine motor difficulties, and a scattered
skill profile with deficits in adaptive
behavior

Figure 2 (continued)
Completed CARS2-HF Rating Booklet for Daniel

42
043-056_Chap4_v2_001-004 chapter 01.qxd 8/13/10 2:33 PM Page 43
4
InterpretatIon and Feedback
The first section of this chapter describes the basic
interpretation of CARS2-ST and CARS2-HF scores. The
second section offers guidance for providing feedback to
parents about CARS2-ST or CARS2-HF results. The second
section also addresses considerations related to giving
parents feedback about the results of a comprehensive
diagnostic evaluation. Guidance is provided in chapter 5
about how CARS2-ST or CARS2-HF results can be used in
combination with other resources to help design interven-
tions for behaviors related to autism.
Interpretation of carS2-St
and carS2-HF Scores
General considerations
Before interpreting CARS2-ST or CARS2-HF scores in
a given case, it is important to summarize the level of
confidence in the accuracy of the information on which
ratings are based in each area of behavior. Ideally, complete,
reliable, consistent information would be obtained from
multiple informants and multiple settings, along with a
thorough developmental history. In many clinical
assessment settings, however, such an ideal array of
information may not be available. One way of determining
the accuracy and reliability of a source is to consider the
degree to which the information is internally consistent or
whether the informant contradicts himself or herself. For
interview or questionnaire data, the concrete examples a
person gives are a very important way of determining if he
or she is in fact talking about the same concept as the one
being rated. You should always take into account and report
the potential impact of any important gaps or potential
biases in the sources that have been drawn upon for making
the ratings. Even when formal scores cannot be interpreted
because key information is unavailable or sources are known
to be biased, documentation of the situation and of the
reliable information that is available can be valuable for
guiding further inquiry or stimulating productive further
discussion with parents or other concerned parties.
Once it has been determined that proceeding to interpret
quantitative results on the CARS2-ST or CARS2-HF is
43
appropriate, it is important to keep in mind the advantages
and limitations of each type of score result available for each
formthe Total raw score and related cutoff values, the
T-score, and the rating value for each individual item. The
appropriate use of each type of result is discussed in the
following sections.
total raw score and cutoff values. The Total raw score
for both the CARS2-ST and CARS2-HF is the sum of all the
rating values for the 15 rating areas. The Total raw score
should not be calculated or interpreted unless all 15 item
areas have been rated and all ratings have been made based
on reasonably reliable sources. Total raw scores may range
from a low of 15, obtained when behavior has been rated as
falling within normal limits in all 15 areas, to a high of 60,
obtained when behavior has been rated as severely abnormal
in all 15 areas.
CARS2-ST. For CARS2-ST ratings, cutoff values for a
categorization system were established based on the
comparison of CARS2-ST scores with the corresponding
expert clinical assessments of over 1,500 children. The
categorizations thus established have been verified in the
Second Edition verification sample of over 1,000 children
and adolescents. (Both samples are described in chapter 6.)
The resulting categories associated with specific CARS2-ST
Total raw score ranges are displayed in Table 2. Using this
categorization system, children younger than 13 years old
with scores of 29.5 or lower and adolescents (13 years or
older) and adults with scores of 27.5 or lower are
categorized as likely to be nonautistic. In these cases, an
autism spectrum diagnosis will be a weak hypothesis in
comprehensive differential diagnosis. Children with scores
of 30 or above and adolescents and adults with scores of 28
or above are categorized as likely to have an autism
spectrum disorder (autism, Aspergers Disorder, or
Pervasive Developmental Disorder Not Otherwise Specified
[PDD-NOS]), and an autism diagnosis should be a strong
hypothesis in comprehensive differential diagnosis. In
addition, scores falling in the higher range, from 30 to 60
(28 to 60 for those 13 years and older), can be divided into
two categories that have been assigned descriptive labels
indicating the severity of the autism-related behavioral
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44 Administration, Scoring, Interpretation, and Intervention Guide

problems noted. For children younger than 13 years, scores
ranging from 30 to 36.5 indicate a mild-to-moderate level of
autistic behaviors, while scores ranging from 37 to 60
indicate a severe level of autistic behaviors. For adolescents
13 years and older and for adults, scores ranging from 28 to
34.5 indicate a mild-to-moderate level of autistic behaviors,
while scores ranging from 35 to 60 indicate a severe level of
autistic behaviors.
CARS2-HF. Cutoff values for categories related to
CARS2-HF Total raw scores are displayed in Table 3. The
cutoff values are applied uniformly without regard to the age
of the individual being evaluated. For those with a Total raw
score of 27.5 or lower, an autism, Aspergers, or PDD-NOS
diagnosis is considered a weak hypothesis. For those with a
Total raw score of 28 or higher, autism, Aspergers, or PDD-
NOS should be a strong hypothesis in comprehensive
differential diagnosis. Scores falling in the higher range,
from 28 to 60, can be divided into two categories that have
been assigned descriptive labels indicating the severity of
the autism-related behavioral problems noted. Scores
ranging from 28 to 33.5 indicate a mild-to-moderate level of
autistic behaviors, while scores ranging from 34 to 60
indicate a severe level of autistic behaviors.
When the DSM-IV diagnostic criteria for Autistic
Disorder are not met for someone whose CARS2-ST Total
raw score is 30 or higher, or criteria for Autistic Disorder,
Aspergers Disorder, or PDD-NOS are not met for someone
whose CARS2-HF Total raw score is 28 or higher, differential
diagnostic hypotheses should include Retts Disorder and
Childhood Disintegrative Disorder.
Limitations of cutoff values. It must be emphasized that
these cutoff values should not be applied in an overly precise
manner and that all inferences based on obtained CARS2-ST
or CARS2-HF Total raw scores must be moderated by all
information available in a given case. It is possible for an
individual to obtain a CARS2-ST Total raw score of 30 or
higher or a CARS2-HF Total raw score of 28 or higher and
not qualify for a DSM-IV diagnosis of a PDD. Likewise, it is
possible for an individual to qualify for a DSM-IV diagnosis
of a PDD and obtain a CARS2-ST Total raw score lower than
30 or a CARS2-HF Total raw score lower than 28. The DSM-
IV criteria are categorical, and diagnosis requires knowledge
of the developmental history that indicates 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 DSM-IV criteria for Autistic
Disorder are met for an individual whose CARS2-ST score is
under 30 or criteria for Autistic Disorder, Aspergers
Disorder, or PDD-NOS are met for someone whose CARS2-
HF score is under 28, the use of a specifier such as mild or
moderate may be appropriate, depending on the overall
functional level of the individual in question.
The cutoff points recommended in this section for
postreferral screening purposes are not the only cutoff points

table 2
Interpretive categories associated With carS2-St total raw Score ranges
total raw score by age
012 years 13 years and older diagnostic hypothesis descriptive level

1529.5 1527.5 Nonautistic Likely nonautistic

3036.5 2834.5 Autism spectrum Mild-to-moderate level of
behaviors related to autism
3760 3560 Autism spectrum Severe level of behaviors
related to autism

Note. SEM = 0.68.

table 3
Interpretive categories associated With carS2-HF total raw Score ranges
total raw score diagnostic hypothesis descriptive level

1527.5 Nonautistic Likely nonautistic

2833.5 Autism spectrum Mild-to-moderate level of
behaviors related to autism
3460 Autism spectrum Severe level of behaviors
related to autism
Note. SEM = 0.73.
043-056_Chap4_v2_001-004 chapter 01.qxd 8/13/10 2:33 PM Page 45

Chapter 4 Interpretation and Feedback 45

possible when using CARS2-ST or CARS2-HF scores to
make distinctions among clinical groups. There are other
valid differentiations or groupings to be achieved,
depending on the purpose of the assessment (Schopler &
Rutter, 1978). In addition, other cutoff points may be used
for specific research purposes. Further discussion of this
issue is presented in chapter 6. However, in assessing for the
possible presence of autism in children in a postreferral
educational setting, the use for which the CARS2-ST and
CARS2-HF were originally designed, the cutoff points
described herein may be considered optimal.
Finally, it is always valuable to remember that classifi-
cation using the CARS2-ST or CARS2-HF is not intended as
an endpoint in any assessment. Instead, it is intended as the
first step in diagnosis or categorical grouping and should
serve as the starting point of an assessment process to point
the way for the individualized assessment needed for under-
standing other aspects of an individuals problems, whether
in language, behavior, or biological functioning. Other in-
struments, such as the Psychoeducational Profile, Third
Edition (PEP-3) for younger children (Schopler, Lansing,
Reichler, & Marcus, 2005), and a developmental history will
be needed to complete the diagnostic process. Unlike the
CARS2-ST, the CARS2-HF requires that you have extensive
information from both a direct observation or interaction
with the individual suspected of having autism and from an
observer such as a parent or teacher who knows the persons
behaviors in other settings. This extensive information, when
coupled with a through developmental history, may provide
sufficient information to reach a diagnostic conclusion.
T-scores. The CARS2-ST and CARS2-HF were devel-
oped with the conceptualization of autism as occurring along
a continuum of behavior problems (Wing & Gould, 1978).
Using cutoff values to specify ranges within the continuum of
scores to aid in developing diagnostic hypotheses is thus
somewhat arbitrary and can result in a loss of the comparative
information that is available when examining continuous
scores. Accordingly, the Total score can be interpreted to
reflect a continuum of the behavioral problems that are relat-
ed to autism. The lower the score, the fewer autism-related
behaviors the individual exhibits; the higher the score, the
more such behaviors are exhibited. When the goal of a clini-
cian or researcher is to make comparative judgments regard-
ing the level of autism-related behaviors present in a given
individual or group, or to evaluate changes in the level of such
behaviors, continuous T-scores or percentile ranks may be
more useful than categorical results. Even in the context of
diagnosis, the ability to make interpretations based on relative
score elevations is likely to be of use.
The T-score values that correspond to the CARS2-ST and
CARS2-HF Total raw scores have a mean of 50T and a
standard deviation of 10T. They represent clinical norms,
calibrated on a sample of over 2,000 individuals with autism,
aged 2 to 57. Clinical norms rather than U.S. population
norms make the most sense for these instruments. Because
most typical individuals do not exhibit any of the behaviors
that are asked about, U.S. population norms would be so
restricted as to preclude making meaningful comparisons
among scores beyond simply identifying the individual with a
higher-than-average score as deviant in some way. Further,
the CARS2-ST and CARS2-HF are not intended as screeners
for use in the general population. Their primary value lies in
their providing brief yet comprehensively based summary
information that can be used to help develop diagnostic
hypotheses among referred individuals or for helping to char-
acterize functional profiles to guide intervention planning.
Apart from occasional research interest, there is virtually no
clinical value in making comparisons regarding CARS2-ST
or CARS2-HF scores observed in the general population.
Thus, an individual with a T-score of 50T exhibits an average
level of autism-related behaviors compared to individuals
diagnosed with autism. Someone with a T-score of 65T may
be said to have a significantly higher level of such behaviors
than the average autism-diagnosed individual, while someone
with a T-score of 38T may be said to have a significantly
lower level of such behaviors. Useful descriptors for different
ranges of CARS2-ST or CARS2-HF T-scores are provided in
Table 4. It is extremely important that users of CARS2-ST or
CARS2-HF T-scores understand that because these scores
are calibrated on a clinical sample, they cannot be used in any

table 4
Interpretive categories associated With carS2-St or carS2-HF T-Score ranges
T-score range description

>70 Extreme level of autism-related symptoms compared to those with an autism diagnosis
6070 Very high level of autism-related symptoms compared to those with an autism diagnosis
5559 High level of autism-related symptoms compared to those with an autism diagnosis
4554 Average level of autism-related symptoms compared to those with an autism diagnosis
4044 Low level of autism-related symptoms compared to those with an autism diagnosis
2539 Very low level of autism-related symptoms compared to those with an autism diagnosis
<25 Minimal-to-no autism-related symptoms compared to those with an autism diagnosis
Note. For CARS2-ST T-scores, the SEM = 2.7T. For CARS2-HF T-scores, the SEM = 2.8T.
043-056_Chap4_v2_001-004 chapter 01.qxd 8/13/10 2:33 PM Page 46
46
formulaic decision process about service qualification in the
same way that scores for performance-based ability tests are
often used in educational settings. These scores simply re-
flect the severity of symptom presentation observed in the
evaluated individual in comparison with a clinical sample of
individuals with autism-related diagnoses. Further, as with
the cutoff values for Total raw scores, it must be emphasized
that these interpretive ranges should not be applied in an
overly precise manner, and all inferences based on obtained
CARS2-ST or CARS2-HF scores must be moderated by all
information available in a given case.
It will be noted that in addition to T-score range
descriptions, Table 4 also indicates a standard error of
measurement (SEM) value of 2.7 T-score points for CARS2-
ST and 2.8 T-score points for CARS2-HF T-scores. The SEM
provides a way of taking into account external factors not
directly related to the characteristics being measured that
might influence a test score. Estimates of the reliability and
variability of a given test score are used to determine a range
within which an individuals true test score would fall
without the influence of any such external factors. The ranges
are created by adding or subtracting the SEM value, or a
multiple of the SEM value, from the obtained score. Ranges
thus specified are associated with particular levels of certainty
about where a true scorea score uninfluenced by any
external factorswould fall. For CARS2-ST or CARS2-HF
T-scores, the true score will fall in a range of 3 T-score
points (or 1 SEM) above or below the obtained score 68% of
the time, or in a range of 6 T-score points (or 2 SEMs) above
or below the obtained score 95% of the time. For a score of
65T, it can be inferred that 68% of the time a true score for
the individual will fall between 62T and 68T or that 95% of
the time a true score for the individual will fall between 59T
and 71T. For a score of 38T, it can be inferred that 68% of the
time a true score for the individual will fall between 35T
and 41T or that 95% of the time a true score for the
individual will fall between 32T and 44T. Further discussion
of the SEM for the CARS2-ST and CARS2-HF is provided in
chapter 7.
table 5
carS2-St Items Most and Least Likely to receive High Item ratings for Individuals With autism
IQ 79
Items most likely to receive high ratings
11. Verbal Communication
1. Relating to People
15. General Impressions
Items least likely to receive high ratings
8. Listening Response
13. Activity Level
9. Taste, Smell, and Touch Response and Use
Administration, Scoring, Interpretation, and Intervention Guide
Item rating values and patterns. Although the Total
scores on the CARS2-ST and CARS2-HF provide the most
stable summary of an individuals status with regard to
autism-related behavior, the rating value for each item can
also be very useful. The estimates of reliability for item
rating values that are provided and discussed in chapter 7 are
relatively high and support their informal use as reference
values for describing an individuals level of autism-related
behavior. The ratings offer an informal basis for comparing
the rated individuals functioning across different areas or at
different points in time, or for characterizing the different
service needs of different individuals. More importantly,
because the ratings in each area rely on comprehensive
information, notes and background information used for
each rating provide rich material for deepening effective
therapeutic relationships among all concerned parties in a
given case. CARS2-ST or CARS2-HF item rating values
should never be used by themselves as a formal quantitative
basis for making decisions for clinical diagnosis or
intervention.
Tables 5 through 11 list, for various groups, the three
CARS2-ST or CARS2-HF items that are most likely and
least likely to receive high ratings. More detailed informa-
tion about CARS2-ST and CARS2-HF item rating patterns
is provided in chapter 7. The briefer listings provided in
these tables may be useful secondary information to aid in
formulating diagnostic hypotheses when considered in light
of all available information in a given case. However, this
information should be applied only if you are familiar with
the more complete context of item rating patterns and
estimates of the reliability of pattern differences that can be
found in chapter 7. Moreover, it should be noted that while
the indicated patterns are generally consistent with current
knowledge in the field, they must be considered tentative in
that they are based on rather small clinical samples. Further
research examining CARS2-ST and CARS2-HF item rating
patterns is needed.
IQ 8085 with notably impaired communication
6. Adaptation to Change
1. Relating to People
11. Verbal Communication
4. Body Use
2. Imitation
9. Taste, Smell, and Touch Response and Use
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table 6
carS2-St Items Most and Least Likely to receive High Item ratings for
Younger and older Individuals With autism
ages 212 ages 13+
Items most likely to receive high ratings
11. Verbal Communication 3. Emotional Response
1. Relating to People 11. Verbal Communication
15. General Impressions 15. General Impressions

Items least likely to receive high ratings

8. Listening Response 8. Listening Response
13. Activity Level 7. Visual Response
9. Taste, Smell, and Touch Response and Use 2. Imitation

table 7
carS2-HF Items Most and Least Likely to receive High Item ratings for
Individuals With High Functioning autism or aspergers disorder
High functioning autism aspergers disorder
Items most likely to receive high ratings
2. Emotional Expression and Regulation of Emotions 2. Emotional Expression and Regulation of Emotions
1. Social-Emotional Understanding 1. Social-Emotional Understanding
3. Relating to People 6. Adaptation to Change/Restricted Interests

Items least likely to receive high ratings

7. Visual Response 8. Listening Response
8. Listening Response 14. Level and Consistency of Intellectual Response
5. Object Use in Play 5. Object Use in Play

table 8
carS2-HF Items Most and Least Likely to receive High Item ratings for
Individuals With High Functioning autism or pdd-noS
High functioning autism pdd-noS
Items most likely to receive high ratings
2. Emotional Expression and Regulation of Emotions 2. Emotional Expression and Regulation of Emotions
1. Social-Emotional Understanding 1. Social-Emotional Understanding
3. Relating to People 10. Fear or Anxiety

Items least likely to receive high ratings

7. Visual Response 4. Body Use
8. Listening Response 14. Level and Consistency of Intellectual Response
5. Object Use in Play 5. Object Use in Play

47
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table 9
carS2-HF Items Most and Least Likely to receive High Item ratings for
Individuals With High Functioning autism or add
High functioning autism add
Items most likely to receive high ratings
2. Emotional Expression and Regulation of Emotions 14. Level and Consistency of Intellectual Response
1. Social-Emotional Understanding 2. Emotional Expression and Regulation of Emotions
3. Relating to People 10. Fear or Anxiety

Items least likely to receive high ratings

7. Visual Response 15. General Impressions
8. Listening Response 7. Visual Response
5. Object Use in Play 5. Object Use in Play

table 10
carS2-HF Items Most and Least Likely to receive High Item ratings for
Individuals With High Functioning autism or Ld
High functioning autism Ld
Items most likely to receive high ratings
2. Emotional Expression and Regulation 10. Fear or Anxiety
1. Social-Emotional Understanding 2. Emotional Expression of Emotions
3. Relating to People 11. Verbal Communication

Items least likely to receive high ratings

7. Visual Response 7. Visual Response
8. Listening Response 15. General Impressions
5. Object Use in Play 5. Object Use in Play

table 11
carS2-HF Items Most and Least Likely to receive High Item ratings for
Individuals With High Functioning autism or other clinical diagnoses
High functioning autism other clinical diagnoses
Items most likely to receive high ratings
2. Emotional Expression and Regulation of Emotions 2. Emotional Expression and Regulation of Emotions
1. Social-Emotional Understanding 10. Fear or Anxiety
3. Relating to People 3. Relating to People

Items least likely to receive high ratings

7. Visual Response 8. Listening Response
8. Listening Response 7. Visual Response
5. Object Use in Play 9. Taste, Smell, and Touch Response and Use

48
043-056_Chap4_v2_001-004 chapter 01.qxd 8/13/10 2:33 PM Page 49
Chapter 4 Interpretation and Feedback
case example: Michaels diagnosis
As has been noted, the chief purpose of the CARS2-ST
is to assist in the clinical diagnosis of an autism spectrum
disorder (ASD). A section in chapter 2 showed how
individual CARS2-ST items were rated for 4-year-old
Michael based on direct observation. A section in chapter 5
discusses how the pattern of item ratings obtained for
Michael on the CARS2-ST can contribute to intervention
planning for him. This section relates how Michaels ratings
assisted in reaching a diagnostic decision. As always, it is
important to keep in mind that an early developmental
history supportive of autism is an essential component of the
diagnostic decision tree. CARS2-ST ratings alone are not
sufficient evidence for a diagnosis of an ASD.
Michaels CARS2-ST scores are displayed in Figure 1
(see chapter 2). His Total raw score of 36.5, well above the
standard clinical cutoff value of 30, suggests he is likely to
have an ASD. The corresponding T-score value of 48 is
consistent with the presence of an average level of autistic
behaviors, relative to children diagnosed with an ASD.
Below is Michaels pattern of item ratings (excluding the
rating for General Impressions) on the CARS2-ST:
ratings of 3.0 or greater
Relating to People
Imitation
Object Use
Adaptation to Change
Visual Response
Nonverbal Communication
Level and Consistency of Intellectual Response
ratings of 2.0 or 2.5
Emotional Response
Listening Response
Verbal Communication
Activity Level
ratings under 2.0
Body Use
Taste, Smell, and Touch Response and Use
Fear or Nervousness
Michaels observed pattern of atypical behavior was
consistent with his parents report of his early development
and current behavior at home. The pattern is also consistent
with his teachers report of his current social-communicative
behavior at school.
In accordance with current diagnostic criteria for autism
(DSM-IV-TR), Michaels CARS2-ST ratings indicate that he
has significantly impaired social and communication skills,
demonstrates repetitive play, and has many associated
features of autism, such as difficulty with change, a scattered
skill profile, emotional regulation difficulty, and sensory
differences. Coupled with his parents report of early
developmental problems, including both verbal and
49
nonverbal language delays, limited interest in other people,
focused and unusual interests, and a failure to develop pretend
play skills, a clinical diagnosis of autism was deemed
appropriate for Michael.
case example: daniels diagnosis
The chief purpose of the CARS2-HF is to incorporate
multiple sources of information to help with the clinical
decision regarding a diagnosis of an ASD. Eight-year-old
Daniels CARS2-HF item ratings, based on multiple sources
of information, and his CARS2-HF scores have been
provided in Figure 2 (see chapter 3). His Total raw score of
37, well above the standard clinical cutoff value of 28,
suggests he is likely to have an ASD. The corresponding
T-score value of 55 is consistent with the presence of a
slightly higher-than-average level of autistic behaviors,
relative to high-functioning children diagnosed with an ASD.
In this section Daniels pattern of item ratings is
discussed in light of how they assisted the clinician in
reaching a diagnostic decision. A section in chapter 5
provides a description of how Daniels intervention planning
was influenced by his CARS2-HF ratings. As always, it is
important to keep in mind that an early developmental history
supportive of autism is an essential component of the
diagnostic decision tree and this information is not included in
rating CARS2-HF items.
Below is Daniels pattern of item scores (excluding the
rating for General Impressions) on the CARS2-HF:
ratings of 3.0 or greater
Social-Emotional Understanding
Body Use
Object Use in Play
Verbal Communication
Thinking/Cognitive Integration Skills
Level and Consistency of Intellectual Response
ratings of 2.0 or 2.5
Emotional Expression and Regulation of Emotions
Relating to People
Adaptation to Change/Restricted Interests
Visual Response
Taste, Smell, and Touch Response and Use
Fear or Anxiety
Nonverbal Communication
ratings under 2.0
Listening Response
The CARS2-HF does not explicitly address the current
DSM-IV-TR diagnostic criteria for an ASD. However, the
following description of Daniels item scores illustrates how
information collected in rating the CARS2-HF can be used to
determine the presence or absence of diagnostic criteria.
Sources of information used in making Daniels ratings on the
CARS2-HF included a parent interview, a teacher interview, a
043-056_Chap4_v2_001-004 chapter 01.qxd 8/13/10 2:33 PM Page 50
50
review of school records and prior evaluation reports, as
well as direct interaction with Daniel.
From his CARS2-HF ratings, it is evident that Daniel
demonstrates a pattern of difficulties that is a strong fit with
a diagnosis of autism, high-functioning type. His assessed
verbal and nonverbal intellectual abilities fall in the average
range, suggesting an individual with high functioning
autism, as opposed to a more classic presentation of autism
that involves significant impairment in intellectual abilities.
Despite these higher level cognitive skills, Daniel has
significant impairment in his social-communicative
development and development of imaginative thinking as
seen in his play. He has developed strong and focused
interests that are unusual for his age and a thinking pattern
that is quite detail focused, and he has repetitive motor
excesses such as flapping arms. These characteristics of
autism are demonstrated across settings and are reported
across informants. His parents report early developmental
difficulties around his language development, social
interactions, and pretend play that are also supportive of a
diagnosis of autism.
Associated diagnostic features of autism that Daniel
demonstrates include qualitative delays in his fine motor
development; difficulties with social-emotional under-
standing, expression, and regulation; difficulty with
changes to his school routine; a focus on details with
accompanying difficulty integrating detailed information
into conceptual meaning; a scattered skill profile, with
adaptive behavior skills well below intellectual abilities;
and sensory sensitivities.
bridging the Gap:
providing diagnostic Feedback to parents
The demonstrated value of the original CARS and the
need for an instrument like the CARS2-HF in helping to make
a diagnosis for individuals at the higher end of the autism
spectrum has been previously discussed in this manual. The
development of new instruments and diagnostic measures is
clearly as important to the field of autism services as is the
introduction of new interventions and treatment procedures.
However, bridging the gap between these two areas of
concernclinical identification (What is it?) and clinical
intervention (What can we do about it?)is the interpretive
communication or feedback of the information obtained in the
evaluative process to the relevant parties seeking clarification
and assistance with identification and intervention. The
feedback process is intrinsic to the work of many clinical
organizations. For Division TEACCH, where the CARS2-ST
and CARS2-HF were developed, the feedback process is
indispensable in cultivating the collaborative relationships
with families for which the program has been recognized over
the years (see the chapter Providing Diagnostic Information
to Parents in The TEACCH Approach to Autism Spectrum
Disorders, Mesibov, Shea, & Schopler, 2005). Information
that is gleaned from the CARS2-ST or CARS2-HF is
Administration, Scoring, Interpretation, and Intervention Guide
subsequently shared with families and can be useful in
helping them focus on qualitatively different functional areas
associated with various manifestations of ASDs that may be
targeted for intervention.
Providing feedback to parents is an individualized
process that must take into account the parents main
concerns, educational level, cultural background, and
knowledge of the autism spectrum and any previous
differential diagnoses. The clinician must cultivate a
sensitivity to how much information should be presented at a
given time. Past evaluative and feedback sessions that the
parents have experienced certainly impact the ease and
sensitivity with which they enter into subsequent
interpretive sessions. How previous diagnoses were shared
with parents in feedback sessions and whether parents felt
their perspectives were taken into account, whether they
were given ample time to ask clarifying questions or inquire
about different facets of what a particular diagnosis might
mean for their family, or even the way the information
related to the diagnosis was shared, all effect what emotions
and expectations parents carry with them into the
interpretive session. Parents previous experiences with
receiving clinical feedback about their child may range from
situations characterized by warmth and compassion,
specifically tailored to the familys needs, to situations
characterized by a hurried and brusque manner, without any
offer of supportive strategies, as if to say Your child has an
autism spectrum disordergood luck!
When the parents express differing perspectives on
what they believe to be their childs main issue, or about the
meaning of a diagnosis, these differences can increase the
complexity of the feedback session. Such situations require
careful attention to each parents perspective. One strategy is
to offer a description of the referred individuals presentation
that integrates the two views and builds a common under-
standing between the parents about what they have observed
in their child and how to focus energy and resources to
address the issues presented. Differences between parents in
their expectations about receiving a particular diagnosis and
the way they have conceptualized the issues or behaviors
related to a diagnostic label or term, combined with differ-
ences between the parents views and how the professional
views the diagnosis, can also present challenges. Occasionally
one may encounter parents who seem to have all their hopes
and fears wrapped into confirming a particular diagnosis, who
deem one diagnosis superior to another, or who obtain one
evaluation after another until they receive the diagnosis they
want to hear, regardless of evidence to the contrary that has
already been shared with them by previous professionals.
Parents may express anger, disappointment, or disbelief when
the professionals view of the diagnosis does not agree with
their own. Although such cases are not necessarily in the
majority, nonetheless, when dealing with these issues careful
attention and tact are required. The more extreme cases serve
to illustrate and emphasize a critical aspect of any feedback
sessionthat the emotional framework parents bring into
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Chapter 4 Interpretation and Feedback
the feedback situation is as important to consider as the
information being shared by the professional if effective
communication in the best interests of the referred individu-
al is to be achieved.
When the diagnosis Is an autism Spectrum disorder
Receiving a diagnosis of autism can often be heart-
breaking for parents for several reasons. First, they are
receiving confirmation that their loved one is not typical or
is not demonstrating normal development. Further, they are
given feedback about weaker or impoverished skills or func-
tioning in areas where the referred individual may be having
particular (and sometimes quite marked) difficulty. In addi-
tion, specific challenges with fitting in and communicat-
ing with others in the social world are acknowledged in their
loved one. Great care should be taken to not just provide a
diagnosis, but to help the family understand what the diag-
nosis of an ASD means and what the next steps are in
addressing the issues presented by parents or identified in
the evaluation session. Identifying and explaining the
referred individuals strengths, as well as weaknesses, is
very important in order to provide a balanced presentation of
the diagnosis as well as in considering possibilities for inter-
vention. Even when a diagnosis of an autism spectrum
condition is ruled out, and parents have completed that
portion of the diagnostic journey in which they have
achieved a better understanding of how their child thinks or
learns differently, they may still need support and further
direction on what steps to take next, such as further evalua-
tion, understanding the diagnoses that do apply, obtaining
particular services, becoming familiar with strategies to try
that might help at home, and so forth.
Within the TEACCH program, three primary aspects that
must be covered in the parent feedback conference are (1)
explaining the diagnostic decision; (2) thoroughly discussing
information gleaned from the evaluationwhether obtained
by direct testing or observation with the referred individual or
through interviews or record reviewthat supports or does
not support the diagnosis; and (3) conferring about what to do
next and what resources can be brought to bear to address the
identified parental concerns or referral issues. Each aspect is
described in the following sections. The CARS2-ST and
CARS2-HF are helpful in all three areas because they offer a
comprehensive profile of the breadth and intensity of symp-
toms associated with an ASD, thus contributing to diagnostic
clarification. At the same time, the instruments provide a
simple quantitative reference point or cutoff value for sum-
marizing that rich fund of information. The CARS2-HF form,
in particular, helps to give parents an expanded perspective by
integrating into their own thinking observed and reported
behaviors and behavioral presentations across multiple
settings. Particular attention to items with higher ratings may
be useful in helping to guide a discussion about interventions
or aiding parents in knowing where to prioritize their efforts
in addressing particular behaviors.
explaining the diagnostic decision. With some
families, it is important to state very soon after the interpretive
51
session begins whether the team feels a diagnosis of an ASD
is warranted. Some parents are quite anxious about this and
the buildup of tension in some cases is almost palpable.
Therefore, compassionately and honestly sharing information
about the diagnosis will likely help to break the tension and
allow parents to share their emotions related to the diagnosis.
Some cry, others question, still others maintain silence; any
or all of these reactions may be expected.
For other families, establishing an informational
foundation for the diagnosis may be required, whereby test
results or observations are integrated into a summative
description of the childs behavior and learning style that
may be unique or different from typical children. The
diagnosis then may be given as a summation of the
observations made and performance on the particular
instruments utilized during the evaluation. How quickly the
professional facilitating the interpretive session turns from
diagnosis to what needs to be done in terms of strategies and
resources must be individualized for each case. Within the
Division TEACCH program, there is a strong commitment
to taking whatever time is necessary in talking about this
emotionally laden issue of receiving a diagnosis and to
pacing the flow of information that is shared according to
the parents emotional state.
Integrating the findings from the evaluation. Once
the diagnosis has been shared, it may be helpful for the team
or facilitator of the feedback session to describe specific
observations made of the referred individuals behavior as it
relates to the ASD and the quality of the interaction during
the evaluation session. Additionally, making reference to
comments or observations the parents have shared in a
diagnostic interview can be useful. When parents hear
statements they have made referenced back to objective
observations of the referred individual made by the
professional or team, this strongly acknowledges the value
of their unique and important perspective as parents,
validates their observations (in essence stating we hear you
and we are familiar with this presentation), and points out
their role as important contributors to the diagnostic process.
With some families, this discussion may be a short
description of observations encountered in the major
domains of development acknowledged to be different with
individuals on the autism spectrumsocial relatedness,
communication, restricted patterns of interest and behavior,
sensory processing, and cognitive aspects.
Trying to provide a balanced presentation of the
particular strengths and weaknesses of the child as
experienced during the evaluative session will generally be
appreciated by most parents. CARS2-ST or CARS2-HF
ratings should be integrated into the discussion of the
qualitative and quantitative findings obtained during the
evaluation and not simply referred to on their own. This
discussion may also involve the interpretation of the referred
individuals results from other measures of adaptive
functioning, such as the Adaptive Behavior Assessment
System, Second Edition (ABAS-II; Harrison & Oakland,
2003), or the Vineland Adaptive Behavior Scales, Second
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52
Edition (Vineland; Sparrow, Balla, & Cicchetti, 2005).
Interpretation of the results from the Autism Diagnostic
Observation Schedule (ADOS; Lord, Rutter, DiLavore, &
Risi, 1999), standardized intellectual testing results, plus
other informal assessment procedures may yield useful
information about the individuals interests, motivation,
sense of self, or social-perspective-taking abilities. This
information can be particularly helpful in providing a well-
rounded view of the individual being assessed.
Addressing the learning difference that results from a
neurologically based disorder such as autism helps to set the
stage for the types of strategies that might be most
applicable to the referred individual and his or her family. A
framework can thus be provided that refers to a different
way of learning, meaning it is necessary to try teaching
strategies different from the usual ones and best suited to
that learning style. Again, how much detail to go into with
different families when integrating the findings must be
individualized based on the parent factors that have been
enumerated previously. However, the goal in all cases
should be that the parents begin to develop greater
understanding about what a diagnosis of an autism spectrum
condition means and how to make sense out of the behaviors
they have seen that may be confusing, frustrating, or
interpreted in any number of ways, but which define the
person they love and care about.
If the referred individual does not have an ASD
diagnosis, the goal is still to help the parents understand why
this diagnosis is not appropriate in their childs case. To this
end, families need help understanding the other diagnostic
categories that may better explain the referred individuals
particular presentation or the concerns that they have
expressed during the interview regarding his or her
development.
discussing the severity of the individuals difficulties.
Upon receiving the diagnosis of autism or an ASD, many
parents ask how severe the disability is. While many parents
have heard terms such as high functioning autism or
Aspergers Disorder, there is a lot of confusion about what
these terms mean as they relate to the degree of impairment
the individual may have in his or her functioning levels. A
widely held assumption is that high functioning autism or
Aspergers Disorder means that the persons autism is mild.
This is, in fact, not always the case.
In a discussion of the degree to which the individuals
adaptation is affected by his or her difficulties, it is helpful to
discuss that persons functioning on two separate dimensions.
The first dimension is the cognitive/language dimension and
the second is the autism dimension, where both social re-
ciprocity and repetitive behavior are assessed. Figure 3 dis-
plays the key aspects of these two dimensions and how they
are related to each other. The figure also indicates where the
two children from the case examples previously discussed
would fall in terms of these dimensions.
The cognitive/language dimension, described on the
horizontal axis, ranges from individuals with severe
intellectual disabilities who may be nonverbal to individuals
Administration, Scoring, Interpretation, and Intervention Guide
at the other extreme who have average or above-average
intelligence, are verbally fluent, and have well-developed
academic skills. Between these two extremes are individuals
with varying degrees of verbal skills and moderate or mild
intellectual disabilities, or IQs above 70 with significant
learning disabilities. It is helpful to point out to families that
most people use the terms high functioning autism or
Aspergers Disorder to refer to people who have at least
average intelligence, good verbal skills, and academic skills
at least at grade level. A study of 8-year-olds published by
the Centers for Disease Control (Rice, 2007) indicated that
the midpoint for the ASD population on this continuum
would be someone with an IQ score of 70. While higher IQ,
better verbal ability, and good academic skills are positive
indicators for future development, they are not equivalent to
mild autism.
The autism dimension is described on the vertical axis
in Figure 3. Individuals who have severe autism typically
have difficulty tolerating being in proximity with others for
long periods of time. They have very intense and persistent
repetitive behaviors, have nonfunctional routines, and are
very rigid. At the milder end of the autism dimension are
individuals who may be poor at social interactions but
generally enjoy them, and whose parents can take them
anywhere. They may have special interests, but they are
relatively flexible.
To answer the parents question about the degree of dis-
ability their child has, one needs to look at both dimensions.
It is easy to see that a person in quadrant B (good cognitive
skills, fewer social problems, greater flexibility) would have
the best prognosis and that an individual in quadrant C
would have the worst prognosis. The relative outcome for
someone in quadrant A or D is not as clear. An individual
with autism and mild intellectual disabilities who is relative-
ly social and flexible may be more successful in a job than
someone who has good intelligence but who becomes
extremely rigid and anxious in social settings. In fact, many
individuals who are in the upper quadrants of the autism
dimension and who have intact cognitive skills may not even
come to the attention of clinicians. The CARS2-ST and the
CARS2-HF ratings can help the clinician separate the indi-
viduals behaviors into these two dimensions, thus clarifying
these issues for the family.
Looking back at the first case example, Michael, aged
4, had CARS2-ST ratings on the autism dimension that were
relatively impaired: Relating to People 3.0, Imitation
3.0, Object Use 3.5, and Adaptation to Change 3.0. His
intellectual skills and verbal skills were also below the
average range: Verbal Communication 2.5, and Level and
Consistency of Intellectual Response 3.0. Taken together
his behaviors suggest a moderate degree of disability, and in
Figure 3 he falls into quadrant C.
The second case example was Daniel, aged 8. His
CARS2-HF ratings indicated that he has average intelli-
gence with fluent language, though his conversational skills
are impaired (Verbal Communication 3.0). He has been
precocious in his early academic skills (Level and
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Chapter 4 Interpretation and Feedback 53

MILd autISM
Social and behavioral difficulties
Minimally affect adaptation
Social reciprocity impaired, with problems with initiation. Responsive to others and enjoys
social situations. Although disorganized, is generally flexible and possible to redirect from
repetitive behaviors or special interests.

a b

Cognitive skills in severe IQ average or above average

intellectual disability range Verbal
Lacks verbal skills Daniel Well-developed academic
Poor academic skills skills
Michael

c d

Severe autISM
Social and behavioral Severely Impaired
Severely affect adaptation
Difficulty tolerating even brief social interactions. Extreme repetitive behaviors. Nonfunctional
routines and rigidity.

Figure 3
dimensions of autism Symptoms

Consistency of Intellectual Response 3.0). His social un-
derstanding is low, but his ability to relate to others is not as
impaired, as he is interested in others and seeks them out to
communicate about his interests. His difficulty with change
is not as persistent or pervasive as that of some other chil-
dren. Taken all together, he would currently be functioning
on the line between quadrants B and D.
discussion of intervention strategies and helpful
home-based activities. Linking the findings from the
evaluation with the expressed parent concerns or referral
questions generated at the start of the evaluation or referral
process is the valued end product of a good assessment.
Gauging what resources and supports parents already have
at their disposal is an important step toward determining
how much direction and assistance to offer. Additionally,
gaining some sense of the level of stress that may exist in
the home around the needs of the referred individual may
help to prioritize whether or how to tackle major behavioral
challenges head on at the outset of intervention, or set
more modest goals, whereby success may be built upon
systematically. Exploring what strategies parents have
already tried or have been previously suggested and whether
the parents may be open to trying other techniques should be
assessed as well. The greatest behavior plan or intervention
strategy will only go as far as resources exist to implement
it, so consideration should be given to how the parents might
deal with yet another demand on their time.
The clinician should try to clarify what contributions to
the home, community, or school situation can be offered
through the agency that has done the evaluation. If the
evaluating organization is not the one that can provide all of
the needed intervention services, which is most likely to be
the case given the pervasive nature of autism spectrum
conditions, the feedback team should specifically identify
other available resources. Thus, making the family aware of
existing resources and directing the family to available
community-based personnel or programs can be quite
helpful to parents who are natural self-starters. For other
parents, it may be necessary to bridge the gap between their
experience with the current clinician and these resources
through professional connections and assistance in the
referral process, if the parents desire.
Prioritizing the identification of specific techniques to
address the referred individuals qualitative differences in
social relating and reciprocity, pragmatic communication, and
flexibility in dealing with an ever-changing and rapidly
shifting social-emotional world may be especially appreciated
by parents because of their potential for offering some
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54
immediate relief in dealing with the core issues the parents
are facing. Consideration of the age of the referred individual
dramatically affects the priority and emphasis that the
clinician may put on particular strategies. For instance, for
young children with autism, focusing on their learning how
to learn from teachers in an educational environment,
identifying functional ways they can communicate their needs
or choices, or engaging the child in more social interaction at
their given comfort level may be paramount. In contrast, an
older, more able person and his or her family may most
urgently need assistance in supporting self-advocacy skills.
Parents as well as their school-aged children, or adults
with ASD, clearly benefit from interventions that start by
building their understanding of the diagnosis and the referred
individuals learning style. The old adage with knowledge
comes power can be particularly useful in preventing the
person with autism from developing a negative self-appraisal
or feelings of poor self-esteem, because an understanding of
the diagnosis can offer explanations as to why social
interactions may have been confusing or challenging, why
communication is important for positively affecting ones
environment, and how the sensory world frequently affects
individuals on the spectrum. Both the parents and the referred
individual may begin to experience a greater sense of comfort
and success when questions are answered and the individuals
strengths and weaknesses are discussed, allowing for a
realistic appraisal of how that individual relates to others and
communicates issues of importance.
The clinician may find it helpful to refer to chapter 5 in
this manual to explore particular strategies that might be
incorporated into the interpretive session or formal report
write-up. Clinicians should maintain familiarity with the
ever-increasing number of resources for working with
individuals with ASD. Because doing so has become more
and more challenging in recent years as the offerings on the
topic have burgeoned, the information in chapter 5 is
provided as a useful starting point.
When the diagnosis Is not an autism Spectrum
disorder
If the referred individual does not have an ASD
diagnosis, the goal should still be to help the parents
understand ASD so that they can accept why this diagnosis is
not appropriate in their childs case. To this end, families need
help understanding the other diagnostic categories that may
better explain the referred individuals particular presentation
or the concerns they have expressed during the interview
regarding his or her development. The CARS2-ST and
CARS2-HF are only two of the many instruments available
to the clinician making differential diagnoses among the
various childhood and adult psychiatric conditions that
present at an autism-specific center, in a general psychiatric or
psychological practice, in public schools, or in the process of
determining whether an individual might be referred for more
thorough evaluation. Although a diagnosis of autism was at
one time relatively rare, with the expansion of the criteria that
define the autism spectrum, many more referrals that are now
Administration, Scoring, Interpretation, and Intervention Guide
made to programs specializing in ASD receive a diagnosis of
autism or Aspergers Disorder. However, individuals will
invariably be evaluated whose behaviors are ultimately not
felt to be appropriately identified as falling on the spectrum,
but who manifest some of the features of the disorder or
display symptoms that are below the threshold for a diagnosis.
For families seeking an evaluation for high functioning autism
or Aspergers Disorder, there sometimes does not exist a clear
classification that captures the referred individuals
presentation. This can be disheartening or even frustrating for
the family because the question still remains open as to what
is at the heart of the behavioral challenges they see in their
loved one.
Autism can be ruled out for a variety of reasons. In
some cases, the presenting behaviors were similar to but not
of the same quality or associated with the same degree of
impairment as behaviors that would clearly meet relevant
diagnostic criteria. In other cases, the core differences in
social relating, communication, and restricted behaviors and
interests are present, but not documented from early
childhood. For some, the behavior is not pervasive across
multiple settings or can be attributed to another childhood
or adult condition, such as mental retardation, learning
disability, or Attention-Deficit/Hyperactivity Disorder. In all
of these cases, sharing information about the scores obtained
on the CARS2-ST or CARS2-HF may be helpful in
elucidating the distinction between other conditions and an
ASD. Such analysis will occur mainly in the context of the
written report, but may be discussed in the feedback session
with the family if it is deemed appropriate to facilitate their
understanding of their situation.
In cases where the diagnostic decision is not autism, the
clinician bears the responsibility for identifying the evidence
upon which his or her decision is based. When describing
why the diagnosis is or is not an ASD, the clinician should
generally place emphasis on the overall presentation of the
individual and the pattern of strengths and weaknesses seen.
Although the pattern of item ratings on the CARS2-ST or
CARS2-HF may be helpful, an item-by-item analysis should
not dominate the discussion. It is important to help the
parents understand that it is the aggregate of the ratings
obtained on the CARS2 instrument, together with other
information, that is important in determining an appropriate
diagnoses. If individual item scores are brought up in
discussion with the family, the scores should be interpreted
as being important in that they either converge with or
diverge from other information considered in determining
the diagnosis. When a relatively high Total score has been
obtained, but the overall impression is not that of an ASD
based on all the available evidence, the pattern of scoring
can be explained as consistent with why an individual may
have been initially referred, and how particular aspects of
his or her behavior may predominate his or her overall
presentation, but yet be most consistent with an alternative
diagnosis.
It cannot be overemphasized that the process of arriving
at any diagnosis requires convergent evidence from a variety
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Chapter 4 Interpretation and Feedback
of sources, including a parent report, past professional eval-
uations and clinical impressions, school reports or observa-
tions, direct observation, and the pattern of performance
on various standardized and specific measures. When the
facilitator of the feedback session is confirming that autism
has been ruled out, he or she is obligated to try to help the
family understand to the best of their ability, and within the
bounds of the clinicians training and practice competence,
what qualitative and quantitative findings support his or her
individual clinical decision or the decision of the team. In
addition, the facilitator should be ready to identify what
areas of development or behavior would seem to be most
important for future evaluation, intervention, or monitoring.
Recommendations related to the educational focus, as well
as the need for additional psychiatric or mental health input
from professionals in the community, may be addressed.
55
Thus, it is incumbent on the professional who rules out a
diagnosis of an ASD to provide support and guidance as to
how the family may proceed in getting to appropriate
service providers or continue on the diagnostic journey to a
point where an eventual clarification of diagnosis or identi-
fication of services or strategies best indicated for the partic-
ular diagnostic presentation may be obtained. It should be
remembered that in the vast majority of cases where a child
is referred for an evaluation of an autism spectrum condi-
tion, there likely have been a number of significant red
flags identifying differences in development compiled or
indications of impaired functioning that are of a sufficiently
marked degree to warrant the initial referral. Thus, while the
end result of diagnosis may not be an ASD, the issues of
concern that prompted the referral will still necessarily
demand attention.
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057-064_Chap5_final_001-004 chapter 01.qxd 1/14/10 11:05 AM Page 57
5
INTERVENTION PLANNING AND RESOURCES
The CARS2-ST and the CARS2-HF offer an immediate
qualitative appraisal of the central diagnostic and associated
features of autism spectrum disorders (ASDs). The next step
in treatment is to link an individuals observed areas of
difficulty to specific intervention strategies. This chapter
will attempt to provide the user of the instruments with some
initial sources of information helpful in working with clients
with more classic presentations of autism, high functioning
autism, or Aspergers Disorder. While the information is in
no way exhaustive of the various resources currently
available, it can offer the professional perhaps newly
acquainted with the features of these developmental
disabilities assistance in sorting through the hundreds of
resources currently in print or available in other visual
media formats, such as DVDs or videotape. Additionally,
because of the breadth of resources currently available, it is
not possible to list all that are available in relation to the
given areas measured by the CARS2-ST and CARS2-HF.
An attempt has been made to group items of the CARS2-ST
and CARS2-HF by similarity of feature, and relevant
resources have been identified that address broad domains
of behaviorsocial skills, communication skills, restricted
interests and stereotyped behaviors, sensory issues, and
thinking style. Listings of the CARS2-ST and CARS2-HF
items that apply to each of the intervention domains
discussed in this chapter are provided in Table 12 and Table
13, respectively. The General Impressions item (Item 15)
has been omitted from the domain item listings because it is
a summary and subjective impression score based on the
entirety of information available to the user of the CARS2-ST
or CARS2-HF in making the ratings.
Structured Teaching as a Foundation for
Understanding and Intervention
A general discussion of Division TEACCHs strategies
and resources can offer users of the CARS2-ST and CARS2-
HF a useful framework into which the various additional
resources may be incorporated. For over 4 decades,
TEACCH has worked intensively in the area of diagnosis and
assessment, parent training and direct intervention, and
interdisciplinary and interagency collaboration with
57
professionals educating and treating persons on the autism
spectrum. Throughout this period of time, the refinement and
individualization of autism-specific supports and autism-
specific problem-solving strategies embraced in the
Structured Teaching approach have been incorporated into
the daily lives of persons on the autism spectrum at all ages
and functioning levels. The effectiveness of these supports
has been identified in the literature (Hume & Odom, 2007;
Krantz, MacDuff, & McClannahan, 1993; MacDuff, Krantz,
& McClannahan, 1993; Mesibov, Browder, & Kirkland,
2002; Ozonoff & Cathcart, 1998; Schopler, Brehm,
Kinsbourne, & Reichler, 1971).
The philosophy and research that underly Structured
Teaching has been in summarized in The TEACCH Approach
to Autism Spectrum Disorders by Mesibov, Shea, and
Schopler (2005). A primary tenet of Structured Teaching is
the importance of recognizing the unique learning style and
needs of each person with autism, represented in the useful
analogy of the culture of autism. Central to the Structured
Teaching approach is the importance of a thorough assess-
ment and evaluation of the particular needs of the individual
and his or her family. Addressing specific challenges faced by
the individual with classic autism, as well those persons with
high functioning autism or Aspergers Disorder, involves
seeking meaningful and practical solutions to the problems
confronted by these populations. The main thrust of the
Structured Teaching approach is to utilize an individuals
strengths, especially his or her visual skills, to teach him or
her new skills and behaviors and to compensate for areas of
weakness. The four main aspects of visual systems utilized
within the Structured Teaching approach can serve as a strong
foundation of support for individuals with autism, and
through their individualization and sound implementation,
yield a scaffold upon which other autism-specific educational
or therapeutic strategies may be systematically introduced.
The four aspects of Structured Teaching are as follows:
Physical organization of the environment
Individualized daily schedules
Work or activity systems
Visual structure incorporated into assessing and
teaching the skills necessary for life
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58 Administration, Scoring, Interpretation, and Intervention Guide

Table 12 Table 13
CARS2-ST Items Related to Areas of Intervention CARS2-HF Items Related to Areas of Intervention
Social Interaction items Social Interaction items
1. Relating to People 1. Social-Emotional Understanding
2. Imitation 2. Emotional Expression and Regulation of Emotions
3. Emotional Response 3. Relating to People
7. Visual Response 7. Visual Response
8. Listening Response 8. Listening Response
11. Verbal Communication 11. Verbal Communication
12. Nonverbal Communication 12. Nonverbal Communication
Communication items Communication items
5. Object Use 5. Object Use in Play
6. Adaptation to Change 6. Adaptation to Change/Restricted Interests
11. Verbal Communication 11. Verbal Communication
12. Nonverbal Communication 12. Nonverbal Communication
Restricted Patterns of Interest and Stereotyped Behavior items Restricted Patterns of Interest and Stereotyped Behavior items
4. Body Use 4. Body Use
5. Object Use 5. Object Use in Play
6. Adaptation to Change 6. Adaptation to Change/Restricted Interests
11. Verbal Communication 11. Verbal Communication
13. Activity Level 13. Thinking/Cognitive Integration Skills
Sensory Issues and Associated Features items Sensory Issues and Associated Features items
3. Emotional Response 2. Emotional Expression and Regulation of Emotions
4. Body Use 4. Body Use
5. Object Use 5. Object Use in Play
7. Visual Response 7. Visual Response
8. Listening Response 8. Listening Response
9. Taste, Smell, and Touch Response and Use 9. Taste, Smell, and Touch Response and Use
10. Fear or Nervousness 10. Fear or Anxiety
13. Activity Level Thinking Style and Cognitive Issues items
Thinking Style and Cognitive Issues items 1. Social-Emotional Understanding
1. Relating to People 6. Adaptation to Change/Restricted Interests
2. Imitation 7. Visual Response
7. Visual Response 8. Listening Response
10. Fear or Nervousness 13. Thinking/Cognitive Integration Skills
14. Level and Consistency of Intellectual Response 14. Level and Consistency of Intellectual Response

The twin goals of increasing independence and promot-
ing spontaneous client-initiated communication, also essen-
tial in the Structured Teaching approach, serve to foster
skills that allow the individual with an autism spectrum con-
dition to positively and more effectively act on his or her
world and interact with persons in the home, school, job set-
ting, and broader community. A number of publications
compiled by TEACCH faculty and staff members can be
helpful in establishing this foundation for learning, coping,
generalization, and problem solving, with the end goal of an
improved quality of life and necessary skill acquisition to
face life circumstances (Boswell, 2005, 2006; Eckenrode,
Fennell, & Hearsey, 20032005; Faherty, 1998, 2000;
Mesibov, Adams, & Klinger, 1997; Mesibov, Shea, & Adams,
2001; Mesibov, Shea, & Schopler, 2005). Complementing
these resources that address the broad needs of the culture
of autism are specific resources addressing particular core
areas of challenge for persons at different points along the
autism spectrum. Needless to say, aiming intervention at
spectrum conditions as broad as those measured by the
CARS2-ST and CARS2-HF necessarily requires some
differentiation between groups of individuals. For ease in
discussing intervention issues with persons with classic
autism presentations, it is helpful to think in terms of
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Chapter 5 Intervention Planning and Resources
subdividing this broad group of individuals with significant
developmental differences, ranging from younger children
up through older individuals, into two subset groups, but
with the recognition that all the members of the broad group
will be demonstrating skills significantly below their
chronological age. Individuals with a higher functioning
presentation are more easily grouped and discussed together.
However, recognizing the diversity of individual presenta-
tions among this subsection of the autism spectrum still
remains an important consideration.
Addressing the Social Interaction Domain
The areas of social-emotional processing, understanding,
and interpersonal relating are the hallmark arenas of challenge
for persons on the autism spectrum. These areas will
undoubtedly require some degree of intervention, and in
many cases substantial intervention, throughout the lifespan
of the individual with autism. This is the case even with high
functioning autism or Aspergers Disorder, despite the
average-to-above-average intellectual ability and more highly
developed expressive language skills seen in individuals
whose presentations fall at this end of the autism spectrum.
With this in mind, it is not surprising that the largest collection
of resources developed over recent years falls into this broad
domain of targeting social skills and social interaction, with
such resources covering this lifespan issue of individuals on
the spectrum. It should be recognized from the outset that the
field of autism is gaining new information on intervention at a
rapid pace as researchers and clinicians apply strategies and
techniques tied to the broad developmental and underlying
neuropsychological deficits that are part of autism. Hopefully
this acquisition of intervention-based information will carry
forward into the future and lead to expansion of this
intervention section of the manual in due course.
Currently, for young children with autism in need of
early intervention, the issues of joint attention, meaningful
engagement, and the development of play skills with others
are primary foci for targeted intervention. Work by Kasari
(Kasari, Freeman, & Paparella, 2006; Paparella & Kasari,
2004) in this respect provides an excellent foundation for the
development and strategy-implementation of building joint
experiences and sharing social moments with another
personareas critical to establishing future growth in social
relatedness and social reciprocity. Similarly useful in
addressing the needs of this younger developmental group are
the Developmental, Individual-Difference, Relationship-
Based (DIR) intervention model or FloorTime procedures
embraced by Greenspan and Wieder (2000). In the DIR
model, practitioners and parents assess and pursue strategies
to open and close circles of communication, foster imitation,
build play skills, and promote meaningful connections
between the childs world and his or her environment. As
individuals with more classic autism grow older, strategies
such as pivotal response training (L. K. Koegel, R. L. Koegel,
Harrower, & Carter, 1999; L. K. Koegel, R. L. Koegel,
Shoshan, & McNerney, 1999; R. L. Koegel & L. K. Koegel,
2006) may be employed to effect change in several areas of
59
development through intervention aimed at particular
pivotal behaviors that can be identified and promoted
within naturalistic teaching settings.
Addressing group or play activities involving waiting or
turn-taking through meaningful visual supports (Eckenrode et
al., 20032005) or layering groups (Faherty, 2009) can be
particularly helpful in building skills in individuals with more
concrete understanding of situations. The Social Skills Picture
Books by Baker (2001, 2006) for both children and older
teens provide clear examples of the correct and less desirable
ways of engaging others in play or relevant social interaction
in a visually supported format.
Mesibov, Shea, and Adams (2001) in Understanding
Asperger Syndrome and High Functioning Autism have
provided a summary of the issues and intervention
techniques that have proven useful with persons at the
higher end of the autism spectrum. In general, the goal is to
make abstract social-emotional information and social rules
visible in order to increase the individuals awareness of
others perspectives and to clarify misunderstandings.
Identifying appropriate coping strategies and organized
ways of solving social problems afford the individual with
higher functioning autism the tools to negotiate and more
effectively handle the myriad social situations that present
themselves to humans on a daily basis. Finally, explicit
information on what to do and how to act in social situations
(presented visually) is essential for concretely offering the
necessary structure for guidance in situations all too
abstract, complex, or potentially ever-changing to those on
the autism spectrum. Visual representations are individualized
to the learning style of the person and can range from the
written word to pictures or three-dimensional objects, and
from checklists or daily planners to PDAs.
Addressing the social world with persons at the higher
end of the spectrum generally requires a multifaceted
approach. Making social situations more comfortable and
predictable can be achieved through incorporating social
events or activities in visually presented schedules and the
use of written reminders to clarify expectations (Remember:
You need to share the markers). Educating the individual
with higher functioning autism about the social world and
the rules that encompass social interaction is often critical
(Bolick, 2001; Buron, 2007). Techniques found in Comic
Strip Conversations or The New Social Story Book
developed by Gray (1994, 2000, respectively) have been
extremely helpful in increasing the social perspective and
understanding of persons on the autism spectrum to various
aspects of the neurotypic world, as have the perspective-
taking techniques discussed by Garcia-Winner (2007).
Helping students to understand the hidden curriculumor
the unwritten aspects of social interaction (Smith-Myles,
Trautman, & Schelvan, 2004 )or to mind read by
looking for relevant contextual or emotional cues that
indicate someone elses feeling or intentions (Howlin,
Baron-Cohen, & Hadwin, 1999) are similarly useful.
Various professionals have offered strategies on helping
individuals to more effectively handle their emotional
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60
regulation through relaxation (Buron, 2006; Cautela &
Groden, 1978), awareness of intensifying emotion and
application of relevant calming strategies (Buron & Curtis,
2003), or the use of emotion meters (McAfee, 2002).
Finally, educating others who will talk to, play with, team
up with, or otherwise participate in social activities with the
individual on the autism spectrum to foster greater
understanding of the variety of issues facing that individual
is essential for yielding a supportive social environment
where skills may be practiced and learned.
Addressing the Communication Domain
Although difficulties in communication are not
particular to the autism spectrum, with many other
disabilities evidencing communication impairments as well,
the combined result of the acknowledged social deficits that
are at the heart of autism together with these communication
challenges can lead to significant obstacles for the child or
adult with autism and those charged with his or her care and
support. Being able to express needs and wants, choices, or
preferences in multiple settings, where others effectively
respond to this initiated communication in turn, can lead to
marked functioning ability, a sense of personal control, and
reduced behavioral issues (e.g., tantrums, aggression, self-
injurious behavior, etc.) for individuals both younger and
older evidencing classic autism. Functional analysis of
behavior procedures has frequently identified communication
deficits as instrumental triggers to behavioral challenges
presented by persons with autism. The development of
effective expressive and receptive communication systems
can be one component of positive behavior support (PBS)
procedures designed to increase client access to preferred
tangibles or social experiences and increase the individuals
ability to understand and respond to various environmental
settings or demands. As a result of the individuals increased
understanding and expressive skill, the degree of disruptive
behavior is reduced. CARS2-ST and CARS2-HF items that
are specifically related to communication and considered in
intervention planning can be found in Tables 12 and 13,
respectively.
TEACCHs focus on the promotion of spontaneous,
meaningful, and functional expressive communication for
persons across the entirety of the autism spectrum
complements the receptive communication advantages
afforded by the visual organization and clarifying structure
of the Structured Teaching approach. This approach to
communication makes the world more accessible, under-
standable, and meaningful (through use of visuals connect-
ed with verbal information) and yields increased
independence for persons with autism. Through a careful
assessment of communication elements (e.g., the context(s)
in which communication most readily occurs, the form(s) it
takes most regularly, and the function(s) underlying the
communication initiation) and then the creation or promotion
of systems of communication specifically addressing these
elements, more meaningful and effective systems to support
spontaneous communication can be established and
Administration, Scoring, Interpretation, and Intervention Guide
implemented (Watson, Lord, Schaffer, & Schopler, 1989). In
essence, for the child or adult with poor communication
skills, the power of communication can be fostered
whereby communicative overtures initiated by the individual
with autism can then be met by more consistent environ-
mental responses on the part of parents, teachers, and others
involved in the individuals support. These overtures can then
be more readily reinforced and generalized to create a
stronger communicative base for the individual. A scaffold-
ing approach is thus applied where assessment identifies
where and with whom, how, and why the person with autism
is most motivated to communicate and about what, and then
what additional supports can be established to strengthen
communicative overtures to others.
In addition to the TEACCH communication curriculum
outlined here, the Hanen Centres communication interven-
tion is very appropriate for basic-level learners. This commu-
nication program is outlined in More Than Words: Helping
Parents Promote Communication and Social Skills in
Children With Autism Spectrum Disorder (Sussman, 1999),
and it is practiced in the More Than Words (Sussman, 1999)
and It Takes Two to Talk (Pepper & Weitzman, 2004) pro-
grams developed by the Hanen Centre. These interventions
embrace a holistic, straightforward, and practical approach
that is immediately accessible to parents and teachers in
working with young children with autism who have emerging
communication skills and those with more well-developed
communication as well. Strategies such as the Picture
Exchange Communication System (PECS; Bondy & Frost,
1994; Frost & Bondy, 1995), with its emphasis on the social
and reciprocal nature of the exchange process inherent in
communication, are well suited to address the needs of indi-
viduals at the concrete or more basic communicative level.
The communication components of the SCERTS (Social
Communication, Emotional Regulation, and Transactional
Support) program, an outward extension of Prizant and
Wetherbys research (Prizant, Wetherby, & Rydell, 2000;
Wetherby, Schuler, & Prizant, 1997), or the work of Landa
(2000), addressing the development of social language, are
useful resources to consult in addressing the assessment and
development of supportive communication programs. Finally,
augmentative communication devices (e.g., a Dynovox) may
be employed as well with individuals who are nonverbal or
minimally verbal, or who demonstrate pronounced articula-
tion difficulties.
Despite an individuals sometimes well-developed
vocabulary, pedantic speaking style, and apparent depth of
understanding of some topics, pragmatic language weak-
nesses and problems with initiation in communication yield
challenges for the person with high functioning autism or
Aspergers Disorder and for those living with, teaching, or
working with him or her. The potential for general miscom-
munication or misinterpretation of expectations exists, and
the approachability of the individual in both the social and
communicative spheres can greatly be affected by how facile
the individual on the spectrum is with his or her use of
language and in reading varying aspects of nonverbal
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Chapter 5 Intervention Planning and Resources
communication. Talking with rather than at others, ask- where some aspects of social interaction may offer less
ing for assistance or help from others, or engaging in
conversation, as opposed to conducting a monologue, as
the basis for communicative social interactions can be
elusive goals for persons on the autism spectrum.
General strategies in the area of communication for
individuals at the higher end of the autism spectrum include
visual supports to aid in the initiation of communication (S.
Freeman & Dake, 1997; Hodgdon, 1995, 1999; Quill, 1995),
which may be promoted through sentence starters or specific
visual cues. Generating ideas about what the individual
would want to talk about with others or what would be
appropriate topics of conversation can be supported through
topic lists, checklists (McConnell, 1998), and scripting
(Krantz & McClannahan, 2005) and practiced through role-
playing.
Helping the individual to understand the reciprocal
nature of communication, which involves listening, making
comments, answering or asking questions, and participating
in sequenced exchanges, is fundamental to increasing his or
her opportunity to talk with others, ascertain relevant infor-
mation, and build mutually satisfying and functional
communicative interactions. The why behind these various
aspects of communication can be addressed through social
stories (Gray, 2000) or visually supported instruction
(Faherty, 2000). Addressing figurative language, such as
metaphors, imagery, similes, or idioms, can help individuals
with higher functioning autism understand what others are
trying to communicate to them and the underlying meaning
of a particular phrase (e.g., Has the cat got your tongue? or
He drives me up the wall!; Terban, 2006; Welton, 2004).
Finally, providing augmentative tools to aid in communica-
tion, such as typing to achieve computer dialogues (e.g.,
typing rather than talking), Comic Strip Conversations
(Gray, 1994), or multiple-choice formats in which the indi-
vidual has to endorse a response, may be explored to foster
communication skills.
Addressing Restricted Interests and
Patterns of Behavior
The individuality of persons on the autism spectrum can
perhaps be best appreciated by looking at the interests and
enthusiasms, preferred objects, topics of conversation, and
desire for sameness or routine that are characteristic of the
condition. Preferred objects or quite specific topics of
interest and conversation can offer comfort and
predictability in a largely novel and open-ended world of
individual pursuits and social conversation. The
restrictiveness with which some individuals on the spectrum
order their lives, or the order and routine that they demand of
others, can at times yield highly stressful situations for all
those involved. This is particularly the case when the
intensity, frequency, peculiarity, pervasiveness, and duration
of the focus of attention or behavior is considered. On the
other hand, such interests and routines can also be the source
of great satisfaction, joy, reassurance, and an outlet for
control in a world that is confusing and vastly changing, and
61
inherent appeal to the individual than they do to
neurotypicals. There may be less inherent difference in the
restricted pattern of interests and behaviors that are shown
by individuals with classic autism and higher functioning
autism (allowing for a general and less differentiated
discussion of intervention strategies to follow), with the
exception that individuals with Aspergers Disorder may be
more facile with memorization and recitation of specific
factual material or have topics of interest that lean toward
more esoteric or circumscribed themes.
Strategies to address this rigidity or single-focus
attention/interaction with the world and the objects and
topics therein include increasing the predictability of the
world through the use of visually individualized schedules
of activities that show what the sequence of events will be
for the child or adult. (Note: To promote flexibility, the
activities and order of events on these schedules must
change on a regular basis so persons with autism learn to
deal with varied schedules.) Scheduling high-interest
activities so that the individual knows when he or she can or
cannot engage in these activities will afford the individual a
predictable way to see when he or she will have access to
preferred toys or materials, or a time to talk about favorite
subjects. Teaching the individual the concept of surprise
or change (e.g., indicating through objects, pictures, or
written information that Today we will not be going to the
gym because there is a special presentation in the media
center) through the use of visual-based schedules will
assist in increasing future flexibility as well. For some
individuals, exposure to a variety of toys or activities
through the use of choice boards, preference assessments,
or one-to-one instruction on how to use new materials can
expand interests in broader directions. For others with
autism, simply exploring their special interests can be
motivating enough to establish new learning patterns or
routines of behavior, such as through the use of Power Cards
(Gagnon, 2001), assignments centering on special interests
(Kluth & Schwarz, 2008), or participation in special interest
groups or clubs. The power of teaching new routines to
replace less effective or problematic ones can be fully
appreciated with individuals with autism when implemented
thoughtfully and carefully, this being one of a number of
procedures falling in the positive behavior support (PBS)
movement (Sugai et al., 1999). However, caution should be
exercised from the outset in selecting initial routines to be
taught so that only routines for activities that will stay the
same throughout the individuals life (e.g., showering) are
most consistently targeted.
Addressing the Sensory World and
Associated Features
Personal accounts of the unique sensory processing
differences and exquisite sensitivity to their surroundings
written autobiographically by persons with higher
functioning autism or Aspergers Disorder can help to
educate the interventionist as to possible stressors,
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antecedent factors, and situational sensory demands that
individuals with autism face on a daily basis (Grandin &
Scariano, 1986). These accounts are particularly helpful in
identifying similar issues that may be present in nonverbal
or minimally verbal individuals with autism who cannot
articulate their experiences and who, for the most part,
demonstrate such overstimulation with things sensory
through their behavioral outbursts and avoidance of certain
stimuli or situations. The experience of the sensory world as
described by Grandin in her books Emergence: Labeled
Autistic (1986), Thinking in Pictures and Other Reports
From My Life With Autism (1995), and Animals in
Translation: Using the Mysteries of Autism to Decode
Animal Behavior (Grandin & Johnson, 2005) particularly
warrants examination by the treatment provider in this
regard. (Note: Grandins descriptions of the thinking style comes into contact, often centers on visual techniques to aid
associated with ASD, described in the next section, is also
quite useful.)
With greater recognition of these issues, strategies and
resources have arisen to address the particular sensory-related
needs of persons on the autism spectrum. Reducing auditory
and visual stimulation in classrooms and vocational and
residential sites through the use of physical structure
(Mesibov, Shea, & Schopler, 2005) can reduce overall
overstimulation and improve focus. Occupational therapists
trained in sensory integration evaluation and treatment
considerations (Ayres, 2005; Kranowitz, 2006; Kranowitz,
Balzer-Martin, Sava, Haber, & Szklut, 2001) are now offering
more comprehensive sensory diets and activities to help
persons on the autism spectrum modulate and respond to
various types of incoming sensory stimuli (e.g., weighted
vests, music, vibrations, vestibular stimulation). Aerobic
exercise has been useful in many situations with individuals in
educational and residential settings as a means of decreasing
self-stimulatory behaviors as well as aggression. Providing
appropriate outlets for the unique sensory needs of persons
with autism, as well as areas to calm down in such as calm
rooms or sanctuary areas, is often useful for both those with
classic autism and higher functioning individuals on the
autism spectrum. Dunn, Saiter, and Rinners (2002)
application of sensory integration evaluation issues to
individuals on the spectrum encompassed in their sensory
processing model, which emphasizes low registration,
sensory sensitivity, sensation seeking, and sensation
avoidance responses to stimuli, is a useful place to start in
identifying how a child or adult with an ASD may react to his
or her environment. Interestingly, Dunn et al.s research
findings have suggested a less consistent response to
environmental sensory stimuli by individuals with Aspergers
Disorder than with other disabilities.
Addressing Thinking Style and Cognitive Issues
The culture of autism results in a unique thinking style
characterized by a focus on details, rule-governed behavior,
difficulty with integration of new information, problems
understanding the meaning underlying concepts or acts,
problems differentiating relevant from irrelevant information,
Administration, Scoring, Interpretation, and Intervention Guide
central coherence issues, and problems with generalization
(Mesibov, Shea, & Schopler, 2005). The research on theory of
mind (Baron-Cohen, 1997; Baron-Cohen, Tager-Flusberg, &
Cohen, 2000) and executive functioning challenges (Hughes,
Russell, & Robbins, 1994; Ozonoff & Jensen, 1999) faced by
persons on the autism spectrum indicates that these cognitive
issues have the potential for causing misinterpretations and
possibly less efficient problem-solving strategies based
largely on details, problems in cognitive set-shifting, and less
big picture understanding of situations without
compensatory systems for organization. Emphasizing rules,
phrased in the positive, can be helpful in teaching the
individual what to do, how to do, and when to do. The why to
do, which more readily addresses the immediate relevance for
an individuals life or for other persons with whom he or she
in promoting understanding and building meaning, while
drawing connections between the individuals thoughts and
acts and those of others (Howlin et al., 1999). Grays Comic
Strip Conversations (Gray, 1994) has proven to be very useful
in helping the individual with autism gain a better
appreciation for how words, thoughts, and intentions affect
behaviors, and The New Social Story Book (Gray, 2000) can
foster an appreciation for how others view situations and what
the expected behaviors are in social situations. In general, a
cognitive-behavioral and directive but supportive framework
is helpful in working with persons at the higher end of the
autism spectrum (Gaus, 2007). Garcia-Winners (2007) work
in teaching social perspective taking for individuals on the
autism spectrum is particularly helpful in this regard.
Supplementing such information with visual supports
provides a more autism friendly channel for conveying this
information for persons at all points along the autism
spectrum. Visual supports should be individualized to match
the cognitive comprehension level of the individual and
should include text, pictures, icons, photos, and objects. Use
of individualized schedules, visually sequenced work or
activity systems, mind or thought mapping techniques,
thought monitoring charts, or organized worksheets can help
the individual more clearly see the relationship between
thinking, emotions, and bodily responses.
In summary, an analysis of the particular pattern of
higher scored items on the CARS2-ST or CARS2-HF can
provide the clinician with a road map to the areas of
development that may be most in need of attention or
intervention. This information will also be obtained through
a careful and thorough interview with parents about the
developmental concerns and behaviors that they would like
assistance with at the time of the diagnostic evaluation or
subsequent assessment. Clinicians have at their disposal a
wide array of techniques and strategies that can be accessed
through the publishing companies that are devoting attention
to autism, such as Western Psychological Services, Future
Horizons, Jessica Kingsley Publishers, Autism Asperger
Publishing Company, and Pro-Ed, as well as any number of
journal publications, such as the Journal of Autism and
Developmental Disorders, the Journal of Applied Behavior
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Chapter 5 Intervention Planning and Resources
Analysis, the Journal of Mental Health and Intellectual
Disabilities, the Journal of Positive Behavior Interventions,
and Research in Development Disabilities, to name a few.
Case Example:
Intervention Planning for Michael
Michaels CARS2-ST ratings and scores are displayed
in Figure 1 (see chapter 2). A brief discussion of his
diagnosis is provided in chapter 4. This section focuses on
how his CARS2-ST ratings assisted in developing his
intervention plan. Since the CARS2-ST is only one measure
used in the assessment of a child with autism, additional
assessment data will be needed to develop interventions for
the full range of language, academic, cognitive, and
developmental needs of a child.
Intervention planning with the CARS2-ST begins with
an analysis of the CARS2-ST item ratings pattern. Michaels
ratings are grouped in the following lists. Ratings greater
than 3.0 would be considered most problematic or atypical,
followed by behaviors rated 2.0 or 2.5; ratings under 2.0
would be considered less problematic, or more typical.
Ratings of 3.0 or greater
Relating to People
Imitation
Object Use
Adaptation to Change
Visual Response
Nonverbal Communication
Level and Consistency of Intellectual Response
Ratings of 2.0 or 2.5
Emotional Response
Listening Response
Verbal Communication
Activity Level
Ratings under 2.0
Body Use
Taste, Smell, and Touch Response and Use
Fear or Nervousness
As stated previously in this chapter, four aspects of
Structured Teaching are considered the scaffold upon which
other, more specific educational or therapeutic strategies
may be systematically introduced. Michaels ratings
indicate he will require a high degree of structure in his
physical environment to help regulate his emotions,
decrease his activity level, and establish clear boundaries as
to where he should be. Physical structure can also minimize
auditory and visual input. Providing this will help him to
attend better and may reduce anxiety or stress from an
environment offering too much sensory input.
Michaels intervention program will also need to
include a visual schedule and work system that provide
information about what activities he will do, when he will do
63
them, what he will do next, and when he will be finished.
Making this information available to Michael in a format
that is visual and at his level of understanding will help to
improve his behavior during times of transition between
places or materials/activities, addressing the difficulties he
has in adapting to change. The fourth aspect of Structured
Teaching, visual structure, can be incorporated into
Michaels intervention plan to work on specific skills,
especially around his need to expand his play with toys,
pretend play skills, and interactive play with another person.
Other important aspects of Michaels intervention plan
will be strategies to develop his social relatedness, including
improving eye contact, increasing responsiveness to others
initiations, engaging in interactive social play, building
imitation skills, and supporting his initiation of social
communications. Important considerations are ways to
engage his attention to practice the social-communication
building blocks around joint attention, shared positive affect,
and turn-taking. Given Michaels splinter skills related to
letters, numbers, and visual memory, these strengths, along
with his special interest in cartoon characters, can be used to
engage his attention in activities designed to build his social
and communication skills. Naturalistic interventions that
provide opportunities for him to communicate throughout the
day are needed. Visual structure through choice boards can be
used to stimulate his spontaneous initiation of communica-
tion, especially around choices for eating or play. Language
stimulation activities, such as adapted books, will help in
building his vocabulary. Adapted books generally increase a
childs engagement by including a manipulative component
to each page, such as matching a picture to each page or
removing a picture from each page.
Case Example:
Intervention Planning for Daniel
Daniels CARS2-HF ratings are displayed in Figure 2
(see chapter 3). His diagnosis is discussed in chapter 4. This
section describes how Daniels CARS2-HF ratings
contributed to intervention planning for him. As with the
CARS2-ST, intervention planning with the CARS2-HF
begins with an analysis of the CARS2-HF item ratings
pattern. Daniels ratings are grouped together in the
following lists. Ratings greater than 3.0 would be considered
most problematic or atypical, followed by behaviors rated
2.0 or 2.5; those rated under 2.0 would be considered less
problematic, or more typical.
Ratings of 3.0 or greater
Social-Emotional Understanding
Body Use
Object Use in Play
Verbal Communication
Thinking/Cognitive Integration Skills
Level and Consistency of Intellectual Response
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64
Ratings of 2.0 or 2.5
Emotional Expression and Regulation of Emotions
Relating to People
Adaptation to Change/Restricted Interests
Visual Response
Taste, Smell, and Touch Response and Use
Fear or Anxiety
Nonverbal Communication
Ratings under 2.0
Listening Response
Based on the information provided on the CARS2-HF
rating form, Daniel presents with two major areas of behav-
ioral difficulty. First, he has great difficulty understanding and
interacting in social situations. He has difficulty understand-
ing others perspectives and difficulty with social rules related
to boundaries, games, and so on (Items 1, 3, and 5). Second,
he has a tendency to become easily overwhelmed by his
feelings, especially if something unexpected happens.
Initial interventions with Daniel should address his
primary sources of difficulty by utilizing his strengths in
reading and his particular interests. Written schedules and
social rules with explanations will make the world more
predictable for him and the expected social behaviors more
Administration, Scoring, Interpretation, and Intervention Guide
explicit (Mesibov, Shea, & Schopler, 2005). The New Social
Story Book (Gray, 2000) and Comic Strip Conversations
(Gray, 1994) can help Daniel learn how other people view
the world. Daniel is approaching an age where directly
educating him about his autism and what it means to him
will be possible and helpful (Faherty, 2000).
For emotion regulation, the visual strategies explaining
his activities for the day and the changes that will occur will
prevent some upsets. He will need to be directly taught
strategies for recognizing his emotions and how to maintain
control when he starts to get upset. Cognitive-behavioral
strategies that help Daniel develop a recognition of his
feelings, a coping response, and problem-solving strategies
will be very important. Utilizing a visual approach (his
reading skills) in these strategies will tie into Daniels
strengths. Using his interest in cars may be a motivator that
draws his attention to the intervention techniques.
A third area of intervention for Daniel should be in the
educational arena. As noted on the CARS2-HF rating form,
he has fine motor difficulties, difficulties with abstract and
conceptual thinking, problems with verbal communication,
and delays in his processing speed. These areas of difficulty
should be addressed through educational remediation
strategies, and modifications and accommodations on his
Individual Education Plan (IEP).
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Part II

Technical Guide
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6
DEVELOPMENT OF THE CARS METHOD
The 1988 edition of the CARS was the result of a
process of use, evaluation, and modification that spanned
approximately 15 years and involved more than 1,500 cases.
The scale was first developed as a research instrument in
response to the limitations of the diagnostic classification
instruments available at that time. This original rating scale,
developed by the Child Research Project at the University
of North Carolina in Chapel Hill, was based primarily on
consensual diagnostic criteria for autism as reported by the
British Working Party (Creak, 1964). It was first referred to
as the Childhood Psychosis Rating Scale (CPRS; Reichler
& Schopler, 1971) to minimize confusion with Kanners
(1943) narrower classic definition of autism. By 1988,
however, because the definition of autism had been
expanded and was no longer restricted to Kanners early use
of the term, the instrument was retitled the Childhood
Autism Rating Scale (CARS).
The original scale was revised to evaluate children
referred to the statewide North Carolina program for
the Treatment and Education of Autistic and related
Communication handicapped Children (Division TEACCH).
Division TEACCH was started in 1966 as the first statewide
program for children and adults with autism and communica-
tion handicaps, designed to offer comprehensive services,
research, and training. Since that time, special interventions
have been offered in the three major areas of the childs life
home, school, and community. Nine regional centers provide
diagnostic evaluation and parent counseling to improve fami-
ly and home adjustment. Center staff members offer consulta-
tion and training workshops to teachers working with students
with autism in either regular education or special
education settings. Although each center is located at a branch
of the state university system, most of the research is centered
at the University of North Carolina in Chapel Hill, where the
CARS was developed.
Relationship of the CARS to
Diagnostic Criteria and Scales
When the CARS was developed, five important systems
for diagnosing autism had been extensively used. These
were the Kanner (1943) criteria, the Creak (1961) points, the
67
definition by Rutter (1978), the definition used by the
National Society for Autistic Children (NSAC, 1978), and
the DSM-II criteria (American Psychiatric Association
[APA], 1968). Although these systems were widely used for
clinical diagnosis and research, none had been connected to
a rating scale or checklist. And while these five overlapped
on the major features of autism, they also represented
significant differences.
When diagnostic ratings were developed for the CARS
(Reichler & Schopler, 1971), the Kanner (1943) definition
was the primary system for diagnosing autism. It was
followed by the nine Creak (1961) points, which were
intended to evolve a broader definition that would also
incorporate childhood schizophrenia. These nine Creak points
were among the first criteria based on behavioral observations
rather than theory. Nevertheless, they were difficult to use for
research because they were never quantified. The lack of a
developmental perspective made them particularly difficult to
use with young children. Although the Creak points included
autism with schizophrenia, DeMyer, Churchill, Pontius, and
Gilkey (1971) reported that Creaks nine points for childhood
schizophrenia corresponded more closely to autism than to
schizophrenia as defined by Rimland (1964). Kolvins
research (1971) demonstrating the distinction between autism
and childhood schizophrenia had not yet been published.
The next three diagnostic systems were of later origin.
Some differences among these three systems reflect the
different purposes for which they were developed. Rutters
(1978) definition was based on the most thorough evaluation
of empirical research published since the Kanner and Creak
publications. The NSAC (1978) definition, developed by the
NSAC Professional Advisory Board under the direction of
Edward Ritvo, was intended for use in shaping social policy,
legislation, and public awareness. DSM represents the
classification system formulated by the APA. All three of
these diagnostic systems agree on three basic features of
autism: (1) early age of onset (before 36 months), (2)
pervasive lack of responsiveness to other people, and (3)
impairment in language and cognitive functions. Rutters
criteria and the DSM-IV (APA, 1994) both consider bizarre
interest in or attachment to objects and resistance to change of
routines as primary aspects of the definition. The NSAC
definition features disturbances of response to sensory
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68
stimuli, which is considered more idiosyncratic under Rutter
and DSM-IV definitions. These diagnostic differences are
discussed further elsewhere (Schopler & Rutter, 1978).
However, the design of the CARS incorporates all five of
these diagnostic systems. In the rationale section that
follows, each item is discussed according to its consistency
with these five systems. The interested user can estimate the
extent to which a child has autism according to each of the
five definitions just described, and thus resolve some of the
diagnostic confusion still existing in his or her community.
Rationale for the 15 CARS Rating Items
This section lists each of the 15 items of the original
CARS, along with each items rationale for inclusion
(Schopler, Reichler, DeVellis, & Daly, 1980). The relation-
ship between each item and the five major diagnostic systems
discussed in the previous section is noted, with an indication
of whether the item is primary, secondary, or not included for
each system.
Item 1. 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, as it
is for the five systems represented in the CARS: Creak
(primary), DSM-IV (primary), Kanner (primary), NSAC
(primary), Rutter (primary).
Item 2. Imitation. This item was included because of
the finding that many children with severe language
difficulties also had problems with both 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. This item has become more important in
recent years and is included in the CARS: Creak (not
included), DSM-IV (primary), Kanner (secondary), NSAC
(not included), Rutter (secondary).
Item 3. Emotional Response. Autism was first
considered a disturbance in affective contact; moreover,
abnormal and inappropriate emotional responses have been
widely considered a feature of this disorder: Creak
(secondary), DSM-IV (primary), Kanner (primary), NSAC
(secondary), Rutter (primary).
Item 4. Body Use. Peculiar body movements, and
especially stereotypical movements such as hand flapping,
tapping, and spinning, have been widely reported by both
clinicians and researchers. Such body use and movements
were included in all diagnostic systems: Creak (primary),
DSM-IV (primary), Kanner (secondary), NSAC (primary),
Rutter (secondary).
Item 5. Object Use. Inappropriate use of objects such
as toys and other materials is closely related to inappropriate
relations with other people. Such behaviors appear
frequently in clinical descriptions and have a primary or
secondary role in most diagnostic schemes: Creak
(secondary), DSM-IV (primary), Kanner (primary), NSAC
(primary), Rutter (primary).
Item 6. Adaptation to Change. Difficulty in this area
Technical Guide
is another of the primary autism features first identified by
Kanner, supported by subsequent research data, and
maintained in most recent definitions of autism: Creak
(primary), DSM-IV (primary), Kanner (primary), NSAC
(primary), Rutter (primary).
The next three scales are measures of sensory peculiar-
ities that have been reported empirically as unusual receptor
preferences by Goldfarb (1961) and Schopler (1965). These
studies showed unusual near-receptor preferences for touch
and smell, but an avoidance of the distance receptors of
vision and audition. Ornitz and Ritvo (1968) identified the
impairment of perceptual inconstancy affecting all sensory
systems. These relate to the overselection of stimuli reported
by Schreibman and Lovaas (1973). Two items involving the
two distance senses and one item involving the near senses
were included because of their direct implications for
educational assessment and planning.
Item 7. Visual Response. Avoidance of eye contact
during personal interactions was widely reported for
children with autism. Whether such avoidance of eye
contact extended equally to visual avoidance of toys and
other materials has been a research question, adding impetus
for inclusion in this instrument: Creak (primary), DSM-IV
(primary), Kanner (primary), NSAC (primary), Rutter
(secondary).
Item 8. Listening Response. This item refers to the
avoidance of auditory stimuli, as described earlier, and
unusual responses to auditory input. Learning functions
assessed by this item have clear implications for the
teaching of speech or alternative communication skills:
Creak (primary), DSM-IV (not included), Kanner
(secondary), NSAC (primary), Rutter (secondary).
Item 9. Taste, Smell, and Touch Response and Use.
This item was included to assess the frequently reported
preoccupation with mouthing, licking, smelling, and
rubbing objects, plus the peculiar reactions to pain
sometimes observed in individuals with autism: Creak
(primary), DSM-IV (not included), Kanner (secondary),
NSAC (primary), Rutter (secondary).
Item 10. Fear or Nervousness. Unusual or unexplain-
able fears are not a primary characteristic of autism. However,
such behavior occurs sufficiently frequently to warrant in-
clusion: Creak (primary), DSM-IV (not included), Kanner
(secondary), NSAC (secondary), Rutter (secondary).
Item 11. Verbal Communication. This item evaluates
the degree of autistic language, ranging from muteness to
the use of bizarre, meaningless language. Most definitions
of autism consider the autistic communication behavior
rated by this item to be a primary feature of the disorder:
Creak (primary), DSM-IV (primary), Kanner (primary),
NSAC (primary), Rutter (primary).
Item 12. Nonverbal Communication. This item
assesses the childs use of, or response to, gestures and other
nonverbal types of communication. It is particularly useful
in assessing the communicative ability of the nonverbal
child: Creak (secondary), DSM-IV (primary), Kanner
(secondary), NSAC (primary), Rutter (primary).
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Chapter 6 Development of the CARS Method
Item 13. Activity Level. While abnormal activity level
generally is not considered a primary feature of autism, it is
frequently observed in children with autism and plays an im-
portant role in the structuring of a childs learning environ-
ment: Creak (not included), DSM-IV (secondary), Kanner
(not included), NSAC (secondary), Rutter (not included).
Item 14. Level and Consistency of Intellectual
Response. This item represents an expansion of one of
Kanners primary autism features to include assessment of
both intellectual disability (formerly retardation) and any
unevenness in intellectual functioning: Creak (primary),
DSM-IV (secondary), Kanner (primary), NSAC (secondary),
Rutter (secondary).
Item 15. General Impressions. This is a 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. This rating is made prior to
reviewing the scores from the previous 14 items.
Development of the CARS2-HF and
Its Relationship to the CARS
The original version of the CARS has considerable
empirical data supporting its validity and reliability as a tool
for screening and support in diagnosis of children with
autism. The goal in developing the CARS2-HF was not to
replace that very well-established instrument. Rather, the
goal was to develop a second instrument built upon the
structure of the CARS, but with rating criteria refined to take
into account the changing definition of autism as a spectrum
that includes high functioning autism and Aspergers
Disorder, and to take into consideration the empirical data
on the subtler aspects of the core criteria that are present in
individuals with at least near-average intelligence. This new
instrument is designed to be used with adults as well as with
children. The requirement for its use is that the individual
being evaluated must have an overall IQ score of at least 80
and must have fluent spontaneous speech. In most cases, the
individual needs to be at least 6 years of age. The CARS is
still the appropriate measure to use with children under 6 or
older individuals whose overall IQ score is less than 80 or
who do not have fluent spontaneous speech.
The general, well-proven framework of the CARS is
maintained in the CARS2-HF. It is a 15-item scale with
ratings of 1 to 4, with higher scores indicating more
persistent and severe symptoms. Where possible, item areas
from the CARS were retained, but the definitions were
refined to include the more subtle aspects of the behavior
that might be shown by someone with near-average or better
intellectual skills. The retained and refined items include
Item 4 Body Use; Item 5 Object Use in Play; Item 6
Adaptation to Change/Restricted Interests; Item 7 Visual
Response; Item 8 Listening Response; Item 9 Taste,
Smell, and Touch Response and Use; Item 11 Verbal
Communication; and Item 12 Nonverbal Communication.
Some areas on the CARS2-HF, while they measure the same
69
basic diagnostic dimension as the corresponding area on the
CARS, required substantial modification to describe the
features of more able people with autism. The modified
rating areas include Item 2 Emotional Expression and
Regulation of Emotions; Item 3 Relating to People; Item
10 Fear or Anxiety; and Item 14 Level and Consistency
of Intellectual Response. Two new items are included on the
CARS2-HF: Item 1 Social-Emotional Understanding and
Item 13 Thinking/Cognitive Integration Skills; their
addition reflects the growing literature on the difficulties
with theory of mind and social perspective taking, and
central coherence and abstract reasoning. The two items
from the CARS that were dropped on the CARS2-HF were
CARS Item 2 Imitation and CARS Item 13 Activity
Level. The first was dropped because the CARS2-HF is not
designed for the younger children in whom imitation
difficulties are more easily observed. The second item was
dropped in part to make room for the new items and in part
due to the fact that this item was not believed to discriminate
between high functioning autism and the diagnostic groups
with whom these older, higher functioning individuals with
autism are often confusedthose with learning disabilities
or Attention-Deficit Disorder. The final item, Item 15
General Impressions, is the same on both forms.
Relationship of the CARS2-HF to
Diagnostic Criteria and Research
High functioning autism (HFA) is a term that has
emerged since the 1980s (Gillberg & Ehlers, 1998, p. 80) and
is used for individuals who have developed verbal
communication skills and have intellectual abilities above the
range that would qualify them as intellectually disabled, yet
meet the diagnostic criteria for Autistic Disorder. Today there
are two primary diagnostic systems used for autism: those of
the DSM-IV and those of the ICD-10 (World Health
Organization [WHO], 1992). The DSM-IV is a clinical tool
primarily used for diagnosis, whereas the ICD-10 is more
research oriented. When the original CARS was developed,
the concept of an autism spectrum had not yet emerged and
five systems were used for diagnosing autism: the Kanner
criteria, the Creak points, Rutters definition, NSACs
definition, and the criteria in the DSM-III-R (Schopler,
Reichler, & Renner, 1986). Both the DSM-IV and the ICD-10
retain the three areas of impairment in autism initially
described by Kanner (1943): reciprocal social interaction,
verbal and nonverbal communication, and restricted and
repetitive activities and interests. Since diagnostic criteria for
autism have changed over time, the emphasis of the CARS2-
HF, as with the CARS2-ST, is on assessing the primary
features of autism that have remained stable over time, as well
as features that are supported in current research.
In 2005, 53% of individuals with an autism spectrum
diagnosis seen at Division TEACCH Centers across North
Carolina had IQ scores above the range that would qualify
them as intellectually disabled, that is, IQ scores greater than
80. At present, there are no established diagnostic criteria
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exclusively for HFA. New in the DSM-IV and not included
in the DSM-III-R (APA, 1987) are criteria for the diagnosis
of Aspergers Disorder (also referred to as Asperger
Syndrome). In 1993, the WHO added research criteria for
Asperger Syndrome. In 1981, Wing first used the term
Asperger Syndrome. According to the criteria of both the
DSM-IV and ICD-10, Aspergers Disorder is defined as
having the same qualitative impairment in reciprocal social
interactions and restricted and repetitive behaviors as
autism, but not having the same impairments of
communication as identified in the criteria for Autistic
Disorder. The DSM-IV and ICD-10 also stipulate that
individuals with Aspergers Disorder have no clinically
significant delay in early language or cognitive development
and do not meet the diagnostic criteria for any other
Pervasive Developmental Disorder (e.g., autism) or
Schizophrenia. Motor clumsiness and fine motor difficulties
are not considered diagnostic criteria in the DSM-IV.
However, both are specifically identified as associated
features of Aspergers Disorder in the DSM-IV-TR (APA,
2000). The ICD-10 research criteria for Aspergers Disorder
(WHO, 1993) also indicate mild motor milestone delays and
motor clumsiness as usual in Aspergers Disorder, but not
a diagnostic feature.
CARS2-HF items reflect current thinking about the
nature of individuals with HFA or Aspergers Disorder. In
addition to the three core areas of impairment, the CARS2-
HF has items that assess the degree of a participants (a)
ability to understand the perspective of others (theory of
mind), (b) focus on details, with limitations in understand-
ing the larger concept of those details (difficulties with
central coherence), (c) difficulty with executive functions
related to flexibility and attention shifting, (d) scatter in their
profile of skill strengths and deficits, (e) emotional regulation
and anxiety, and (f) sensory preoccupations and motor diffi-
culties. The DSM-IV and ICD-10 social criterion of failure
to develop peer relationships is not specifically rated on the
CARS2-HF, but difficulties in social relatedness and
reciprocity are certainly rated on the form. The CARS2-HF
addresses the DSM-IV communication criteria of conversa-
tional abilities, idiosyncratic or stereotyped language, and
pretend play, but the DSM-IV criterion of early delay in
development of spoken language is not addressed through
items on the CARS2-HF. As with the social rating on peer
relationships, information pertaining to early language
development may be obtained during the interview or a
review of records even though it is not specifically rated on
the CARS2-HF.
Although HFA and Aspergers Disorder are accepted
diagnostic labels, it is not accepted or agreed upon that the
two are separate and distinct classifications. Some argue that
because autism itself varies in severity and is associated with
varying levels of intelligence (as evidenced by HFA),
Aspergers Disorder is not a disorder distinct from autism
but is a variation within the continuum of autism (Mesibov,
Shea, & Adams, 2001). Most leading researchers who have
addressed the question of a distinction between HFA and
Technical Guide
Aspergers Disorder have concluded that a clear difference
between them has not been established (Schopler &
Mesibov, 1998, p. 8). Schopler concluded that to date there
is no validity established in identifying Aspergers Disorder
as a distinct clinical subgroup (Schopler, 1998, p. 397).
Since it is agreed that Aspergers Disorder and HFA share
common characteristics, but without consensus as to
whether there are true differences between the diagnoses, in
the development of the CARS2-HF we did not differentiate
between HFA and Aspergers Disorder. Rather, we developed
items that would provide clinicians with information related
to the types of social and communication deficits, behavioral
excesses, or cognitive and sensory differences that are
reported in research on individuals with HFA and Aspergers
Disorder. Information gathered while determining ratings on
CARS2-HF items will guide a clinician in determining
which, if any, diagnosis of an autism spectrum disorder is
appropriate.
Social and Emotional Impairment
Impairment in social interactions is a core deficit in
individuals with an autism spectrum disorder (ASD) and
includes difficulties with social reciprocity as well as
impairment in social perception and social-emotional
understanding. Joint attention is central to establishing
reciprocal interactions. Both retrospective and longitudinal
research with young children later diagnosed with an ASD
have identified deficits in behaviors needed for joint attention.
A longitudinal study of high-risk infants has shown that
deficits in orientation to name, social smile, and social interest
predict autism at age 24 months (Zwaigenbaum, Bryson,
Rogers, Roberts, & Szatmari, 2005). Retrospective research
using home video shows that deficits in pointing to share an
interest, responding to ones name, and looking at another
persons face or gaze are social deficits evidenced as early as
12 months of age in children later diagnosed with autism
(Baranek, 1999; Osterling & Dawson, 1994). Prospective
longitudinal studies from 18-month well baby checks (Baron-
Cohen et al., 1996) have also identified the absence of
behavior indicative of joint attention in very young (12 to 18
months) children with ASD. Klin, Jones, Schultz, Volkmar,
and Cohen (2002) extended eye gaze research to adults by
tracking eye movements while they watched emotionally
loaded movie scenes. Klin et al. showed that individuals with
autism sought visual information from the mouth region as
opposed to eyes, did not visually follow nonverbal social cues
such as a distal point, and disregarded social cues while
focusing on more of the physical information available in the
scenes. Collectively, these findings demonstrate the
observable behavior that appears to express the greater
cognitive deficits in social-emotional understanding attributed
to individuals with ASD. The CARS2-HF items that reflect
social relatedness and/or reciprocity are Item 3 Relating to
People, Item 7 Visual Response, Item 8 Listening
Response, Item 11 Verbal Communication, and Item 12
Nonverbal Communication.
Parent and professional reports, as well as several
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Chapter 6 Development of the CARS Method
different areas of research, indicate that individuals with
ASD have difficulties in the cognitive understanding of
social relationships as well as in the understanding of the
perspective or emotions of others. Research supports that
individuals with autism and Aspergers Disorder have
deficits in the ability to understand, think about, or perceive
how others might be thinking. This cognitive skill is referred
to as theory of mind (ToM) and deficits in ToM have been
shown to be specific to autism and independent of
intellectual disability (Baron-Cohen, Leslie, & Frith, 1985).
Deficits in ones ability to understand or perceive how others
may be thinking significantly impact many aspects of daily
lifethe flow and understanding of communications or
social interactions and the perception of how others may be
feeling. Although research supports that children with
autism and Aspergers Disorder have deficits in ToM, there
are also indications that some children with Aspergers
Disorder are able to pass simple ToM tasks that those with
HFA could not. It has been hypothesized that even if
individuals with Aspergers Disorder can pass simple ToM
tests, they have difficulty with more complex tasks,
including real-life application of ToM in social and
communicative interactions (Twachtman-Cullen, 1998, pp.
210211). A new item on the CARS2-HF, Social-Emotional
Understanding (Item 1), was included to specifically address
the ability to perceive and articulate how another person
may feel or what his or her perspective may be in a situation.
Individuals with ASD also have difficulties with their
own emotional expression, regulation, and understanding.
Abnormality in emotional regulation can be seen in an
overreaction or a lack of emotional reaction. Clinically, at the
North Carolina TEACCH Centers many referrals for
diagnosis are for older children and adolescents who have a
long history of difficulties related to emotional regulation
(i.e., behavioral tantrums or meltdowns as well as lethargy or
a lack of motivation). At age 12 months, young children
diagnosed with autism at age 2 years had more frequent and
intense distress reactions and less inhibitory control than
siblings and low-risk comparison infants in a longitudinal
study (Zwaigenbaum et al., 2005). These same infants were
described at age 6 months as exhibiting marked passivity and
lower activity level. Incongruent expressions of emotion may
be displayed, such as laughing when anxious or crying for no
apparent reason. Negative affect and unusual expressions are
more likely in children with autism than in typically
developing children or children with intellectual disabilities.
The emotional expressions of individuals with autism are less
consistent in reflecting and articulating their underlying
feelings (Mesibov, Adams, & Klinger, 1997, p. 68). Some
individuals with ASD have high levels of anxiety under many
circumstances. It is hypothesized that this anxiety stems from
situations they cannot understand and find confusing. It is also
common for individuals with ASD to develop a fear of usually
harmless things, such as balloons or fans. In contrast, some
children with ASD display a lack of fear in situations where
they should feel fear, such as when running in front of a car
(Wing, 1996). Emotional expression, regulation, and
71
understanding is reflected in three CARS2-HF items: Item 2
Emotional Expression and Regulation of Emotions, Item 4
Body Use, and Item 10 Fear or Anxiety.
Restricted and Repetitive Patterns of Behavior
Restricted and repetitive activities and interests is a
critical area of impairment that is examined when diagnosing
both autism and Aspergers Disorder. These activities and
interests relate to the presence of clearly unusual behavior
rather than absent or limited skills that define the social and
communicative domains of ASD. Individuals with Aspergers
Disorder or autism have interests that may be common to
other children or adults, but these individuals exclusively
pursue them; they may amass tremendous amounts of factual
information about their special interest; or their interest may
be unusual for their age, such as road maps, weather reports,
or farm equipment (Ozonoff, Dawson, & McPartland, 2002,
p. 14). An insistence on routines or rituals can be seen when
individuals become agitated in unpredictable situations or
when their routines are changed. Stereotyped and repetitive
motor mannerisms are another characteristic in this area. This
characteristic may be seen less frequently or less intensely in
individuals with HFA or Aspergers Disorder, and includes
hand flapping, body rocking, or jumping up and down when
something exciting or important is happening. Besides the
well-known feature of a preoccupation with parts of objects
(e.g., the spinning wheels on toy cars, a visual obsession with
strings on clothing, opening/closing doors), in individuals
with HFA or Aspergers Disorder this criterion might
manifest as an overfocus in thinking about details while
missing the larger meaning of things (Mesibov, Shea, &
Adams, 2001, p. 30). The CARS2-HF has five items that
provide information related to restricted and repetitive
activities and interests: Item 4 Body Use, Item 5 Object
Use in Play, Item 6 Adaptation to Change/Restricted
Interests, Item 11 Verbal Communication, and Item 13
Thinking/Cognitive Integration Skills.
Communication Impairment
Diagnostic criteria for communication deficits in autism
have changed over time. Unusual speech patterns such as
echolalia, pronoun reversal, and unusual intonation were
emphasized until 1980. Since that time it has been recognized
that children with autism not only have speech acquisition
difficulties, but also have significant problems understanding
both the verbal and nonverbal communication of others
(National Research Council, 2001, p. 47). It is commonly
agreed that while individuals with Aspergers Disorder may
not have early language delays, as seen in individuals with
HFA, they do have subtle difficulties in the everyday or
pragmatic use of language (Mesibov, Shea, & Adams, 2001;
Twachtman-Cullen, 1998; Wing, 1996). In the DSM-IV-TR (p.
81), language in individuals with Aspergers Disorder is
described as being unusual in regard to preoccupation with
certain topics and verbosity. The DSM-IV-TR also identifies a
failure to appreciate and use the conventional rules of
conversation, a failure to appreciate nonverbal cues, and
limited capacity for self-monitoring. Individuals diagnosed
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72
with Aspergers Disorder have been described as speaking
like little adults, using a large vocabulary, and having a one-
sided communication style with a lack of conversational
reciprocity (Mesibov et al., p. 31). Eight CARS2-HF items
(Item 1 Social-Emotional Understanding, Item 2
Emotional Expression and Regulation of Emotions, Item 3
Relating to People, Item 6 Adaptation to Change/Restricted
Interests, Item 7 Visual Response, Item 8 Listening
Response, Item 11 Verbal Communication, and Item 12
Nonverbal Communication) are impacted by an individuals
receptive and expressive communication skills.
Deficits in the development of imagination and pretend
play are clearly evidenced in individuals with ASD. Wing
(1996, p. 44) describes the impairment in imaginative play as
a continuum from nonexistent in some individuals to
imaginative but repetitive in others. Some children develop
simple functional pretend play (e.g., moving trains along a
track, sweeping with a toy broom), while others may learn to
act out an imagined sequence of events. While the sequenced
play may seem imaginative initially, over time it is seen to be
repetitive and unchanging. Some children may act out a
character, but their enactment is more like living the character,
rather than pretending. One CARS2-HF item, Object Use in
Play (Item 5), reflects the difficulties seen in pretend play for
individuals with HFA or Aspergers Disorder.
Cognitive Features
Central coherence. Frith (1989) has hypothesized that
individuals with ASD have a weak ability to extract meaning
from experiences without being distracted by the details.
This is described as weak central coherence. Weakness in
central coherence is seen in individuals who focus on details
but have difficulty integrating those details into a meaningful
whole concept. Deficits in central coherence impact all areas
of learning, but for individuals with autism, they translate into
an understanding of the social world that is piecemeal and
disjointed, and lacking in meaning (Volkmar, Lord, Bailey,
Schultz, & Klin, 2004). The impact of weak central coherence
is most directly assessed by CARS2-HF Item 13 Thinking/
Cognitive Integration Skills.
Executive function. In a review of studies of executive
function in autism and Aspergers Disorder, Ozonoff found
that over 80% of the studies documented deficits on tests of
executive function. These deficits were across ages and
measured by a variety of tasks. Executive function covers a
wide range of abilities affecting organization and planning,
flexibility, self-regulation, and attention. Ozonoff concluded
from this review that the areas most affected in individuals
with ASD were their flexibility, planning, and organization.
There was little difference between the performance of
individuals with Aspergers Disorder and HFA, suggesting
that executive dysfunction is an impairment shared across
the autism spectrum (Ozonoff, 1998, p. 266).
Research specific to attention suggests that sustained
attention is not impaired in autism, but unlike for people with-
out autism, the ability to shift attention for people with autism
Technical Guide
is impaired. In addition, individuals with autism may show
selective attention by attending to things most salient to them,
such as idiosyncratic stimuli. Therefore, it is difficult to
engage the attention of someone with ASD, and once
engaged, it is equally difficult to disengage or switch the
persons attention to something new (Mesibov, Adams, et al.
1997, p. 72). Deficits in rapid and continuous attention
switching are found in individuals with autism, and these
deficits are hypothesized to interfere with an ability to follow
the rapidly changing events around reciprocal social or com-
municative interactions (Courchesne et al., 1994). Recent
research by Zwaigenbaum et al. (2005) suggests that difficul-
ty in the ability to visually disengage attention and shift to a
competing visual stimulus starts as early as 6 to 12 months of
age. Difficulty in executive function, particularly attention
shifting, is captured by ratings on the following CARS2-HF
items: Item 3 Relating to People, Item 5 Object Use in
Play, Item 6 Adaptation to Change/Restricted Interests, Item
7 Visual Response, and Item 11 Verbal Communication.
Scattered skill profile. Scatter in cognitive profiles has
been found through examination of intellectual test profiles
for HFA and Aspergers Disorder, but no consistent pattern
of cognitive development has been shown to differentiate
HFA from Aspergers Disorder (Schopler, 1998).
Abnormalities in the development of cognitive skills are
considered an associated feature of autism and Aspergers
Disorder (APA, 2000). Wing (1996, p. 55) reports that an
estimated 10% of individuals with an ASD have special
abilities or peak skills in which they excel (e.g., music,
numerical calculations, dates, reading at young ages, draw-
ing, etc.). Many times these skills depend on excellent rote
memory or visual-spatial skills. Skill profile is assessed on
the CARS2-HF with Item 14 Level and Consistency of
Intellectual Response.
Other Associated Features
Motor difficulties and sensory sensitivities in individuals
with ASD are reported by many authors, as well as individu-
als who have ASD. Wing (1996, pp. 4953) discusses abnor-
malities of gait and posture that become more noticeable with
age in children with autism. She also discusses fine motor
coordination problems that are most noticeable during low-
interest activities. Grandin (1995), who is an adult with HFA,
describes the differences in touch, hearing, visual processing,
smell, and taste that she and other individuals with ASD ex-
perience. Fascination, distress, or indifference are responses
to sensory stimulation described by Wing. Unusual responses
to sensory stimuli include over- or underresponsivity to
pain, sounds, touch, lights, or odors, as well as fascination
with certain stimuli. Eating and sleep abnormalities may be
present (restricted diet, Pica, recurrent awakening at night).
These associated features will impact ratings on five
CARS2-HF items: Item 4 Body Use, Item 5 Object Use
in Play, Item 7 Visual Response, Item 8 Listening
Response, and Item 9 Taste, Smell, and Touch Response
and Use.
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7
Psychometric ProPerties
Use of the CARS is supported by academic and clinical
research spanning several decades and by its widespread
adoption by professionals as a standard and effective
component in autism assessment. The CARS2-ST items are
identical to those for the original CARS; thus all work using
either form supports the use of the current onethe
CARS2-ST. Moreover, the reliance of the CARS2-HF on the
original CARS form in terms of design, content, and
method, and the close conceptual and psychometric
relationship between the original CARS ratings and the
CARS2-HF ratings offer strong indication that much of the
psychometric information available about the original
CARS and CARS2-ST applies equally well to the CARS2-
HF. In this chapter, work done using the form or sample
presented in the 1988 edition of the instrument will be
denoted using the modifier original and the older title for the
scalethe original CARS. Work based on the current
CARS2-ST verification sample, described in a later section,
will be described using the current titlethe CARS2-ST.
Researchers engaged in longitudinal research wherein the
original CARS has been used should note that the content of
CARS2-ST items and the recommended clinical cutoff
values have not been changed from the original version.
To summarize the information most pertinent to current
CARS2-ST and CARS2-HF users, this chapter is organized
into five sections. The first section describes the samples
used in the development of the original CARS and CARS2-
HF. The second section describes research related to the
reliability of the two instruments, and the third section
describes research related to their validity. These sections
include descriptions of studies that have appeared in the
professional literature concerning the original CARS.
Because the CARS2-HF is a new form, naturally no external
studies about its use have yet been reported. However, it is
expected that once the form becomes widely available, a
body of work similar to that for the original CARS and
CARS2-ST will become available that examines its
usefulness in more detail over a wide array of clinical and
research settings. The fourth section discusses research uses
of the CARS, and the fifth section concludes the chapter
with a brief summary.
73
Development of the original cArs
and cArs2-hF
Development studies for the original CARS, CARS2-ST,
and CARS2-HF have examined ratings for over 3,500
children and adults from a wide range of settings. Much of
this work rests on three large research samplesthe original
CARS development sample described in the 1988 edition
(N = 1,606), the current CARS2-ST verification sample
(N = 1,034), and the CARS2-HF development sample
(N = 994). In addition, ratings on the original CARS,
CARS2-ST, and CARS2-HF have been studied in a number
of smaller clinical samples designed to allow examination
of ratings by certain types of raters or for particular groups
of referred individuals. The three key research samples that
provide the basis for many analyses and results that are
reported in this chapter are described in the next three
sections. The smaller, more focused samples are described
in the sections on reliability and validity to which their
purpose and data analysis are most closely related.
Development sample for the original cArs
The demographic characteristics of the original CARS
development sample, as described in the 1988 edition, are
displayed in Table 14. The individuals rated in this sample
were referred for evaluation at one of five Division
TEACCH centers over a number of years. The total number
of individuals rated during the original CARS development
was 1,606. However, for each demographic variable,
information was available for only about 90% of the sample.
For most of these cases, the reasons for missing data are
most likely random aspects of longitudinal data collection
in a bureaucratic setting. It should be noted that for IQ
estimates, the majority of the missing data are for
individuals who would most likely be in the lower ranges.
As is typical of developmentally disabled populations,
approximately 72% of the cases are male. It should be noted,
though, that the age distributions are similar for males and fe-
males, with approximately 53% younger than age 6 years at
the time of evaluation, 30% from age 6 to age 10, and 11% at
age 11 or older. Head of household occupation and education
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74 Technical Guide

table 14
Demographic characteristics of the Development sample for the original cArs
n % of sample

Age at referral
05 847 53
610 480 30
11+ 171 11
Missing 108 6

Gender
Female 371 23
Male 1,160 72
Missing 75 5

ethnic background
Black 450 28
White 996 62
Other 43 3
Missing 117 7

education /occupation indexa

I 128 8
II 131 8
III 317 20
IV 466 29
V 371 23
Missing 193 12

iQ at referral
69 841 52
7084 197 12
85+ 153 10
Missing 415 26

Note. N = 1,606.
a
Hollingshead & Redlich, 1958.

are strong indicators of socioeconomic status classification
that can be combined into an average two-factor categorical
index that ranges from the highest level of I to the lowest level
of V (Hollingshead & Redlich, 1958). For the original CARS
development sample, the median value of this two-factor
index is IV, the second lowest of the five categories, and ap-
proximately half of those in the sample (52%) are in the two
lowest categories. Approximately 62% of the sample identi-
fied their ethnic background as White, 28% as Black, and 3%
as other races. This was an accurate reflection of the area
served by Division TEACCH and from which the develop-
ment sample was drawn. Most individuals in the development
sample have moderate-to-severe intellectual deficits, as mea-
sured by standardized tests such as the Wechsler Intelligence
Scale for Children (WISC-IV; Wechsler, 2003), the Merrill-
Palmer (M-P-R; Roid & Sampers, 2004), the Bayley Scales
of Infant and Toddler Development (BSID-III; Bayley, 2005),
and the Leiter International Performance Scale (LIPS-R;
Roid & Miller, 1997). Approximately 52% have IQs below
70, with only about 12% having IQs from 70 through 84, and
10% at or above 85.
cArs2-st Verification sample
The demographic characteristics of the CARS2-ST
verification sample are displayed in Table 15. Individuals
rated in this sample were those with a diagnosis of autism in
various clinical settings around the United States, evaluated
during the preparation of the CARS2-ST. The total number of
individuals in the sample is 1,034. As with the development
sample, over two thirds of the cases are male, which is
consistent with the demographics of individuals with autism.
The ages of this sample range from 2 to 36 and are distributed
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Chapter 7 Psychometric Properties 75

table 15
Demographic characteristics of the cArs2-st Verification sample
total % of sample % U.s. populationa

Age
25 308 30
610 446 43
1115 207 20
1636 73 7

Gender
Male 804 78
Female 230 22

race/ ethnicity
Asian/Pacific Islander 68 7 4
Black /African American 167 16 13
Hispanic/Latino 131 13 13
White 626 60 77
Other 42 4 7

head of household years of education

completed (socioeconomic status)
Did not graduate from high school 138 13 18
High school graduate 350 34 30
Some college 137 13 26
College graduate 205 20 16
Postgraduate 138 13 10
Missing 66 7

Geographical region
Northeast 305 29 19
Midwest 115 11 23
South 440 43 35
West 174 17 23

iQ
79 836 81
8085 198 19

Note. N = 1,034.
a
U.S. Census figures (U.S. Census Bureau, 2000) are based on the U.S. population.

similarly for males and females30% aged 2 to 5, 43% aged
6 to 10, 20% aged 11 to 15, and 7% over age 15. Head of
household educational level, a strong indicator of socioeco-
nomic status, is distributed similarly to the two-factor index
for socioeconomic status in the development sample for the
original CARS, with about half of the sample in the categories
representing lower educational attainment. The ethnic back-
ground of about 60% of the sample is described as White. A
minority ethnic background is indicated for the remaining
40% (16% Black/African American, 7% Asian/Pacific
Islander, 13% Hispanic/Latino, and 4% from other ethnic
backgrounds). The IQ for everyone in the sample is 85 or
lower. Full scale IQ (FSIQ) estimates are based on standard
measures such as the WISC-IV, the Stanford-Binet (Roid,
2003), and the Test of Nonverbal Intelligence (TONI-3;
Brown, Sherbenou, & Johnsen, 1997). Approximately 81%
achieved FSIQ scores below 80. About 19% achieved scores
between 80 and 85. This distribution was intentionally
skewed to represent those with estimated FSIQs lower than
80, because the CARS2-ST is intended to be used for referred
individuals with relatively low cognitive functioning.
However, it is acknowledged that at times CARS2-ST ratings
will be made on higher functioning individuals or may be part
of the existing clinical record. To help inform clinical
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76
judgment in such cases, CARS2-ST ratings for the higher
functioning group of individuals with FSIQ estimates
between 80 and 85 were examined and the results are
described later in this chapter. Information about CARS2-ST
ratings for additional subgroups of individuals with diagnoses
of Aspergers Disorder or PDD-NOS is also provided.
cArs2-hF Development sample
The demographic characteristics of the CARS2-HF
development sample are presented in Table 16. Individuals
rated in this sample had a variety of clinical diagnoses,
including high functioning autism (n = 248), Aspergers
Disorder (n = 231), PDD-NOS (n = 95), ADHD (n = 179),
Learning Disorder (n = 111), and other internalizing and
externalizing clinical disorders (n = 69). A small group of
general education students (n = 21) and nonautistic students
in a special education classroom (n = 40) were also included
to verify an absence of symptoms rated on the CARS2-HF
in those groups. Other participants were evaluated in various
clinical settings around the United States during the
preparation of the CARS2. The total number of individuals
in the sample is 994. As with the samples for the original
CARS and CARS2-ST, over two thirds of the cases are
male, consistent with the population of high-functioning
individuals referred for autism evaluations. The ages of this
sample range from 6 to 57 and are distributed similarly for
males and females. Head of household educational level, a
strong indicator of socioeconomic status, is slightly higher
than average and typical of development samples for
psychological assessments. About 73% of the sample
described their ethnic background as White. Other
participants were Black/African American (14%), Asian/
Pacific Islander (3%), Hispanic/Latino (6%), and Native
American (1%); 3% identified themselves as being from
other ethnic backgrounds. All participants had IQ estimates
of 80 or higher. The distribution of estimated intellectual
functioning was intentionally skewed to focus on higher
functioning individuals and to complement that for the
CARS2-ST verification sample.
reliability
The concept of reliability refers to the consistency and
the relative accuracy with which test results estimate the
characteristic a test is intended to measure. Reliability is a
key concept in test development because it influences the
practical usefulness of a measure. All measurements contain
error, whether the measurements are of physical attributes,
objects, or behaviors. Estimates of reliability help to
evaluate the degree to which such error must systematically
be taken into account when interpreting a test score. Various
aspects of reliability are measured by internal consistency
estimates and correlations between test scores obtained for
the same individual across different raters, settings, and
sources of information. Information about each of these
aspects is available for ratings on the CARS instruments and
is described in the following sections. Information about
Technical Guide
internal consistency and reliability across raters is also
available for CARS2-HF ratings, which are seen to display
characteristics very similar to those for the original CARS
and the CARS2-ST.
internal consistency reliability
Estimates of internal consistency reflect one source of
systematic error that affects the reliability of a test. Internal
consistency is the extent to which a chosen set of items
uniformly represents its domain. This is a key component of
reliability for tests such as the CARS2-ST and CARS2-HF. It
is desirable that a test yield consistent, accurate results across
all item sets that might be taken from a given domain.
Estimates of how well a set of test items reflects the test score
that would have been obtained had all of the possible ques-
tions been asked are commonly referred to as estimates of
internal consistency reliability. The statistic typically used to
examine this form of reliability is Cronbachs alpha coeffi-
cient (Cronbach, 1951). Alpha coefficients can be thought of
as offering an estimate of the sufficiency of content
sampling. Alpha-based reliability estimates are also consid-
ered to represent a lower bound of reliability (Cronbach,
1988; Rajaratnam, Cronbach, & Glesser, 1965; SPSS, 1992).
Alpha coefficients range from 0 to 1.00. For psychological
tests such as the CARS2-ST and CARS2-HF, Total scale
estimates of .70 and higher are considered adequate, as are
estimates of .30 and higher for individual items.
During its development, the original CARS was
subjected to rigorous evaluation to determine its reliability
and validity. CARS ratings were made during administration
of the Psychoeducational Profile (PEP; Schopler & Reichler,
1979) at each of 537 referred individuals first diagnostic
session. These diagnostic sessions took place at five regional
centers in rooms provided with one-way observation and
listening facilities. Raters observed the sessions through the
one-way windows and completed the ratings immediately
following each session. (A detailed description of the study is
available in Schopler, Reichler, DeVellis, & Daly, 1980.) To
assess the internal consistency of the Total scores on the
original CARS, coefficient alpha was computed for these
ratings. The Total raw score alpha estimate for the original
CARS in this sample was .94. Other authors have reported
scale alphas for various samples and translations of the CARS
ranging from .73 to .94 (Garfin, McCallon, & Cox, 1988, n =
22; Nordin, Gillberg, & Nyden, 1998, n = 25; Saemundsen,
Magnusson, Smari, & Sigurdardottir, 2003, n = 54; Sturmey,
Matson, & Sevin, 1992, n = 34).
In the CARS2-ST verification sample, a similarly high
internal consistency estimate of .93 was obtained. In the
CARS2-HF development sample, an estimate of .96 was
observed, indicating a high degree of internal consistency for
the new form as well. The corrected item-to-total correlations
of individual CARS2-ST and CARS2-HF items with their
respective Total raw score are displayed in Table 17 and Table
18, respectively. Those values range from .43 to .81, with a
median value of .69, for the CARS2-ST, and from .53 to .88,
with a median value of .79, for the CARS2-HF. These results
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table 16
Demographic characteristics of the cArs2-hF Development sample
total % of sample % U.s. populationa

Age
610 348 35
1115 404 41
1657 242 24

Gender
Male 780 78
Female 214 22

race/ethnicity
Asian/Pacific Islander 29 3 4
Black/African American 138 14 13
Hispanic/Latino 65 6 13
Native American 8 1 2
White 724 73 77
Other 30 3 7

head of household years of education

completed (socioeconomic status)
Did not graduate from high school 78 8 18
High school graduate 302 30 30
Some college 148 15 26
College graduate 165 17 16
Postgraduate 142 14 10
Missing 159 16

Geographical region
Northeast 203 20 19
Midwest 208 21 23
South 481 48 35
West 102 10 23

clinical diagnosis
Autism spectrum diagnoses
High functioning autism 248
Aspergers Disorder 231
PDD-NOS 95
Other groups
ADHD 179
Learning disorder 111
Other clinical diagnoses 69
Special education students 40
General education students 21

Note. N = 994.
a
U.S. Census figures (U.S. Census Bureau, 2000) are based on the U.S. population.

77
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78 Technical Guide

indicate the degree to which the CARS2-ST or CARS2-HF,
taken as a whole, measures a unitary phenomenon rather
than numerous unrelated facets of behavior. It provides
justification for combining the 15 individual ratings into a
single Total score. It is from the Total score that initial
diagnostic hypotheses are addressed using the CARS2-ST
or CARS2-HF, and from which T-scores are derived.
interrater reliability
Interrater reliability estimates examine whether similar
CARS2-ST or CARS2-HF ratings are given by different
professionals based on the same clinical information about a
given referred individual. As with alpha coefficients,
correlations range from 0 to 1.00, and estimates of .70 and
higher are considered adequate. Interrater correlation values
for Total scores are expected to be higher than correlations
between item ratings, because the Total score is based on
ratings across many behavioral areas and is thus inherently a
more stable and general measure than a single rating value
for one kind of behavior.
To assess interrater reliability for the original CARS,
individual item rating values have been examined for ratings
made by several sets of two independent, trained raters for
280 of the cases in the development sample for the original
CARS. Additional studies, described later, were conducted
to examine correlations for Total scores on the original
CARS obtained across different types of raters and settings,
and using varying sources of information. Interrater
reliability estimates for the individual CARS item ratings
reported in the current study are displayed in Table 19. The
estimates center around a median correlation of .71. Values
across the 15 items range from .55 for Item 14, Level and
Consistency of Intellectual Response, to .93 for Item 1,
Relating to People, indicating generally good agreement
between the raters for each item.
For the CARS2-HF, interrater reliability was examined
for ratings made by several sets of two independent, trained
raters for 239 individuals in the CARS2-HF development
sample. A correlation of .95 was obtained for Total scores.
The correlations between individual item rating values for
the CARS2-HF items are presented in Table 20. These
interrater reliability estimates for item ratings center around
a median correlation of .73 and range from .53 for Item 14,
Level and Consistency of Intellectual Response, to .93 for
Item 15, General Impressions. Weighted kappa estimates
were also calculated for the pairs of raters in this study. This
statistic evaluates categorical, absolute agreement between
pairs of raters across the seven rating categories for each
item, but also takes into account consistent selection of
nearby categories when absolute agreement is not achieved.
For example, if a rating value of 2 is given by one rater, but
not the second, this method takes into account whether the
second rater made a very similar rating, such as one with a
value of 1.5 or 2.5, or a very distant one, such as one with a
value of 1 or 4. The values can be roughly interpreted as the
percent of agreement that is observed above what would be
expected by chance. Results indicate a median level of
agreement of .73that is, 73% above what would be
expected based on chance aloneand values range from .51
to .90. These results are wholly consistent with interrater
reliability results for the original CARS items and indicate
similarly good agreement between the raters.

table 17 table 18
corrected item-to-total correlations for cArs2-st corrected item-to-total correlations for cArs2-hF
item ratings in the cArs2-st Verification sample item ratings in the cArs2-hF Development sample
item r item r
1. Relating to People .74 1. Social-Emotional Understanding .83
2. Imitation .72 2. Emotional Expression and Regulation of Emotions .80
3. Emotional Response .62 3. Relating to People .83
4. Body Use .69 4. Body Use .71
5. Object Use .72 5. Object Use in Play .74
6. Adaptation to Change .56 6. Adaptation to Change/Restricted Interests .80
7. Visual Response .71 7. Visual Response .79
8. Listening Response .73 8. Listening Response .75
9. Taste, Smell, and Touch Response and Use .68 9. Taste, Smell, and Touch Response and Use .67
10. Fear or Nervousness .57 10. Fear or Anxiety .70
11. Verbal Communication .61 11. Verbal Communication .78
12. Nonverbal Communication .74 12. Nonverbal Communication .79
13. Activity Level .56 13. Thinking/Cognitive Integration Skills .70
14. Level and Consistency of Intellectual Response .43 14. Level and Consistency of Intellectual Response .53
15. General Impressions .81 15. General Impressions .88
Total score internal consistency estimate .93 Total score internal consistency estimate .96

Note. N = 1,034. Note. N = 994.

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Chapter 7 Psychometric Properties 79

interrater reliability of ratings on the original by the two groups showed 92% agreement. Unweighted
cArs made by professionals in different disciplines. The coefficient kappa for visitors and clinical directors ratings
original CARS was initially developed and used by profes- was very high, at .81, indicating agreement of 81% beyond
sionals with extensive experience in the field of autism. what would be expected by chance. These data indicate that
However, this scale is also intended for use by professionals valid CARS2-ST ratings and diagnostic screenings can be
in other fields who may have more limited experience with made by professionals from related fields who have had
autism, but who would find the scale useful in helping to minimal training or experience in the field of autism.
identify individuals requiring further assessment and treat- reliability of ratings on the original cArs made
ment by experts in the field. from different sources of clinical information. These
To test the reliability of ratings on the original CARS interrater reliability estimates examine whether similar
made by professionals who are not experts in autism, such CARS2-ST or CARS2-HF ratings are given by different
professionals visiting a clinic to observe diagnostic sessions professionals based on different sources of clinical informa-
were given a brief introduction to the instrument and asked to tion about a given referred individual. As with other interrater
make ratings based on their observations during PEP correlations, these range from 0 to 1.00, and for psychological
administrations. One hour prior to observing the diagnostic tests such as the CARS2-ST and CARS2-HF, estimates of .70
sessions, the visitors were asked to read the manual for the and higher are considered adequate. Clinical facilities vary in
original CARS and, when time permitted, to view a 30- the procedures they employ and the sources of information
minute training tape. Ratings made by these visitors were that are available for making clinical assessments. Therefore,
compared with ratings made by clinical directors observing it is important for a rating scale to produce consistent scores
the same diagnostic sessions. The 18 visitors participating in across a range of settings. To examine the reliability of ratings
this study included medical students, pediatric residents and on the original CARS made based on varying sources of
interns, special educators, school psychologists, speech information, several groups of children were assigned ratings
pathologists, and audiologists. The mean of the ratings made based on information gathered during a PEP session. A
by the visiting professionals was not significantly different second rater completed the instrument based only on infor-
from the mean of the ratings made by the expert clinical mation gained from (a) a parent interview, (b) a classroom
directors observing the same diagnostic sessions (visitor X = observation, or (c) a chart (case history) review. Results from
32.46; clinical director X = 33.15; t = 0.92, p > .10). The Total each of these latter settings were compared with results based
scores obtained for visitors ratings showed a high significant on the PEP session to determine the criterion-related validi-
correlation with those obtained for ratings by the clinical ty of ratings made in each of these settings.
directors (r = .83, p < .01). Similarly, diagnostic screening
categorizations resulting from ratings on the original CARS
table 20
item rating reliability for cArs2-hF items
Weighted
table 19 item r kappa
interrater reliability for item ratings on the
original cArs 1. Social-Emotional Understanding .70 .70
2. Emotional Expression and Regulation
item r of Emotions .58 .61
1. Relating to People .93 3. Relating to People .73 .75
2. Imitation .79 4. Body Use .76 .76
3. Emotional Response .71 5. Object Use in Play .72 .70
4. Body Use .70 6. Adaptation to Change/Restricted
Interests .81 .79
5. Object Use .76
7. Visual Response .87 .86
6. Adaptation to Change .63
8. Listening Response .64 .62
7. Visual Response .73
9. Taste, Smell, and Touch Response
8. Listening Response .71
and Use .72 .71
9. Taste, Smell, and Touch Response and Use .78
10. Fear or Anxiety .74 .73
10. Fear or Nervousness .67
11. Verbal Communication .73 .75
11. Verbal Communication .69 12. Nonverbal Communication .75 .72
12. Nonverbal Communication .62 13. Thinking/Cognitive Integration Skills .83 .80
13. Activity Level .67 14. Level and Consistency of Intellectual
14. Level and Consistency of Intellectual Response .55 Response .53 .51
15. General Impressions .76 15. General Impressions .93 .90
Total raw score .84 Total raw score .95 n/a

Note. N = 280. Note. N = 239.

073-102_Chap7_v2_001-004 chapter 01.qxd 8/13/10 2:35 PM Page 80
80
Forty-one children from the development sample for the
original CARS were rated by a therapist who met with the
parents for approximately 1 hour on the diagnostic day to
discuss the childs behavior. When Total scores based on the
parent interview were compared to Total scores for ratings
completed during the PEP session, mean scores for the two
settings (PEP X = 32.74; interview X = 33.67) showed no
significant difference (t = 1.26, p > .10) and correlations
indicated good agreement (r = .82, p < .01). Similarly,
screening results categorizing a case as likely autistic or
likely not autistic based on the parent interview or PEP
administration agreed in 90% of the cases. Unweighted
coefficient kappa for PEP-based ratings and those based on
the parent interview was .75, indicating agreement of 75%
beyond what would be expected by chance. These data
suggest that consistent ratings on the CARS instruments and
screening-based referral decisions can be made based on
information gathered during parent interviews.
Next, trained raters visited several TEACCH classrooms
for 1- to 2-hour observations of 20 children from the
development sample for the original CARS who were
scheduled to have PEP administrations in the clinic. Again,
mean ratings based on observations in the classroom did not
differ significantly from mean ratings based on observations
made during PEP administration (PEP X = 32.48; classroom
X = 34.18; t = 1.55, p > .10). The correlation of these ratings
(r = .73, p < .01) also indicated good agreement. Similarly,
screening classifications as likely autistic or likely not
autistic based on ratings obtained on the original CARS
using the classroom observation or the PEP administration
agreed in 86% of the cases. Unweighted coefficient kappa
for PEP-based ratings and those based on classroom
observation was .86. These data again suggest that consistent
ratings on the CARS instruments and diagnostic referral
decisions can be made based on information gathered during
observation of children in the classroom.
Finally, trained raters made ratings using the original
CARS based on a review of the behavioral information
contained in the case history charts of 61 children from the
development sample who had also received ratings in the
clinic during administration of the PEP. Once again, mean
ratings did not differ significantly between these two
situations (PEP X = 32.32; chart review X = 32.47; t = 0.20,
p > .10), and the correlation of these ratings (r = .82, p < .01)
indicated good agreement. Screening diagnoses based on
ratings using the original CARS form and made from the
review of behavioral information contained in client charts
and from observations made during the PEP administration
agreed in 82% of the cases. Coefficient kappa for PEP-based
ratings and those made on the basis of the case history charts
was .63. These data again suggest that consistent ratings and
diagnostic referrals can be made using the CARS instruments
based on a review of behavioral information contained
in client charts, although this method is likely to be less
consistent than ratings made on the basis of a parent interview
or observation session with the referred individual.
Technical Guide
stability of ratings over time
Ratings given on the original CARS for referred
individuals at different points in time have been examined.
As with interrater correlations, these range from 0 to 1.00,
and estimates of .70 and higher are considered adequate.
Total scores from two separate test occasions approximately
1 year apart were compared for 91 cases in the CARS
development sample. The resulting correlation is an
indication of the scales stability over time. Total scores
from the second and third yearly evaluations were chosen to
avoid the effects of improvement in autistic behavior
frequently seen during the first and second assessment
period and following the initial intensive treatment effort.
The resulting correlation was .88 (p < .01) and the means
(second evaluation X = 31.5; third evaluation X = 31.9) were
not significantly different. These results indicate that ratings
on the CARS instruments are stable over time. In addition,
since the instruments can aid in the screening of referred
individuals for subsequent evaluation as likely autistic or
likely nonautistic, the data were analyzed to assess the
stability of these screening categorizations. Results from the
second and third evaluations using the original CARS
agreed 82% of the time, and coefficient kappa was .64,
indicating categorical agreement that was 64% above what
would be expected by chance. These data, taken as a whole,
indicate that the stability of the CARS rating instruments is
good, even over a period as long as a year.
The stability of Total scores from the original CARS
has also been reported in the professional literature for a
number of other samples. Perry and Freeman (1996) found
Total score retest correlations of .90 (n = 11) 1 year apart
and .78 (n = 30) 2 years apart for children and adolescents
receiving autism-related interventions. In a more recent
study, Perry, Condillac, Freeman, Dunn-Geier, and Belair
(2005) examined the retest stability of the Total score in a
sample of preschool children (n = 47) who were either
receiving early intervention for autism-related behaviors or
who were on a waitlist for such intervention. They reported
a 3-month retest correlation of .77, indicating good stability.
standard error of measurement
Reliability estimates such as alpha coefficients or retest
reliabilities can be used, in combination with standard
deviation estimates, to calculate a standard error of
measurement (SEM; SEM = SD * (1 r)1/2) value. In an
attempt to account for the possible effect of random
variation due to measurement error, the SEM indicates the
range in which a true score would likely fall (with a 68%
probability), given the obtained score. For a T-score, a
standard score with a mean of 50T and a standard deviation
of 10T, a SEM value of 4T, for example, indicates that if an
actual test score of 50T is obtained, the true test score in
the absence of measurement error would likely fall between
50T minus 4T and 50T plus 4T, or between 46T and 54T.
The SEM for the CARS2-ST Total raw score is 0.68. For
practical purposes, this indicates that a true CARS2-ST
Total raw score is likely (with a 68% probability) to be within
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Chapter 7 Psychometric Properties
a single point above or below the obtained score. For the
CARS2-ST T-score, the SEM is 2.7T, indicating that a true
T-score is likely (with a 68% probability) to be within less
than 3 T-score points above or below the obtained T-score.
The SEM for the CARS2-HF Total raw score is 0.73. Thus, as
is the case for the CARS2-ST Total raw score, it is likely (with
a 68% probability) that a true CARS2-HF Total raw score is
within a single point above or below the obtained score. For
the CARS2-HF T-score, the SEM is 2.8T. Similar to the
CARS2-ST, the true CARS2-HF T-score is likely (with a
68% probability) to be within less than 3 T-score points above
or below the obtained T-score.
The 68% confidence level associated with the SEM
value is frequently used for psychological tests and thus
provides a familiar standard for CARS2-ST or CARS2-HF
score interpretation. However, if a higher level of confidence
is desired, it can be achieved in at least two ways. First, a
higher level of confidence is achieved if the SEM is used to
specify a range in which a true score falls that is either above
or below the obtained score 1 SEM, instead of both above
and below the obtained score. Thus, in the example of the
obtained test score of 50T, it can be said with an 84% level
of certainty either that the true score falls somewhere below
50T plus 4T, or below 54T, or conversely, that there is an
84% level of certainty that the true score falls somewhere
above 50T minus 4T, or above 46T. This approach is
appropriate when it is primarily the implication of scores at
only one end of a given scale that is of concern, as is
generally true for CARS2-ST and CARS2-HF scores.
Another way to enhance the level of confidence in test
score interpretation is to multiply the SEM value before
applying it. For example, multiplying the SEM by 1.5 allows
one to specify with an 86% confidence level the range in
which a true score falls. In the previous example using a test
score of 50T, this range would be specified as falling between
50T minus 6T and 50T plus 6T, or between 44T and 56T. An
even higher level of certainty (95%) can be achieved by
doubling the SEM value. In the example, a SEM value of 4T
indicates the true test score, given the obtained score of 50T,
would likely fall (with a 95% probability) between 50T
minus 8T and 50T plus 8T, or between 42T and 58T.
Incorporating these estimates into test score interpreta-
tion requires that the professional consider the purpose of the
assessment and strive to balance statistical precision with
practical coherence and usefulness appropriate to a particular
setting and purpose. The use of confidence intervals in this
manner acknowledges the imprecision inherent in any
psychological or educational test score. It also avoids placing
too much emphasis on a single number as an exact or near-
exact representation of a respondents characteristics.
Validity
Validity as a psychometric concept is the degree to which
evidence and theory support the interpretation of scores from
a specific test for a particular purpose in a particular setting
(American Educational Research Association [AERA],
81
American Psychological Association, & National Council
on Measurement in Education [NCME], 1999). More
generally, validity can be said to refer to the accuracy and
appropriateness of the interpretation of a test score in a given
setting. Validity is not a static concept, but represents an
ongoing process of the accumulation and evaluation of
research, theory, and concept development and refinement.
Evaluating a tests validity involves the continuing synthesis
of available information by researchers and clinical users of
tests. The evidence associated with the interpretative
guidance for CARS2-ST and CARS2-HF scores presented
in this manual is necessarily a static summary of such
information. Those who use the CARS2-ST and CARS2-HF
should follow the literature on the constructs assessed by
these two forms as well as reports of research specifically
focused on the use and interpretation of the results from
these instruments.
Common types of validity evidence considered impor-
tant for instruments such as the CARS2-ST and CARS2-HF
are theory-based evidence, evidence based on the test
content, information about the internal relationships of the
item ratings and Total scores, and the relationship of item
ratings and Total scores to variables external to the instru-
ment. A thorough discussion of the theoretical basis of
CARS2-ST and CARS2-HF rating areas and the relationship
of item content to prevailing knowledge about autism diag-
nosis has been provided in chapter 4. Information pertinent to
the internal relationships of CARS2-ST and CARS2-HF item
ratings and Total scores has been discussed earlier in this
chapter in the context of internal consistency. Additional
information about the internal relationships of CARS2-ST
and CARS2-HF ratings and Total scores is considered in this
section. Information about the relationships of CARS2-ST
and CARS2-HF ratings and Total scores to external variables
such as diagnostic outcome, other autism-related measures,
and demographic characteristics is also considered in this
section.
internal structure of cArs2-st and
cArs2-hF item ratings
Correlations between CARS2-ST item ratings and the
Total raw score are displayed in Table 21 for the CARS2-ST
verification sample. Correlations between CARS2-HF item
ratings and the Total raw score are displayed in Table 22 for
the CARS2-HF development sample. The general pattern is
similar across the two forms. Moderate-to-high correlations
among item ratings are evident, and correlations of item
ratings with the Total raw score are uniformly higher for
each item than for inter-item ratings. In Table 22, correlations
among CARS2-HF item ratings and the Total raw score are
displayed below the diagonal for individuals in clinical
settings without a diagnosis of autism. For those ratings, the
intercorrelations are consistently high, although still lower
for each item with the Total raw score than among the items.
A simplified representation of these results can be seen by
examining the underlying patterns in the form of factor
analytic results.
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table 21
correlations Between item ratings on the cArs2-st for individuals in the cArs2-st Verification sample
total
item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 raw score
1. Relating to People
2. Imitation .65
3. Emotional Response .62 .49
4. Body Use .62 .61 .51
5. Object Use .65 .73 .47 .64
6. Adaptation to Change .61 .56 .68 .47 .48
7. Visual Response .71 .67 .55 .61 .66 .61
8. Listening Response .65 .67 .58 .58 .61 .70 .72
9. Taste, Smell, and Touch Response and Use .56 .53 .54 .56 .63 .53 .56 .63
10. Fear or Nervousness .54 .51 .62 .42 .45 .66 .53 .58 .48
11. Verbal Communication .56 .71 .42 .57 .71 .45 .63 .59 .49 .39
12. Nonverbal Communication .67 .75 .53 .62 .70 .59 .67 .68 .59 .52 .77
13. Activity Level .53 .49 .54 .49 .53 .63 .58 .59 .51 .49 .47 .50
14. Level and Consistency of Intellectual Response .46 .62 .37 .52 .57 .42 .57 .54 .45 .39 .71 .61 .55
15. General Impressions .67 .64 .64 .59 .65 .56 .68 .63 .62 .55 .65 .65 .45 .52
Total raw score .81 .83 .73 .75 .81 .77 .83 .84 .74 .70 .78 .84 .72 .72 .81

Note. N = 1,034.

table 22
correlations Between item ratings on the cArs2-hF for individuals in the cArs2-hF Development sample
total
item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 raw score
1. Social-Emotional Understanding .56 .68 .56 .47 .58 .62 .57 .49 .51 .59 .55 .64 .49 .68 .78
2. Emotional Expression and Regulation
of Emotions .78 .61 .53 .50 .62 .53 .54 .40 .53 .51 .54 .51 .40 .62 .73
3. Relating to People .79 .87 .59 .58 .61 .63 .62 .43 .51 .61 .55 .54 .51 .68 .80
4. Body Use .62 .63 .62 .61 .52 .63 .55 .51 .41 .58 .53 .52 .51 .63 .76
5. Object Use in Play .62 .69 .68 .65 .45 .56 .53 .52 .35 .58 .58 .54 .52 .58 .74
6. Adaptation to Change/Restricted Interests .73 .77 .72 .59 .74 .57 .62 .44 .62 .46 .48 .48 .46 .63 .74
7. Visual Response .69 .70 .71 .67 .74 .70 .75 .49 .47 .53 .64 .58 .46 .66 .80
8. Listening Response .72 .68 .70 .55 .59 .70 .66 .45 .58 .50 .63 .54 .45 .62 .79
9. Taste, Smell, and Touch Response and Use .63 .62 .62 .66 .74 .68 .67 .58 .44 .50 .52 .55 .41 .62 .69
10. Fear or Anxiety .70 .70 .73 .56 .65 .70 .75 .65 .58 .39 .44 .42 .35 .56 .66
11. Verbal Communication .65 .72 .70 .56 .59 .71 .75 .68 .58 .68 .69 .67 .63 .65 .78
12. Nonverbal Communication .64 .74 .73 .58 .69 .69 .75 .67 .67 .68 .79 .62 .50 .62 .78
13. Thinking/Cognitive Integration Skills .70 .66 .65 .58 .58 .60 .66 .67 .61 .60 .58 .57 .64 .67 .78
14. Level and Consistency of Intellectual Response .66 .74 .68 .61 .69 .63 .69 .53 .60 .65 .59 .61 .63 .54 .71
15. General Impressions .78 .76 .79 .74 .73 .77 .85 .74 .74 .76 .68 .78 .71 .75 .85
Total raw score .86 .89 .88 .76 .83 .86 .87 .81 .79 .84 .82 .84 .78 .81 .92

Note. N = 994. Values above the diagonal are for ratings of individuals with an autism spectrum disorder (n = 574). Values below the
diagonal are for ratings of individuals without an autism spectrum disorder (n = 420).

82
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Chapter 7 Psychometric Properties 83

Factor analytic results for CARS2-ST item ratings in the emotional, cognitive, and sensory. Three factors account for
CARS2-ST verification sample are displayed in Table 23. As 59% of the variance in the ratings. The first factor appears
would be expected, principal components analysis yielded a related to social and emotional issues, with the highest load-
pattern of communalities very similar to the corrected item- ings for Item 2 Emotional Expression and Regulation of
to-total correlations reported in Table 17. A varimax rotation Emotions, Item 1 Social-Emotional Understanding, and
yielded two component factors accounting for 59% of the Item 3 Relating to People. The second factor reflects cogni-
variance in item ratings. The first factor appears related to tive functioning and verbal ability, with the highest loadings
communication and sensory issues. The highest loadings are on Item 11 Verbal Communication, Item 14 Level and
for Item 2 Imitation, Item 11 Verbal Communication, Consistency of Intellectual Response, and Item 13
Item 5 Object Use, Item 7 Visual Response, and Item 12 Thinking/Cognitive Integration Skills. The third factor relates
Nonverbal Communication. This factor accounted for 37% to sensory issues, with the highest loadings on Item 9 Taste,
of the variance in CARS2-ST item ratings. The second factor Smell, and Touch Response and Use, Item 8 Listening
appears related to emotional issues, with the highest loadings Response, and Item 4 Body Use. For CARS2-HF ratings of
for Item 6 Adaptation to Change, Item 3 Emotional individuals without an autism diagnosis, essentially the same
Response, Item 13 Activity Level, and Item 10 Fear or three factors emerged, with the item loadings displayed in
Nervousness. Twenty-two percent of the variance in ratings Table 25. The results support the specificity of the CARS2-
is accounted for by this factor. HF items to autism-related behaviors. Further results related
Factor analytic results for CARS2-HF item ratings for to CARS2-HF item rating patterns in individuals with or
individuals with and individuals without an autism spectrum without an autism spectrum disorder are presented in a later
disorder are displayed in Table 24 and Table 25, respectively. section, in the discussion of CARS2-HF scores obtained for
For these ratings, as for the CARS2-ST ratings, communal- various diagnostic groups.
ities are similar to the corrected item-to-total correlations Other factor analyses of item ratings on the original
reported in Table 18. For individuals with an autism diagno- CARS have been reported in the professional literature.
sis, component factors are somewhat different from those DiLalla and Rogers (1994) analyzed item ratings for 69
for CARS2-ST item ratings, reflecting more clearly the children between 24 and 73 months of age who had a variety
three key behavioral dimensions pertinent to autism: social- of diagnoses, including Autistic Disorder, Pervasive
Developmental Disorder Not Otherwise Specified (PDD-
NOS), and other non-PDD disorders. They identified three
factors in this sample that reflected social impairment, nega-
tive emotionality, and distorted sensory response. A factor
table 23 analysis of item ratings on the original CARS for 90 children
Factor Analytic results for item ratings in the with the clinical diagnosis of autism or PDD-NOS based on
cArs2-st Verification sample the DSM-III-R criteria yielded five factors reflecting social
item Factor 1 Factor 2 communication, emotional reactivity, social orienting, cogni-
tive and behavioral consistency, and odd sensory exploration
1. Relating to People .65 .45 (Stella, Mundy, & Tuchman, 1999). These authors suggested
2. Imitation .78 that the use of subscores based on these factors might increase
3. Emotional Response .76 the sensitivity of results on the original CARS with younger
4. Body Use .67 .33 or higher functioning individuals on the autism spectrum.
5. Object Use .75 A subsequent study by Stella (2002) found that the only
6. Adaptation to Change .81 symptom dimension that differentiated between higher and
7. Visual Response .75 lower functioning groups with autism was that reflected in the
8. Listening Response .66 .41 social orienting factor score reported in the prior study.
9. Taste, Smell, and Touch Response Magyar and Pandolfi (2007) also investigated the factor
and Use .59 .44 structure of the original CARS. Their results did not replicate
10. Fear or Nervousness .66 the earlier factors of DiLalla and Rogers (1994) or of Stella et
11. Verbal Communication .77 al. (1999). Instead, in this study of 164 children aged 20 to 82
12. Nonverbal Communication .75 .31
months with a diagnosis of Autistic Disorder or PDD-NOS,
they identified four factors reflecting social communication,
13. Activity Level .44 .67
social interaction, stereotypes and sensory abnormalities, and
14. Level and Consistency of
Intellectual Response .77
emotional regulation. These authors point out that although
the factors identified differed across studies, all the studies
15. General Impressions .72 .45
identify factors consistent with various DSM-IV diagnostic
% variance 37 22 criteria, distinguishing social-communication and interac-
tions, emotional regulation, and sensory components.
Note. N = 1,034.
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table 24
Factor Analytic results for item ratings of individuals With an
Autism spectrum Disorder in the cArs2-hF Development sample
item Factor 1 Factor 2 Factor 3
1. Social-Emotional Understanding .73 .33
2. Emotional Expression and Regulation of Emotions .76
3. Relating to People .70 .38
4. Body Use .33 .62
5. Object Use in Play .48 .50
6. Adaptation to Change/Restricted Interests .69 .41
7. Visual Response .33 .33 .56
8. Listening Response .37 .67
9. Taste, Smell, and Touch Response and Use .75
10. Fear or Anxiety .49 .50
11. Verbal Communication .74
12. Nonverbal Communication .32 .58
13. Thinking/Cognitive Integration Skills .68
14. Level and Consistency of Intellectual Response .71
15. General Impressions .64 .46 .18
% variance 22 19 18

Note. N = 574.

table 25
Factor Analytic results for item ratings of individuals Without an
Autism spectrum Disorder in the cArs2-hF Development sample
item Factor 1 Factor 2 Factor 3
1. Social-Emotional Understanding .69
2. Emotional Expression and Regulation of Emotions .72 .37
3. Relating to People .77 .32 .31
4. Body Use .31
5. Object Use in Play .32 .72 .39
6. Adaptation to Change/Restricted Interests .73 .67
7. Visual Response .51 .36
8. Listening Response .72 .51
9. Taste, Smell, and Touch Response and Use
10. Fear or Anxiety .74 .67
11. Verbal Communication .76 .31
12. Nonverbal Communication .73
13. Thinking/Cognitive Integration Skills .44 .33 .73
14. Level and Consistency of Intellectual Response .80
15. General Impressions .53 .56 .37
% variance 33 18 13

Note. N = 420.

84
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Chapter 7 Psychometric Properties
relationship of clinical Diagnosis to cArs2-st and
cArs2-hF total scores
original cArs. Ratings on the original CARS for
individuals in the development sample were compared with
expert clinical classifications to determine the relationship
of scores to three clinical diagnostic categories: not autistic,
autistic with a mild-to-moderate level of symptoms, and
autistic with a severe level of symptoms. Receiver operating
characteristics were examined related to using Total raw
scores for distinguishing among the autistic versus
nonautistic groupings in the development sample. The
results for these comparisons are presented in Table 26.
For these analyses, several statistics are reported,
including sensitivity, specificity, positive predictive value
(PPV), and negative predictive value (NPV). Sensitivity refers
to a tests ability to correctly identify individuals with a given
disorder, whereas specificity refers to a tests ability to
correctly identify those without the disorder. The PPV is the
percentage of individuals classified by the test as having a
disorder who truly do have it, whereas the NPV is the
percentage of individuals classified by the test as not having
the disorder who truly do not have it. It is especially important
to remember that sensitivity, specificity, PPV, and NPV are
not invariant properties of a test; they are influenced by the
cutoff points used to make the distinction in question and by
the percentage of people in the sample being discussed who
truly do have the disorder, and they are related to each other.
Four axioms characterize these relationships:
1. Lowering a tests cutoff score to identify cases increases
the tests sensitivity and decreases its specificity
2. Raising the test threshold to identify cases decreases the
tests sensitivity and increases its specificity
3. At constant sensitivity and specificity, a tests PPV is
higher in samples where disease prevalence is greater
4. At constant sensitivity and specificity, a tests NPV is
higher in samples where disease prevalence is lower
Depending on the purpose of a researcher or clinician,
cutoff scores might be selected to optimize the sensitivity or
specificity of the scale (Hsiao, Bartko, & Potter, 1989;
Mossman & Somoza, 1989). Further detail regarding the
descriptive statistics of test performance can be found in
Kessel and Zimmerman (1993).
table 26
relationship Between total score categories and
Autism Diagnosis in the Development sample for the original cArs
original cArs
total raw score range Present
30 or higher 716
29.5 or lower 95
Total 811
Note. Sensitivity = .88. Specificity = .86. False positives = 14%. False negatives = 12%. Positive
predictive value = .88. Negative predictive value = .86. Base rate = 53%.
85
For ratings of individuals in the development sample for
the original CARS, first the instruments ability to
distinguish autism from nonautism cases based on the Total
raw score was examined. It was observed that using a Total
raw score cutoff value of 30 correctly identified 87% of the
individuals in the development sample as autistic or not
autistic. The identification of those with or without an autism
diagnosis using only the Total raw score resulted in a
sensitivity value of .88 and a specificity value of .86. The
corresponding false negative rate was 12% and false positive
rate 14%. The PPV value was .88, and the NPV was .87.
These latter values indicate that among individuals referred
for autism-related evaluations, in a sample where the base
rate of the disorder is known to be around 50%, 88% of those
identified by a Total raw score of 30 or higher as likely to
have autism can be expected to receive a diagnosis of autism
following comprehensive evaluation. Conversely, 87% of
those identified by a Total raw score of 29.5 or lower as not
likely to have autism can be expected to have a diagnosis of
autism ruled out following comprehensive evaluation. The
average CARS2-ST ratings obtained for the CARS2-ST
verification sample are consistent with these findings. The
average CARS2-ST Total raw score obtained for those 1,034
individuals with an autism diagnosis is 38.5 (SD = 8.4). This
observation supports the established screening cutoff score
of 30, or one standard deviation below the mean for
diagnosed autism cases.
Agreement was also examined for the original CARS for
autism cases rated as severe, using the Total raw score cutoff
value of 37, and independent diagnostic categorization of a
case as severe by a clinical expert in autism. The two methods
agreed for 88.8% of the cases examined, with a false negative
rate of 14% and a false positive rate of 10%.
In the development sample for the original CARS, the
Total raw score was used to designate a case as likely not
autistic, likely autistic with a mild-to-moderate level of
symptoms, or likely autistic with a severe level of symptoms.
Approximately 46% of those evaluated (702) obtained Total
raw scores in the likely nonautistic category, while
approximately 54% (818) obtained scores in the likely autistic
category. Of the 54% who were classified as autistic,
approximately half (405) were identified as mildly to
moderately autistic while the other half (413) were identified
Autism diagnosis
Absent total
102 818
607 702
709 1,520
073-102_Chap7_v2_001-004 chapter 01.qxd 8/13/10 2:35 PM Page 86
86
as severely autistic, using the Total raw score cutoff values of
30 to indicate the likely presence of autism and 37 to indicate
the likely presence of autism with severe symptoms. These
category boundaries are consistent with the distribution of
Total scores observed in the CARS2-ST verification sample.
Several other studies of the relationship of Total scores
on the original CARS to autism diagnosis are reported in the
professional literature. A multisite study of 274 preschool
children with Autistic Disorder, PDD-NOS, mental
retardation, delayed, and other (Perry et al., 2005) reported
highly effective discrimination between children with and
without an autism diagnosis using Total scores. Sensitivity
reported in the sample was .94, and specificity was .85. In a
study of 138 children, Van Bourgondien, Marcus, and
Schopler (1992) reported a strong positive relationship
between Total scores and a clinical diagnosis of autism
based on DSM-III-R criteria. Garcia-Villamisar and Muela
(1998) reported a strong association between the Total
scores on the original CARS and the DSM-IV criteria in all
diagnostic categories in their study of a Spanish translation
of the CARS. Ventola et al. (2006), in a study of 45 toddlers,
found good agreement between the Autism Diagnostic
Observation Schedule (ADOS; Lord, Rutter, DiLavore, &
Risi, 1999), the original CARS, and clinical judgment using
DSM-IV criteria, but not with the Autism Diagnostic
InterviewRevised (ADI-R; Rutter, LeCouteur, & Lord,
2003). Compared to clinical judgment as the gold
standard, the original CARS had very good sensitivity (.89)
and excellent specificity (1.00).
Teal and Wiebe (1986) reported that the original CARS
Total score and the number of items on the original CARS
rated 3 or higher predicted classification of autism with
100% accuracy in samples of children with autism (N = 20)
and mental retardation (N = 20). Garfin et al. (1988) found
that the original CARS adequately discriminated between
samples of autistic and nonautistic adolescents. Sevin,
Matson, Coe, Fee, and Sevin (1991) reported that 92% of
respondents who met DSM-III-R criteria for autism also
received Total scores on the original CARS of 30 or higher.
Eaves and Milner (1993) reported that the original CARS
ratings and the Autism Behavior Checklist (ABC; Krug,
Arick, & Almond, 1980) agreed on 83% of all diagnostic
classifications; sensitivity was reported at 98% on the
original CARS, but specificity data were not obtained.
Sponheims and Spurklands data (1996) suggested that
scores on the original CARS can distinguish autism from
nonautism; however, they do not distinguish between autism
and Aspergers Disorder. In contrast, Rellini, Tortolani,
Trillo, Carbone, and Montecchi (2004) found that while the
original CARS was very sensitive in identifying children
with autism, it did not identify individuals with Aspergers
Disorder or PDD-NOS as having autism. Perry et al. (2005)
found significantly lower average Total scores (X = 28.31)
for individuals with PDD-NOS than for individuals with an
autism diagnosis (X = 36.06). Nordin et al. (1998) reported
sensitivity of 100% for autism and 85% to 90% for autism
spectrum disorder; specificity indexes were reported at 70%
Technical Guide
for autism and 80% to 100% for autism spectrum disorder.
Lord and Corsello (2005) note that classification and
correlations between raters for Total scores have been high
across different procedures (p. 749). Several studies have
found that clinicians tend to rate behaviors as more severe
than do fathers or mothers (Bebko, Konstantareas, &
Springer, 1987; Konstantareas & Homatidis, 1989), while
other studies have found few differences (N. L. Freeman,
Perry, & Factor, 1991; Schopler, Reichler, & Renner, 1988).
Although the original CARS is one of the most widely
researched and employed rating scales of autism in the world,
some claim that the scores do not correspond to current
formal diagnostic frameworks such as the DSM-IV or the
ICD-10 (Lord & Corsello, 2005). At the same time, as can be
seen from the studies reviewed in this section, many studies
report good to excellent agreement between the original
CARS (now the CARS2-ST) and clinical diagnosis using
DSM-IV criteria (Perry et al., 2005; Rellini et al., 2004;
Sponheim & Spurkland, 1996; Ventola et al., 2006). In fact,
Magyar and Pandolfi (2007) note that despite being devel-
oped more than a decade before the publication of the DSM-
IV, the original CARS remains a clinically relevant screening
tool that assesses autism-specific constructs consistent with
current diagnostic conceptualizations. If there is a weakness
to the original CARS, it is in the identification of individuals
who have Aspergers Disorder, PDD-NOS, or autism with
average or above-intelligence and with good verbal skills who
are in elementary school or higher (Rellini et al.; Sponheim &
Spurkland). With the addition of the CARS2-HF form,
designed for the higher end of the autism spectrum and an
older age group, this weakness has been addressed.
cArs2-hF. In the CARS2-HF development sample,
Total raw scores were examined for high-functioning individ-
uals (IQ estimates of 80 or higher) with known diagnoses of
high functioning autism (n = 248), Aspergers Disorder (n =
231), or PDD-NOS (n = 95), with known nonautism diag-
noses related to other behavior problems (n = 399), or with no
behavior problems (n = 21). Average Total raw scores and the
corresponding T-score values for each group are displayed in
Table 27. CARS2-HF Total scores are clearly sensitive to the
presence of high functioning autism or a related diagnosis.
For the nonautism clinical groups, those with nonautism
clinical diagnoses or with definite symptoms but for whom no
diagnosis had been determined had the highest average
scores, but their average was still more than a standard devia-
tion below the average scores for those with autism spectrum
disorders. All differences for those with nonautism diagnoses
are statistically significant (p < .01). The effect sizes for
several of the group differences are striking. Effect sizes are
used to evaluate whether a statistically significant difference
is also likely to be a clinically meaningful one (Cohen, 1992;
Horst, Tallmadge, & Wood, 1975). In general, effect sizes of
0.1 to 0.3 pooled deviation units (or 1 to 3 T-score points) are
considered small and not to be of much practical import,
effect sizes between 0.3 and 0.5 deviation units (or 3 to 5
T-score points) are considered moderate, and an effect size
greater than 0.5 deviation units (or 5 T-score points) is
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Chapter 7 Psychometric Properties
table 27
Average cArs2-hF scores for Various clinical Groups
Diagnosis
High functioning autism (n = 248)
Aspergers Disorder (n = 231)
PDD-NOS (n = 95)
Mixed clinical (n = 69)
ADHD (n = 179)
Learning disorder (n = 111; includes individuals
specified as having nonverbal learning disorder)
Nonverbal learning disorder (n = 59)
Special education students (n = 40)
General education (n = 21)
considered large. Moderate-to-large effect sizes indicate clin-
ically meaningful differences, particularly when observed
across a variety of scores in a pattern that is consistent with
other knowledge about the comparisons being made. Effect
sizes for the differences between average scores in the
nonautism versus autism spectrum clinical groups were also
uniformly large, ranging from 1.3 for cases with other clinical
diagnoses to 2.6 for the difference between average scores for
those with learning disorders versus those with high function-
ing autism. The effect size for ratings of individuals in a
general education setting compared with individuals given an
autism diagnosis was very large, at over 3.0.
Average ratings for the 15 CARS2-HF items for each
high-functioning clinical group are displayed in Table 28. Not
surprisingly, with few exceptions item ratings for those with
autism spectrum disorders averaged 2 or higher across all 15
items. Ratings for those with other clinical diagnoses
averaged ratings close to 2 or higher on only 5 items: Item 1
Social-Emotional Understanding, Item 2 Emotional
Expression and Regulation of Emotions, Item 3 Relating to
People, Item 6 Adaptation to Change/Restricted Interests,
and Item 10 Fear or Anxiety. High-functioning individuals
with Attention-Deficit/Hyperactivity Disorder (ADHD) or
learning disorders (LD), or in a general education classroom,
had averaged ratings of 1 or 1.5 on all items. More
information about patterns of CARS2-HF items ratings for
different clinical groups is provided later in this chapter.
Receiver operating characteristics were examined related
to the use of CARS2-HF Total raw scores for distinguishing
high-functioning individuals with an autism spectrum disor-
der from all nonautism groups in the CARS2-HF develop-
ment sample. Results are displayed in Table 29. For these
analyses, the same statistics are reported as for the study on
the original CARS, described previously. In addition, the area
under the curve (AUC) statistic is available, providing an
index of the overall effectiveness of the classification. AUC
values of .80 and higher indicate good overall discrimination.
Results for those with a diagnosis related to high functioning
autism are shown in the top panel of Table 29. The AUC value
87
mean SD T-score
35.3 6.9 53T
32.7 6.1 49T
33.6 7.2 50T
24.8 7.7 37T
19.6 5.1 27T
18.7 5.1 24T
19.0 6.4 26T
17.0 2.6 <20T
17.3 2.1 <20T
is .93, indicating very effective overall discrimination.
Sensitivity is .81 and specificity is .87, with a corresponding
false positive rate of 11% and false negative rate of 23%. The
PPV is .89 and the NPV is .77. These latter values indicate
that in this sample of those with diagnosed behavior prob-
lems, where the base rate of autism is known to be around
58%, 89% of those identified by a CARS2-HF Total raw score
of 28 or higher are likely to have autism and can be expected
to receive a diagnosis of autism following comprehensive
evaluation. Conversely, 77% of those identified by a CARS2-
HF Total raw score of 27.5 or lower are not likely to have
autism and can be expected to have a diagnosis of autism
ruled out following comprehensive evaluation.
Results for a randomly selected subset of those with
autism spectrum diagnoses (n = 100) and a mixed group with
nonautism clinical diagnoses (n = 69) are shown in the
bottom panel of Table 29. The AUC value is .76, again
indicating effective overall discrimination. Sensitivity is .79
and specificity is .58, with a corresponding false positive rate
of 27% and false negative rate of 36%. The PPV is .73 and the
NPV is .64. These latter values indicate that in this sample of
those with diagnosed behavior problems, where the base rate
of an autism spectrum disorder is known to be around 59%,
73% of those identified by a CARS2-HF Total raw score of 28
or higher are likely to have autism and can be expected to
receive a diagnosis of autism following comprehensive
evaluation. Conversely, only 64% of those identified by a
CARS2-HF Total raw score of 27.5 or lower are not likely to
have autism and can be expected to have a diagnosis of autism
ruled out following comprehensive evaluation. The PPV and
NPV results reported in Table 29 will likely change in
samples with different base rates.
relationship of total scores on the original cArs
and cArs2-hF to other measures of Autism
Correlations are available for Total raw scores and
independent overall clinical ratings of autism symptoms
obtained for those in the development sample for the
original CARS. The resulting correlation, r = .84 (p < .001),
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table 28
Average ratings for cArs2-hF items
Groupa
item 1 2 3 4 5 6 7 8 9
1. Social-Emotional Understanding 2.6 2.6 2.5 1.8 1.3 1.2 1.3 1.2 1.3
2. Emotional Expression and Regulation of Emotions 2.6 2.7 2.4 2.2 1.5 1.3 1.3 1.3 1.2
3. Relating to People 2.6 2.5 2.4 1.9 1.4 1.3 1.4 1.3 1.1
4. Body Use 2.1 2.0 2.0 1.4 1.2 1.2 1.1 1.1 1.3
5. Object Use in Play 2.1 1.8 1.8 1.4 1.1 1.1 1.0 1.0 1.0
6. Adaptation to Change/Restricted Interests 2.6 2.6 2.5 1.8 1.2 1.2 1.3 1.1 1.1
7. Visual Response 2.1 2.1 2.2 1.4 1.2 1.2 1.2 1.1 1.0
8. Listening Response 2.1 2.0 2.1 1.4 1.2 1.2 1.2 1.0 1.4
9. Taste, Smell, and Touch Response and Use 2.0 1.8 2.0 1.2 1.1 1.1 1.1 1.0 1.0
10. Fear or Anxiety 2.3 2.4 2.4 2.0 1.4 1.3 1.4 1.1 1.2
11. Verbal Communication 2.5 2.2 2.2 1.6 1.2 1.3 1.3 1.2 1.2
12. Nonverbal Communication 2.3 2.1 2.1 1.5 1.2 1.2 1.4 1.2 1.1
13. Thinking/Cognitive Integration Skills 2.2 1.9 2.1 1.5 1.4 1.3 1.3 1.3 1.3
14. Level and Consistency of Intellectual Response 2.2 1.8 1.9 1.5 1.6 1.2 1.1 1.1 1.1
15. General Impressions 2.5 2.5 2.3 1.3 1.1 1.1 1.2 1.0 1.0
a
1 = High functioning autism (n = 248). 2 = Aspergers Disorder (n = 231). 3 = PDD-NOS (n = 95).
4 = Nonautism internalizing or externalizing disorders (n = 69). 5 = ADHD (n = 179).
6 = Learning disorder, including nonverbal learning disorder (n = 111). 7 = Nonverbal learning disorder only (n = 59).
8 = Special education, nonautism-related (n = 40). 9 = General education classroom (n = 21).

table 29
relationship Between cArs2-hF total score categories and
Autism Diagnosis in the cArs2-hF Development sample
Autism spectrum disorder
cArs2-hF (autism, Aspergers Disorder, or PDD-Nos)
total raw score range Present Absent total
28 or higher 465 55 520
27.5 or lower 109 365 474
Total 574 420 994

Note. Sensitivity = .81. Specificity = .87. False positives = 13%. False negatives = 19%. Positive predictive value = .89.
Negative predictive value = .77. Base rate = 58%. AUC = .93.

Autism spectrum disorder vs. mixed clinical nonautistic disorders

cArs2-hF mixed clinical
total raw score range Autism spectrum nonautistic total
28 or higher 77 29 106
27.5 or lower 23 40 63
Total 100 69 169

Note. Sensitivity = .77. Specificity = .58. False positives = 42%. False negatives = 23%. Positive predictive value = .73.
Negative predictive value = .63. Base rate = 59%. AUC = .76.

88
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Chapter 7 Psychometric Properties
indicates that the scores have high validity when compared
with the clinical ratings. Total raw scores were also correlated
with independent clinical assessments made by a child
psychologist and a child psychiatrist based on the information
they obtained from referral records, parent interviews, and
unstructured clinical interviews with the child. The resulting
correlation, r = .80 (p < .001), again indicates that the results
for the original CARS are in agreement with expert clinical
judgments.
For CARS2-ST and CARS2-HF ratings, correlations
between Total raw scores and ADOS Total scores are
available for individuals in the CARS2-HF development
sample. It should be noted that the ADOS is a very different
kind of instrument from the CARS2-ST and CARS2-HF.
The ADOS is a comprehensive set of structured tasks
presented to the individual undergoing a diagnostic
evaluation whose behavior during each task is observed and
rated by the clinician. A subset of the clinicians ratings
related to the individuals communication and social
behavior are summed to obtain the ADOS Total score,
which can range from 0 to 22. ADOS scores do not take into
account information about the onset of symptoms or early
developmental history. The correlation value is .79 for the
CARS2-ST Total score (n = 37) and .77 for the CARS2-HF
Total score (n = 76), indicating a reasonably strong
relationship between clinician ratings on these two very
different measures.
Correlations between clinician-generated CARS2-HF
Total scores and mothers SRS (Social Responsiveness
Scale; Constantino & Gruber, 2005) Total scores are
available for 293 individuals in the CARS2-HF development
sample. The SRS is a 65-item pencil-and-paper measure that
asks someone who knows an individual well to rate his or
her behavior related to social interactions on a scale of 1 to
4. Correlation values are .38 for the CARS2-ST Total score
and .47 for the CARS2-HF Total score. These values
indicate a moderate relationship between clinician ratings
of a comprehensive range of an individuals autism-related
behaviors and mothers ratings focused on social inter-
actions. The moderate relationship is consistent with what
is typically observed between clinician and parent ratings of
childrens behaviors. As would be expected, the relationship
is stronger for higher functioning individuals rated on the
CARS2-HF than for individuals rated on the CARS2-ST.
Sevin et al. (1991) found that the Total raw scores from
the original CARS correlated significantly with the Ritvo-
Freeman Real Life Rating Scale (B. J. Freeman, Ritvo,
Yokota, & Ritvo, 1986), but not with one component of the
Autism Behavior Checklist (ABC), which is the Autism
Screening Instrument for Educational Planning (ASIEP;
Krug, Arick, & Almond, 1979). Eaves and Milner (1993)
reported 76% of correlations involving individual CARS2-ST
items and the ABC Total score and six ABC domains were
statistically significant. The CARS2-ST Total score and the
ABC Total score correlated at .67. However, Rellini et al.
(2004), in a sample of 65 children from 1 to 11 years, found
89
that the ABC did not differentiate individuals with autism
from other types of developmental disorders as well as the
original CARS. The original CARS and the DSM-IV were in
complete agreement. Sponheim and Spurkland (1996) found
significant diagnostic agreement between the original CARS,
ICD-10, DSM-IV, DSM-III-R, and ABC for 132 children with
suspected autism. Recent studies examined the relationship
between the original CARS and the ADI-R. Pilowsky,
Yirmiya, Shulman, and Dover (1998) reported 85.7%
diagnostic agreement between the ADI-R and the original
CARS in a study of 83 children and adults. However, the
instruments agreed on 91.8% of the cases for positive autism
diagnosis and 44.4% for nonautism diagnosis, resulting in an
overall kappa of .36. Saemundsen et al. (2003) reported that
the original CARS scores correlated significantly with the
ADI-R, with Pearson correlations ranging from .60 on the
ADI-R Communication subscale to .81 for the ADI-R Social
Impairment subscale and the Total score.
relationship of scores on the original cArs to Age
A child diagnosed as having autism 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 CARS2-
ST can be used for this purpose (Garfin et al., 1988; Van
Bourgondien & Mesibov, 1993). Mesibov, Schopler,
Schaffer, and Landrus (1988) identified 59 individuals aged
13 to 18 in the TEACCH program who were evaluated with
the original CARS form and diagnosed as having autism
prior to age 10. The same individuals were then reevaluated
using the original CARS after age 13. Their scores tended to
decrease over time. The average decrease reported by these
authors was 2.2 points. When the cutoff score of 30, used to
determine the presence of mild-to-moderate autism in
children, was adjusted to 28 for these 59 individuals, 54 of
them, or 92%, were correctly identified as having autism
based solely on their second evaluations with the original
CARS. Garcia-Villamisar and Muela (1998), in a study of
55 adults in Spain, also found that a lower cutoff score of 28
on the original CARS provided good sensitivity and
specificity for their sample. Thus, when using the CARS2-
ST Total score for evaluating adolescents and adults, a cutoff
value of 28 is recommended as a useful criterion for
indicating the likely presence of autism, and a cutoff value
of 35 is recommended as most useful for distinguishing
between moderate autism and severe autism. As with
children, the diagnosis of autism for adolescents and adults
using the CARS2-ST should mark the beginning of an
individualized assessment process. The TEACCH Transition
Assessment Profile (TTAP; Mesibov, Thomas, Chapman, &
Schopler, 2007) is designed to facilitate such additional
individualized assessment. Currently, there is no evidence
that CARS2-HF cutoff values differ for older individuals.
cArs2-st and cArs2-hF item rating Patterns
related to Diagnosis, cognitive Functioning, and Age
CARS2-ST and CARS2-HF item rating patterns have
been examined to evaluate how patterns of ratings compare
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90 Technical Guide

across groups with different diagnoses, levels of cognitive
function, and age. Results of Rasch analyses (Linacre, 2009)
are displayed in Tables 30 through 39. Rasch analysis
examines the systematic relationship between test items and
total scores. The tables presented in this section can be
thought of as maps that show the Total score value above
which each CARS2-ST or CARS2-HF item is likely to have
a higher than average rating for a given group. In general,
items associated with lower Total scores are the most likely
to contribute to an elevated score for a given group, whereas
items associated with higher Total scores are less likely to
contribute to an elevated Total score.
Although the results presented in this section are
generally consistent with current clinical understanding, it
must be noted that these findings are based on rather small
samples of convenience. Further research is needed to
examine the typical patterns of CARS2-ST and CARS2-HF
item ratings for a variety of clinical groups. The information
here is provided to aid in the development of research
questions related to item rating patterns. Meanwhile, the
current information can also provide secondary information
to compare against all other available information when a
clinician is formulating diagnostic hypotheses in a given case.
cArs2-st item rating patterns. Table 30 shows the

table 30
relationship Between cArs2-st item ratings and total score
for individuals in the cArs2-st Verification sample
total score item (diagnosis of autism, iQ 79)
30.0
30.5
31.0
31.5 11. Verbal Communication
32.0
32.5
33.0
33.5
34.0 1. Relating to People; 15. General Impressions
34.5
35.0 3. Emotional Response
35.5
36.0
36.5
37.0 6. Adaptation to Change
37.5
38.0 10. Fear or Nervousness; 14. Level and Consistency of Intellectual Response
38.5
39.0 12. Nonverbal Communication
39.5 4. Body Use
40.0 2. Imitation; 5. Object Use
40.5 7. Visual Response; 8. Listening Response; 13. Activity Level
41.0
41.5
42.0
42.5
43.0 9. Taste, Smell, and Touch Response and Use
43.5
44.0
44.5
45.0
45.5
46.0

Note. N = 1,034.
073-102_Chap7_v2_001-004 chapter 01.qxd 8/13/10 2:35 PM Page 91
Chapter 7 Psychometric Properties
item rating pattern for the CARS2-ST verification sample.
Individuals who obtained scores as low as 31.5 were still
likely to obtain higher than average ratings on Item 11
Verbal Communication. Those with Total scores in the mild-
to-moderate range were likely to have high ratings on this
item, as well as Item 1 Relating to People, Item 15 General
Impressions, Item 3 Emotional Response, and Item 6
Adaptation to Change. Those with Total scores in the severe
range were more likely than those with lower scores to receive
high ratings on Item 10 Fear or Nervousness, Item 14
Level and Consistency of Intellectual Response, Item 12
Nonverbal Communication, Item 4 Body Use, Item 2
Imitation, Item 5 Object Use, Item 7 Visual Response,
Item 8 Listening Response, and Item 13 Activity Level.
Only those with the highest scores were likely to have high
ratings on Item 9 Taste, Smell, and Touch Response and Use.
Table 31 shows how the CARS2-ST item rating pattern
differs for those with a diagnosis of autism and a higher level
of cognitive functioning. Although many of the items in the
list have shifted in position relative to the Total score above
which a higher than average rating is likely, for most the
change is only a few Total score points or is not statistically
significant. For comparing these differences in patterns of
item ratings, statistical significance is evaluated using the
Mantel statistic (Mdif; Linacre, 2009). Like the familiar t
statistic, Mdif indicates the probability that the difference is 0
between groups in terms of the relationship, for each group, of
ratings on an item with the total obtained test score. Three of
the shifts in item position of CARS2-ST ratings observed for
individuals with autism with IQs between 80 and 85 are mod-
erate to large in size, are statistically significant (Mdif < .01),
and make clinical sense. First, even those with the lowest
Total scores are likely to receive high ratings on Item 6
Adaptation to Change, whereas they are not as likely as their
lower functioning counterparts to obtain high ratings on Item
11 Verbal Communication. For both groups, high ratings
for Item 2 Imitation are most likely to be observed for
those who obtain Total scores in the severe range (Total
scores of 37 or higher). But the higher functioning group
who have scores in the severe range are less likely to have
high ratings on this item.
It has been documented that older individuals with
autism obtain slightly lower CARS2-ST scores than do
younger individuals with autism. Table 32 displays results
suggesting a difference in the pattern of item ratings as well
for older individuals. Higher than average ratings on Item 2
Imitation, Item 8 Listening Response, and Item 12
Nonverbal Communication are associated with higher Total
scores for older individuals with autism than for younger
ones. Conversely, higher ratings on Item 3 Emotional
Response and Item 4 Body Use are observed at lower Total
score levels for older individuals than for younger ones.
Table 33 displays the patterns of CARS2-ST ratings for
lower functioning individuals with a diagnosis of autism or
PDD-NOS. The results must be considered with due caution
because the PDD-NOS sample is small (n = 59). The change
in position of ratings on Item 14 Level and Consistency of
Intellectual Response suggests that for those with atypical
91
symptom patterns of developmental delay, unusual variability
in cognitive functioning is likely to have greater salience in the
overall clinical picture as expressed in the CARS2-ST Total
score than for those with symptom patterns more typical of
autism. High ratings on Item 2 Imitation and Item 5 Object
Use were more likely to be obtained at lower Total score levels
for those with autism relative to those with PDD-NOS.
cArs2-hF item rating patterns. Table 34 displays the
pattern of ratings on the CARS2-ST for children younger than
age 6 and lower functioning individuals with autism along
with the pattern of ratings on the CARS2-HF for higher func-
tioning individuals with autism. Even though direct statistical
comparisons cannot be made given differences in the forms
and samples in the current study, inspection of the rating
patterns for the two item rating sets is informative. On both
forms, for the item ratings that evaluate Relating to People;
General Impressions; Social-Emotional Under standing;
Taste, Smell, and Touch Response and Use; Nonverbal
Communication; and Fear or Nervousness/Anxiety, the rela-
tionship between high Total scores and high item ratings
follow a similar pattern. The patterns are somewhat less
similar for items related to Emotional Response/ Expression,
Adaptation to Change, Body Use, Visual Response, Listening
Response, and Level and Consistency of Intellectual
Response. The biggest difference is observed in the relation-
ship of high ratings on Verbal Communication and Object
Use with Total scores. Higher than average ratings on those
two items appear more likely for those with lower Total scores
on the CARS2-ST than on the CARS2-HF. The result for the
Verbal Communication ratings is consistent with what was
observed in CARS2-ST ratings for higher functioning
individuals with autism.
It was previously observed that CARS2-HF Total scores
are significantly different for individuals in the development
sample diagnosed with autism and those diagnosed with
Aspergers Disorder. Those with Aspergers Disorder reliably
obtain, on average, slightly lower Total scores. Examination
of the results displayed in Table 35 reveals that the patterns of
CARS2-HF item ratings for these two groups is also substan-
tially different. Among those diagnosed with Aspergers, even
those with the lowest scores in the clinical range are likely to
have received high ratings on Item 2 Emotional Expression
and Regulation of Emotions and Item 1 Social-Emotional
Understanding. For those with an Aspergers diagnosis, rela-
tively higher item ratings on Item 6 Adaptation to Change/
Restricted Interests and Item 15 General Impressions are
also observed for those with lower scores relative to those
diagnosed with autism. However, individuals with Aspergers
Disorder who have high CARS2-HF scores are less likely
than their autistic counterparts to have higher than average
ratings on Item 11 Verbal Communication, Item 13
Thinking/Cognitive Integration Skills, Item 14 Level and
Consistency of Intellectual Response, and Item 5 Object
Use in Play.
Individuals with a diagnosis of PDD-NOS obtain average
CARS2-HF Total scores that are more similar to average Total
scores for those with autism than are the average Total scores
of those with Aspergers Disorder. Table 36 reveals that
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92 Technical Guide

table 31
relationship of cArs2-st item ratings and total score
for individuals With Low or high cognitive Functioning and a Diagnosis of Autism
item (diagnosis of autism, iQ 79)a total score item (diagnosis of autism, iQ 8085)b
30.0
30.5
31.0
11. Verbal communication 31.5
32.0 6. Adaptation to change
32.5
33.0
33.5
1. Relating to People; 15. General impressions 34.0 1. Relating to People; 3. Emotional Response
34.5 11. Verbal communication
3. Emotional Response 35.0
35.5 10. Fear or Nervousness
36.0 15. General impressions
36.5
6. Adaptation to change 37.0
37.5 13. Activity Level;
14. Level and Consistency of Intellectual Response
10. Fear or Nervousness 38.0 8. Listening Response
14. Level and Consistency of Intellectual Response
38.5
12. Nonverbal Communication 39.0
4. Body Use 39.5 12. Nonverbal Communication
2. imitation; 5. Object Use 40.0
7. Visual Response; 8. Listening Response; 40.5
13. Activity Level
41.0 7. Visual Response
41.5 5. Object Use; 4. Body Use
42.0
42.5 2. imitation
9. Taste, Smell, and Touch Response and Use 43.0
43.5
44.0
44.5 9. Taste, Smell, and Touch Response and Use
45.0
45.5
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 836. bn = 198.

individuals with PDD-NOS also receive item ratings in a
pattern more similar to item ratings for those with autism than
do individuals with Aspergers Disorder. The most salient
difference is that those with a PDD-NOS diagnosis are likely
to have higher ratings on Item 7 Visual Response and Item 8
Listening Response at lower Total score levels than those
with a diagnosis of autism.
The last three tables in this series present maps showing
the relationship between the CARS2-HF ratings of those
with clinical diagnoses other than one involving pervasive
developmental disorder whose symptoms are sometimes
confused with those of autism. Table 37 displays findings for
those with a diagnosis of ADHD. Table 38 displays findings
for those diagnosed with a learning disorder. Table 39
displays findings for a mixed group of individuals with other
clinical diagnoses or with definite clinical symptoms but for
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Chapter 7 Psychometric Properties
whom no diagnosis could be determined (Anxiety Disorders,
n = 13; Mood Disorders, n = 12; Disruptive Behavior
Disorders, n = 33; diagnosis undetermined, n = 32). As has
already been discussed, all three groups had significantly
lower average Total scores than those with an autism diagno-
sis. Item rating patterns were also markedly different in ways
that would be expected. For example, individuals with ADHD
obtained high ratings on Item 14 Level and Consistency of
Intellectual Response and Item 2 Emotional Expression and
Regulation of Emotions at lower Total score levels than did
those with autism. High ratings on Item 15 General
Impressions were associated with much higher scores for
those with ADHD than for those with autism. A similar
pattern was observed for Item 11 Verbal Communication
and Item 12 Nonverbal Communication, though for these
two items the difference was slightly less consistent.
Individuals with a diagnosed learning disorder (LD), like
those with ADHD, obtained high ratings on Item 15 General
Impressions at a much higher Total score level than did indi-
viduals with autism, and a similar pattern is evident for ratings
on Item 1 Social-Emotional Understanding. Conversely, for
the LD group, high ratings on Item 10 Fear or Anxiety were
observed at a low Total score level relative to those with
autism. For the mixed group, as one might expect, high
ratings for Item 2 Emotional Expression and Regulation of
Emotions, Item 10 Fear or Anxiety, and Item 3 Relating to
People are assigned at markedly lower Total score levels,
relative to those with autism, and high ratings on Item 15
General Impressions are observed only for those who
obtained Total scores in the highest range, at 44.0 and above.
research Uses of the cArs
The original CARS has been used as a component in a
large number of research settings. Researchers are
encouraged to use the established CARS2-ST or CARS2-
HF form connected with the current CARS2 whenever
possible. In this way, scientific knowledge regarding autism
behaviors can be generalized across studies to achieve a
stable foundation of knowledge for future clinicians and
researchers. However, it is acknowledged that at times
study-specific factors may require the use of an adapted or
translated form. Those interested in using an adapted or
translated version of the CARS2-ST or CARS2-HF for
research or any other purpose must contact the WPS Rights
and Permissions Office at 12031 Wilshire Blvd., Los
Angeles, CA, 90025, to obtain permission and make suitable
arrangements. Educational and research discounts on
materials are available for qualifying projects.
The original CARS has been demonstrated to be useful in
a variety of research studies. It has been used to verify
diagnosis (Abel & Russell, 2005; Reitman, 2006), support
differential diagnosis (Baieli, Pavone, Meli, Fiumara, &
Coleman, 2003; Bailey et al., 1998; Konstantareas & Hewitt,
2001; Matese, Matson, & Sevin, 1994), and document
behavior profiles and symptom severity of research
participants (Handleman & Harris, 2001; Hobson & Bishop,
2003; Hrdlicka et al., 2005).
93
In addition to being used to document the severity of
symptoms or verify diagnosis in clinical intervention
studies, the original CARS has also been used in some
studies as an outcome measure for early intervention
(Alonim, 2004; Weiss, 1999), other interventions (Chez et
al., 2000; Garcia-Villamisar, Ross, & Wehman, 2000), and
medication trials (Diler, Firat, & Avci, 2002; Masi, Cosenza,
Mucci, & Brovedani, 2001).
The original CARS form has been translated into many
different languages (Japanese, Swedish, Korean, Spanish,
French, Chinese) over the years with subsequent studies of
the psychometric properties of these translated versions.
Garcia-Villamisar and Muela Morente (2000) found good
internal consistency for a Spanish translation of the original
CARS in a study of 55 adolescents and adults. Two factors
were identified: one associated with interpersonal
relationships, affectivity, and appearance; and one
associated with symbolization, sensitivity, and adaptation to
the environment. Garcia-Villamisar and Muela (1998) also
report a strong association between the original CARS and
DSM-IV criteria in all three diagnostic categoriessocial,
communication, and stereotypy of behaviors.
Shin and Kim (1998) examined the psychometric
properties of a Korean translation of the original CARS and
demonstrated good reliability, with an interrater reliability
estimate of .94, an internal consistency estimate of .87, and
a test-retest reliability of .91. Tachimori, Osada, and Kurita
(2003) demonstrated good internal consistency using a
Japanese translation with a large sample (N = 430). The
authors successfully used this translated form to distinguish
between children with high functioning atypical autism and
childhood autism (Kanai et al., 2004). They also
successfully distinguished children with high-functioning
PDDs from those with ADHD (Otsuka et al., 2003).
summary
After reviewing the original CARS, Morgan (1988)
concluded that When all measures of reliability and
validity are consideredthe CARS clearly emerges as the
strongest scale. The many CARS-related studies reported
since that time and the additional development studies
reported in this chapter continue to support this view.
CARS2-ST and CARS2-HF Total scores show a consistent
and strong, positive, specific relationship with autism
diagnosis. The ratings have been demonstrated to be reliable
across different settings, for different sources of information
for the same individual, for different raters, and across time.
With a new form extending the CARS method to higher
functioning individuals with autism, verified calibration of
CARS2-ST scores in a recent autism sample, a structured
format for gathering caregiver information, and guidance for
using CARS2-ST and CARS2-HF ratings to plan autism-
related interventions, the CARS2 remains a stable and
useful element in the assessment of referred individuals
related to autism diagnosis or intervention.
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table 32
relationship of cArs2-st item ratings and total score for younger and older
individuals in the cArs2-st Verification sample
item (diagnosis of autism, age 12)a total score item (diagnosis of autism, age 13)b
30.0
30.5
11. Verbal Communication 31.0
31.5 3. emotional response
32.0
32.5 11. Verbal Communication
33.0
33.5 15. General Impressions
1. Relating to People 34.0
15. General Impressions 34.5 1. Relating to People
35.0
35.5
3. emotional response 36.0 6. Adaptation to Change;
14. Level and Consistency of Intellectual Response
36.5
37.0 4. Body Use; 10. Fear or Nervousness
6. Adaptation to Change 37.5
38.0
10. Fear or Nervousness; 38.5
12. Nonverbal communication;
14. Level and Consistency of Intellectual Response
2. imitation 39.0
5. Object Use 39.5
4. Body Use; 7. Visual Response; 40.0
8. Listening response
13. Activity Level 40.5 13. Activity Level
41.0 5. Object Use;
9. Taste, Smell, and Touch Response and Use;
12. Nonverbal communication
41.5
42.0 7. Visual Response
42.5
43.0 2. imitation; 8. Listening response
9. Taste, Smell, and Touch Response and Use 43.5
44.0
44.5
45.0
45.5
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 459. bn = 575.

94
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table 33
relationship of cArs2-st item ratings and total score for individuals
With Low cognitive Functioning and a Diagnosis of Autism or PDD-Nos
item (diagnosis of autism, iQ 79)a total score item (diagnosis of PDD-Nos, iQ 79)b
30.0
30.5 14. Level and consistency of intellectual response
31.0
11. Verbal Communication 31.5
32.0 11. Verbal Communication
32.5
33.0 3. Emotional Response
33.5
1. Relating to People; 15. General Impressions 34.0
34.5
3. Emotional Response 35.0 1. Relating to People; 15. General Impressions
35.5 6. Adaptation to Change
36.0
36.5 13. Activity Level
6. Adaptation to Change 37.0
37.5
10. Fear or Nervousness; 38.0 10. Fear or Nervousness
14. Level and consistency of intellectual response
38.5 8. Listening Response
12. Nonverbal Communication 39.0
4. Body Use 39.5 12. Nonverbal Communication
2. imitation; 5. object Use 40.0
7. Visual Response; 8. Listening Response; 40.5
13. Activity Level
41.0
41.5
42.0 4. Body Use; 7. Visual Response
42.5
9. Taste, Smell, and Touch Response and Use 43.0 2. imitation; 5. object Use
43.5
44.0
44.5
45.0 9. Taste, Smell, and Touch Response and Use
45.5
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 836. bn = 59.

95
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table 34
relationship of cArs2-st item ratings With total score and cArs2-hF
item ratings With total score for individuals With a Diagnosis of Autism
cArs2-st/cArs2-hF
cArs2-st itema total score cArs2-hF itemb
30.0
30.5
31.0
11. Verbal communication 31.5
32.0
32.5 2. Emotional Expression and Regulation of Emotions
33.0
33.5 1. Social-Emotional Understanding;
3. Relating to People
1. Relating to People; 15. General Impressions 34.0
34.5 6. Adaptation to Change/Restricted Interests
3. Emotional Response 35.0
35.5 15. General Impressions; 11. Verbal communication
36.0
36.5
6. Adaptation to Change 37.0 10. Fear or Anxiety
37.5 13. Thinking/Cognitive Integration Skills
10. Fear or Nervousness; 38.0
14. Level and Consistency of Intellectual Response
38.5 12. Nonverbal Communication
12. Nonverbal Communication 39.0
4. Body Use 39.5
2. Imitation; 5. object Use 40.0
7. Visual Response; 8. Listening Response; 40.5 14. Level and Consistency of Intellectual Response
13. Activity Level
41.0
41.5 4. Body Use
42.0 9. Taste, Smell, and Touch Response and Use
42.5
9. Taste, Smell, and Touch Response and Use 43.0 7. Visual Response; 8. Listening Response;
5. object Use in Play
43.5
44.0
44.5
45.0
45.5
46.0

Note. For items in bold, Mdif < .05.

a
n = 1,034. bn = 248.

96
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table 35
relationship of cArs2-hF item ratings With total score for individuals
With a Diagnosis of Autism or Aspergers Disorder
item (diagnosis of autism)a total score item (diagnosis of Aspergers)b
29.0
29.5 2. emotional expression and regulation of
emotions
30.0
30.5
31.0 1. social-emotional Understanding
31.5
32.0
2. emotional expression and regulation 32.5 6. Adaptation to change/restricted interests
of emotions
33.0 3. Relating to People
1. social-emotional Understanding; 33.5
3. Relating to People
34.0 15. General impressions
6. Adaptation to change/restricted interests 34.5 10. Fear or Anxiety
35.0
15. General impressions; 35.5
11. Verbal communication
36.0
36.5
10. Fear or Anxiety 37.0
13. thinking/cognitive integration skills 37.5
38.0
12. Nonverbal communication 38.5
39.0 11. Verbal communication
39.5
40.0
14. Level and consistency of intellectual response 40.5 12. Nonverbal communication
41.0 13. thinking/cognitive integration skills
4. Body Use 41.5 4. Body Use; 7. Visual response
9. Taste, Smell, and Touch Response and Use 42.0 9. Taste, Smell, and Touch Response and Use
42.5 8. Listening Response
7. Visual response; 8. Listening Response; 43.0 14. Level and consistency of intellectual
5. object Use in Play response
43.5
44.0
44.5
45.0
45.5 5. object Use in Play
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 248. bn = 231.

97
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table 36
relationship of cArs2-hF item ratings With total score for individuals
With a Diagnosis of Autism or PDD-Nos
item (diagnosis of autism)a total score item (diagnosis of PDD-Nos)b
30.0
30.5
31.0
31.5
32.0
2. Emotional Expression and Regulation of Emotions 32.5
33.0 2. Emotional Expression and Regulation of Emotions
1. Social-Emotional Understanding; 33.5 1. Social-Emotional Understanding;
3. Relating to People 6. Adaptation to Change/Restricted Interests
34.0 10. Fear or Anxiety
6. Adaptation to Change/Restricted Interests 34.5
35.0
15. General impressions; 11. Verbal communication 35.5 3. Relating to People
36.0
36.5
10. Fear or Anxiety 37.0
13. Thinking/Cognitive Integration Skills 37.5 15. General impressions
38.0
12. Nonverbal Communication 38.5 13. Thinking/Cognitive Integration Skills;
11. Verbal communication
39.0
39.5 7. Visual response; 12. Nonverbal Communication
40.0 9. Taste, Smell, and Touch Response and Use;
8. Listening response
14. Level and Consistency of Intellectual Response 40.5
41.0
4. Body Use 41.5
9. Taste, Smell, and Touch Response and Use 42.0 4. Body Use
42.5 14. Level and Consistency of Intellectual Response
7. Visual response; 8. Listening response; 43.0
5. object Use in Play
43.5
44.0
44.5
45.0 5. object Use in Play
45.5
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 248. bn = 95.

98
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table 37
relationship of cArs2-hF item ratings With total score for individuals
With a Diagnosis of Autism or ADhD
item (diagnosis of autism)a total score item (diagnosis of ADhD)b
28.0
28.5
29.0 14. Level and consistency of intellectual response
29.5 2. emotional expression and regulation of emotions
30.0
30.5
31.0
31.5
32.0
2. emotional expression and regulation of emotions 32.5
33.0
1. Social-Emotional Understanding; 33.5 10. Fear or Anxiety;
3. Relating to People 13. Thinking/Cognitive Integration Skills
34.0
6. Adaptation to Change/Restricted Interests 34.5
35.0
15. General impressions; 11. Verbal communication 35.5
36.0 3. Relating to People
36.5 1. Social-Emotional Understanding
10. Fear or Anxiety 37.0 6. Adaptation to Change/Restricted Interests
13. Thinking/Cognitive Integration Skills 37.5
38.0
12. Nonverbal communication 38.5
39.0
39.5
40.0 11. Verbal communication
14. Level and consistency of intellectual response 40.5 4. Body Use
41.0
4. Body Use 41.5
9. Taste, Smell, and Touch Response and Use 42.0 8. Listening Response;
9. Taste, Smell, and Touch Response and Use
42.5
7. Visual Response; 8. Listening Response; 43.0 12. Nonverbal communication
5. Object Use in Play
43.5
44.0 15. General impressions; 7. Visual Response
44.5
45.0
45.5 5. Object Use in Play
46.0

Note. For items in bold only, Mdif < .05. For items in bold and underlined, Mdif < .01.
a
n = 248. bn = 179.

99
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table 38
relationship of cArs2-hF item ratings With total score for individuals
With a Diagnosis of Autism or a Learning Disorder
item (diagnosis of autism)a total score item (diagnosis of learning disorder)b
30.0
30.5 10. Fear or Anxiety
31.0
31.5
32.0
2. Emotional Expression and Regulation of Emotions 32.5
33.0
1. social-emotional Understanding; 33.5
3. Relating to People
34.0 2. Emotional Expression and Regulation of Emotions
6. Adaptation to Change/Restricted Interests 34.5
35.0 11. Verbal Communication
15. General impressions; 11. Verbal Communication 35.5
36.0 6. Adaptation to Change/Restricted Interests;
14. Level and Consistency of Intellectual Response
36.5
10. Fear or Anxiety 37.0 3. Relating to People;
13. Thinking/Cognitive Integration Skills
13. Thinking/Cognitive Integration Skills 37.5 9. Taste, Smell, and Touch Response and Use
38.0 1. social-emotional Understanding;
12. Nonverbal Communication
12. Nonverbal Communication 38.5 4. Body Use
39.0
39.5
40.0
14. Level and Consistency of Intellectual Response 40.5
41.0
4. Body Use 41.5 8. Listening Response
9. Taste, Smell, and Touch Response and Use 42.0
42.5
7. Visual Response; 8. Listening Response; 43.0 7. Visual Response
5. Object Use in Play
43.5 15. General impressions
44.0
44.5
45.0
45.5
46.0
46.5
47.0
47.5 5. Object Use in Play

Note. For items in bold and underlined, Mdif < .01.

a
n = 248. bn = 111.

100
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table 39
relationship of cArs2-hF item ratings With total score for individuals
With an Autism or a Non-Autism-related clinical Diagnosis
item (diagnosis of autism) total score item (other clinical diagnosesa)
25.5 2. Emotional Expression and Regulation of Emotions
26.0
26.5
27.0
27.5
28.0
28.5
29.0
29.5 10. Fear or Anxiety
30.0 3. relating to People
30.5
31.0
31.5
32.0
2. Emotional Expression and Regulation of Emotions 32.5
33.0 6. Adaptation to Change/Restricted Interests
1. Social-Emotional Understanding; 33.5
3. relating to People
34.0
6. Adaptation to Change/Restricted Interests 34.5 1. Social-Emotional Understanding
35.0
15. General impressions; 11. Verbal Communication 35.5
36.0
36.5
10. Fear or Anxiety 37.0 14. Level and Consistency of Intellectual Response
13. Thinking/Cognitive Integration Skills 37.5
38.0 11. Verbal Communication
12. Nonverbal Communication 38.5
39.0
39.5
40.0
14. Level and Consistency of Intellectual Response 40.5 13. Thinking/Cognitive Integration Skills
41.0
4. Body Use 41.5 12. Nonverbal Communication
9. Taste, Smell, and Touch Response and Use 42.0
42.5 4. Body Use
7. Visual Response; 8. Listening Response; 43.0 5. Object Use in Play
5. Object Use in Play
43.5
44.0 15. General impressions
44.5 8. Listening Response
45.0 7. Visual Response
45.5 9. Taste, Smell, and Touch Response and Use
46.0

Note. For items in bold and underlined, Mdif < .01.

a
Anxiety Disorders (n = 13). Mood Disorders (n = 12). Disruptive Behavior Disorders (n = 33). Diagnosis undetermined (n = 32).

101
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103-110_Refs_final_054-058 references.qxd 1/14/10 10:23 AM Page 110
111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 111

Questionnaire for Parents or Caregivers CARS2-QPC

( to be used with the CARS2-ST or CARS2-HF )
G. Janette Wellman, Ph.D., Eric Schopler, Ph.D., Mary E. Van Bourgondien, Ph.D., and Steven R. Love, Ph.D.

Date: __________________________________________________________ Date of birth of person to be rated: _________________________________________________________

Case ID Number: ____________________________________________ Name of person to be rated: _________________________________________________________________

Your name: _________________________________________________________________ Your relationship to the person to be rated: __________________________________

INSTRUCTIONS

L E
shown these behaviors.

M P
This form asks about behaviors in several areas where people may
have difficulty. The person you are rating may or may not have ever

For each behavior listed, please make a check mark under the

A
description that best describes the person you are rating. Check
the box under Dont Know if you do not have enough information
about a behavior to give a rating. It is important to provide an answer

S
for every behavior. After each section, there is space for you to give
one or more brief, specific examples that relate to your ratings in
that section. Use the blank page at the end of the form if you need
extra space. The final section of this questionnaire provides spaces
where you can describe any other behaviors that you would like us
to know about.

Additional copies of this form (W-472C) may be purchased from WPS. Please contact us at 800-648-8857, Fax 310-478-7838, or www.wpspublish.com.
W-472C Copyright 2010 by WESTERN PSYCHOLOGICAL SERVICES. Not to be reproduced in whole or in part without written permission. All rights reserved. Printed in U.S.A.
111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 112

)
m
l e em
SECTION 1

le
)
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ob
m
pr o

pr
a Pr

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t h ow
a
es ate

pa
s

in n
How does the person you are rating communicate?

al m
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el

i m er

m
ve m

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w
w

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n ob

w
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oe ro

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( S - to

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n
ild

t
t

No

Do
No

Se
M
1. Imitates sounds, words, and movements of others .................................... ........ ........ ........ ........

2. Responds to facial expressions, gestures, and

different tones of voice used by others ..................................................... ........ ........ ........ ........

3. Responds to his or her name being called by turning and

making eye contact with the person calling his or her name ...................... ........ ........ ........ ........

4. Directs facial expressions to others to show the emotions

he or she is feeling .................................................................................. ........ ........ ........ ........

E
5. Uses a variety of gestures (pointing, nodding the head, showing
the size of something) that are coordinated with words or used to
explain things when he or she doesnt have the words to do so ................. ........ ........ ........ ........

If the person you are rating is not using words, skip ahead to Section 2.

P
6. Uses made-up words or repeats specific words or phrases ........................
L........ ........ ........ ........

M
7. Has an unusual tone, rhythm, loudness, or rate of speech ......................... ........ ........ ........ ........

8. Speech is overly formal; for example, uses vocabulary that

A
seems more sophisticated than usual for a person of his or
her age or for the situation ....................................................................... ........ ........ ........ ........

S
9. Carries on a conversation with another person that flows back and
forth, at a level you would expect for someone of his or her age ................

10. Can talk with another person about that persons interests .......................
........

........

Examples: Give one or more brief but specific examples of the problem behaviors rated above. If you need more space to write,
........

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

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

........

use the blank page at the end of this form.

continue on next page

111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 113

)
m
l e em
SECTION 2

le
)
o b bl

ob
m
pr o

pr
a Pr

e ,
st
t h ow
a
es ate

pa
s

in n
How does the person you are rating relate to others and show emotion?

al m
l)

ay
i m er
el

m
ve m

o r le
w
w

e t od

as l e
s bl e

n ob

w
t w rob
ry

o m -M

no
f te P r
oe ro

tK
( S - to

bu a p
(D a P

( O re
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n
ild

t
t

No

Do
No

Se
M
1. Makes eye contact when speaking with or listening to another person ....... ........ ........ ........ ........

2. Points to and shares things of interest with others .................................... ........ ........ ........ ........

3. Follows another persons gaze or points toward an object

that is out of reach ................................................................................... ........ ........ ........ ........

4. Is responsive to social initiations from others ........................................... ........ ........ ........ ........

5. Initiates social interactions with adults and peers

(not just to get a basic need met) .............................................................. ........ ........ ........ ........

6. Sustains an interaction with others in an easy, flowing,

back-and-forth manner .............................................................................

7. Makes and maintains friendships with peers of same

L E
........ ........ ........ ........

P
developmental level ................................................................................. ........ ........ ........ ........

8. Shows a range of emotional expressions that match the situation

M
(for example, smiles, frowns, conveys different emotions through
eyes and facial expressions, etc.) ............................................................. ........ ........ ........ ........

A
9. Understands and responds to how another person may be thinking
or feeling (for example, tries to comfort someone in distress, does
something because he or she thinks the other person will like it) .............. ........ ........ ........ ........

S
Examples: Give one or more brief but specific examples of the problem behaviors rated above. If you need more space to write,
use the blank page at the end of this form.

continue on next page

111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 114

)
m
l e em
SECTION 3

le
)
o b bl

ob
m
pr o

pr
a Pr

e ,
st
t h ow
a
es ate

pa
s

in n
How does the person you are rating move his or her body?

al m
l)

ay
i m er
el

m
ve m

o r le
w
w

e t od

as l e
s bl e

n ob

w
t w rob
ry

o m -M

no
f te P r
oe ro

tK
( S - to

bu a p
(D a P

( O re
ve

n
ild

t
t

No

Do
No

Se
M
1. Has unusual ways of moving fingers, hands, arms, legs; or
spins or rocks body .................................................................................. ........ ........ ........ ........

2. Does things that might result in self-injury, like scratching,

head banging, picking at his or her skin ................................................... ........ ........ ........ ........

3. Is clumsy, stumbles, or has an awkward walk or run .................................. ........ ........ ........ ........

4. For school-aged children or adults: Has difficulty tying shoes or

difficulty with handwriting or other tasks that require fine
motor coordination .................................................................................. ........ ........ ........ ........

SECTION 4
How does the person you are rating play?
(For an older individual, how did he or she play as a child?)

L E
P
1. Uses only parts of toys instead of whole toys, or plays with objects
(e.g., opens and closes toy barn doors, spins wheels on cars,
wobbles or spins household objects) ........................................................ ........ ........ ........ ........

M
2. Plays with the same things in the same way over and over ......................... ........ ........ ........ ........

A
3. Uses toys or other materials to represent something they are not
(e.g., uses a banana as a phone or a microphone)...................................... ........ ........ ........ ........

S
4. Engages in make-believe play, taking on a role (not based on
scripts from movies or TV shows) .............................................................. ........ ........ ........ ........

Examples: Give one or more brief but specific examples of the problem behaviors rated above. If you need more space to write,
use the blank page at the end of this form.

continue on next page

111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 115

)
m
l e em
SECTION 5

le
)
o b bl

ob
m
pr o

pr
a Pr

e ,
st
t h ow
a
es ate

pa
s

in n
How does the person you are rating react to new experiences and

al m
l)

ay
i m er
el

m
ve m

o r le
w
w

e t od

as l e
s bl e

n ob

w
t w rob
changes in routine?

ry

o m -M

no
f te P r
oe ro

tK
( S - to

bu a p
(D a P

( O re
ve

n
ild

t
t

No

Do
No

Se
M
1. May show anxiety or worry in facial expression or body movement,
or by becoming overly impatient ............................................................... ........ ........ ........ ........

2. May show worry about the same thing over and over again ....................... ........ ........ ........ ........

3. Copes with changes in routine or the environment

(for example, moving furniture) ................................................................ ........ ........ ........ ........

4. Has specific routines or specific ways things must be done

by self or others ....................................................................................... ........ ........ ........ ........

E
5. Has special interests or topics (for example, dinosaurs,
trains, clocks, weather, license plates) .................................................... ........ ........ ........ ........

SECTION 6
How does the person you are rating use his or her senses of vision,
hearing, touch, and smell?
1. Tends to look at objects from unusual angles or

P L
M
out of the corner of his or her eyes ........................................................... ........ ........ ........ ........

2. Is overly interested in light from mirrors or light reflecting off objects ........ ........ ........ ........ ........

A
3. Is overly sensitive to some sounds, smells, or textures;

S
seeks some out, actively avoids others .....................................................

4. Has an unusual response to touch; may overreact to touch or

pain or may not respond to things that others would find
uncomfortable or painful ..........................................................................
........

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

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

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

........

Examples: Give one or more brief but specific examples of the problem behaviors rated above. If you need more space to write,
use the blank page at the end of this form.

continue on next page

111-116 Samples_final_001-004 chapter 01.qxd 1/14/10 10:28 AM Page 116

SECTION 7
Other Behaviors
1. Does this individual have any extremely unusual mathematical, reading, or artistic abilities? No Yes (please explain)

2. Are there other unusual behaviors you have noticed that you would like to tell us about?

E
Please list the specific behavior, and give an example or two.

P L
M
Additional Behavior Examples or Comments:

SA
Please specify the number of the question that is related to your example or comment: ___________________________

Additional Behavior Examples or Comments:

Please specify the number of the question that is related to your example or comment: ___________________________

Additional Behavior Examples or Comments:

Please specify the number of the question that is related to your example or comment: ___________________________