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A Practical Evaluation of the Childhood Autism Rating Scale- Second Edition

There are children everyday who are effected by and diagnosed with autism. They often
have behavioral, developmental, cognitive, psychological, and sensitivity struggles. There are a
wide range of tests that are used when diagnosing children with autism; one of those being the
Childhood Autism Rating Scale- Second Edition. This being said, what is the Childhood Autism
Rating Scale- Second Edition, what does this test address, and is it an effective test overall for
diagnosing children on the autism spectrum?
What is the Childhood Autism Rating Scale?
Description of Test
The Childhood Autism Rating Scale- Second Edition (CARS2) authored by Eric
Schopler, Ph.D., Mary E. Van Bourgondien, Ph.D., Glenna Janette Wellman, Ph.D., and Steven
R. Love, Ph.D. is an assessment tool developed for children 2 years of age and older. Since being
recently updated in 2010, there are two tests that fall under the CARS branch: the Childhood
Autism Rating Scale Standard Version (CARS2- ST) and the Childhood Autism Rating Scale
High- Functioning Version (CARS2- HF). The CARS2- ST is created for the use of diagnosing
individuals younger than 6 years of age and those with difficulties communicating or with IQ
levels 79 or below. The CARS2- HF was created as an alternative for testing those 6 years of age
and older, with fluent verbal skills, and at or above IQ scores of 80. The CARS2 is published by
Western Psychological Services. The test includes a testing manual, a 25 pack of standard
version and high- functioning version rating booklets, and 25 questionnaires for the parents or
caregivers of the child being tested for $193. One can also purchase individual packets of the
rating booklets for clinician administration for $46.25. Additional response forms for parents or
caregivers are offered for $32.50. The testing manual can also be purchased independently for

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$88. The test can be administered by anyone other than a parent who has had a thorough training
in the tests running and interpretation of scoring.
Discussion of Testing Manuals, Materials, Protocols, and Item Testing Manuals
The test manual are very user friendly. It is written in person centered language; there is
not a whole lot of jargon and psychological lingo used. When opening up the manual there
immediately is a lengthy table of contents that is very detailed and organized in a fashion that
would be easy to use for any user. There is a small introduction about the overall test in which it
is mentioned that the test has been in use and constantly updated since 1971. Originally, the
CARS was primarily used by diagnosticians during test sessions of those that would now fall
under the CARS2- ST branch. Those who were characterized as below the age of 6, with notably
impaired communication or below average IQ levels for their age were tried. As noted in the
introduction of the test, the revision of the CARS examination brought in the addition of testing
for high- functioning individuals with autism presences such as Aspergers Syndrome and
Pervasive Developmental Disorder- Not Otherwise Specified (PDD-NOS). The CARS2 testing
manual is filled with tables and in depth explanations on administration of the test, the reasoning
behind what is being questioned on the test, and how to interpret scorings. The manual gives an
in depth explanation as to how the test is administered and how to execute the test for the most
accurate results in the end for diagnosing children. The test is directed through rating scales of
individual behavior ratings completed by the clinician and parents or caregivers. The manual is
made of heavy weighted paper and seems as though it would hold up to a great length of time.
Testing Materials
The test materials are a total of three forms; the CARS2- ST rating booklet, CARS2- HF
rating booklet, and the rating booklet for parents or caregivers. Ratings that are filled out in these

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booklets are made on frequency of behavior, intensity of that behavior, peculiarity, and duration.
The forms also ask about 15 areas of behavior to determine the identification of autism spectrum
disorders. There are not any physical objects or distractions that are needed for this test other
than a writing utensil for note taking and marking. Though this seems like a modest and
lackluster test for administration, materials wise, the minimal amount of distractions is key in the
diagnosis of autism spectrum disorders. If those who are effected by autism or other related
spectrum disorders are being tested, there must be a minimal amount of distraction for the child
to achieve the greatest and most accurate results scoring. The materials are also very simple for
the parents or caregivers to use which is also a large positive about this test in terms of materials.
Parents will already be on edge and thinking a million things during the time of their childs
assessment. By keeping the materials as simple as pencil and paper, parents are able to provide
accurate, well rounded responses to the scales to aid in the clinicians results. Some other tests
for various disabilities have a multitude of parts, lengthy manuals, or arent written in a person
centered language; thus, a lack of ease for administration and understanding for both clinician
and parent. The materials are of heavy weighted paper and minimal amounts of pages; again,
benefitting in the ease of use. It is important to note though, that all materials are of a one- time
use with the exception of the test manual.
Testing Protocols
The test protocols seem to be clear and of good quality. The protocols and materials are
together in that the rating scales and information being used are one in the same. The protocols
have boxes for checking or bubbling in to indicate the severity of the 15 key areas being tested.
Those 15 items that are addressed in the CARS2 differ based on whether the CARS2- ST or
CARS2- HF is being used. Which test shall be used is determined upon by the examiners through

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a prior verbal sample assessment. The items addressed in the CARS2- ST include the following:
relating to people, imitation, emotional response, body use, object use, adaptation to change,
visual response, listening response, taste smell and touch response and use, fear or nervousness,
verbal communication, nonverbal communication, activity level, level and consistency of
intellectual response, and general impressions. The matters addressed in the CARS2- HF consist
of: relating to people, social-emotional understanding, emotional expression and regulation of
emotions, body use, object use in play, adaptation to change/ restricted interests, visual response,
listening response, taste smell and touch response and use, fear or anxiety, verbal
communication, nonverbal communication, thinking/ cognitive integration skill, level and
consistency of intellectual response, and general impressions. Klose and authors note that the
items addressed in the CARS2 are also aligned with the Individuals with Disabilities Education
Act (2012). As one can see, there are very similar areas looked at between the CARS2- ST and
CARS2- HF for the determination of autism spectrum disorders. All of the 15 questions are
asked and put on a 4-point rating scale by the administrator of the test; again, ratings based on
frequency of behavior, intensity of that behavior, peculiarity, and duration. Rating values are
them added up to produce a Total Raw Score (T Score) and compared to on a basis and graph of
normed values. The rating scale for parents or caregivers is an unscored form on the child being
assessed. This rating scale serves as an information tool to clarify and give way to the outcomes
found through the CARS2 rating results formed by the clinician. As a whole, the rating scales for
marking are of heavy weighted paper and for one time use only per scale given. They consist of
small amounts of pages and are easy to understand how to fill out, compile rating scores to figure
the childs T Score, and interpret the value given.

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Testing Items
The test items are easy to understand and fill out as a whole. The CARS2 in its entirety
takes about 5-10 minutes for rating administration; all depending on the individual child being
assessed the time needed for completion. The 15 item rating scales for clinician to fill out are
short in sentence structure and appropriately worded. The questionnaire for parents or caregivers
is simple and written in a person-centered form; thus an easy, basic understanding. Through the
use of the well written and informative manual and straight forward rating scales, the test seems
as though it would be easy for someone to use who has not had previous high levels of training
on test delivery. There are not any extra pictures, physical objects, or large uses of space needed
for the administration of the test, so this would greatly appeal to being able to be administered in
any location. The way in which the questions are written, and lack of pictures, also pleas to
generations across multiple years in terms of appropriateness to the time of delivery.
Technical Evaluation
Norms
The CARS2 was normed on a total sample of 3,500 individuals with autism spectrum
disorders among the ages of 2 to 57; 1,606 of the original CARS test for comparison, 1,034 for
the CARS2- ST, and 994 for the CARS2- HF sample. 78% of those in the summed norm sample
were male, with the remaining 22% being female. The author also noted that ratings of the forms
used for the test were studied in multiple clinical samples; this was not just a one and done type
of normed sample (Vaughan, 2011). Though initially it might seem like this is an
overrepresentation of males in the sample, this ratio of male to female individuals is reasonable
for the ratio of those diagnosed with autism spectrum disorders. The ethnic breakdown in this
sample for the CARS2-ST was 7% Asian/ Pacific Islander, 16% African American, 13%

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Hispanic, and 60% Caucasian; all ranging in age from 2 to 36. For the CARS2- HF, the ethnic
breakdown is similar to that of the Standard Version with individuals ranging in age of 6 to 57 of
various previously diagnosed individuals with high functioning autism, Aspergers, PDD-NOS,
ADHD, learning disorders, other learning disorders, and a small group of general education
students. Again, this might seem like an underrepresentation of various ethnic communities for
both test versions, but when in comparison to the rest of the United States population these
percentage representations aligned accurately.
The norms representative were of the total United States population in the Northeast,
Midwest, South, and West with a greater amount of representation of those in the South and
underrepresentation of those in the West; this applies for both the Standard and High Functioning
Versions of the CARS2 tests. The test lacks in specific identification of what states and where the
norms were developed through testing.
Overall, there is one major concern with these norms: the representation throughout the
United States. There is a need for specificity of what is considered south, Midwest, etc. In
terms of appropriateness of use of those in Texas and special populations, the norms would be in
favor of such. The CARS2 is heavily represented in the south; thus a helpfulness and accuracy
when looking at Texas. Both versions of the test were normed against specific and a wide
varieties of special populations that are fair in representation of overall population percentages.
The CARS2- HF was especially specific and covered a wide range of special populations.
Reliability
The reliability section in the testing manual provides great detail and description stating
that this element of testing is important because it gives way and influences practical usefulness.
The CARS2 uses three measures of reliability. One measure being internal consistency, the other

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interrater reliability, and test retest reliability. Internal consistency refers to making sure that the
test items refer to what is stated. It was found that the test CARS2- ST had an internal
consistency reported at .93 and the CARS2- HF at .96. A scoring of .70 is needed for
achievement in order to be deemed adequate. These high levels of scoring indicate a high degree
achieved in internal consistency. The test also used interrater reliability to test for making sure
the test can be administered by multiple people and the results will still remain the same.
Interrater reliability is reported as a score of .73 for the CARS2- HF and compared to the original
CARS score of .71. The CARS2- ST was not reported in terms of interrater reliability. With the
original CARS and CARS2- HF having similar results, which indicates a fair agreement among
raters. The reliability results were very clearly compared to those without autism yet still falling
under the special education branch for other circumstances and those with autism. There is no
discrimination against age in terms of those compared. Test retest reliability was figured by
looking at those who were highly trained in the administration of the CARS2 and those who
were not. Those who were not highly trained in the administration of the test include medical
student/ pediatric interns, special educators, school psychologists, speech pathologists, and
audiologist (Malcolm & McLellan, 2014). It was found that those who performed testing
correlated 92% of the time to those with extensive experience in the autism field and running of
the test. These data indicate that the CARS2 ratings and diagnostic screening can be made by
multiple people who are associated with the field of autism or have minimal training.
Validity
Just as the reliability section in the CARS2 did, the validity portion of the testing manual
gives light as to why validity is important to testing; accurateness and suitability in the
interpretation of the test is vital. Construct validity was assessed through comparing ratings and

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T Scores with the relationship to the students clinical diagnosis. The author noted that the
CARS2 compared across groups with various diagnoses, cognitive function, and age of those
diagnosed (Malcolm & McLellan, 2014). Content validity was accounted for when comparing
the rating scores of the 15 areas addressed on the test items and the childs diagnosis. It was
found that there was a positive connection between the multiple children diagnosed and their
ratings. Concurrent validity was demonstrated by comparing T Scores on the Standard Version
and high Functioning Version of the tests and the results obtained. When comparing results, there
was a strong relationship between the clinicians ratings and diagnoses. According to Klose and
authors, the validity measures taken for this test are of good, accurate degree (2012). Through
reading articles about the validity portion of the CARS2 and investigation of the test itself, I
agree with Klose and authors in that the validity of the test is of good measure.
Journal Reviews
Journal Review #1
Malcolm and McLellans (2014) review of the CARS2 is one that provides the reader
with an in depth description and recommendations for the autism diagnostic process. The authors
provide information stating that one of the strongest points of the assessment are the test
materials. The recording forms in the updated CARS2 allow for more notetaking and feedback
than that of the original CARS assessment allowed. They state that the CARS2 is very user
friendly and written in a language that is clear for understanding. The article states that multiple
personnel can administer this test; something that was addressed in and tested in reliability
portion of the CARS2 test itself. The article also states that the manual gives intervention
planning and helpful tips as to how to address parents with diagnosing a child; being one of the
sturdiest portions of the assessment. Malcolm and McLellan also heavily evaluate the technical

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aspects of the CARS2 exam. They note that the reliability and validity measures taken by the test
form a useful tool for supporting the diagnosis that are made from the CARS2. Reliability was
deemed satisfactory for making a diagnosis and validity was adequately established across
settings and age groups. The authors also note as a whole that the CARS2 is a valid,
comprehensive measure for autism assessment and identification.
Journal Review #2
Klose, Plotts, Kozenski, and Skinner- Fosters (2012) review is one that talks about
various assessment tools for the diagnosis of autism spectrum disorders and usefulness for
diagnosis in regards to IDEA eligibility. The authors compare the CARS2 against the Autism
Diagnostic InterviewRevised, the Autism Diagnostic Observation Schedule, the
Psychoeducational Profile3rd Edition, and its final sister test, the Gilliam Autism Rating Scale
2nd Edition. The review focuses on looking at the diagnostic criteria and whether to deem an
assessment as appropriate or not. According to the journal, the test items on the CARS2
addressing social interaction and verbal communication meet minimal standards because these
areas are only addressed on a single dimension and informant. The CARS2 also meets adequate
requirements in areas of nonverbal communication, repetitive activities, sensory experiences, and
change in daily routine; these items are addressed satisfactorily but not in depth or on multiple
scopes. When looking at the comparison graphs provided, the Gilliam Autism Rating Scale- 2nd
Edition meets minimal requirements on all criteria addressed as the least appropriate for testing
with the CARS2 falling right above it in adequacy of diagnosis out of the five tests evaluated.
The authors further note that overall Autism Diagnostic InterviewRevised, Autism Diagnostic
Observation Schedule, and Psychoeducational Profile3rd Edition are the best options for
accurate assessment of children for autism and the CARS2 being one of the last tests that one

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should use for diagnosis. The findings in this article were quite interesting because the first
journal article found was very fond of the CARS2 assessment. The authors finally make
suggestions that report how to improve overall autism spectrum disorder testing and areas that
the current tests should go beyond in focusing.

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References
Klose, L. M., Plotts, C., Kozeneski, N., & Skinner-Foster, J. (2012). A Review of Assessment
Tools for Diagnosis of Autism Spectrum Disorders: Implications for School Practice.
Assessment For Effective Intervention, 37(4), 236-242.
Malcolm, K., McLellan, M.. (2014). Review of Childhood Autism Rating Scale, Second Edition.
J. F. Carlson, K. F. Geisinger, & J. L. Jonson (Eds.), The Nineteenth Mental
Measurements Yearbook. Lincoln, NE: Buros Institute.
Schopler, E., Elizabeth, V. B., Wellman, G. J., & Love, S. R. (2010). The childhood autism rating
scale, second edition (CARS). Los Angeles, CA: Western Psychological Services.
Vaughan, C. A. (2011). Test Review: E. Schopler, M. E. Van Bourgondien, G. J. Wellman, & S.
R. Love "Childhood Autism Rating Scale" (2nd Ed.). Los Angeles, CA--Western
Psychological Services, 2010. Journal Of Psychoeducational Assessment, 29(5), 489-493.