Best Practice Review: Childhood Autism Rating Scale, Second Edition (CARS 2)

The Childhood Autism Rating Scale, Second Edition (CARS 2), consists of two 15-item rating scales completed by the practitioner and a Parent/Caregiver Questionnaire. The Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and is used with children younger than 6 years of age and those with communication difficulties or below-average cognitive ability. The High-Functioning Version Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent children and youth, 6 years of age and older, with average or above intellectual ability. The Questionnaire for Parents or Caregivers (CARS 2-QPC) is an unscored questionnaire designed to obtain pertinent developmental information from parents or caregivers. 

The CARS 2-ST and CARS 2-HF each include 15 items addressing the following functional areas:

• Relating to People
• Imitation (ST); Social-Emotional Understanding (HF)
• Emotional Response (ST); Emotional Expression and Regulation of Emotions (HF)
• Body Use
• Object Use (ST); Object Use in Play (HF)
• Adaptation to Change (ST); Adaptation to Change/Restricted Interests (HF)
• Visual Response
• Listening Response
• Taste, Smell, and Touch Response and Use
• Fear or Nervousness (ST); Fear or Anxiety (HF)
• Verbal Communication
• Nonverbal Communication
• Activity Level (ST); Thinking/Cognitive Integration Skills (HF)
• Level and Consistency of Intellectual Response
• General Impressions

Items on the Standard form duplicate those on the original CARS, while items on the HF form have been modified to reflect current research on the characteristics of higher functioning children with autism spectrum disorder (ASD). To complete the ratings on the CARS 2-HF, the professional must have convergent information from MULTIPLE sources such as direct observation, parent and teacher interviews, prior assessments of cognitive functioning and adaptive behavior, and information from the Questionnaire for Parents or Caregivers (CARS 2-QPC). Ratings are based not only on frequency of the behavior in question, but also on its intensity, atypicality, and duration. Rating values for all items are summed to produce a Total Raw Score. Each form includes a graph that allows the practitioner quickly convert the Total Raw Score to a standard score or percentile rank (based on a clinical sample of individuals diagnosed with autism spectrum disorders). 

The psychometric properties of the CARS 2-HF indicate a high degree of internal consistency and good interrater reliability. Validity information reports an overall discrimination index value of .93, with sensitivity and specificity values of .81 and .87, respectively. The HF form also demonstrates a relatively strong relationship with the “gold standard” Autism Diagnostic Observation Schedule (ADOS).

The following are critical features of the CARS 2-HF.

1. Parents and teachers should NOT be asked to complete the CARS 2 forms. Only well-informed professionals should complete the ratings.

2. The CARS 2 should NOT be used for screening in the general school-age population.

3. The practitioner must have a good understanding of the criteria for making the ratings and be in a position to collect information from multiple sources (direct observation, parent and teacher reports, prior assessments and clinical impressions).

4. The ratings from the CARS 2 should be considered as only one part of a multimodal, multidisciplinary decision-making process in the identification of children with ASD.

5. Direct observation and a developmental history MUST always be included in the assessment process.

6. Scores on the CARS 2 are interpreted relative to the level (severity) of autism-related behaviors compared to a clinical sample of individuals diagnosed with autism, NOT the typical individual.

In summary, The CARS 2-HF represents an important alternative that will be welcomed by school-based professionals such as school psychologists and speech/language pathologists. It is a sensitive and reliable instrument that will find a place in the school-based professional’s assessment “Tool Box.” Given the dramatic increase in the numbers of students being referred for screening and assessment, the CARS 2-HF is a useful instrument that helps quantify the level of symptom severity and importantly, assist with intervention and program planning. The CARS 2-HF scores are particularly helpful in identifying more capable children with autism spectrum disorder. Of course, the CARS 2 is not intended to be and should not be used as the sole instrument in making diagnostic or classification decisions. An example of a comprehensive assessment battery can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism Rating Scale, Second Edition. Los Angeles, CA: Western Psychological Services.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)

The Fourth “R” – Relationship Skills in Our Schools

The Fourth R

The three R’s - Reading, Writing and Arithmetic - reflect the traditional basic skills approach to education which focuses on academic benchmarks, measurable standards, and high-stakes testing. However, the school experience is about much more than mastering the three R’s. The ability to relate and interact with others is the foundation for successful human connection and adjustment to the social world. In fact, one of the best childhood predictors of adult adaptation and well-being is not IQ or school grades, but rather, the competence with which children relate to both peers and adults. Given the life-long consequences of poor social functioning, we should move beyond a focus on academic competencies to include Relationship and social learning as the fourth ‘R’ in our schools. 

Social Relationship Skills

Although teaching the fourth R benefits all children, it has the greatest potential to help students with autism. Most autistic children are educated in general education classrooms, and even though many successfully master the 3 R’s, all experience varying degrees of social relationship problems. This includes difficulty communicating with others, establishing and maintaining reciprocal social relationships, taking another person’s perspective, and inferring the interests of others. Consequently, (social) relationship skills should be taught alongside reading, writing, and arithmetic. For children with social-communication challenges to learn relationship skills, we must teach them. Social relationship instruction commonly involves teaching specific skills (e.g., maintaining eye contact, listening, initiating conversation) through behavioral and social learning techniques. Instructional goals usually include skill acquisition, performance, generalization and maintenance of prosocial behaviors, and the reduction or elimination of competing behaviors.

The overarching goal of social skills instruction should be the development of social and communicative competency through direct teaching, modeling, coaching, and role-playing activities in real-world situations. Strategies designed to promote skill acquisition in building social relationships may include direct instruction, modeling, role-play, structured activities, social stories, incidental teaching, video role-play with feedback, communication scripts, formal social groups, pivotal response training, self-monitoring, and coaching. Although there is no “one-size-fits-all” approach that will help children to be socially successful, the following are promising strategies for facilitating and reinforcing social-communication competency in the classroom.

Increase social motivation by encouraging self-awareness - Begin with simple, easily-learned skills and intersperse new skills with those previously mastered.  Also, provide social skills training and practice opportunities in a number of settings to encourage students to apply new skills to multiple, real life situations.

Increase social initiations and improve age-appropriate social responding by making social rules clear and concrete - Teach simple social response scripts for common situations, and use natural reinforcers for social initiations and response attempts. In addition, utilize modeling and role-play to teach and reinforce prosocial skills, and build social activities around preferred activities/interests.

Promote skill generalization and coordinate peer involvement (e.g., prompting and initiating social interactions; maintaining physical proximity - Use several individuals with whom to practice skills, including parents, and provide opportunities to apply learned skills in safe, natural settings (e.g., field trips). Look for opportunities to teach and reinforce social skills as often as possible throughout the school day.

Teach effective social interaction and communication as replacements for challenging behavior - Model, demonstrate, coach, and/or role-play the appropriate interaction skills. Teach students to ask for help during difficult activities or to negotiate alternative times to finish work. Encourage positive social interactions such as conversational skills to help students with challenging behavior obtain positive peer attention. 

Conclusion

Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Teaching the fourth R can have both preventive and remedial effects that can help reduce the risk for negative outcomes not only for children with autism, but for all children. 

Lee A. Wilkinson, PhD, NCSP is the author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© Lee A. Wilkinson, PhD