CARS2-ST REPORT
Submitted in the Partial Fulfilment of the Requirements for
the Award of Degree of
Master of Science in Psychology (Clinical)
Submitted By,
Sulagna Datta
3MPCL-A
Register Number: 2337457
Department of Psychology
Introduction
Autism Spectrum Disorder (ASD) is a multifaceted neurodevelopmental disorder
marked by difficulties with communication, social relationships, and a propensity for
repetitive behaviors. People with ASD can have a wide range of symptoms and abilities,
varying substantially in severity, due to the disorder's spectrum aspect. While some people
may have profound intellectual limitations, others may be exceptionally gifted in particular
fields like music, painting, or mathematics. For people with ASD to live better lives, acquire
necessary life skills, and reach their full potential, early diagnosis and intervention are
critical. A combination of behavioral therapy, educational assistance, and occasionally
medication to address specific symptoms is usually used for effective management.
The Childhood Autism Rating Scale, Second Edition (CARS2) includes three forms
and this updated manual. The three forms are the two Rating Booklets—Childhood Autism
Rating Scale, Second Edition–Standard Version (CARS2-ST; formerly titled CARS) and the
Childhood Autism Rating Scale, Second Edition–High-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 functional 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 functional
profiles, and guiding intervention planning.
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.
M-CHAT-R/F (Revised with Follow-Up: Modified Checklist for Autism in Toddlers):
A popular parent-report screening technique called M-CHAT-R/F is used to find toddlers
between the ages of 16 and 30 months who might be at risk for Autism Spectrum Disorder
(ASD). It has 20 questions that center on early indicators of autism, like not making eye
contact, showing interest in other kids, and reacting to their name. In order to minimize false
positives and guarantee a more accurate assessment, a follow-up interview is done if the first
screening results point to a concern. Early identification with the use of this tool allows for
prompt intervention during a crucial developmental stage.
Ages and Stages Questionnaire (ASQ): This developmental screening instrument
evaluates infants ranging in age from one month to five and a half years. It addresses
important developmental domains such communication, fine and gross motor skills,
problem-solving, and personal-social abilities, albeit it is not autism-specific. The ASQ
assists in identifying developmental concerns that might necessitate an additional ASD
evaluation. The ASQ can identify any problems early on by giving a wide picture of a child's
developmental progress. This allows for more thorough examinations and interventions when
necessary.
The Social Communication Questionnaire (SCQ) is a 40-item, quick parent-report
screening tool that is intended for children four years of age and up. It gives a brief evaluation
of social and communication behaviors and is based on the Autism Diagnostic
Interview-Revised (ADI-R). The SCQ highlights possible areas of concern, which aids in
identifying children who might benefit from a thorough ASD screening. It is a useful
instrument in both clinical and research settings because of its simplicity of use and efficacy
in identifying children who are at risk for autism.
The Childhood Autism Rating Scale, Second Edition (CARS2) has demonstrated
versatility in various applications. It has been used to assess film portrayals of autism
spectrum disorders (ASD), providing insights into media representations (Garner et al.,
2015). The Lebanese version of CARS2-HF showed high reliability and validity for
screening high-functioning individuals with ASD (Falissard et al., 2019). A proposed brief
diagnostic observational scale, CARS-2, based on the first eight items of CARS2, showed
promise in expediting ASD diagnosis, though further validation is needed (Fein, 2020). The
Arabic version of CARS2 demonstrated high reliability and construct validity, with a
three-factor structure aligning with DSM-5 symptom domains (Alotaibi & Alotaibi, 2021).
These studies highlight the CARS2's adaptability across cultures and its potential for
streamlined diagnostic processes, while also emphasizing the need for continued research to
refine its application in various contexts and age groups.
The goal of screening tools in psychometric evaluations is to spot those at risk for
mental health issues or cognitive deficits as soon as possible. These tools aid in the early
detection and prompt intervention of mental health issues by providing a comprehensive
review of an individual's cognitive status. Screening tools are typically used as the first phase
in the assessment process. They are made to swiftly evaluate big populations and identify
individuals that require a more thorough examination. For instance, in the healthcare industry,
they evaluate patients for symptoms of anxiety, sadness, or other difficulties, and in schools,
they assist in identifying kids who might require additional testing for behavioral problems or
learning challenges. These brief instruments are straightforward to use in a variety of settings
and cover a wide range of symptoms or behaviors.
On the other hand, diagnostic instruments offer an extensive and thorough assessment
in order to precisely identify particular mental health or cognitive disorders. Diagnostic tools,
which include structured interviews, standardized tests, and behavioral observations, are used
by qualified experts following an initial screening that shows additional evaluation is
necessary. To get an accurate diagnosis, they collect a great deal of data regarding a person's
functioning in many spheres of life, history, and symptoms. For the purpose of creating
treatment plans, directing therapeutic actions, and tracking advancement over time, this
comprehensive data is essential.
When it comes to the early detection of Autism Spectrum Disorder (ASD) in young
children, generally those under the age of thirteen or those with less developed
communication skills, the CARS2-ST (Standard Version) is an indispensable instrument. The
timely adoption of therapies that might considerably improve developmental outcomes is
made possible by the early identification of autism spectrum disorders (ASD). The
CARS2-ST assesses a variety of behaviors, including emotional reactions, social interactions,
verbal and nonverbal communication, and sensory sensitivity, to provide a thorough picture
of the child's strengths and weaknesses. Customizing intervention tactics that target particular
requirements and encourage optimal development is made possible with the help of this
knowledge.
The CARS2-ST is a crucial tool in educational settings for creating Individualized
Education Plans (IEPs) for preschoolers and elementary schoolers. These programs are
tailored to each child's specific educational needs, offering resources and support that are in
line with their challenges and areas of strength. Parents and other caregivers can better
comprehend their child's needs and behaviors by using the insights gleaned from the
CARS2-ST evaluation. This knowledge aids in developing nurturing home situations and
putting into practice successful communication techniques that promote the development and
wellbeing of the child.
In addition, the CARS2-ST is a valuable tool for investigations and research. It assists
in identifying participants who have ASD and monitors the development and efficacy of
different therapeutic approaches. This advances both the creation of evidence-based
treatments and our understanding of ASD in general. The CARS2-ST ensures that children
obtain accurate diagnoses and appropriate interventions, hence enhancing their quality of life,
by offering a systematic method to assessment.
The CARS2-HF (High-Functioning Version) is intended primarily for older kids (six
years old and up) who have higher cognitive functioning and stronger verbal communication
abilities. This version is essential for diagnosing ASD in people who have severe social and
behavioral difficulties but do not show typical early developmental symptoms. The
CARS2-HF assists physicians in providing a more precise diagnosis and a better knowledge
of the individual's requirements by concentrating on behaviors and skills pertinent to this
group, such as advanced language use, peer connections, and sophisticated social
interactions.
The CARS2-HF enables the creation of focused educational methods and supports for
school-age children and adolescents in educational environments. This includes making
adjustments to the classroom setting, teaching social skills, and providing these people with
other tools that support their academic and social success. In order to ensure that children
receive targeted and appropriate interventions, the comprehensive profile offered by the
CARS2-HF also helps to distinguish ASD from other developmental or behavioral disorders,
such as Attention Deficit Hyperactivity Disorder (ADHD) or anxiety disorders.
Sociodemographic Details
Name: S.D
Age: 6
D.O.B: 21.03.18
Gender: Male
Education: Class 1
Referred by: NA
Presenting Concerns: None
Test Administered: CARS2-ST
Purpose of Testing: Educational Purpose
Sources: Informant (mother and father) and patient
Information is adequate and satisfacrory
Behavioural Observations: Rapport was easily built. The subject was calm and cooperative
during the test.
Result and Analysis
Table 1
Raw Score Interpretation
22 Minimal to-no symptoms of Autism
Spectrum Disorder
Table 2
T-score Interpretation
30 Very low level of autism-related symptoms
compared to those with an autism diagnosis
Table 2: Raw Scores
Rating 1.0 and above Imitation
Emotional Response
Object use
Adaptation to change
Visual Response
Taste, smell and touch response
Fear or nervousness
Verbal communication
Nonverbal communication
Activity level
Level and consistency of intellectual response
Rating 2,0 and above Relating to people
Body Use
Listening Response
Rating 3.0 and above None
According to his raw score (22), it can be interpreted that he’s likely non-autistic. His
T-score of 30 indicates that he might have a very low level of autism.
The patient avoided looking the examiner in the eye, became fussy if the interaction
was forced and was shy. He tends to cling to his mother. The patient was clumsy and had
somewhat poor coordination. He sometimes did not respond to the examiner and instructions
had to be repeated to gain his attention.
His parents did not report on any abnormal behaviour at home. According to them he
sometimes does not show any facial reaction to a situation. Once they bought him a car, he
just took the car and left, with no facial expression. Very rarely, he would be stuck up on a
word and repeat it for the whole day. He is sometimes not able to continue a conversation and
that’s why has some difficulty indulging in peer play. He sometimes avoids making eye
contact with people at school, but according to his parents, it can be situational. He can be
clumsy and keeps stumbling upon things. He holds a very special interest in cars and knows a
lot about their engines and new models. He gets stimulated by different textures. At times, he
would keep touching the switchboard and the table, trying to understand the texture.
All these findings from questionnaires to parents and caregivers matches with the
finding on the CARS2-ST administered by the examiner based on their observation.
Impression and Recommendation
Individuals with Autism Spectrum Disorder (ASD) often face significant challenges
in social-emotional processing, understanding, and interpersonal relating. These areas
necessitate continuous intervention, even for those with high-functioning autism or
Asperger’s Disorder, who typically exhibit average-to-above-average intellectual abilities and
more developed expressive language skills. Recognizing these challenges, a considerable
array of resources has been developed to target social skills and interactions throughout an
individual's lifespan. Research and clinical practice in the field of autism are evolving rapidly,
providing new intervention strategies and techniques. Early intervention for young children
with autism often focuses on issues of joint attention, meaningful engagement, and the
development of play skills. For instance, Kasari’s work emphasizes the importance of
building joint experiences and sharing social moments to foster social relatedness and
reciprocity. Similarly, the Developmental, Individual-Difference, Relationship-Based (DIR)
model, or FloorTime, developed by Greenspan and Wieder, encourages practitioners and
parents to enhance communication, imitation, play skills, and meaningful connections
between the child and their environment.
As individuals with more classic forms of autism grow older, strategies such as
pivotal response training can be employed to bring about developmental changes by targeting
pivotal behaviors in naturalistic teaching settings. Techniques to enhance group or play
activities, such as using visual supports for turn-taking and waiting, or layering groups, are
effective for building social skills in those with more concrete understandings. The Social
Skills Picture Books by Baker provide visual examples for children and teens on how to
engage in play and social interactions appropriately. For higher-functioning individuals,
intervention techniques often focus on making abstract social-emotional information visible
and understandable. This includes using visual aids, social stories, and comic strip
conversations to clarify social rules and expectations. Strategies to enhance
perspective-taking, such as understanding the "hidden curriculum" or "mind reading" to
interpret contextual and emotional cues, are crucial. Emotional regulation techniques,
including relaxation methods and emotion meters, help individuals manage their emotions
effectively. Educating peers and others who interact with individuals on the autism spectrum
fosters a supportive environment where social skills can be practiced and refined, ultimately
contributing to the individual’s ability to navigate social situations successfully.
Communication difficulties are common in individuals with Autism Spectrum
Disorder (ASD), compounding the social deficits that are characteristic of the condition.
These combined challenges can lead to significant obstacles for both the individuals with
autism and those responsible for their care and support. Being able to express needs, wants,
choices, or preferences in various settings, where others effectively respond to this initiated
communication, can significantly enhance the individual’s functioning, sense of personal
control, and reduce behavioral issues such as tantrums, aggression, and self-injurious
behavior. Functional analysis of behavior often identifies communication deficits as key
triggers for behavioral challenges in individuals with autism. Developing effective expressive
and receptive communication systems is a vital component of positive behavior support
(PBS) procedures. These systems help increase access to preferred activities and social
experiences, and improve the individual’s ability to understand and respond to various
environmental demands. The TEACCH program, for example, emphasizes the promotion of
spontaneous, meaningful, and functional expressive communication, complementing the
receptive communication benefits provided by visual organization and structured teaching
approaches. These methods make the world more accessible and understandable, leading to
increased independence for individuals with autism.
The development of communication systems that address the specific needs and
contexts of individuals with autism is crucial. This involves assessing communication
elements such as the contexts in which communication most readily occurs, the forms it
takes, and the functions underlying communication initiation. By creating or promoting
systems that address these elements, more meaningful and effective communication can be
established. The Hanen Centre’s programs, such as "More Than Words" and "It Takes Two to
Talk," offer a holistic and practical approach for parents and teachers working with young
children with emerging or more developed communication skills. The Picture Exchange
Communication System (PECS) is particularly effective for individuals at a more basic
communicative level, emphasizing the social and reciprocal nature of communication. For
higher-functioning individuals, interventions often focus on making abstract social-emotional
information visible and understandable. This includes using visual supports, social stories,
and techniques like Comic Strip Conversations to enhance perspective-taking and
understanding of social rules. Addressing pragmatic language weaknesses and problems with
communication initiation is also essential for these individuals, as it can improve their ability
to engage in reciprocal communication, understand figurative language, and participate in
meaningful social interactions. Additionally, augmentative communication devices can be
employed for nonverbal or minimally verbal individuals, enhancing their ability to
communicate effectively.
Personal accounts written by individuals with higher functioning autism or Asperger’s
Disorder offer profound insights into their unique sensory processing differences and
heightened sensitivity to their surroundings. These autobiographical narratives are invaluable
for interventionists, providing detailed perspectives on the specific stressors, antecedent
factors, and sensory challenges individuals with autism encounter daily. Temple Grandin’s
autobiographical works, such as "Emergence: Labeled Autistic" and "Thinking in Pictures,"
exemplify how sensory stimuli are processed differently in autism and offer strategies for
coping with sensory overload. These narratives have spurred the development of targeted
strategies and resources, including environmental modifications to reduce sensory stimuli in
educational and residential settings, sensory integration therapies, and the use of
sensory-friendly spaces like "calm" rooms. By integrating these personal insights with
evidence-based interventions, interventionists can effectively support individuals with autism
in navigating their sensory experiences and improving their overall well-being.
The unique thinking style characteristic of individuals on the autism spectrum, often referred
to as the "culture of autism," is marked by a strong focus on details, adherence to rules, and
challenges in integrating new information. This cognitive profile includes difficulties in
understanding the underlying meanings of concepts or actions, distinguishing relevant from
irrelevant information, and issues with central coherence and generalization. Research
underscores challenges in theory of mind and executive functioning, indicating potential for
misinterpretations and less efficient problem-solving strategies that prioritize details over
holistic understanding. Strategies such as emphasizing rules positively, using visual
techniques like Gray’s Comic Strip Conversations and The New Social Story Book, and
employing cognitive-behavioral frameworks are crucial in supporting individuals with higher
functioning autism. These approaches help in promoting understanding of social perspectives,
teaching adaptive behaviors, and fostering connections between the individual’s thoughts,
actions, and those of others. Visual supports tailored to the individual’s cognitive
comprehension level, including schedules, visual work systems, and thought mapping
techniques, play a vital role in enhancing clarity and facilitating learning across the autism
spectrum.
Conclusion
In summary, S.D, a six-year-old boy, currently in Class 1, was assessed using the
CARS2-ST test, revealing minimal to no symptoms of Autism Spectrum Disorder (ASD)
based on a raw score of 22 and a T-score indicating very low autism-related symptoms
compared to diagnosed individuals. While presenting no immediate concerns, observations
noted his avoidance of eye contact, occasional clumsiness, and difficulty in maintaining
conversations or showing facial expressions appropriately. His keen interest in cars and
tactile stimulation tendencies were highlighted, alongside sensory sensitivities.
Recommendations emphasize ongoing support in social-emotional processing,
communication development tailored to his interests, and sensory integration strategies to
enhance his interaction skills and emotional regulation.
Reference
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