Childhood Autism Rating Scale, CARS Test - the question form

1. No evidence of difficulty relating to people. The child’s behavior is appropriate for age. Some shyness, fussiness, or anxiety may be seen when the child is asked to do something, but it is not atypical.

1.5

2. Mildly abnormal relationships. The child may avoid the adult’s eye contact, avoid the adult, or become distressed if interaction is imposed; may be excessively shy, may not respond to the adult in the usual way, or may be more dependent on the adult than children of the same age (may be “clingy”).

2.5

3. Moderately abnormal relationships. The child shows aloofness (at times seems unaware of the adult). Sometimes strong and persistent efforts are needed to get the child’s attention. The child initiates contact to a minimal degree.

3.5

4. Severely abnormal relationships. The child is completely aloof or unaware of what the adult is doing. He or she almost never responds to or initiates contact with an adult. Only very persistent attempts may gain any response and get the child’s attention.

1. Imitation is age-appropriate. The child can imitate sounds, words, and movements that match their level of skill development.

1.5

2. Mild impairment in imitation. Most of the time, the child imitates simple behaviors such as clapping or individual speech sounds; occasionally imitates only after some prompting from an adult or after a delay.

2.5

3. Moderate impairment in imitation. The child imitates only some of the time, or requires a considerable degree of persistence and assistance from an adult; often imitates only after a delay.

3.5

4. Severe impairment in imitation. The child almost never imitates sounds, words, or movements, even with help or support.

1. Emotional response is age-appropriate and appropriate to the situation. The child shows the appropriate type and degree of emotional response, reflected in changes in facial expression, posture, or behavior.

1.5

2. Emotional response is mildly abnormal. The child unexpectedly shows an emotional response that is inappropriate in type or intensity. At times, the child’s reactions are unrelated to objects or events occurring around them.

2.5

3. Emotional response is moderately abnormal. The child shows definite signs of an emotional response that is inappropriate in type or degree. Reactions may be delayed or excessive and unrelated to the situation; the child may grimace, laugh, or show rigidity without showing any emotion toward objects or events.

3.5

4. Emotional response is severely abnormal. Responses rarely fit the situation; if the child is in a particular mood, it is very difficult to change that mood. Conversely, the child may show a wide range of emotions when nothing is happening.

1. Body use is age-appropriate. The child moves freely and easily, with age-appropriate coordination.

1.5

2. Mild abnormality in body use. Minor oddities may be present, such as clumsiness, repetitive movements, poor coordination, or the appearance of unusual movements.

2.5

3. Moderate abnormality in body use. The child shows behavior that is strange or unusual for their age and may include unusual finger movements, unusual body or finger postures, posturing, pinching the body, self-injury, rocking, spinning, or toe-walking.

3.5

4. Severe abnormality in body use. Intense and frequent movements as described above are a sign of severe disturbance in body use. The behavior may continue despite attempts to stop it or to engage the child in other activities.

1. Appropriate use of toys and other objects. The child shows normal interest in toys and other objects appropriate for his/her age and skill level, and uses these toys as intended.

1.5

2. Mildly inappropriate use of toys and other objects. The child may show unusual interest in a toy or play with it in an unusual or more immature way (e.g., patting, sucking).

2.5

3. Moderately inappropriate use of, and interest in, toys and objects. The child may show little interest in toys and other objects, or may be preoccupied with using a toy or object in an unusual way. He/she may focus on an insignificant part of a toy, may be fascinated by light reflecting off an object, may repeatedly move parts of an object, or may play with an object in an unusual way.

3.5

4. Severely inappropriate use of, and interest in, toys and other objects. The child may show the behaviors described above with high frequency and intensity. When the child is engaged in this activity, it is difficult to distract him/her.

1. Age-appropriate adaptation to change. When the child notices or comments on changes in routines, he/she accepts these changes without significant stress.

1.5

2. Mildly abnormal adaptation to change. When an adult tries to change the task, the child may continue the previous activity or continue using the same materials.

2.5

3. Moderately abnormal adaptation to change. The child actively resists changes in routines, tries to continue the previous activity, and is difficult to redirect. He/she becomes angry or appears unhappy when an established routine is disrupted.

3.5

4. Severely abnormal adaptation to change. The child shows extreme distress in response to change. If change is forced, he/she may show marked displeasure or refuse to cooperate and respond with a tantrum.

1. Normal use of vision, appropriate for age. Vision is used along with other senses to explore a new object.

1.5

2. Mildly abnormal use of vision. The child may sometimes look at an object when it is mentioned. The child may be more interested in mirrors and light than in peers, may at times stare into space, and may avoid eye contact with other people.

2.5

3. Moderately abnormal use of vision. The child needs frequent reminders to look at objects. He/she may stare into space, avoid eye contact, look at objects from unusual angles, or hold objects very close to the eyes.

3.5

4. Severely abnormal use of vision. The child persistently avoids looking at others’ eyes and may show extreme forms of the unusual visual behaviors described above.

1. Age-appropriate. The child’s response to sounds and speech is normal for age. The child uses hearing along with other sensory modalities.

1.5

2. Mildly abnormal use of hearing. The child does not always respond or shows a mild overreaction to some sounds. Response to sound may be delayed; sounds must be repeated to get the child’s attention. Some outside sounds may upset the child.

2.5

3. Moderately abnormal listening response. The child’s response to sounds varies; the child often ignores a sound after the first few repetitions and may cover the ears when hearing some everyday sounds.

3.5

4. Severely abnormal use of hearing. The child shows marked overreaction and/or underreaction to sounds, regardless of the type of sound.

Normal use of smell, touch, and taste. The child explores new objects in an age-appropriate way, mainly by looking and handling. Smell and taste are used when appropriate. If the child experiences mild, typical pain, the child shows discomfort but does not overreact.

1.5

Mildly abnormal use of smell, touch, and taste. The child may refuse to put objects in the mouth; may smell or taste inedible objects; and may ignore mild pain or overreact to mild pain in situations where a typical child would show only discomfort.

2.5

Moderately abnormal use of smell, touch, and taste. The child may be preoccupied with touching, smelling, or tasting objects or people. The child’s reactions may be either too strong or too weak.

3.5

Severely abnormal use of smell, touch, and taste. The child is engaged in touching, smelling, or tasting objects more than is typical, rather than exploring or using them normally. The child may completely ignore pain or react very strongly to mild discomfort.

1. Normal fear or nervousness. The child’s behavior is appropriate to both the situation and the child’s age.

1.5

2. Mildly abnormal fear or nervousness. At times, the child shows too much fear, or too little, compared with other children of the same age in similar situations.

2.5

3. Moderately abnormal fear or nervousness. The child shows markedly more or less fear compared with the reactions of children who are older or younger in similar situations.

3.5

4. Severely abnormal fear or nervousness. Fear does not occur even after repeated experience with dangerous events or objects. The child is very difficult to calm and comfort. Conversely, the child may show no concern in dangerous situations that children of the same age avoid.

1. Verbal communication is normal for age and situation.

1.5

2. Mildly abnormal verbal communication. Speech may be delayed. Most speech is meaningful; however, some echolalia or pronoun reversal may be present. Occasionally, odd, unusual words or jargon are used.

2.5

3. Moderately abnormal verbal communication. Speech may be absent. If speech is present, it is a mixture of some meaningful communication and peculiar words (e.g., jargon), echolalia, or pronoun reversal. Peculiarities may include persistent questioning or preoccupation with certain topics.

3.5

4. Severely abnormal verbal communication. Meaningful speech is absent. The child may squeal, make odd sounds, imitate animal sounds, make sounds that only remotely resemble speech, or repeatedly use certain unnatural words or phrases.

1. Use of nonverbal communication is appropriate for age and situation.

1.5

2. Use of nonverbal communication is mildly impaired. Nonverbal communication is immature; the child may point vaguely or try to get what they want in situations where a child of the same age would point or use a more specific gesture to indicate what they want.

2.5

3. Use of nonverbal communication is moderately impaired. For the most part, the child cannot express needs or wants nonverbally and cannot understand others' nonverbal communication.

3.5

4. Use of nonverbal communication is severely impaired. The child uses only strange or unusual gestures with no obvious meaning, or shows no understanding of other people's gestures and facial expressions.

1. The child’s activity level is appropriate for age and situation. The child is no more and no less active than other children of the same age in a similar situation.

1.5

2. The child’s activity level is mildly abnormal. The child may be somewhat restless or, conversely, “lazy” and slow-moving. The activity level slightly interferes with functioning.

2.5

3. The child’s activity level is moderately abnormal. The child may be extremely active and difficult to control, with seemingly boundless energy and may not be ready to go to sleep at night. Conversely, the child may be sleepy and require considerable effort to get moving.

3.5

4. The child’s activity level is severely abnormal. The child shows extreme overactivity or passivity, or alternates between overactivity and passivity.

1. Intellectual functioning is normal, and the child is evenly developed across areas. The child’s intellectual functioning is age-appropriate; there are no unusual intellectual skills or difficulties.

1.5

2. Mildly abnormal intellectual functioning. The child is not as bright as other children of the same age; skills are about equally developed across all areas.

2.5

3. Moderately abnormal intellectual functioning. In general, the child is not as bright as other children of the same age; however, in one or more intellectual areas the child functions close to normal.

3.5

4. Severely abnormal intellectual functioning. Although the child is not as bright as peers, in one or more areas he or she may function even better than other children of the same age.

1. Not autistic. The child does not show symptoms of autism.

1.5

2. Mildly autistic. The child shows a few symptoms to a mild degree.

2.5

3. Moderately autistic. The child shows a number of symptoms or a moderate degree of autism.

3.5

4. Severely autistic. The child shows many symptoms or a severe degree of autism.