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Use of the Childhood Autism Rating Scale (CARS) for Children With High
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Use of the Childhood Autism Rating Scale (CARS) for Children With High Functioning Autism or
Asperger Syndrome
Susan Dickerson Mayes, Susan L. Calhoun, Michael J. Murray, Jill D. Morrow, Kirsten K. L. Yurich, Shiyoko Cothren,
Heather Purichia, Fauzia Mahr, James N. Bouder and Christopher Petersen
Focus Autism Other Dev Disabl 2012 27: 31 originally published online 20 May 2011
DOI: 10.1177/1088357611406902

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 Focus on Autism and Other

Use of the Childhood Autism Rating

Developmental Disabilities
27(1) 31­–38
© 2012 Hammill Institute on Disabilities

Scale (CARS) for Children With High Reprints and permission:

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DOI: 10.1177/1088357611406902
Functioning Autism or Asperger http://focus.sagepub.com

Syndrome

Susan Dickerson Mayes, PhD1, Susan L. Calhoun, PhD1, Michael J. Murray, MD1,
Jill D. Morrow, MD2, Kirsten K. L.Yurich, MS3, Shiyoko Cothren, MS1,
Heather Purichia, PhD1, Fauzia Mahr, MD1, James N. Bouder, MS3,
and Christopher Petersen MD1

Abstract
The authors of the Childhood Autism Rating Scale (CARS) state in the manual that the best cutoff score for distinguishing
low functioning autism (LFA) from intellectual disability is 30 for children and 28 for adolescents and adults. This study
determined that a cutoff score of 25.5 was most accurate in differentiating between high functioning autism or Asperger
syndrome (HFA; n = 197) and ADHD (n = 74) in a sample of 1- to 16-year-olds with IQs of 80 or higher. Classification
accuracy was 96% using clinician scores and 72% using parent scores. Children with LFA (n = 193) had significantly higher
clinician and parent scores than children with HFA, and scores were negatively correlated with IQ. None of the typical
children (n = 64) earned parent scores greater than 21.

Keywords
Childhood Autism Rating Scale (CARS), high functioning autism, Asperger syndrome, low functioning autism, ADHD

The Childhood Autism Rating Scale (CARS; Schopler,
Reichler, & Renner, 1986) has strong psychometric support
for identifying children with low functioning autism (LFA),
and it compares favorably with other autism instruments in
studies of children with autism, most of whom also have
intellectual disability. In a study of toddlers with autism,
Ventola et al. (2006) found high diagnostic agreement
among the CARS, Autism Diagnostic Observation System–
Generic, and clinical judgment but lower agreement for the
Autism Diagnostic Inventory–Revised. The CARS was
more accurate in identifying children with autism than the
Autism Behavior Checklist (Eaves & Milner, 1993; Rellini,
Tortolani, Trillo, Carbone, & Montecchi, 2004; Sevin,
Matson, Coe, Fee, & Sevin, 1991).
As stated in the CARS manual, the purpose of the CARS
is “to identify children with autism and to distinguish them
from developmentally handicapped children without
autism” (Schopler et al., 1986, p. 1). The CARS consists of
15 items rated on a 7-point scale from normal to severely
abnormal. The CARS is designed to be rated by a variety of
professionals (e.g., psychologists, physicians, teachers, and
therapists) who are trained on the use of the CARS and base
their ratings on observations during school and psychologi-
cal testing, parent report, and relevant medical records
(Schopler et al., 1986). The CARS standardization sample
consisted of 1,606 children with autism. Most (71%) had
IQs less than 70, 17% had IQs from 70 through 84, and 13%
had IQs of 85 or greater. According to the authors, the
CARS is appropriate for children of all ages, including pre-
schoolers. The possible range of scores on the CARS is 15
to 60, and scores of 30 or higher are in the autism range for
children. This cutoff score was determined by comparing
1,520 CARS scores with corresponding expert clinical
diagnoses (Schopler et al., 1986, p. 14). Overall percentage
agreement between the CARS and clinical diagnoses was
1
Penn State College of Medicine, Hershey, PA, USA
2
Commonwealth of Pennsylvania, Harrisburg, PA, USA
3
The Vista Foundation, Hershey, PA, USA
Corresponding Author:
Susan Dickerson Mayes, Hershey Medical Center, 500 University Dr.,
Hershey, PA 17033
Email: smayes@psu.edu
32 Focus on Autism and Other Developmental Disabilities 27(1)
87% using a CARS cutoff of 30. Mean interrater reliability
between two trained raters was .71 for the individual CARS
items (Schopler et al., 1986).
Researchers independently support the validity of the
CARS. In studies of children with clinical diagnoses of
autism 2 to 22 years of age, Eaves and Milner (1993) identi-
fied 98% with autism using the CARS and Sevin et al.
(1991) identified 92%. In samples of children with autism
and other disorders, agreement between the CARS and
diagnoses from the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association, 1994) was 100% in one study
(Rellini et al., 2004) and 88% in another study (Perry,
Condillac, Freeman, Dunn-Geier, & Belair, 2005).
Diagnostic agreement was 86% between the CARS and the
Autism Diagnostic Interview–Revised in a study of individ-
uals 1 to 32 years with suspected autism (Pilowsky, Yirmiya,
Shulman, & Dover, 1998). Teal and Wiebe (1986) demon-
strated that CARS scores significantly differentiated chil-
dren with autism from children with intellectual disability
and no autism. We found that classification accuracy was
98% for CARS clinician scores and 93% for CARS parent
scores in a sample of children with clinical diagnoses of
LFA versus attention-deficit/hyperactivity disorder (ADHD;
Mayes et al., 2009). Diagnostic agreement was 98%
between clinician scores on the CARS and the Checklist for
Autism Spectrum Disorder (Mayes & Calhoun, 1999).
Diagnostic accuracy using CARS parent scores also was
high (93%). However, we found that CARS validity data
for children with high functioning autism or Asperger syn-
drome (HFA) were not as positive, and 25% of these chil-
dren scored below the CARS autism cutoff of 30.
CARS scores are significantly negatively correlated with
IQ and mental age (Perry et al., 2005; Pilowsky et al., 1998).
This is probably because the CARS has some developmen-
tal items (e.g., level of intelligence, language skills, and
imitation ability), so that children with LFA tend to earn
higher scores than children with HFA. CARS scores also
tend to decrease with age, and the CARS manual recom-
mends a cutoff score of 28 for adolescents and adults
(Schopler et al., 1986). In a study of individuals with both
autism and intellectual disability, Garfin, McCallon, and
Cox (1988) showed that all children had CARS scores of 30
or greater, whereas some of the adolescents and young
adults had scores less than 30.
Further research is needed to determine if the CARS
autism cutoff should be lowered for children with HFA (as
it has been for adolescents and adults), so that the CARS
can identify children with HFA as effectively as it identifies
children with LFA. In this study, we analyze CARS scores
for children with autism, ADHD, and typical development.
We selected ADHD as a comparison group because ADHD
is a common childhood disorder that, together with autism,
composes a large portion of referrals for child diagnostic
evaluations. Children with ADHD and autism have many
overlapping features, including inattention, overactivity,
mood and behavior problems, early language delay, and dif-
ficulty with social skills (de Boo & Prins, 2007; Mayes &
Calhoun, 1999, 2007; Miniscalco, Hagberg, Kadesjo,
Westerlund, & Gillberg, 2007; Miniscalco, Nygren,
Hagberg, Kadesjo, & Gillberg, 2006; Van der Oord et al.,
2005). These shared symptoms complicate a differential
diagnosis. Therefore, identifying a CARS cutoff score that
accurately differentiates between children with HFA and
ADHD is of clinical value. The goals of our study are to
(a) determine the CARS cutoff score that differentiates
best between children with HFA and children with ADHD,
(b) determine if children with LFA earn significantly higher
CARS scores than children with HFA, thus justifying a
lower cutoff score for HFA, and (c) determine if a lower
CARS cutoff for HFA results in misclassification of typical
children as having autism.
Method
Sample
Our sample comprises 528 children 1 to 16 years of age,
including 193 children with diagnoses of autism and full-
scale IQs less than 80 (LFA), 197 children with diagnoses
of autism or Asperger syndrome and full-scale IQs of 80 or
greater (HFA), 74 children with ADHD combined or inat-
tentive type and an IQ of 80 or above, and 64 typical chil-
dren. Demographic data for the sample are presented in
Table 1. The most common tests administered to estimate
overall IQ were the Wechsler Intelligence Scale for
Children–Fourth Edition (WISC-IV; Wechsler, 2003),
Wechsler Preschool and Primary Scale of Intelligence–
Third Edition (Wechsler, 2002), and Bayley Scales of Infant
Development Mental Scale–Second Edition (Bayley, 1993).
An IQ cut point of 80 for differentiating HFA and LFA was
chosen for several reasons. In the WISC-IV, normal to
above normal intelligence is defined as an IQ of 80 or
greater, and children with an IQ less than 80 qualify for
intellectual disability special education services as speci-
fied by the department of education where our study was
conducted. Furthermore, 80 is the cutoff used in many pre-
vious research studies to distinguish between LFA and HFA
(Mayes & Calhoun, 2003a, 2003b, 2007, 2008; Mayes,
Calhoun, Murray, Ahuja, & Smith, 2011).
Typical children, who did not have an identified diagno-
sis of autism or other neuropsychiatric disorder according
to parent report, were recruited from colleagues and day
care centers. Children with autism or ADHD were patients
evaluated in our diagnostic clinics by licensed PhD psy-
chologists, board-certified child psychiatrists, or a board-
certified developmental pediatrician using DSM-IV criteria.
Components of the diagnostic evaluation included a struc-
tured interview with the parent focusing on early history
and current symptoms; behavior and autism rating scales
Mayes et al. 33
Table 1. Demographic Data for Children With HFA, LFA, ADHD, and Typical Development
HFA (n = 197) LFA (n = 193)
Age
  M 6.0 5.5
  SD 3 3
 Range 1–16 1–16
IQ
  M 105 54
  SD 15 17
 Range 80–146 8–79
Male (%) 84 86
Professional (%)b 42 30
White (%) 93 91
N = 528. HFA = high functioning autism or Asperger syndrome; LFA = low functioning autism; ADHD = attention-deficit/hyperactivity disorder.
a. Bonferroni p < .05.
b. One or both parents has a professional or managerial occupation.
completed by parents, teachers, and child care providers;
observations of the child during testing; and a review of
early intervention, school, and medical records.
In addition to a clinical diagnosis of autism, all children
with autism had a score in the autistic range on the Checklist
for Autism Spectrum Disorder (CASD; Mayes & Calhoun,
1999; Mayes et al., 2009). The CASD consists of 30 items
scored as present (either currently or in the past) or absent
by the clinician based on a semistructured interview with
the parent, information from the child’s teacher or child
care provider, observations of the child, and other available
records. The CASD can be administered and scored in 15
minutes. The CASD is based on the belief that autism is a
single spectrum disorder, consistent with what is proposed
by the DSM-V Work Group (www.dsm5.org). The CASD is
normed on more than 800 children with autism 1 to 17 years
of age with IQs of 9 to 146. All children in the normative
study had a total CASD score at or above the autism cutoff
of 15, which is the cutoff for both HFA and LFA. The CASD
has strong validity and reliability (Mayes & Calhoun, 1999,
2004; Mayes, Calhoun, & Crites, 2001; Mayes et al., 2009;
Tryon, Mayes, Rhodes, & Waldo, 2006). These researchers
demonstrate that the CASD differentiates children with
autism from children with ADHD (99.5% accuracy) and
from typical children (100% accuracy), is equally effective
in identifying children at both ends of the autism spectrum,
has high diagnostic agreement with other autism instru-
ments (98% with the CARS for LFA and 94% with the
Gilliam Asperger Syndrome Scale for HFA), has excellent
congruence with DSM-IV-based clinical diagnoses, and has
good clinician–parent agreement (90%). In a recent study,
the authors showed that diagnostic agreement between the
Autism Diagnostic Interview–Revised and the CASD com-
pleted independently by parents was 93.1% (cite).
ADHD (n = 74) Typical (n = 64) ANOVA and χ2 statistics
 
7.2 6.8 F(3, 524) = 6.0,
LFA < ADHD, Typicala
3 4  
3–15 1–16  
 
107 NA F(2,442) = 582.9,
LFA < ADHD, HFAa
13 NA  
80–140 NA  
72 41 χ2(3) = 63.9, p < .0001
50 94 χ2(3) = 81.8, p < .0001
85 84 χ2(3) = 6.9, p = .08
Of the children with LFA, HFA, and ADHD in our study,
62% had an independent confirmatory diagnosis (i.e., a sepa-
rate diagnosis apart from the research team’s clinical diagno-
sis). Differences in CARS clinician and parent scores between
children with and without independent diagnoses were all
nonsignificant at .01 for these three groups (t = 2.5, p = .012;
t = 1.2, p = .24; t = 0.7, p = .50; t = 0.9, p = .37; t = 0.5, p =
.60; and t = 0.0, p = 1.00; respectively; df = 36 to 195).
We did not attempt to differentiate between HFA and
Asperger syndrome in our study because of the consensus
that HFA and Asperger syndrome are on the same contin-
uum. Researchers show that most, if not all, children with a
clinical diagnosis of Asperger syndrome actually meet
DSM-IV criteria for autism (Eisenmajer et al., 1996; Howlin,
2003; Manjiviona & Prior, 1995; Mayes et al., 2001; Miller
& Ozonoff, 1997; Szatmari, Archer, Fisman, Streiner, &
Wilson, 1995; Tryon et al., 2006). This is because children
with an Asperger syndrome diagnosis meet DSM-IV criteria
for communication impairment (impaired ability to initiate
and sustain a conversation or stereotyped, repetitive, or
idiosyncratic language), which excludes them from a
DSM-IV diagnosis of Asperger syndrome (Mayes et al.,
2001). Furthermore, researchers attempting to differentiate
children diagnosed with autism versus Asperger syndrome
suggest these subgroups differ only in symptom severity or
IQ (Miller & Ozonoff, 2000; Myhr, 1998; Ozonoff, South,
& Miller, 2000), suggesting that HFA and Asperger syn-
drome are not separate disorders. Also, diagnostic agree-
ment for autism spectrum disorder is excellent, whereas
agreement for the DSM-IV pervasive developmental disor-
der subtypes is far lower (Mahoney et al., 1998; Stone et al.,
1999; Volkmar et al., 1994). Most clinicians and researchers
now concur that autism is a spectrum disorder and that
Asperger syndrome is not a separate or distinct disorder but
34 Focus on Autism and Other Developmental Disabilities 27(1)
is at the high functioning or mild end of the autism contin-
uum (Eisenmajer et al., 1996; Frith, 2004; Macintosh
& Dissanayake, 2004; Manjiviona & Prior, 1995; Mayes &
Calhoun, 2003c, 2004; Mayes et al., 2001; Miller &
Ozonoff, 2000; Myhr, 1998; Ozonoff et al., 2000; Prior et
al., 1998; Schopler, 1996, 1998). Wing (1998), who intro-
duced and defined the term Asperger syndrome, contends
that Asperger syndrome and HFA are the same, and Hans
Asperger (1944/1991) used the term autism (not Asperger
syndrome) to describe his patients. As mentioned, the
DSM-V Work Group (www.dsm5.org) has proposed using
a single term, autism spectrum disorder, and eliminating
Asperger syndrome as a separate diagnosis.
Instruments and Procedure
For children with HFA, LFA, or ADHD (n = 464), the
CARS was completed by clinicians who had extensive
experience and expertise with autism and ADHD and were
familiar with the CARS, including two licensed PhD psy-
chologists, three board-certified child psychiatrists, one
board-certified developmental pediatrician, and one certi-
fied school psychologist working at a school for children
with autism. A subset of parents of these children and the
parents of typical children (n = 232) independently com-
pleted the CARS for their children. For our study, clinicians
and parents were simply asked to complete the CARS with-
out having watched the CARS training DVD and without
instructions beyond those included on the instrument itself
(as is often the case in clinical practice). Researchers have
found good validity and reliability when the CARS is com-
pleted in this manner by clinicians (Mayes et al., 2009;
Ozonoff, Goodlin-Jones, & Solomon, 2005).
For comparative purposes, clinicians also completed the
32-item Gilliam Asperger’s Disorder Scale (GADS;
Gilliam, 2001) and the CASD. Researchers support the
validity of these instruments in identifying children with
HFA or Asperger syndrome (Gilliam, 2001; Mayes &
Calhoun, 1999, 2004; Mayes et al., 2001; Mayes et al.,
2009; Tryon et al., 2006). All clinicians who completed the
instruments were involved in the diagnosis or treatment of
children in the study and were, therefore, not blind to the
child’s diagnosis.
Data Analyses
The most accurate cutoff score for differentiating between
children with HFA and ADHD was determined by calculat-
ing the cutoff that maximized overall classification accu-
racy and yielded approximately equivalent sensitivity and
specificity. Sensitivity is the number of children with
autism scoring in the autistic range divided by the total
number of children with autism, and specificity is number
of children without autism scoring in the nonautistic range
divided by the total number of children without autism.
Positive predictive power (number of children with autism
scoring in the autistic range divided by the total number of
children scoring in the autistic range) and negative predic-
tive power (number of children without autism scoring in
the nonautistic range divided by the total number of chil-
dren scoring in the nonautistic range) also were calculated
to assess the accuracy of the modified CARS cutoff score
in identifying children with and without clinical diagnoses
of autism. Diagnostic agreement and accuracy percentages
were calculated for the CARS (using the modified cutoff
score), the GADS, and the CASD. Pearson correlation
coefficients and the effect size statistic r2 (explained vari-
ance) were used to indicate the degree of relationship
between CARS scores and IQ. The significance of differ-
ences in variable frequencies between groups was calcu-
lated using chi-square. ANOVA, ANCOVA (covarying
differences between groups in age, gender, and parent occu-
pation), post hoc Bonferroni t tests, independent t tests, and
Cohen’s d effect size were calculated to determine the sta-
tistical and clinical significance of differences between
diagnostic groups.
Results
Differences in CARS Scores Among Groups
Clinician and parent CARS scores for children with LFA,
HFA, ADHD, and typical development are reported in
Table 2. Children with LFA had significantly higher clini-
cian and parent scores than children with HFA (d = 1.6 and
1.1). Similarly, CARS clinician and parent scores were
significantly negatively correlated with IQ (r = −.74 and
−.49, p < .0001, explained variance = 55% and 24%).
CARS clinician and parent scores were significantly higher
for children with HFA than for children with ADHD (d =
3.3 and 1.4).
Classification Accuracy of CARS Cutoff
Scores
Using CARS clinician scores, only 3% of children in the
LFA group scored below the recommended CARS cutoff of
30, in contrast to 25% of the children with HFA. Using
CARS parent scores, 10% of the children with LFA scored
less than 30, whereas 54% of the children with HFA earned
scores less than 30. Comparing children with HFA and
ADHD, the clinician cutoff score that maximized overall
classification accuracy and equalized sensitivity and speci-
ficity was 25.5. As shown in Table 3, 95% of the children
with HFA earned scores of 25.5 or greater (sensitivity
95%), whereas only 3% of the children with ADHD
did (specificity 97%), yielding 96% overall classification
accuracy. Using the traditional CARS cutoff score of 30,
Mayes et al. 35

Table 2. Childhood Autism Rating Scale Clinician and Parent Scores

LFA (n = 193) HFA (n = 197) ADHD (n = 74) Typical (n = 64) ANCOVA statistics
Clinician  
  M 41 33 20 NA F(2, 460) = 534.4, LFA >
HFA > ADHDa
  SD 5 5 3 NA  
 Range 27.0–56.5 23.0–49.0 15.0–26.5 NA  
Parent  
  M 37 30 22 16 F(3, 228) = 126.8, LFA >
HFA > ADHD > Typicala
  SD 7 7 5 1  
 Range 21.5–49.0 19.5–44.0 15.0–38.5 15.0–21.0  

HFA = high functioning autism or Asperger syndrome; LFA = low functioning autism; ADHD = attention-deficit/hyperactivity disorder. The possible
range of scores is 15 to 60.
a. Bonferroni p < .0001, covarying age, gender, and parent occupation.

Table 3. Classification Accuracy Percentages for Children With HFA or ADHD Using a Childhood Autism Rating Scale Autism Cutoff
Score of 25.5

Overall classification Positive predictive Negative predictive

accuracy Sensitivity Specificity power power
Clinician scores 96 95 97 99 89
Parent scores 72 72 72 70 75

HFA = high functioning autism or Asperger syndrome; ADHD = attention-deficit/hyperactivity disorder.

sensitivity was 75%, specificity was 100%, and overall
classification accuracy was 82%. Interestingly, the most
accurate cutoff using parent scores also was 25.5. However,
overall classification accuracy was higher for clinician
scores (96%) than for parent scores (72%). Using a cutoff
score of 25.5, none of the typical children were misclassi-
fied as having autism by their parents.
Diagnostic Agreement With Other
Instruments
For the children with HFA or ADHD (n = 271), classifica-
tion accuracy using clinician scores was 99% for the CASD
and 93% for the GADS, compared with 96% for the CARS
(using a cutoff score of 25.5). Diagnostic agreement was
95% between the CARS and the CASD and 90% between
the CARS and GADS.
Discussion
Based on data reported in the CARS manual (Schopler
et al., 1986), 30 is the best cutoff score for differentiating
children with LFA and intellectual disability. In the CARS
manual, Schopler et al. (1986) recommend a cutoff score of
28 for adolescents and adults with LFA because CARS
scores decrease somewhat with age. We and other research-
ers (Perry et al., 2005, Pilowsky et al., 1998) have shown
that CARS scores decrease with increasing mental age and
IQ. Therefore, a lower cutoff score may be more accurate
in identifying children with HFA than the cutoff of 30. We
found that the most accurate CARS cutoff score for distin-
guishing between children with HFA and ADHD was 25.5.
This was true for both clinician and parent scores. Overall
classification accuracy was 96% using clinician scores and
72% using parent scores. This level of accuracy is similar
to the 87% reported in the CARS manual for children with
LFA versus intellectual disability (Schopler et al., 1986). In
other studies of children with LFA, researchers reveal high
classification accuracy percentages as well, including 98%
(Eaves & Milner, 1993), 92% (Sevin et al., 1991), and 98%
(Mayes et al., 2009). The 96% classification accuracy of
clinician scores obtained in our study compares positively
with the accuracy percentages for LFA, suggesting that
the CARS is clinically useful for children with HFA as well
as LFA.
We found somewhat lower parent than clinician CARS
scores for children with LFA and HFA and lower classifica-
tion accuracy for parent scores (72%) than for clinician
36 Focus on Autism and Other Developmental Disabilities 27(1)
scores (96%). The minimum and maximum CARS scores
for LFA and HFA were approximately 5 points lower for
parents than for clinicians, and the maximum score for the
ADHD group was 12 points higher for parents than clini-
cians. The clinicians who completed the instruments for our
study had extensive experience with autism and ADHD.
This high level of expertise, combined with the fact that
accuracy was measured by agreement with the child’s clini-
cal diagnosis, may in part explain the higher classification
accuracy for clinicians than parents. Furthermore, neither
clinicians nor parents were given specific training on how
to complete the CARS. Training may be more important for
parents than for the experienced clinicians, which may have
negatively affected the parent scores. Therefore, parent
scores should be interpreted with caution and should be a
supplement to other information in the diagnostic process.
Instruments like the CARS and CASD offer simple and
cost-effective means of collecting standardized, reliable,
valid, and norm-referenced data from multiple sources and
settings to aid the diagnostic process. Information from
these tests completed by clinicians, parents, teachers, and
child care givers can be combined with data from other
tests, parent interviews (focusing on early history and cur-
rent symptoms), standardized observations of the child, and
a review of records to assist clinicians in evaluating whether
or not the child meets diagnostic criteria for autism.
Our study has several limitations, which need to be
addressed in future studies. Correlations among the CARS,
CASD, and GADS scores may be inflated by common
source variance because raters were the same. Furthermore,
raters who completed these scales were not blind to the
child’s diagnosis. Different tests were used to estimate IQ in
our study depending on the child’s age and level of func-
tioning, and separate analyses were not conducted for ver-
bal versus nonverbal IQ. Our age range was very broad, and
groups were not matched on demographic variables, so we
statistically controlled for differences among groups in age,
gender, and parent occupation using ANCOVA. ADHD was
the only clinical comparison group. Research is needed com-
paring children with HFA to children who have clinical disor-
ders other than ADHD to determine if 25.5 is indeed the best
cutoff for HFA. Furthermore, the difference in CARS scores
between LFA and HFA may be the result of a few develop-
mental items on the CARS. A CARS item analysis is needed
to explore this possibility, which may have implications for
scoring the CARS with individuals who have HFA.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
American Psychiatric Association. (1994). Diagnostic and statis-
tical manual of mental disorders (4th ed.). Washington, DC:
Author.
Asperger, H. (1991). Die “autistischen psychopathen” im kinde-
salter [Autistic psychopathy in childhood]. In U. Frith (Ed.),
Autism and Asperger syndrome (pp. 37–92). Cambridge, UK:
Cambridge University Press. (Original work published 1944)
Bayley, N. (1993). Bayley Scales of Infant Development Mental
Scale–Second edition. San Antonio, TX: Psychological Cor-
poration.
de Boo, G. M., & Prins, P. J. M. (2007). Social incompetence in
children with ADHD: Possible moderators and mediators in
social skills training. Clinical Psychology Review, 27, 78–97.
Eaves, R. C., & Milner, B. (1993). The criterion-related validity of
the Childhood Autism Rating Scale and the Autism Behavior
Checklist. Journal of Abnormal Child Psychology, 21, 481–
491.
Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Gould, J.,
Welham, M., & Ong, B. (1996). Comparison of clinical symp-
toms in autism and Asperger’s disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 1523–1531.
Frith, U. (2004). Emanuel Miller lecture: Confusions and contro-
versies about Asperger syndrome. Journal of Child Psychol-
ogy and Psychiatry and Allied Disciplines, 45, 672–678.
Garfin, D. G., McCallon, D., & Cox, R. (1988). Validity and reli-
ability of the Childhood Autism Rating Scale with autistic
adolescents. Journal of Autism and Developmental Disorders,
18, 367–378.
Gilliam, J. E. (2001). Gilliam Asperger’s Disorder Scale manual
(2nd ed.). Austin, TX: Pro-Ed.
Howlin, P. (2003). Outcome on high-functioning adults with
autism with and without early language delays: Implications
for the differentiation between autism and Asperger syndrome.
Journal of Autism and Developmental disorders, 33, 3–13.
Macintosh, K. E., & Dissanayake, C. (2004). Annotation: The sim-
ilarities and differences between autistic disorder and Asperg-
er’s disorder: A review of the empirical evidence. Journal of
Child Psychology and Psychiatry and Allied Disciplines, 45,
421–434.
Mahoney, W. J., Szatmari, P., MacLean, J. E., Bryson, S. E.,
Bartolucci, G., Walter, S. D., . . . Zwaigenbaum, L. (1998).
Reliability and accuracy of differentiating pervasive develop-
mental disorder subtypes. Journal of the American Academy of
Child and Adolescent Psychiatry, 37, 278–285.
Manjiviona, J., & Prior, M. (1995). Comparison of Asperger syn-
drome and high-functioning autistic children on a test of motor
impairment. Journal of Autism and Developmental Disorders,
25, 23–39.
Mayes, S. D., & Calhoun, S. L. (1999). Symptoms of autism in
young children and correspondence with the DSM. Infants
and Young Children, 12, 90–97.
Mayes, S. D., & Calhoun, S. L. (2003a). Ability profiles in chil-
dren with autism: Influence of age and IQ. Autism, 7, 65–80.
Mayes et al. 37
Mayes, S. D., & Calhoun, S. L. (2003b). Analysis of WISC-III,
Stanford-Binet:IV, and academic achievement test scores in
children with autism. Journal of Autism and Developmental
Disorders, 33, 329–341.
Mayes, S. D., & Calhoun, S. L. (2003c). Learning and behavior
problems in Asperger syndrome. In M. Prior (Ed.), Learning
and behavior problems in Asperger syndrome (pp. 15–34).
New York, NY: Guilford.
Mayes, S. D., & Calhoun, S. L. (2004). Influence of IQ and age
in childhood autism: Lack of support for DSM-IV Asperger’s
disorder. Journal of Developmental and Physical Disabilities,
16, 257–272.
Mayes, S. D., & Calhoun, S. L. (2007). Learning, attention, writ-
ing, and processing speed in typical children and children with
ADHD, autism, anxiety, depression, and oppositional- defiant
disorder. Child Neuropsychology, 13, 469–493.
Mayes, S. D., & Calhoun, S. L. (2008). WISC-IV and WIAT-II
profiles in children with high- functioning autism. Journal of
Autism and Developmental Disorders, 38, 428–439.
Mayes, S. D., Calhoun, S. L., & Crites, D. L. (2001). Does DSM-IV
Asperger’s disorder exist? Journal of Abnormal Child Psy-
chology, 29, 263–271.
Mayes, S. D., Calhoun, S. L., Murray, M. J., Ahuja, M., & Smith,
L. A. (2011). Anxiety, depression, and irritability in children
with autism relative to children with other neuropsychiatric
disorders and typical development. Research in Autism Spec-
trum Disorders, 5, 474–485.
Mayes, S. D., Calhoun, S. L., Murray, M. J., Morrow, J. D., Yurich,
K. K. L., Mahr, F., . . . Petersen, C. (2009). Comparison of
scores on the Checklist for Autism Spectrum Disorder, Child-
hood Autism Rating Scale (CARS), and Gilliam Asperger’s
Disorder Scale (GADS) for children with low functioning
autism, high functioning autism, Asperger’s disorder, ADHD,
and typical development. Journal of Autism and Developmen-
tal Disorders, 39, 1682–1693.
Miller, J. N., & Ozonoff, S. (1997). Did Asperger’s cases have
Asperger disorder? A research note. Journal of Child Psychol-
ogy and Psychiatry, 38, 247–251.
Miller, J. N., & Ozonoff, S. (2000). The external validity of Asperger
disorder: Lack of evidence from the domain of neuropsychol-
ogy. Journal of Abnormal Psychology, 109, 227–238.
Miniscalco, C., Hagberg, B., Kadesjo, B., Westerlund, M., &
Gillberg, C. (2007). Narrative skills, cognitive profiles and
neuropsychiatric disorders in 7–8-year-old children with late
developing language. International Journal of Language and
Communication Disorders, 42, 665–681.
Miniscalco, C., Nygren, G., Hagberg, B., Kadesjo, B., & Gillberg,
C. (2006). Neuropsychiatric and neurodevelopmental outcome
of children at age 6 and 7 years who screened positive for lan-
guage problems at 30 months. Developmental Medicine and
Child Neurology, 48, 361–366.
Murray, M. J., Mayes, S. D., & Smith, L. A. (in press). Brief
report: Excellent agreement between two brief autism scales
(Checklist for Autism Spectrum Disorder and Social Respon-
siveness Scale) completed independently by parents and the
Autism Diagnostic Interview-Revised. Journal of Autism and
Developmental Disorders.
Myhr, G. (1998). Autism and other pervasive development disor-
ders: Exploring the dimensional view. Canadian Journal of
Psychiatry, 43, 589–595.
Ozonoff, S., Goodlin-Jones, S., & Solomon, M. (2005). Evidence-
based assessment of autism spectrum disorders in children and
adolescents. Journal of Clinical Child and Adolescent Psy-
chology, 34, 523–540.
Ozonoff, S., South, M., & Miller, J. N. (2000). DSM-IV-defined
Asperger syndrome: Cognitive, behavioral and early his-
tory differentiation from high-functioning autism. Autism, 4,
29–46.
Perry, A., Condillac, R. A., Freeman, N. L., Dunn-Geier, J., &
Belair, J. (2005). Multi-site study of the Childhood Autism
Rating Scale (CARS) in five clinical groups of young chil-
dren. Journal of Autism and Developmental Disorders, 35,
625–634.
Pilowsky, T., Yirmiya, N., Shulman, C., & Dover, R. (1998). The
Autism Diagnostic Interview–Revised and the Childhood
Autism Rating Scale: Differences between diagnostic sys-
tems and comparison between genders. Journal of Autism and
Developmental Disorders, 28, 143–151.
Prior, M., Eisenmajer, R., Leekam, S., Wing, L., Gould, J., Ong,
B., & Dowe, D. (1998). Are there subgroups within the autis-
tic spectrum? A cluster analysis of a group of children with
autistic spectrum disorders. Journal of Child Psychology and
Psychiatry, 39, 893–902.
Rellini, E., Tortolani, D., Trillo, S., Carbone, S., & Montecchi, F.
(2004). Childhood Autism Ratings Scale (CARS) and Autism
Behavior Checklist (ABC) correspondence and conflicts with
DSM-IV criteria in diagnosis of autism. Journal of Autism and
Developmental Disorders, 34, 703–708.
Schopler, E. (1996). Are autism and Asperger syndrome (AS) dif-
ferent labels or different disabilities? Journal of Autism and
Developmental Disorders, 26, 109–110.
Schopler, E. (1998). Premature popularization of Asperger syn-
drome. In E. Schopler, G. B. Mesibov, & L. J. Kunce (Eds.),
Asperger syndrome or high-functioning autism? (pp. 385–
399). New York, NY: Plenum.
Schopler, E., Reichler, R. J., & Renner, B. R. (1986). The Child-
hood Autism Rating Scale (CARS). Los Angeles, CA: Western
Psychological Services.
Sevin, J. A., Matson, J. L., Coe, D. A., Fee, V. E., & Sevin, B. M.
(1991). A comparison and evaluation of three commonly used
autism scales. Journal of Autism and Developmental Disor-
ders, 21, 417–432.
Stone, W. L., Lee, E. B., Ashford, L., Brissie, J., Hepburn, S. L.,
Coonrod, E. E., & Weiss, B. H. (1999). Can autism be diag-
nosed accurately in children under 3 years? Journal of Child
Psychology and Psychiatry, 40, 219–226.
38 Focus on Autism and Other Developmental Disabilities 27(1)
Szatmari, P., Archer, L., Fisman, S., Streiner, D. L., & Wilson,
F. (1995). Asperger’s syndrome and autism: Differences in
behavior, cognition, and adaptive functioning. Journal of the
American Academy of Child and Adolescent Psychiatry, 34,
1662–1671.
Teal, M. B., & Wiebe, M. J. (1986). A validity analysis of selected
instruments used to assess autism. Journal of Autism and
Developmental Disorders, 16, 485–494.
Tryon, P. A., Mayes, S. D., Rhodes, R., & Waldo, M. (2006).
Can Asperger’s disorder be differentiated from autism using
DSM-IV criteria? Focus on Autism and Other Developmental
Disabilities, 21, 2–6.
Van der Oord, S., Van der Meulen, E. M., Prins, P. J., Oosterlaans,
J., Buitelaar, J. K., & Emmelkamp, P. M. (2005). A psycho-
metric evaluation of the social skills rating system in chil-
dren with attention deficit hyperactivity disorder. Behaviour
Research and Therapy, 43, 733–746.
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Ventola, P. E., Kleinman, J., Pandey, J., Barton, M., Allen, S., Green,
J., . . . Fein, D. (2006). Agreement among four diagnostic instru-
ments for autism spectrum disorders in toddlers. Journal of
Autism and Developmental Disorders, 36, 839–847.
Volkmar, F. R., Klin, A., Siegel, B., Szatmari, P., Lord, C.,
Campbell, M., . . . Towbin, K. (1994). Field trial for autistic
disorder in DSM-IV. American Journal of Psychiatry, 151,
1361–1367.
Wechsler, D. (2002). Wechsler Preschool and Primary Scale of
Intelligence–Third Edition. San Antonio, TX: Psychological
Corporation.
Wechsler, D. (2003). Wechsler Intelligence Scale for Children–
Fourth Edition. San Antonio, TX: Psychological Corporation.
Wing, L. (1998). The history of Asperger syndrome. In E.
Schopler, G. B. Mesibov, & L. J. Kunce (Eds.), Asperger
syndrome or high-functioning autism? (pp. 11–28). New York,
NY: Plenum.