Journal of Autism and Developmental Disorders, Vol. 34, No.

6, December 2004 (
2004)

Childhood Autism Rating Scale (CARS) and Autism Behavior

Checklist (ABC) Correspondence and Conflicts with DSM-IV
Criteria in Diagnosis of Autism

E. Rellini,1,2 D. Tortolani,1 S. Trillo,1 S. Carbone,1 and F. Montecchi1

Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC) are tests
widely used for screening and diagnosis of autism. This study verified their correspondence
and conflict with a diagnosis made with DSM-IV criteria. The sample consisted of 65 chil-
dren, aged 18 months to 11 years. We found complete agreement between DSM-IV and
CARS. We show that ABC does not distinguish individuals with autistic disorders from
other cases of developmental disorders as well as CARS: the number of false negatives is
high (46%) with ABC as opposed to 0% with CARS.

KEY WORDS: Autism; diagnosis; childhood autism rating scale, autism behavior checklist, DSM-IV.

INTRODUCTION The disorder was originally described by Kan-

At present, the DSM-IV international classifi-
cation includes Autistic Disorder, in the strict sense
of the term, in the category of ‘‘Pervasive Develop-
mental Disorders’’, a group of dysfunctions with
common characteristics such as severe difficulty in
relations and communication associated with diffi-
culty in regulating sensory, attention, cognitive,
motor and affective processes (American Psychiatric
Association, 1994).
By definition, the onset of Autistic Disorder
occurs before age 3 years and the diagnostic crite-
ria, the so-called autistic triad, include:

qualitative impairment in social interaction

qualitative impairment in communication

restricted, repetitive and stereotyped patterns
of behavior, interests and activities.
1
Ospedale Pediatrico Bambino Gesu¢ di Roma.
2
Correspondence should be addressed to Emanuela Rellini,
L.go Russell, 6 sc. C1 00137 Roma; e-mail: erellini@tiscali.it
703
ner, who defined the characteristics in 1943 and for
the first time considered autism as a specific syn-
drome. Since then, a number of authors have
attempted to classify the peculiar clinical features of
childhood autism in order to establish guidelines for
diagnosis (Lelord, & Sauvage, 1990; Rutter, 1978;
Wing, 1978).
The Childhood Autism Rating Scale (CARS)
(Schopler & Reichler, 1971, 1980) and Autism
Behavior Checklist (ABC) (Krug, Arick, & Almond,
et al., 1978, 1980) are two well-established instru-
ments for the screening and diagnosis of childhood
autism.
Estimates of reliability presented in the CARS
manual are high (Schopler, Reichler, & Renner,
1988). After a 12-month interval, the test–retest reli-
ability for 91 cases was .88 for total score (r ¼ .94).
An independent investigation of CARS by Garfin,
McCallon, & Cox, (1988) found lower alpha coeffi-
cients for childhood and adolescence groups (r ¼ .79
and .73, respectively). In a comparison of autistic
adolescents and non-autistic handicapped adoles-
cents, Garfin et al. (1988) obtained significant mean
differences in total CARS scores of the two groups.
0162-3257/04/1200-0703/0
2004 Springer Science+Business Media, Inc.
704
Some reliability estimates for total scores have
been reported for ABC by its authors (Krug et al.,
1980). The correlation resulted of .94; Volkmar
et al. (1988) found a split-half reliability of .70. The
authors investigated the discriminating validity of
ABC using 94 autistic and 63 clinically non-autistic
subjects. It would appear that the rate of diagnoses
is 78%.
Eaves and Milner (1993) examined 77 individu-
als: 48 subjects had been formally diagnosed as
autistic, while the suggestion of autism was found
in the remaining records.
For CARS, 47 of the 48 subjects diagnosed as
autistic received scores above the autism cutoff
(total CARS score 29.5) indicating a sensitivity of
98%. For ABC, 42 of the 48 subjects had scores
above the autistic cutoff (total ABC score ¼ 53),
indicating a sensitivity of 88%.
Starting from this paper, the aim of our study
was to verify if the two tests could be included in a
standard diagnostic protocol to be proposed for use
in Italy.
Our objective was to verify agreement between
DSM-IV diagnostic criteria and total scores for
CARS and ABC in the diagnosis of autism and to
study the correlation between the two diagnostic
scales.
METHOD
Sample
The authors observed 65 children referred to
the Psychiatry and Psychotherapy Unit at Bambino
Gesu’ Children’s Hospital in Rome between 1998
and 2000 for disturbances related to autistic spec-
trum disorders. The sample consisted in 58 boys
and 7 girls, aged 18 months to 11 years (mean
4.9 years, SD 2.2). The ratio of males to females
was 8:1.
All 65 children completed the diagnostic pro-
cess (cf. PROCEDURES, p. 705). We tested 45 chil-
dren for the first time. The others were already
diagnosed as autistic at other centers: we confirmed
the diagnosis for all 20 children.
None of the patients were receiving treatment;
only the 20 autistic children had a support teacher.
The diagnostic process took place in day hospital.
All diagnoses were made by the same physician with
a specific background in child neuropsychiatry. The
same psychologist administered CARS and ABC.
Rellini et al.
We recorded all the diagnostic meetings on video-
tape. Another psychologist diagnosed the patients
by viewing the videotape and obtained the same
diagnoses.
The results of the diagnostic process are sum-
marized in Table I. Mean age of children with autis-
tic disorder (54) was 4.9 years; 49 males and 5
females. The ratio of 10 males to 1 female observed
in this study on autistic disorder differs from the
data reported in the literature (4:1). Mean age of
five children, all boys, with Asperger’s disorder was
7.2 years. All cases of autistic disorder are primary,
without any of the syndromes known to be corre-
lated with childhood autism and with negative find-
ings for fragile X.
To study the correspondence between DSM-IV
and CARS/ABC, we used only the children with
autistic disorder.
Materials: Description of Tests Used in Protocol
CARS by Shopler & Reichler (1971)
We briefly summarize the CARS setting:
The scale assesses behavior in 14 domains that
are generally affected by severe problems in autism,
plus one general category of impressions of autism,
with the aim of identifying children with autism, as
differentiated from the other developmental disor-
ders. The 15 items in the scale are: Relating to peo-
ple; Imitative behavior; Emotional response; Body
use; Object use; Adaptation to change; Visual
response; Listening response; Perceptive response;
Fear or anxiety; Verbal communication; Non-verbal
communication; Activity level; Level and consis-
tency of intellective relations; General impressions.
The examiner assigned a score of 1 to 4 for
each item: 1 indicates behavior appropriate for age
level, while 4 indicates severe deviance with respect
to normal behavior for age level. The scores for the
Table I. Diagnosis using DSM-IV
DSM-IV DIAGNOSIS % No. cases 65
Autistic disorder 83% 54
Asperger’s disorder 8% 705
Pervasive developmental disorder, 6% 4
not otherwise specified
ADHD 1.5% 1
Language delaya 1.5% 1
a
Receptive-Expressive Language Disorder.