Journal of Autism and Developmental Disorders, Vol. 28, No.

2, 1998

The Autism Diagnostic Interview-Revised and the

Childhood Autism Rating Scale: Differences Between
Diagnostic Systems and Comparison Between Genders

Tammy Pilowsky,1 Nurit Yirmiya,1,2 Cory Shulman,1 and Ronit Dover1

Diagnoses for autism based on the Autism Diagnostic Interview-Revised (ADI-R) and the
Childhood Autism Rating Scale (CARS) were examined for 83 individuals with suspected
autism. Agreement between systems reached 85.7%. Participants receiving diagnosis of
autism based on only one system were significantly younger in age than individuals receiving
diagnoses according to both systems. Individuals who did not receive diagnosis of autism on
the ADI-R had lower chronological and mental ages and lower CARS scores compared to
individuals who received diagnosis of autism based on the ADI-R. Eighteen females and 18
males were matched to examine possible gender differences. No significant findings were
revealed, suggesting that the symptoms of autism according to the ADI-R and CARS do
not differ between males and females when matched for chronological and mental ages.
KEYWORDS: Autism; diagnosis; Autism Diagnostic Interview-Revised; Childhood Autism Rating Scale.

INTRODUCTION & Rochen-Renner, 1988) have all been developed for

Several diagnostic instruments are presently in
use by professionals who attempt systematically to di-
agnose individuals with autism. Diagnostic evaluations
for autism usually consist of a combination of care-
fully collected developmental history, direct observa-
tion of behavior, and psychometric measure/s,
including the use of diagnostic instruments developed
for autism. Questionnaires or checklists (e.g., Autism
Behavior Checklist [ABC]; Krug, Arick, & Almond,
1980), standardized interviews with caregivers (e.g.,
Autism Diagnostic Interview-Revised [ADI-R]; Le
Couteur et al., 1989; Wing & Gould, 1978), and direct
observation on behavior (e.g., Autism Diagnostic Ob-
servation Schedule [ADOS]; Lord, Rutter, et al.,
1989; Childhood Autism Rating Scale [CARS]; Mesi-
bov, Schopler, Schaffer, & Michal, 1989; Schopler,
Reichler, DeVellis, & Daly, 1980; Schopler, Reichler,
'Hebrew University of Jerusalem, Israel 91905.
2Address all correspondenceto Nurit Yirmiya, Department of Psy-
chology or School of Education, Hebrew University of Jerusalem,
Mount Scopus, Jerusalem, Israel 91905.
the diagnosis of autism. In this study, individuals with
suspected autism were evaluated by interviewing their
parents with the ADI-R (Le Couteur et al., 1989;
Lord, Rutter, & Le Couteur, 1994) and by completing
the CARS (Mesibov et al., 1989; Schopler et al., 1980;
Schopler et al., 1988), after observation and interac-
tion with the individuals. In addition, mental ability
was assessed using standardized tests.
The diagnostic instruments for autism differ in
the role of the clinician (e.g., observer, interviewer),
the informant who is supplying the information (e.g.,
parent, teacher), and the method of collecting infor-
mation (e.g., yes/no statements, observation, inter-
view). Therefore it is important to compare different
systems used for diagnosis of autism. Psychometric
properties of some of the available diagnostic instru-
ments were examined in several studies with low-
functioning individuals with autism (Mesibov et al.,
1989; Sevin, Matson, Coe, Fee, & Sevin, 1991; Teal
& Weibe, 1986; Volkmar et al., 1988), and with high-
functioning individuals with autism (Yirmiya, Sig-
man, & Freeman, 1994). Disagreement resulting

143
0162-3257/98/0400-0143$15.00/0 © 1998 Plenum Publishing Corporation
144
from the use of different diagnostic instruments may
cause confusion to the child's caregivers, and may in-
fluence decisions regarding appropriate intervention.
A high degree of agreement between diagnostic pro-
cedures can enhance validity of the diagnostic instru-
ments. It is of importance, as well, to examine the
existence of specific characteristics of individuals who
receive diagnosis according to one system but not ac-
cording to another, in order to identify systematic
differences among inclusion and exclusion criteria of
different diagnostic systems. Systematic differences
between diagnostic procedures may reflect charac-
teristics of the instrument that must be taken in ac-
count when used clinically. Thus, the first aim of this
study was to examine the characteristics of individu-
als who received diagnosis of autism based on the
ADI-R and/or the CARS.
The second aim of this study was to examine and
compare the clinical picture of autism as derived
from the ADI-R and the CARS for a matched sam-
ple of males and females, with suspected autism.
Gender differences in the incidence of autism have
been systematically reported (Coleman, 1978; Wing,
1976, in Lord, Schopler, & Revicki, 1982), but rela-
tively few empirical studies compared characteristics
of males with autism to those of females with autism.
In a sample of high-functioning individuals with
autism, Lord, Goode, Rutter, and Schopler (1989)
found an elevated rate of nonoptimal pre-, peri-, and
neonatal factors for the total sample. The only gen-
der difference found was a tendency for females to
be firstborn, while males tended to be first-, fourth-,
or later-born, and for males to come from larger
families than females. In the general population, fe-
males tend to have better verbal and social skills
while males tend to have superior visual-spatial abili-
ties, therefore, Wing (1981) suggested that females
with autism may have poorer compensatory visual-
spatial abilities. Following Wing (1981), Lord et al.
(1982) reported that boys with autism performed bet-
ter than girls with autism on eye-hand integration
and on perceptual tasks, although these differences
disappeared when IQ was controlled. Females were
found to perform less well than males on receptive
vocabulary, but again when IQ was controlled, the
difference disappeared. The only gender difference
that remained when IQ was controlled was the
higher frequency of unusual visual interests and the
lower levels of appropriate play in males with autism
as compared to females with autism.
Pilowsky, Yirmiya, Shulman, and Dover
Some researchers documented the relation be-
tween gender and IQ in autism, showing that as a
group, females tend to have lower levels of mental
ability compared to males (Lord et al., 1982; Isai,
Stewart, & August, 1981; Wing, 1981), and that the
sex ratio in favor of males in the category of severe
mental retardation is higher than in moderate and
mild retardation (Lord et al., 1982; Volkmar, Szat-
mari, & Sparrow, 1993). Wing (1981) suggested that
the relationship between gender and IQ in autism is
linear. However, Lord et al. (1982) found that within
the range of severe mental retardation, there was
such a trend, but when the IQ range was divided into
more narrow categories, linearity was not found
(Lord & Schopler, 1985). A possible explanation for
the different findings may be the different criteria
employed for diagnosing autism in the various stud-
ies, as suggested by Lord and Schopler (1985).
In gender studies of autism, different criteria for
matching the participants were employed. Lord et al.
(1982) described a similar distribution of chronologi-
cal age and socioeconomic status for both males and
females. Other researchers suggested controlling for
date of birth and current residence (Lord, Mulloy,
Wendelboe, & Schopler, 1991) or chronological age
and place of birth (Lord, Rutter, et al., 1989). Al-
though Volkmar et al. (1993) suggested that control-
ling for intelligence can cause over-matching
between males and females with autism, it is possible
that the dominance of the intelligence difference be-
tween the genders may mask other gender differ-
ences.
To prevent findings from relating to level of
mental retardation rather than to severity of autism,
participants should be matched for mental ability. In
the present study males and females with suspected
autism were matched on chronological age (CA) and
on mental age (MA) to enable the examination of
other possible differences between males and fe-
males with autism, beyond the difference in intelli-
gence reported previously.
Furthermore, as noted by Volkmar et al. (1993)
much of the available research has tended to equate
severity of autism with severity of mental retardation,
or to overlook the severity of autism. If gender dif-
ferences in the incidence of autism are so prominent,
it may be that the difference between genders is
manifested in other domains, such as the distribution
of severity of symptoms associated with autism. Thus,
Volkmar et al. (1993) studied individuals with autism,
individuals with Pervasive Developmental Disorder,