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.
Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC) Correspondence and Conflicts
single items are added together into a total score,
which classifies the child as not autistic (below 30),
mild or moderately autistic (30–36.5) or severely
autistic (above 36.5).
Assessment of severe autism uses further sug-
gestions by the same authors of the scale (Schopler
et al., 1980), who advise counting the number of
items in which the child obtained a score equal to
or greater than 3. Diagnosis of severe autism is
appropriate if the items are at least 5.
In this study, a score of 30 or higher was used
as threshold value for diagnosis of autism.
ABC by Krug et al. (1978)
This scale describes a series of typical autistic
behaviors and aims to assess the presence of these
behaviors in a certain subject. The assessment
form consists in 57 items, each of which corre-
sponds to a single score referring to a single sym-
ptomatological area. Five areas are considered:
sensory, relating, stereotypes and object use, lan-
guage, and self-help and social. The total score is
obtained by adding the scores for the different
areas. The 57 items are divided as follows: 9 items
for sensory area, 12 for relating, 12 for stereotypes
and object use, 13 for language, 11 for self-help
and social.
The score assigned in presence of the behavior
described by the single item varies from 1 to 4,
depending on the importance of the item with
respect to the diagnosis of the problems correlated
with the autism.
According to the authors’ table that shows
mean scores for the five areas and the total scores,
the subjects are divided into normal, severe emotion
disturbances, deaf/blind, severe mental retardation
and autistic.
In this study, a score of 53 was used as thresh-
old value for diagnosis of autism.
Procedures
All subjects in the sample underwent the fol-
lowing diagnostic protocol: MRI; wake/sleep EEG;
metabolic screening for levels of amino acid and
organic acid; blood tests and assessment of thyroid
function; allergy tests; virology tests; complete
examination of hearing function (audiometry;
acoustic impedance test, evoked potential audiome-
ter); karyotype and fragile-X molecular analysis.
705
All subjects were clinically diagnosed according
to DSM-IV criteria by a child neuropsychiatrist,
using clinical interviews of 1.5 hours each with par-
ents and child, in a room equipped with play mate-
rial appropriate for age level. An accurate history
of the child’s development was recorded during the
interview with the parents using Vineland Adaptive
Behavior Scales (Cicchetti, Sparrow, & Balla, 1984)
and the diagnostic protocol of the hospital unit.
Later, another examiner (the same for all sub-
jects) conducted a symptomatological and func-
tional evaluation of each child, using the following
assessment scales during three or more video-
recorded sessions of an hour each: CARS, ABC,
ERC-A, PEP-r and Leiter International Perfor-
mance Scale.
Assessment was conducted in the following
order: DSM-IV criteria, CARS, ABC. Clinical diag-
nosis and the study with CARS and ABC were
totally independent of each other.
Diagnostic protocol concluded with assessment
of family structure and free play sessions for the
child, with subsequent discussion involving the
entire team.
RESULTS
Diagnosis with DSM-IV
According to the DSM-IV criteria, of the 65
children that completed the diagnostic process, 54
had Autistic Disorder, 9 had Autistic Spectrum Dis-
orders (precisely 5 with Asperger’s Disorder and 4
with PDD-NOS), 1 had ADHD and 1 had Recep-
tive-Expressive Language Disorder (Table I, Fig. 1).
100% 83%
80%
60%
40%
20%
8%
6%
1,5% 1,5%
0%
Autistic Asperger's PDD-NOS ADHD Language
disorder disorder delay
Fig. 1. Diagnostic classification according to DSM-IV criteria
(N ¼ 65).
706
Mild-moderate
autism
44%
severe autism
56%
Fig. 2. Diagnostic classification according to CARS
(N ¼ 54 Autistic disorder).
Diagnosis with CARS Test
The 54 children with Autistic Disorder, as
defined by DSM-IV criteria, had a CARS score
above 30 (cutoff for diagnosis of childhood autism),
therefore sensitivity of CARS was 100% (54/54
cases).
The CARS test allows the group of autistic
children to be divided into two sub-groups: (a) 24
children (44%) with mild-moderate autism (scores
between 30 and 36.5) and (b) 30 (56%) with severe
autism (scores above 36.5) (Fig. 2). In our sample,
all children (30) with a total score greater than 36.5
also had more than 5 items with scores above or
equal to 3.
The five cases of Asperger’s Disorder, the four
cases of PDD-NOS, the case of ADHD and the
case with Language Delay had CARS scores below
30 (Not Autistic). The scale does not appear to
identify Asperger’s Disorder or PDD-NOS as
belonging to the autistic spectrum disorders, and it
cannot distinguish them from non-autistic cases.
Diagnosis with ABC Test
Of the 54 children with Autistic Disorder, as
defined by DSM-IV criteria, 29 (54%) had a total
ABC score that was greater than or equal to 57
(cutoff for diagnosis of autism); 2 (4%) had a severe
emotional disorder (mean 42.12); 19 (35%) had
severe mental retardation (mean 43.95); 4 (7%) were
deaf/blind (mean 41.43) (Fig. 3). The sensitivity of
ABC was 54%.
Mental
Retardation
35%
Autism
Deaf-Blind 54%
7% Emotional
disorders
4%
Fig. 3. Diagnostic classification according to ABC
(N ¼ 54 Autistic disorder).
Rellini et al.
The five cases of Asperger’s Disorder had a
mean total score in the deaf/blind category (mean
41.3). The four cases identified as PDD-NOS using
criteria DSM-IV, the ABC categorized two as nor-
mal and two were as deaf/blind category.
The subject with Receptive-Expressive Lan-
guage Disorder was deaf/blind, as was the subject
with ADHD.
Summarizing Figure
The Fig. 4 summarizes all the results, showing
the diagnosis for each subject using CARS and
ABC. This distribution will be discussed in the next
section. Next, we calculated the number of false
positives in ABC (Table II): ABC vs. DSM-IV (or
the same, vs. CARS) Autistic vs. Not Autistic con-
dition. Result: v210.67, p ¼ .001. False negative in
ABC is statistically significant.
CONCLUSIONS
This study shows complete agreement between
DSM-IV and CARS. (a). The CARS scale is effec-
tive in differentiating individuals with autism from
individuals with other disorders in a population
with developmental disorders, when referred exclu-
sively to Autistic Disorder in the strict sense of the
term. The CARS does not clearly differentiate to
the same degree individuals with other autistic spec-
trum disorders, represented in our study by Asper-
ger’s Disorder and PDD-NOS, from individuals
with other developmental disorders (non-autistic).
On the other hand, the fact that CARS cannot
identify individuals with Asperger’s Disorder should
not surprise anyone, because both CARS and ABC
were developed before the concept of Asperger’s
Disorder was included in the autistic spectrum and
became part of the Pervasive Developmental Disor-
ders in DSM-IV (APA-1994).
The CARS is clearly a particularly useful
instrument for research which, at the same time,
can provide descriptive information about the path-
ological behavior of autistic children and the degree
of severity.
Lastly, we can identify the points of interest of
ABC:

Examination of the 25 cases in which CARS
and ABC produced different assessments of
behavior disorder shows that 16 cases were
Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC) Correspondence and Conflicts
DSM-IV
AUTISM
# of children 54
29
ABC 2 19
AUTISME
29
DSM-IV
AUTISM
# of children 54
CARS
24 + 30 (Moderate + Severe)
in the mild-moderate autism category accord-
ing to CARS and in different categories
according to ABC (10 mental retardation; 2
emotional disorders; 4 deaf/blind), and that 9
cases were in severe autism category accord-
ing to CARS, but in mental retardation cate-
gory according to ABC. The ABC thus
seems to be a less discriminating scale than
CARS, particularly concerning cases of mild-
moderate autism, for which the number of
false negatives is higher (16/54 as compared
to 9/54 of severe autism cases).

CARS identified 100% of cases of Autistic
Disorder and ABC only 54%. Eaves and
Milner (1993) reported similar data in a
study in which CARS correctly identified
approximately 98% of cases, while ABC
identified only 88%.

Finally, our study shows that ABC does not
distinguish individuals with autistic disorders
from other cases of developmental disorders
as well as CARS (b). Using 53 as cutoff, the
number of false negatives is high: 46% as
TABLE II. ABC vs. DSM-IV: false positive and false negative
ABC YES
DSM-IV YES 29
DSM-IV NO 0 11
*
Significantly different (p < .001).
707
Asperger PDD-NOS ADHD Language delay Normal
5 4 1 1 0
5 1 1
2
4 2
motional disorder Mental retardation Deaf/blind Normal
2 19 11 2
Asperger PDD-NOS ADHD Language delay Normal
5 4 1 1 0
11
Fig. 4. Summarizing figure.
opposed to 0% with CARS. A series of other
studies arrived at the same conclusion (Spon-
heim, 1996).
Of particular interest for future research is the
data concerning the children of families that immi-
grated from non-European countries. Four of four
were not autistic at ABC and presented similar
peculiar behavior characteristics at clinical observa-
tion: spontaneous seeking and insisting on body
contact, even very close; lack of gaze avoidance,
total absence of imitation and verbal and non ver-
bal communication. Hyperactivity and attention
deficit were, on the contrary, comparable with the
rest of the sample.
If confirmed by further studies, these peculiar
behavior characteristics could demonstrate the influ-
ence of environmental elements at least in some
forms of autism. We hypothesize that the isolation
of these immigrant families, with a total upheaval
of their ways of social life, leads to such a condition
of depression and loss of affective and cultural ref-
erences, that it constitutes an additional concomi-
tant cause in a neurobiologically pre-determined
situation. Some authors recently advanced the pos-
sibility that at the basis of some forms of autism
there may be a connection with affective disorders
(DeLong & Nothria, 1994; Zappella, 1997).
ABC NO Our hope is to formulate a diagnostic protocol
that can be shared nationally and internationally,
25*
taking into account the results of the numerous
research projects in this field. The exclusive use of
assessment scales with poor potential for differentia-
708
tion could be the cause of the variability observed
in the incidence of autism in different countries
(Zappella, 1997).
We propose that the CARS, not the ABC, be
adapted for the standard diagnostic protocol for use
in Italy.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statisti-
cal manual of mental disorders (4th ed.). Washington, DC:
Author.
Cicchetti, D., Sparrow, S. S., & Balla, D. A. (1984). Vineland
Adaptive Behavior Scale, A.G.S. Circle Pines, Minnesota.
De Long, G. R., & Nothria, C. (1994). Psychiatry family history
and neurologic disease in autism spectrum disorders. In
Developmental Medicine and Child Neurology, 36, pp. 441–
448.
Eaves, R. C. & Milner, B. (1993). The Criterion-relate Validity of
The Childhood Autism Rating Scale and the Autism Behav-
ior Checklist. Journal Abnormal Child Psychology, 21, 481–
491.
Garfin, D., McCallon, D., & Cox, R. (1988). Validity and reli-
ability of Childhood Autism Rating Scale with autistic ado-
lescents. Journal of Autism and Developmental Disorders, 18,
367–378.
Kanner, L. (1943). Autistic disturbances of affective contact. Ner-
vous Child, 2, 217–250.
Krug, D. A., Arick, J. R., & Almond, P. J. (1978). Autism
Screening Instrument for Educational Planning: Background
and Development. In J. Gillam (Ed.), Autism: Diagnosis,
Instruction, Management and Research. Austin (Texas): Uni-
versity of Texas Press
Rellini et al.
Krug, D. A., Arick, J. R., & Almond, P. J. (1980). Behavior
checklist for identifying severely handicapped individuals
with high levels of autistic behavior. Journal of Child Psy-
chology and Psychiatry, 21, 221–229.
Lelord, G., & Sauvage, D. (1990). L¢autismo infantile. Milano,
Masson.
Rutter, M. (1978). Diagnosis and definition. In M. Rutter, & E.
Schopler (Eds.), Autism: A reappraisal of concepts and treat-
ment. New York: Plenum Press
Schopler, E., & Reichler, J. (1971). Individualized assessment and
treatment for autistic and developmentally delayed children.
Vol. I, psychoeducational profile. University Park Press: Balti-
more.
Schopler, E., & Reichler, J. (1980). Toward Objective Classification
of Childhood Autism: Childhood Autism Rating Scale
(C.A.R.S.). Journal of Autism and Developmental Disorders,
10, 91–103.
Schopler, E., Reichler, J., & Renner, B. (1988). The Childhood
Autism Rating Scale (C.A.R.S.). Los Angeles: Western Psy-
chological 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 Dis-
orders, 21, 417–432.
Sponheim, E. (1996). Changing criteria of autistic disorders: a
comparison of the ICD-10 research criteria and DSM-IV
with DSM-III-R, Cars, and ABC. Journal of Autism Devel-
opmental Disorders, 26(5), 513–525.
Volkmar, F. R., Cicchetti, D. V., Dykens, E., Sparrow, S. S.,
Lekman, J. F., & Cohen, D. J. (1988). An evaluation of the
Autism Behavior Checklist. Journal of Autism and Develop-
mental Disorders, 18, 81–97
Wing L., & Gould J. (1979). Severe Impairments of social inter-
action and associated abnormalities in children: Epidemiol-
ogy and classification. Journal of Autism and Developmental
Disorders, 9, 11–29.
Zappella M. (1997). Autismo Infantile.Roma: La Nuova Italia
Scientifica.