Measurement invariance of the Childhood Autism Rating Scale (CARS) across six countries

Abstract

The Childhood Autism Rating Scale (CARS) is a simple and inexpensive tool for Autism spectrum disorder (ASD) assessments, with evidenced psychometric data from different countries. However, it is still unclear whether ASD symptoms are measured the same way across different societies and world regions with this tool, since data on its cross-cultural validity are lacking. This study evaluated the crosscultural measurement invariance of the CARS among children with ASD from six countries, for whom data were aggregated from previous studies in India (n = 101), Jamaica (n = 139), Mexico (n = 72), Spain (n = 99), Turkey (n = 150), and the United States of America (n = 186). We analyzed the approximate measurement invariance based on Bayesian structural equation modeling. The model did not fit the data and its measurement invariance did not hold, with all items found non-invariant across the countries. Items related to social communication and interaction (i.e., relating to people, imitation, emotional response, and verbal and nonverbal communication) displayed lower levels of cross-country noninvariance compared to items about stereotyped behaviors/sensory sensitivity (i.e., body and object use, adaptation to change, or taste, smell, and touch response). This study found that the CARS may not provide cross-culturally valid ASD assessments. Thus, cross-cultural comparisons with the CARS should consider first which items operate differently across samples of interest, since its cross-cultural measurement non-invariance could be a source of cross-cultural variability in ASD presentations. Additional studies are needed before drawing valid recommendations in relation to the cultural sensitivity of particular items.

The Impact of the Urban Built Environment on the Play Behavior of Children with ASD

“…Marcus also discussed children’s communication behaviors in People Places: Design Guidelines for Urban Open Space, and divided children’s play behaviors in the urban built environment: observation-participation-avoidance-concealment [ 6 ]. However, due to regional differences, urban built environment impacts vary widely between developed and developing countries [ 7 ], and due to differences in cultural backgrounds, diagnoses of children with ASD in other countries may not provide cross-culturally valid results [ 8 ]. Therefore, this study uses the Autism Diagnostic Scale ( Table 1 ), which is suitable for China’s national conditions, as a reference and combines the Autism Children’s Development Assessment Scale ( Table 2 ) issued by the China Disabled Persons’ Federation to describe the play behavior of children with ASD.…”

Autism Spectrum Disorder Diagnostic Criteria Changes and Impacts on the Diagnostic Scales-Utility of the 2nd and 3rd Versions of the Gilliam Autism Rating Scale (GARS)

“…In addition, there are indications that the GARS utilizes family, caregiver, and service provider inputs relevant to culturally and linguistically diverse populations [43]. Nevertheless, cultural/regional effects on its measurements may be reflected through variable levels of sensitivity and specificity across studies through some locally published non-English studies, such as Gorji et al [44], as reported when using other ASD scales [45], which may result in cross-cultural variability in ASD [2,46].…”

A study of the effects of screen exposure on the neuropsychological development in children with autism spectrum disorders based on ScreenQ

“…The CARS is a widely used diagnostic scale in China that has strong reliability and validity [ 25 – 27 ]. It consists of 15 items covering children’s social interaction, language, behavior and sensory aspects.…”