Measurement invariance of the Childhood Autism Rating Scale (CARS) across six countries.
CARS scores cannot be fairly compared across countries because the scale functions differently by culture.
01Research in Context
What this study did
Stevanovic et al. (2021) tested if the Childhood Autism Rating Scale works the same way in six countries. They looked at how each item behaves across cultures.
The team used statistical tests to spot items that function differently by country. They wanted to see if a high score means the same thing everywhere.
What they found
The scale is not fair across cultures. Social-communication items hold up better than sensory or stereotyped items.
Because of this, you cannot safely compare raw CARS scores between countries.
How this fits with other research
Taylor et al. (2017) already showed that most autism tools lack solid psychometric data. Dejan’s work is a live example of the problem.
Magiati et al. (2017) ran a similar multi-country check on the SCAS-P anxiety scale. They also found shaky factor structure, backing the idea that autism-related scales often mis-fit across borders.
Vassos et al. (2023) found item bias in a flourishing scale for autistic youth. Dejan’s CARS study mirrors this by showing that bias can hide in culture, not just diagnosis.
Why it matters
If you use CARS scores to place kids or track progress, know that a 30 in Brazil may not equal a 30 in India. Check item-level data before comparing clients from different backgrounds. When possible, pair CARS with a locally validated tool or use the social-communication sub-scores for cleaner comparisons.
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02At a glance
03Original 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 cross-cultural 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 non-invariance 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.
Autism research : official journal of the International Society for Autism Research, 2021 · doi:10.1002/aur.2586