Measurement invariance of the Childhood Autism Rating Scale (CARS) across six countries
Creators
- Dejan Stevanovic1
- Floriana Costanzo2
- Elisa Fucà2
- Giovanni Valeri2
- Stefano Vicari2
- Diana L. Robins3
- Maureen Samms-Vaughan4
- Handan Ozek Erkuran5
- Ferhat Yaylaci6
- Smita N. Deshpande7
- Vaishali Deshmukh8
- Narendra K. Arora8
- Lilia Albores-Gallo9
- Cristina García-Lopez10
- Gabriel Gatica-Bahamonde11
- Maia Gabunia12
- Medea Zirakashvili13
- Fernanda Prada Machado14
- Miruna Radan15
- Sayyed Ali Samadi16
- Teck-Hock Toh17
- Windham Gayle18
- Laura Brennan19
- Tatjana Zorcec20
- Alejandra Auza21
- Maretha de Jonge22
- Noordeen Shoqirat23
- Anita Marini24
- Rajna Knez25
- 1. Department of Psychiatry, Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
- 2. Child and Adolescent Neuropsychiatry Unit, Bambino Gesù Children's Hospital, Rome, Italy
- 3. A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
- 4. University of the West Indies, Kingston, Jamaica
- 5. Child and Adolescent Psychiatry Unit, Dr Behcet Uz Children's Research and Training Hospital, Izmir, Turkey
- 6. Child Psychiatry Unit, Bursa Dortcelik Children's Hospital, Bursa, Turkey
- 7. Department of Psychiatry, Centre of Excellence in Mental health, Atal Bihari Vajpayee Institute of Medical Sciences; Dr. Ram Manohar Lohia Hospital, New Delhi, India
- 8. INCLEN Trust, New Delhi, India
- 9. Research Division, Hospital Psiquiatrico Infantil "Dr. Juan N. Navarro," Secretaría de Salud, Mexico City, Mexico
- 10. Hospital Sant Joan de Déu, Barcelona, Spain
- 11. Hospital de Villarrica, Department of Mental Health, Universidad de La Frontera, Temuco, Chile
- 12. Mental Health Center, Tbilisi, Georgia
- 13. Ilia State University, Tbilisi, Georgia
- 14. Pontifícia Universidade Catolica de S~ao Paulo, S~ao Paulo, Brazil
- 15. National Institute for Maternal and Child Health, Bucharest, Romania
- 16. Institute of Nursing and Health Research, University of Ulster, Coleraine, UK
- 17. Clinical Research Centre & Department of Pediatrics, Sibu Hospital, Ministry of Health Malaysia, Sibu, Malaysia
- 18. Environmental Health Investigations Branch, California Department of Public Health, Richmond, California, USA
- 19. University of Connecticut, Storrs, Connecticut, USA
- 20. Developmental Department, University Children's Hospital, Skopje, Macedonia
- 21. Language and Cognition Laboratory, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico
- 22. Faculty of Social Science, Education and Child Studies, Clinical Neuroscience and Developmental Disorders, Leiden University, Leiden, The Netherlands
- 23. Faculty of Nursing, Mu'tah University, Mu'tah, Jordan
- 24. World Health Organization, Geneva, Switzerland
- 25. Department of Women's and Children's Health, Skaraborgs Hospital, Skövde, Sweden
Description
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.