Introduction

Neurodevelopmental disorders

Neurodevelopmental disorders are disabilities associated primarily with the functioning

of the neurological system and brain. They cause difficulties in social, cognitive and emotional

functioning of an individual. Children with neurodevelopmental disorders can experience

difficulties with language and speech, motor skills, behavior, memory, learning, or other

neurological functions. While the symptoms and behaviors of neurodevelopmental disabilities

often change or evolve as a child grows older, some disabilities are permanent. The usual onset

of neurodevelopmental disorders is during stages of development. This means that they usually

first appear in toddlers, children and adolescents. However, they continue to persist into

adulthood or may go undiagnosed until adulthood. But there are instances in which a child

outgrows the symptoms associated with a neurodevelopmental disorder. Examples of

neurodevelopmental disorders in children include attention-deficit/hyperactivity disorder

(ADHD), autism spectrum disorder (ASD), learning disabilities, intellectual disability, conduct

disorders, cerebral palsy and impairments in vision and hearing. The diagnosis and treatment of

these disorders can be difficult; treatment often involves a combination of professional therapy,

pharmaceuticals along with home- and school-based programs (“America's Children and the

Environment”, 2015).
Types of Neurodevelopmental disorders

Attention-Deficit/Hyperactivity Disorder (ADHD): ADHD is a neurodevelopmental

disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that

interferes with functioning or development. According to the DSM-5, individuals with ADHD

show symptoms in two domains: Inattention and Hyperactivity-Impulsivity.

Learning Disabilities (LD): Learning disabilities are neurodevelopmental disorders that

affect specific cognitive processes related to learning. According to DSM-5, the most common

types include: Dyslexia, Dysgraphia & Dyscalculia. The National Joint Committee on Learning

Disabilities (NJCLD) defines LD as a "heterogeneous group of disorders manifested by

significant difficulties in the acquisition and use of listening, speaking, reading, writing,

reasoning, or mathematical abilities" (NJCLD, 2011).

Intellectual Disability (ID): Intellectual Disability (ID) is a disorder characterized by

significant limitations in both intellectual functioning (reasoning, learning, problem-solving) and

adaptive behavior (conceptual, social, and practical skills), which begin before the age of 18

(Schalock et al., 2010). ID is classified into mild, moderate, severe, or profound based on the

severity of deficits in adaptive functioning and the level of support needed for daily activities.

Genetic conditions such as Down syndrome or environmental factors like prenatal exposure to

toxins may contribute to ID.

Conduct Disorder (CD): Conduct Disorder is a behavioral disorder marked by a

repetitive and persistent pattern of behavior in which the basic rights of others or societal norms
are violated. According to the DSM-5, individuals with CD may exhibit aggressive behavior

towards people and animals, destruction of property, deceitfulness, theft, and serious violations

of rules. CD is more common in males and may lead to a diagnosis of Antisocial Personality

Disorder in adulthood if untreated.

Cerebral Palsy (CP): Cerebral Palsy is a group of permanent movement disorders that

appear in early childhood, primarily affecting body movement, muscle tone, and coordination. It

is caused by abnormal development or damage to the brain, particularly the areas that control

motor functions, often occurring before or during birth (Bax et al., 2005).

Impairments in Vision: Visual impairments refer to conditions where a person’s ability

to see is significantly diminished, even with corrective measures such as glasses. It includes

partial sight and complete blindness.

Impairments in Hearing: Hearing impairment refers to a partial or total inability to hear

sounds. It can be classified as mild, moderate, severe, or profound, and it may affect one or both

ears. According to the World Health Organization (WHO), 2020 hearing loss is present when

there is a loss of 30 dB or more in either ear. Causes can include genetic factors, infections (like

meningitis), exposure to loud noises, or aging (presbycusis).

Autism Spectrum Disorder (ASD): ASD is a neurodevelopmental disorder

characterized by deficits in social communication and interaction, alongside restricted, repetitive

behaviors, interests, or activities (DSM-5, 2013). ASD encompasses a broad spectrum, meaning
that symptoms and severity can vary significantly among individuals. Common signs include

difficulties in understanding non-verbal communication, developing peer relationships, and

exhibiting stereotypical behaviors. Research suggests that ASD is influenced by a combination of

genetic and environmental factors. Studies on the brain structure of individuals with ASD show

atypical neural connectivity and differences in synaptic functioning (Lord et al., 2020).

Prevalence in India

Globally, the prevalence of Autism Spectrum Disorder (ASD) is estimated to be around 1

in 54 children, according to recent Centers for Disease Control and Prevention (CDC) data.

The prevalence of Autism Spectrum Disorder (ASD) in India has been difficult to

establish precisely due to variations in diagnostic practices, cultural factors and limited

large-scale epidemiological studies. However, several research findings provide estimates

suggesting approximately 1 in 100 children may be affected, according to Action for Autism

(2018). Research by Kumar et al. (2019) estimated a prevalence of 0.9% (9 per 1000 children),

with boys being four times more likely to be diagnosed. A study in Kerala found a rate of around

1 in 500 children (Narayan et al., 2015), while Arora et al. (2018) reported that

neurodevelopmental disorders, including ASD, affected 1.3-2.5% of Indian children. These

figures likely reflect underdiagnosis and limited awareness, as ASD prevalence in India appears

lower than global estimates but may not capture the full extent of the condition.
Clinical Picture

The clinical picture of Autism Spectrum Disorder (ASD) varies significantly in its

presentation due to the wide spectrum of symptoms, but it is primarily characterized by

persistent difficulties in social communication and interaction and restricted, repetitive patterns of

behavior, interests, or activities (American Psychiatric Association, 2013).

Core Features:

1.Social Communication and Interaction Deficits:

● Individuals with ASD often exhibit difficulties with social-emotional reciprocity, such as

trouble engaging in back-and-forth conversations, understanding social cues, or

expressing emotions appropriately. Many also struggle with non-verbal communication,

such as maintaining eye contact or interpreting facial expressions (Lord et al., 2020).

● Children with ASD may show early signs of impaired joint attention (the ability to share

focus on objects or events with others), a key developmental milestone that impacts social

learning.

2.Restricted and Repetitive Behaviors:

● Individuals with ASD often engage in repetitive behaviors such as hand-flapping,

rocking, or insistence on routines and sameness. Some may exhibit intense interests in

specific topics or objects. Sensory sensitivities (e.g., hypersensitivity to sounds, textures,

or lights) are also common (Baranek et al., 2015). These behaviors and interests often
 emerge in early childhood and can be a key diagnostic feature, particularly in

combination with social deficits.

Heterogeneity in Presentation: ASD is highly heterogeneous, meaning its manifestations can

range from mild to severe. While some individuals may be non-verbal or have intellectual

disabilities, others (often referred to as "high-functioning" or having Asperger’s syndrome under

previous diagnostic systems) may have average or above-average intelligence but struggle with

social nuances (Geschwind & Levitt, 2007).

Co-occurring Conditions: Many individuals with ASD have co-occurring conditions such as

anxiety, attention-deficit/hyperactivity disorder (ADHD), or epilepsy, which further complicate

the clinical presentation (Simonoff et al., 2008). These comorbidities often require tailored

intervention strategies that address both ASD symptoms and the additional challenges presented

by these overlapping conditions.

Diagnostic Criteria for Autism Spectrum Disorder (DSM-5 C)

A. Persistent deficits in social communication and social interaction across multiple contexts, as

manifested by the following, currently or by history (examples are illustrative, not exhaustive,

see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of

interests, emotions, or affect; to failure to initiate or respond to social interactions.

 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for

example, from poorly integrated verbal and nonverbal communication; to abnormalities

in eye contact and body language or deficits in understanding and use of gestures; to a

total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behavior to suit various social contexts; to difficulties

in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity: Severity is based on social communication impairments and restricted

repetitive patterns of behavior.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two

of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor

stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal

nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions,

rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong

attachment to or preoccupation with unusual objects, excessively circumscribed or

perseverative interest).
 4. Hyper- or hypo reactivity to sensory input or unusual interests in sensory aspects of the

environment (e.g., apparent indifference to pain/temperature, adverse response to specific

sounds or textures, excessive smelling or touching of objects, visual fascination with

lights or movement).

Specify current severity: Severity is based on social communication impairments and restricted,

repetitive patterns of behavior.

C. Symptoms must be present in the early developmental period (but may not become fully

manifest until social demands exceed limited capacities or may be masked by learned strategies

in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important

areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay. Intellectual disability and autism

spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder

and intellectual disability, social communication should be below that expected for general

developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s

disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social

communication, but whose symptoms do not otherwise meet criteria for autism spectrum

disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:

● With or without accompanying intellectual impairment

● With or without accompanying language impairment

(Coding note: Use additional code to identify the associated medical or genetic

condition.)

● Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated neurodevelopmental,

mental, or behavioral disorder[s].)

● With catatonia

● Associated with a known medical or genetic condition or environmental factor

Need for Assessment

The need to assess Autism Spectrum Disorder (ASD) is crucial for several reasons,

rooted in early intervention, individualized support, and the improvement of quality of life for

individuals with ASD:

1. Early Diagnosis Leads to Early Intervention: Early assessments enable targeted

interventions, such as behavioral therapies, speech therapy, and occupational therapy, which can

significantly enhance cognitive, social, and communication skills during key developmental

windows (Dawson et al., 2010). Early intervention can also prevent secondary challenges, such

as anxiety and behavior issues, that might develop without proper support.

2. Individualized Treatment Planning: ASD is a highly heterogeneous condition, meaning

individuals display varying levels of social, communicative, and behavioral challenges.

Comprehensive assessments help identify the specific needs and strengths of each individual,

allowing clinicians to develop tailored treatment plans (Zwaigenbaum et al., 2015).

3. Educational and Social Support: This includes special education services, individualized

education programs (IEPs), and additional resources to support learning. Beyond the educational

setting, assessing ASD helps inform social support structures, ensuring that individuals with

ASD receive assistance in daily functioning and social integration (Lord et al., 2020).

4. Monitoring Developmental Progress: Regular assessments are vital to monitor the progress

of individuals with ASD. Over time, these assessments allow professionals and families to

evaluate the effectiveness of interventions, make necessary adjustments, and ensure that the

individual is developing and adapting optimally in response to their environment and challenges

(Anderson et al., 2014).

5. Understanding and Managing Co-occurring Conditions: Many individuals with ASD

experience co-occurring conditions, such as anxiety, ADHD, intellectual disabilities, or epilepsy.

Proper assessment helps to identify these conditions, which can complicate the clinical picture

and require additional treatment strategies (Simonoff et al., 2008).

6. Supporting Families and Caregivers: Assessing ASD not only benefits the individual but

also provides families and caregivers with insights into the child's behavior, challenges, and

potential. This enables families to understand their child's needs, access appropriate resources,

and make informed decisions about their care and future (Karst & Van Hecke, 2012).

Assessments available for Autism

A variety of assessments are available to diagnose Autism Spectrum Disorder (ASD) and

evaluate the specific needs of individuals on the spectrum.

1. Autism Diagnostic Observation Schedule, Second Edition (ADOS-2): The ADOS-2 is one

of the most commonly used observational tools to assess communication, social interaction, and

play or imaginative use of materials in individuals suspected of having ASD. It involves

structured activities and tasks designed to elicit behaviors that are important for diagnosing ASD.

It is appropriate for individuals of various ages and developmental levels (Lord et al., 2012).

2. Autism Diagnostic Interview – Revised (ADI-R): The ADI-R is a structured interview

conducted with the parents or caregivers of an individual suspected of having ASD. It covers key

areas such as social communication, language development, and repetitive behaviors. The

interview allows for the assessment of the child’s developmental history, focusing on ASD

symptoms in early childhood (Rutter et al., 2003).

3. Social Communication Questionnaire (SCQ): The SCQ is a parent-report questionnaire that

screens for symptoms of ASD. It is often used as an initial screening tool before more in-depth

diagnostic assessments. The SCQ is designed to be used for individuals over the age of four and

asks questions regarding the child’s communication abilities, social functioning, and repetitive

behaviors (Rutter et al., 2003).

4. Gilliam Autism Rating Scale, Third Edition (GARS-3): The GARS-3 is a norm-referenced

instrument that helps identify the severity of ASD symptoms. It includes questions about social

interaction, communication, and stereotyped behaviors. GARS-3 is widely used in schools and

clinical settings for screening and diagnosis (Gilliam, 2014).

5. Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R): A screening tool used

for toddlers between 16 and 30 months to identify early signs of ASD. Parents complete the

questionnaire, which is designed to detect communication, social, and play behavior difficulties

(Robins et al., 2009).

Childhood Autism Rating Scale

Background

The Childhood Autism Rating Scale (CARS) is a diagnostic tool used to identify autism

in children and determine the severity of the condition. CARS is one of the most widely used

autism assessment instruments today. It was developed by Eric Schopler and his colleagues in

the early 1980s. Schopler, a prominent figure in autism research, was one of the founding
members of the TEACCH (Treatment and Education of Autistic and Related

Communication-Handicapped Children) program at the University of North Carolina at Chapel

Hill. The TEACCH program aimed to improve the lives of individuals with autism through a

comprehensive approach that emphasized structured teaching and individualized support.

Before the development of CARS, autism was often diagnosed based on subjective

observations and anecdotal evidence, leading to inconsistencies in diagnosis and treatment. In the

late 1970s and early 1980s, there was a growing recognition of autism as a distinct category

within the broader field of developmental disorders. However, the DSM-III (published in 1980)

introduced a more formal diagnostic criteria for autism, which created a greater need for

standardized assessment tools. In response to this need, Dr. Schopler and his team developed the

CARS as a means of providing a more objective assessment of autism. The scale was based on

clinical observations and input from parents and professionals who worked closely with children

on the autism spectrum.

The Childhood Autism Rating Scale (CARS) was designed to assess children aged 2 to 6

years by focusing on observable behaviors rather than relying solely on parental reports or

subjective impressions. This emphasis on observable criteria allows clinicians to quantify the

presence and severity of autism symptoms effectively. The development of CARS was grounded

in empirical research, with Eric Schopler and his colleagues conducting numerous studies to

refine the scale and ensure its reliability and validity. The items on the scale were derived from

extensive clinical observations of children with autism, creating a robust framework for assessing

key areas of functioning, including social interaction, communication, and behavioral patterns.
The first version of CARS was published in 1980 and quickly became a standard assessment tool

widely used by clinicians, educators, and researchers. Its introduction contributed to the

standardization of autism diagnosis, providing a clear framework for evaluation and helping to

reduce discrepancies across different settings.

Furthermore, the availability of a reliable assessment tool like CARS emphasized the

importance of early intervention, as research indicates that early diagnosis and treatment can lead

to significantly improved outcomes for children with autism, such as enhanced social skills and

reduced behavioral issues. By enabling timely identification, CARS supports the implementation

of effective interventions when they are most beneficial. Over time, CARS has evolved to include

updated versions, such as CARS-2, reflecting ongoing research and changes in our understanding

of autism spectrum disorder, ensuring that the tool remains relevant and effective in

contemporary assessments.

Description of the Test

The Childhood Autism Rating Scale (CARS) is highly regarded for its reliability and

validity, making it a crucial instrument for diagnosing autism in clinical, educational, and

research settings.

Number of Items/Questions in the Test: The Childhood Autism Rating Scale (CARS) consists

of 15 items. Each item assesses specific behaviors associated with autism, allowing for a

comprehensive evaluation of the child's functioning.

Target Population: CARS is designed for children aged 2 to 6 years, although it can be used for

older children and individuals with developmental delays as well. It is particularly beneficial for
those suspected of having Autism Spectrum Disorder (ASD).

Domains/Areas Assessed: CARS evaluates multiple domains associated with autism symptoms,

including:

● Social Interaction: Assesses the child's ability to engage with peers and respond to social

cues.

● Communication: Evaluates both verbal and non-verbal communication skills, including

the use of gestures and expressions.

● Repetitive Behaviors: Measures the presence and frequency of stereotyped behaviors,

insistence on sameness, and restricted interests.

● Emotional Responses: Looks at how the child expresses emotions and relates to their

environment.

● Adaptation to Change: Assesses the child’s ability to cope with changes in routine or

environment.

Time Taken: The administration of the CARS typically takes about 15 to 30 minutes. The time

may vary depending on the child's behavior and the level of detail required during the

assessment.

Psychometric Properties

Reliability: CARS has demonstrated strong reliability. Studies have shown good internal

consistency (Cronbach’s alpha=0.79), test-retest reliability (ICC=0.81) and inter-rater reliability

(ICC=0.74).

Validity: The validity of CARS has been well-established through numerous studies. It has been
shown to effectively distinguish between children with autism and those with other

developmental disorders, supporting its criterion-related validity. Studies have found that the

CARS correctly identified 98% of autistic subjects, and 69% of those considered possibly autistic

as autistic. Having good test retest reliability signifies the internal validity of a test and ensures

that the measurements obtained in one sitting are both representative and stable over time.

Administration

Scoring

Interpretation

Clinical Application

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