Description

Information on the M-CHAT screening test and sample test.

Learning objectives

Identification of autism

Know how to recognize autism in the course of well child care through observation of play and communication.

Know specific screening instruments

Be aware of specific screening instruments with appropriate sensitivity, specificity, and ease of use in primary care.

Secondary screening and referral criteria

Know about indications for doing secondary screening versus referral in a primary care setting. Secondary screening may not improve accuracy and lead to under-referral.

---

Background

Autistic Spectrum Disorders (ASDs) are estimated to affect as many as 1 in 250 to 1 in 1000 children [Volkmar, et al., 2004; Baird, et al., 2000]. Studies suggest that there is a significant gap from when parental concerns are first expressed to child health providers at an average of 1.5 years of age, and when a definitive diagnosis of autism is made, sometimes as late as 4 years old [Flannagan & Nuallain, 2001; De Giacomo & Fombonne, 1998; Siegel, 1988]. Retrospective studies conducted with children diagnosed with an autistic spectrum disorder have found that lack of response to name at one year of age may be the most consistent specific symptom [Osterling, et.al 2002; Werner, 2000; Baranek, 1999; Osterling & Dawson, 1994]. These retrospective findings of behaviors at age one, the start of parental concerns often before age two, and the benefits of early intervention suggest that early screening is appropriate.

Psychometry of the M-CHAT

Developed at the University of Connecticut Department of Psychology, the Modified Checklist for Autism in Toddlers (M-CHAT) is a 23 item (yes/no) parent report checklist developed to screen children ages 16 months to 30 months old [Robins et al, 2001]. The original population screened by the M-CHAT consisted of 1,293 children (Robins et al, 2001). Six critical items were identified by discriminant functional analyses: item 2 (taking interest in other children), item 7 (use index finger to point, to indicate interest in something), item 9 (bringing objects over to show the parent), item 13 (imitating), item 14 (child responding to his or her name when called) and item 15 (child follows point across the room). Sensitivity was found to be good, but was based on children diagnosed at age 2 after screening positive on the M-CHAT, rather than predictively.

Ongoing Research

Additional research on the MCHAT is under way, funded by the National Institute of Child Health and Development (NICHD). To date 4200 children have been screened. The sample is drawn from primary care practices, as well as early intervention sites. Children who screen positive (any 3 of the total items or any 2 of the 6 critical items failed) receive a confirmatory follow up telephone call. Those who fail both the initial screening and the telephone follow up are evaluated by a team of evaluators using the Autism Diagnostic Interview- Revised (ADI-R) [Lord, et al., 1994]; Autism Diagnostic Observation Schedule – Generic (ADOS-G) [ Lord, et al., 2000]; Childhood Autism Rating Scale (CARS) [Schopler, et al., 1988]; Mullen Scales of Early Learning [Mullen, 1995 ], Vineland Adaptive Behavior Scales [Sparrow, et al., 1984]; and clinical diagnosis based on the Diagnostic and Statistical Manual (DSM-IV) criteria [APA, 1994].

Of 236 children who have been evaluated, 165 were found to have an ASD, 67 have been diagnosed with a non-ASD developmental disorder, and 4 have been assessed as typically developing. Follow up data has been collected from 940 (mean age = 55.35 months) of the 1937 children who were screened at Time 1 and have reached eligibility for the re-screening at Time 2. At re-screening, parents complete the M-CHAT, and indicate whether between Times 1 and 2 the child has been referred for or diagnosed with an ASD. 

Sixty three children evaluated at Time 1 have been re-evaluated at Time 2. Six children have been identified as possible misses, of which 2 have been confirmed. Based on the M-CHAT score at Time 1 and the evaluation outcome at Time 2, the sensitivity of the M-CHAT is 0.85 (counting possible as well as confirmed misses) or .95 (counting only confirmed misses), and the specificity is 0.93. Positive predictive power from Time 1 screening to Time 2 diagnosis is 0.36, and negative predictive power is 0.99. When including the telephone follow-up, specificity is 0.97, PPP is 0.57, and NPP is 0.99.

So far, 18 children from the unselected pediatrician sample have been diagnosed with an ASD. Nonparametric correlation of the rank order of the items failed by these children compared to the larger sample of children with ASD screened at early intervention sites indicates a very close relationship (Spearman’s Rho = .880, p < .01). This suggests that the same items will detect ASD in unselected and high risk samples.

Recommendations for Practice

At this time, early identification and early intervention are the best response to Autistic Spectrum Disorders. Given this fact, the development of reliable tools for screening young children is imperative. The M-CHAT is one of a few tools which show promise as a screening tool in different populations of unselected children. It has been translated into Turkish, Japanese, and Spanish, and one study has been published which used the M-CHAT translated into Chinese [Wong V., et al., 2004]. It will be important to evaluate the findings of ongoing studies using the M-CHAT in these different languages and cultures.

You can get the M-CHAT here.

About the authors:

Thyde Dumont-Mathieu, M.D., M.P.H. is a Developmental-Behavioral pediatrician. She is an Assistant Professor in the Departments of Pediatrics and Psychology at the University of Connecticut. Her research interests include findings ways of eliminating racial and ethnic health disparities by enhancing our understanding of the perceptions and expectations of patients/parents from all ethno-cultural backgrounds. Her clinical practice focuses on the assessment of preschoolers with developmental-behavioral difficulties, including autistic spectrum disorders.

Deborah Fein, Ph.D. is Board of Trustees Distinguished Professor of Psychology at the University of Connecticut. Her research interests include various aspects of autism, including early detection, early intervention, and children with ASD who reach optimal outcomes. She has a small private practice in which she does neuropsychological evaluations of children with a variety of disorders, particularly ASDs.

Jamie Kleinman, B.A. is from the Department of Psychology, University of Connecticut, Storrs, Connecticut.

Please address correspondences to: Thyde Dumont-Mathieu, M.D., M.P.H., Department of Psychology, University of Connecticut, 406 Babbidge Rd., Storrs, CT 06269-1020, Phone: 860-714-5612; Fax: 860-714-8054; tdumont@stfranciscare.org

 

---

Available media

• MCHAT form

---

References

• Wong V., et al., 2004. A Modified Screening Tool for Autism (Checklist for Autism in Toddlers [CHAT-23] for Chinese children. Pediatrics 114(2): e166-76. [258]
• Baird, G., Charman, T., Baron-Cohen, S., et al. 2000. A screening instrument for autism at 18 months of age: A six-year follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry 39(6): 694-702. [242]
• Baird, G., Charman, T., Baron-Cohen, S., et al. 2000. A screening instrument for autism at 18 months of age: A six-year follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry 39(6): 694-702. [242]
• Flanagan, O., & Nuallain, S. 2001. A study looking at the effectiveness of developmental screening in identifying learning disabilities in early childhood. Irish Medical Journal 94: 148-50. [246]
• Volkmar F., et.al. 2004. Autism and Pervasive Developmental Disorders. Journal of Child Psychology and Psychiatry 45(1): 135-170. [256]
• Lord, C., Rutter, M., & Le Couteur, A. 1994. Autism Diagnostic Interview-Revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders 24: 659-685. [247]
• Baranek, GT. 1999. Autism during infancy: a retrospective video analysis of sensory-motor and social behaviors. Journal of Autism and Developmental Disorders 29: 213-224. [243]
• Werner E., et al. 2000 Brief report: recognition of Autism Spectrum Disorder before one year of age: a retrospective study based on home videos. Journal of Autism and Developmental Disorders 30(2): 157-162. [257]
• Baron-Cohen, S., Allen, J., & Gillberg, C. 1992. Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry 161: 839-843. [244]
• American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. [225]
• Osterling J., Dawson G., Munson J. 2002. Early recognition of 1-year-old infants with autism spectrum disorder versus mental retardation. Development and Psychopathology 14: 239-251. [251]
• Osterling, J. & Dawson, G. 1994. Early recognition of children with autism: a study of first birthday home videotapes. Journal of Autism and Developmental Disorders, 24, 247-257. [250]
• Siegel, B., et al. 1988. How children with autism are diagnosed: Difficulties in identification of children with multiple developmental delays. Journal of Developmental and Behavioral Pediatrics 9: 199-204. [254]
• Mullen, E. 1995. Mullen Scales of Early Learning. Circle Pines, MN: American Guidance. [249]
• DeGiacomo, A., & Fombonne, E. 1998. Parental recognition of developmental abnormalities in autism. European Journal of Child and Adolescent Psychiatry, 7:131-6. [245]
• Lord, C., et al. 2000. The Autism Diagnostic Observation Schedule – Generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30(3): 205-223. [248]
• Schopler, E., Reichler, RJ., & Renner, BR. 1988. The Childhood Autism Rating Scale. Los Angeles: Western Psychological Services. [253]
• Robins, DL., Fein, D., Barton, ML., & Green, JA. 2001. The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders 31: 131-144. [252]
• Sparrow S., Balla, D., & Cichetti, D. 1984. The Vineland Adaptive Behavior Scales. Circles Pines, MN: American Guidance Services. [255]

Keywords: autism,autism spectrum,autism spectrum disorder,autistic,autistic spectrum,M-CHAT,mchat,screening,Screening Tests
Publication date: Mar 1, 2005
Revise date: Jun 10, 2005
TextID: 377

Comments: