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Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-RF)

Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-RF) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


DOI: 10.1542/peds.2013-1813
; originally published online December 23, 2013;Pediatrics
Dumont-Mathieu and Deborah Fein
Diana L. Robins, Kar s Casagrande, Marianne Barton, Chi-Ming A. Chen, Thyde
Follow-up (M-CHAT-R/F)
Validation of the Modified Checklist for Autism in Toddlers, Revised With



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Validation of the Modi�ed Checklist for Autism in
Toddlers, Revised With Follow-up (M-CHAT-R/F)
WHAT’S KNOWN ON THIS SUBJECT: Screening for autism
spectrum disorders (ASDs) using the Modi�ed Checklist for
Autism in Toddlers (M-CHAT) improves early detection and long-
term prognosis of ASD. Reducing the false-positive rate may
increase implementation of screening for ASDs.
WHAT THIS STUDY ADDS: The Modi�ed Checklist for Autism in
Toddlers, Revised with Follow-up (M-CHAT-R/F), simpli�es wording
of the original M-CHAT. The current validation study indicates that
the M-CHAT-R/F improves the ability to detect autism spectrum
disorders in toddlers screened during well-child care visits.
abstract
OBJECTIVE: This study validates the Modi�ed Checklist for Autism in
Toddlers, Revised with Follow-up (M-CHAT-R/F), a screening tool for low-
risk toddlers, and demonstrates improved utility compared with the
original M-CHAT.
METHODS: Toddlers (N = 16 071) were screened during 18- and 24-
month well-child care visits in metropolitan Atlanta and Connecticut.
Parents of toddlers at risk on M-CHAT-R completed follow-up; those who
continued to show risk were evaluated.
RESULTS: The reliability and validity of the M-CHAT-R/F were demon-
strated, and optimal scoring was determined by using receiver operating
characteristic curves. Children whose total score was $3 initially and
$2 after follow-up had a 47.5% risk of being diagnosed with autism
spectrum disorder (ASD; con�dence interval [95% CI]: 0.41–0.54) and
a 94.6% risk of any developmental delay or concern (95% CI: 0.92–0.98).
Total score was more effective than alternative scores. An algorithm
based on 3 risk levels is recommended to maximize clinical utility and to
reduce age of diagnosis and onset of early intervention. The M-CHAT-R
detects ASD at a higher rate compared with the M-CHAT while also
reducing the number of children needing the follow-up. Children in
the current study were diagnosed 2 years younger than the national
median age of diagnosis.
CONCLUSIONS: The M-CHAT-R/F detects many cases of ASD in toddlers;
physicians using the 2-stage screener can be con�dent that most
screen-positive cases warrant evaluation and referral for early
intervention. Widespread implementation of universal screening can
lower the age of ASD diagnosis by 2 years compared with recent
surveillance �ndings, increasing time available for early intervention.
Pediatrics 2014;133:37–45
AUTHORS: Diana L. Robins, PhD,
a,b
Karís Casagrande, BS,
a
Marianne Barton, PhD,
c
Chi-Ming A. Chen, PhD,
c
Thyde
Dumont-Mathieu, MD, MPH,
c,d
and Deborah Fein, PhD
c,d
a
Department of Psychology,
b
Neuroscience Institute, Georgia
State University, Atlanta, Georgia; and
c
Department of Psychology,
d
Department of Pediatrics, University of Connecticut, Storrs,
Connecticut
KEY WORDS
autism, screening, toddlers
ABBREVIATIONS
ASD—autism spectrum disorder
CI—con�dence interval
GSU—Georgia State University
M-CHAT—Modi�ed Checklist for Autism in Toddlers
M-CHAT/F—Modi�ed Checklist for Autism in Toddlers with
Follow-up
M-CHAT-R—Modi�ed Checklist for Autism in Toddlers, Revised
M-CHAT-R/F—Modi�ed Checklist for Autism in Toddlers, Revised
with Follow-up
PPV—positive predictive value
STAT—Screening Tool for Autism in Two-Year-Olds
UConn—University of Connecticut
WCC—well-child care
Dr Robins conceptualized and designed the study, contributed to
the proposal for National Institutes of Health funding,
participated in data collection, analyzed the data, and drafted
the initial manuscript; Ms Casagrande participated in data
collection and assisted with management of the study, data
analyses, and drafting and editing of the initial manuscript;
Dr Barton contributed to the conceptualization of the study,
participated in data collection, and critically reviewed the
manuscript; Dr Chen contributed to data analyses and critically
reviewed the manuscript; Dr Dumont-Mathieu contributed to
conceptualization of the study, participated in data collection,
and critically reviewed the manuscript; Dr Fein conceptualized
and designed the study, led the efforts to obtain National
Institutes of Health funding, participated in data collection,
contributed to the interpretation of data, and critically reviewed
the manuscript; and all authors approved the �nal manuscript
as submitted.
(Continued on last page)
PEDIATRICS Volume 133, Number 1, January 2014 37
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Autism spectrum disorder (ASD) is
a neurodevelopmental disorder iden-
ti�ed by impairments in social in-
teraction and communication and the
presence of repetitive and restricted
behaviors/interests.
1
The prevalence of
ASD has increased in recent years and
is now estimated at 1 in 88 children.
2
Aggressive early intervention leads to
the best long-term prognosis.
3
Because
ASD can often be detected before
a child’s third birthday, the American
Academy of Pediatrics recommends
autism-speci�c screening at 18- and
24-month well-child care (WCC) visits.
4
However, the median age of diagnosis
is after the fourth birthday
2
and even
later for children of low socioeconomic
status or minority backgrounds.
5
The Modi�ed Checklist for Autism in
Toddlers (M-CHAT)
6
is currently one of
the most widely used ASD screening
instruments both in the United States
and internationally,
7,8
providing an ac-
cessible, low-cost
9
option for universal
toddler screening. The M-CHAT with
Follow-Up (M-CHAT/F) has been shown
to have adequate sensitivity and spec-
i�city
10,11
; in a sample of nearly 19 000
toddlers aged 16 to 30months,
12
54% of
children classi�ed as at risk on the
basis of the M-CHAT/F were diagnosed
with ASD, and 98% of screen-positive
cases presented with developmental
delay or concerns. The purpose of re-
vising the M-CHAT was to reduce the
number of cases who initially screen
positive and need the follow-up, while
maintaining high sensitivity. The cur-
rent study validates the M-CHAT, Re-
vised with Follow-Up (M-CHAT-R/F), in
a low-risk sample.
METHODS
Participants
A total of 16 115 toddlers were screened
(see Fig 1) in metropolitan Atlanta
(Georgia State University [GSU]) or
Connecticut (University of Connecticut
[UConn]) (see Table 1). Participants
with insuf�cient data (n =459) were
excluded from analyses: 303 did not
complete follow-up and 156 did not
complete the evaluation. Additional
participants (n = 44) were excluded for
insuf�cient English pro�ciency (n = 15),
previous ASD diagnosis (n = 4), a med-
ical condition that precluded evalua-
tion (n = 13), withdrawal from the
study (n = 2), or being outside the
study’s screening age (n = 10).
The remaining 15 612 toddlers (mean
age: 20.95 months; SD: 3.30 months;
range: 16.00–30.95 months) included
7793 boys and 7570 girls (249 with
gender unspeci�ed). Twenty-two per-
cent (22.7%) were screened twice be-
fore 30 months. The �rst screen was
used in analyses unless the second
screen triggered evaluation (n = 16;
0.1%). Of the 419 children invited for
diagnostic evaluation, 263 completed
evaluations (see Table 2).
Measures
The M-CHAT-R/F is a 2-stage screener
(see www.mchatscreen.com and Sup-
plemental Appendix), which is free for
clinical, research, and educational use
and requires little or no training for
health care professionals. Initially,
parents answer 20 yes/no questions,
which takes ,5 minutes; if children
screen positive, parents are asked
FIGURE 1
Flowchart indicating screening results.
a
Evaluations based on cases detected through STAT screen positive (n = 20), physician concern (n = 18), and alternate
scoring (n = 4).
b
Detected through STAT (n = 6), physician concern (n = 9), and alternate scoring (n = 3). Neg, negative; Pos, positive.
38 ROBINS et al
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structured follow-up questions to ob-
tain additional information and exam-
ples of at-risk behaviors, which takes
∼5 to 10 minutes with a professional
(ie, nurse or physician’s assistant).
13
The M-CHAT-R/F
14
incorporated 5 mod-
i�cations to improve utility. Three items
that performed poorly were dropped
(peek-a-boo, playing with toys, and
wandering without purpose). The re-
maining 20 items were reorganized
to remove agreement bias. The items
that comprised the Best7 score (see
Supplemental Information) were placed
within the �rst 10 items. Language was
simpli�ed to improve comprehension.
For example, “Does your child ever use
his/her index �nger to point…” was
rephrased as “Does your child point
with one �nger….” Finally, examples
provided developmental context and
clarity.
The original M-CHAT recommended
a threshold of $3 items total or $2
critical items identi�ed through dis-
criminant function analysis.
15
However,
analyses of larger samples indicated
that the critical score did not improve
sensitivity above the total score.
12
The
current study tested several scoring
methods. A threshold based on total
score had strong psychometric prop-
erties and was more parsimonious
than combinations of total and alter-
native scorings (see Supplemental In-
formation).
Clinical measures included the Autism
Diagnostic Observation Schedule,
16
Childhood Autism Rating Scale–2,
17
the
Toddler Autism Symptom Interview,
18
Mullen Scales of Early Learning,
19
Vineland Adaptive Behavior Scales–II,
20
Behavioral Assessment System for
Children–2,
21
and a developmental his-
tory form.
Procedures
Parents completed the M-CHAT, Revised
(M-CHAT-R), and provided informed
consent and demographic character-
istics during their child’s 18- or 24-
month WCC visit (41 sites at GSU, 44
sites at UConn). Pediatricians were
asked to indicate concern about ASD,
based on their clinical judgment, by
checking a box at the top of the
screener. Completed M-CHAT-R forms
were scored at GSU or UConn. Re-
search staff contacted parents of
screen-positive children to complete
the follow-up by telephone; children
who continued to screen positive on
the M-CHAT-R/F or whose physician had
concerns were offered a diagnostic
evaluation. Evaluations were conducted
by a team consisting of a licensed
psychologist/developmental pediatri-
cian supervising a graduate student
and research assistants; team mem-
bers were research reliable on all mea-
sures they administered.
The �nal diagnosis integrated all
available information and used the
psychologist/developmental pediatri-
cian’s clinical judgment to assess Di-
agnostic and Statistical Manual of
Mental Disorders, 4th edition, text re-
vision (DSM-IV-TR)
22
criteria for Autistic
Disorder and Pervasive Developmental
Disorder, Not Otherwise Speci�ed.
When ASD was ruled out, diagnoses of
Global Developmental Delay, Language
Delay, or other DSM-IV-TR disorders
were considered. Children who did
not meet criteria for any diagnosis
were classi�ed as typically developing
or as having developmental concerns,
which were operationally de�ned as
TABLE 1 Total Sample Demographic Characteristics by Site and Level of Completion
UConn GSU Total
Complete Incomplete Complete Incomplete
Total sample 5932 115 9680 344 16 071
Sex
Male 3048 71 4745 192 8056
Female 2877 43 4693 143 7756
Not reported 7 1 242 9 259
Race
White/Caucasian 3712 47 4850 89 8698
Black/African American 426 15 2874 185 3500
Asian/Paci�c Islander 316 15 412 9 752
Native American/ Alaskan Native 26 0 11 1 38
Bi- or multiracial 464 9 465 17 955
Other 46 3 56 5 110
Unknown 942 26 1012 38 2018
Ethnicity
Hispanic 1361 35 435 7 1838
Non-Hispanic 4571 80 9245 337 14233
Maternal education
Less than high school 429 15 379 36 859
High school/GED 1149 36 1389 82 2656
Some college 1356 25 2201 70 3652
College degree 1512 19 2477 60 4068
Advanced degree 1284 14 1764 29 3091
Unknown 202 6 1470 67 1745
ASD concerns
a
13 6 32 13 65
Age at screening, mean (SD), mo 20.86 (3.20) 20.53 (3.04) 21.01 (3.36) 20.71 (3.57) 20.94 (3.30)
M-CHAT-R total score, mean (SD)
b
0.68 (1.22) 4.63 (2.54) 0.64 (1.24) 4.10 (2.96) 0.76 (1.44)
M-CHAT-R/F total score, mean (SD)
b
1.24 (2.09) 3.15 (1.75) 1.17 (2.15) 3.06 (2.20) 1.43 (2.20)
Data are presented as n unless otherwise indicated. Incomplete cases were eligible to complete additional steps based on
M-CHAT-R scores but did not complete the study. Incomplete cases include those who initially screened positive and did not
complete the follow-up as well as those who continued to screen positive on follow-up and did not attend the evaluation.
Completed cases completed all eligible steps of the study, but in most cases, children who screened negative were not asked
to continue to any additional assessment. GED, general educational diploma.
a
Physicians noted ASD concerns by checking a box on the M-CHAT-R protocol.
b
Note that the incomplete columns contain those cases who screened positive but did not complete the follow-up or
evaluation. Therefore, it is expected that they show elevated scores relative to the completed cases.
ARTICLE
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subthreshold/mild weaknesses pre-
cluding a label of typical development.
Parents received oral and written
feedback, including local intervention
resources. When parents declined to
complete follow-up or evaluation, the
physician was informed of M-CHAT-R re-
sults; parentswerewelcome to rejoin the
study at any time. Institutional review
boards at both sites approved this study.
At GSU, a strati�ed random sample of
children who screened negative on the
M-CHAT-R/Fwere invited tocomplete the
Screening Tool for Autism in Two-Year-
Olds (STAT),
23
a brief autism-speci�c
play-based screening. To maximize the
chance of �nding missed cases, chil-
dren who initially screened positive on
M-CHAT-R but then screened negative
on follow-up were most heavily re-
cruited for the STAT; among those
who screened negative on the initial
M-CHAT-R, strati�cation overrecruited
those who scored 2 compared with
those who scored 1 or 0. Of 375 chil-
dren who completed the STAT, 20 were
evaluated on the basis of a screen-
positive STAT.
RESULTS
Reliability
Across all M-CHAT-R items, internal
consistency was below the threshold
for adequate (Cronbach’s a = 0.63),
which is not surprising given that the
M-CHAT-R items do not assess a unitary
dimension, and some motor items
were created to be foils. When the 2-
stage screen was examined, internal
consistency for M-CHAT-R/F was ade-
quate (Cronbach’s a = 0.79).
Outcomes for Screen-Positive
Cases
The majority of cases (92.6%) who
completed an M-CHAT-R screened neg-
ative. More than half (n = 598; 63.2%) of
children whose parents completed the
second stage of the M-CHAT-R/F (follow-
up), no longer screened positive. The
mean age at evaluation was 26.23
months (SD: 5.45 months).
Optimal Scoring for M-CHAT-R/F
To evaluate scoring for the M-CHAT-R/F
in a low-risk sample, receiver operating
characteristic curves veri�ed optimal
cutoff scores for the2-stageM-CHAT-R/F.
Sensitivity was calculated as the pro-
portion of all ASD children identi�ed
by any means (M-CHAT-R/F, physician
concern, STAT) who screened positive.
Speci�city was calculated as the pro-
portion of all presumed non-ASD cases
who screened negative.
Initial M-CHAT-R Scoring
Area under the curve was 0.977. The
threshold forwhich both sensitivity and
speci�city exceeded 0.90 was 3, sup-
porting the established cutoff score;
increasing or decreasing the cutoff led
to a notable drop in sensitivity or
speci�city.
Two-Stage M-CHAT-R/F Scoring
Initially, the same cutoff score of$3on
the total score (Total3) was used for
the follow-up. However, as a result of
increased efforts to ascertain missed
cases (ie, physician concerns and STAT
screening), 7 screen-negative cases
were diagnosed with ASD, 5 of whom
scored 2 on the M-CHAT-R/F. This result
led to a change in the threshold for
those who were offered evaluations on
the basis of results of the follow-up to
Total2 (cutoff score of $2 on the total
score). Results indicated that using
TABLE 2 Sample Characteristics of Children Who Completed Evaluations
Evaluated Based on Total
Screen Positive (84%) Screen Negative
(16%)
Total sample 221 42 263
ASD 105 18 123
Autistic 52 10 62
PDD-NOS 53 8 61
Non-ASD 116 24 140
GDD 55 6 61
Language 23 2 25
Other diagnosis 1 0 1
No diagnosis 25 5 30
Typical 12 11 23
Sex
Male 146 29 175
Female 75 13 88
Race
White/Caucasian 96 17 113
Black/African American 64 16 80
Asian/Paci�c Islander 14 2 16
Native American/ Alaskan Native 0 0 0
Bi- or multiracial 19 2 21
Other 1 1 2
Unknown 27 4 31
Ethnicity
Hispanic 36 5 41
Non-Hispanic 185 37 222
Maternal education
Less than high school 28 3 31
High school/GED 41 8 49
Some college 59 8 67
College degree 53 13 66
Advanced degree 40 10 50
Data are presented as n. GDD, global developmental delay; GED, general educational diploma; PDD-NOS, pervasive develop-
mental disorder, not otherwise speci�ed.
40 ROBINS et al
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Total2 as the threshold on the follow-up
halves the number of missed cases,
signi�cantly increasing sensitivity
(McNemar’s test, P , .001) and dem-
onstrates an area under the curve of
0.907 (see Table 3 and Fig 2). Psycho-
metrics were veri�ed on the sub-
sample ascertained after the score
change was implemented (n=7579; 60
diagnosed with ASD).
To increaseutility of a 2-stage screening
tool in busy pediatric settings, it would
be helpful to bypass the follow-up in
cases who are likely to continue to
screen positive. The sample was ex-
amined to determine (1) the number of
cases who reverted from screen posi-
tive to screen negative during the
follow-up and (2) the initial M-CHAT-R
scores for those children diagnosed
with ASD to arrive at the following risk
classi�cations: low risk (total score:
0–2; requires no further evaluation
unless other risk factors are present),
medium risk (total score: 3–7; requires
administration of the follow-up to de-
termine whether referrals are war-
ranted), and high risk (total score:
8–20; warrants immediate referral
for evaluation and intervention) (see
Fig 3). In the current sample, 75 chil-
dren scored in the high-risk range on
M-CHAT-R and completed the evalua-
tion, all of whom were diagnosed with
developmental disorders or concerns
(44 ASDs, 27 non-ASD disorders, 4
developmental concerns). Compared
with a positive predictive value (PPV) of
the initial questionnaire of 0.26 for any
developmental delay or concern (con-
�dence interval [95% CI]: 0.20–0.32),
the PPV for high-risk scores is 1.0. It is
TABLE 3 Psychometric Properties of M-CHAT-R and M-CHAT-R/F Scores
TP (hit) FN (miss) FP TN Sensitivity
(95% CI)
Speci�city
(95% CI)
PPV NPV LR+ LR2
M-CHAT-R initial scoring
Total3
a
112 11 700 14 798 0.911 (0.86–0.96) 0.955 (0.95–0.96) 0.138 0.999 20.160 0.094
M-CHAT-R/F scoring
Total3 w/follow-up Total3
b
82 41 79 15 419 0.667 (0.58–0.75) 0.995 (0.99–0.99) 0.509 0.997 130.785 0.335
Total3 w/follow-up Total2
c
105 18 116 15 382 0.854 (0.79–0.92) 0.993 (0.99–0.99) 0.475 0.999 114.052 0.147
Subsample of Total3 w/follow-up Total2
d
50 10 61 7458 0.833 (0.73–0.93) 0.992 (0.98–0.99) 0.450 0.999 103.087 0.168
FN, false-negative cases; FP, false-positive cases; LR+, likelihood ratio of positive screen; LR2, likelihood ratio of negative screen; NPV, negative predictive value; TN, true-negative cases,
presumed based on screening negative without other indicators of ASD risk; TP, true-positive cases.
a
Total3: classi�cation as TP, FN, FP, or TN based on a threshold of 3 on the total score.
b
w/follow-up: these scores are represented by the threshold(s) applied to the initial screening with the additional threshold(s) applied to the follow-up.
c
Total2: classi�cation as TP, FN, FP, or TN based on a threshold of 2 on the follow-up total score.
d
Subsample after score change for follow-up implemented to verify Total3 – with/follow-up Total2 scoring in a prospective sample.
FIGURE 2
A: ROC curve for 2-stage M-CHAT-R/F. AUC, area under the curve; ROC, receiver operating characteristic. B: Table showing sensitivity and speci�city for each
M-CHAT-R/F total score.
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important to note that many children
with ASD will score lower than these
higher cutoffs, emphasizing the need to
complete the follow-up with medium-
risk cases.
Finally, examining speci�c diagnostic
outcomes for screen-positive cases on
the 2-stageM-CHAT-R/F (Total3 initially +
Total2 on follow-up) indicated 47.5%
(n = 105) diagnosed with ASD, yielding
a likelihood ratio for positive screens
of 114.052. Among the remaining cases,
35.7% (n = 79) had other delays, 11.3%
(n = 25) had developmental concerns
but no formal diagnosis, and only 5.4%
(n = 12) were judged to be typically
developing; the PPV for any develop-
mental delay or concern was 0.946
(95% CI: 0.92–0.98).
Among cases �agged by the physician
for ASD concerns (n = 64), 45 attended
the evaluation; of these cases, 42 had
delays or concerns, 30 of whom were
diagnosed with ASD; this �nding indi-
cates that physician concern alone has
a sensitivity of 0.244 (30 of 123 ASD
cases; 95% CI: 0.17–0.32). Notably, phy-
siciansweremore likely to express ASD
concerns when parents were highly
educated. See Table 4 for clinical char-
acterization of the sample by screening
status.
Comparison of M-CHAT-R/F to the
Original M-CHAT/F
To investigate whether revision to the
M-CHAT improved the tool for use in
low-risk samples, the outcomes from
the current validation study forM-CHAT-
R/F were compared with the original
M-CHAT/F sample as reported in
Chlebowski et al.
12
There was a signi�-
cant reduction in the initial screen-
positive rate (from 9.15% to 7.17%; x
2
[1, n = 35 060] =39.62; P , .001); the
PPV for the 2-stage screening was not
signi�cantly different across versions
(P = .492). The rate of ASD detection was
signi�cantly higher for the M-CHAT-R/F,
which detected 67 cases per 10 000
compared with the original M-CHAT/F,
which detected 45 cases per 10 000 (x
2
[1, n = 35 060] = 8.63; P = .003).
DISCUSSION
The current study validates the M-CHAT-
R/F, a 2-stage, level 1 ASD screening tool
that requires little time and cost
9
to
administer to toddlers attending 18-
and 24-month WCC visits. Analyses in-
dicated that optimal scoring relies only
on total, rather than alternate, scoring.
The recommended algorithm classi�es
children into 3 risk ranges on the basis
of the initial questionnaire. Children
who score in the low-risk range (93% of
cases) are not in need of M-CHAT-R
follow-up or additional evaluation un-
less surveillance indicates ASD risk.
Children should be rescreened if they
are younger than 24 months, as rec-
ommendedby theAmericanAcademyof
Pediatrics.
4
Children whose scores are
in the medium-risk range (6% of cases)
require administration of the follow-up,
which gathers additional detail about
at-risk items. Approximately one-third
of children whose parents complete
the second stage of M-CHAT-R/F con-
tinue to show ASD risk and require
referrals for evaluation and possible
early intervention. Children who score
in the high-risk range (1% of cases)
FIGURE 3
Recommended algorithm based on 2-stage M-CHAT-R/F screening.
TABLE 4 Clinical Data by Screening Status
True Positive
(n = 105)
False Negative
(n = 18)
False Positive
(n = 116)
True Negative
(n = 24)
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Age at screen, mo 21.87 (3.83) 22.74 (4.08) 20.80 (3.43) 22.27 (3.63)
Age at evaluation, mo 26.22 (4.91) 29.57 (3.58) 25.34 (6.11) 28.04 (4.17)
M-CHAT-R total 7.23 (3.24) 3.50 (3.19) 5.96 (2.35) 2.50 (2.50)
M-CHAT-R/F total 5.22 (3.17) 0.80 (0.92) 3.55 (1.57) 0.40 (0.70)
ADOS-2 comparison
a
6.54 (1.98) 6.89 (1.88) 1.85 (1.29) 2.13 (1.26)
CARS2
b
32.66 (5.02) 33.19 (4.36) 21.11 (3.39) 20.23 (4.09)
MSEL VR
c
29.64 (10.86) 31.94 (12.99) 38.18 (13.77) 44.21 (15.65)
MSEL FM 27.59 (10.30) 31.33 (11.55) 35.16 (11.06) 39.21 (14.05)
MSEL EL 25.44 (8.63) 25.44 (7.24) 31.68 (10.65) 36.79 (10.64)
MSEL RL 23.70 (8.97) 26.17 (9.41) 33.14 (12.44) 39.75 (11.64)
VABS-II Communication
d
71.85 (12.57) 79.89 (12.32) 85.11 (12.76) 95.46 (9.56)
VABS-II DL 80.00 (14.36) 85.06 (10.40) 90.11 (15.04) 98.29 (13.03)
VABS-II Socialization 77.23 (10.10) 80.78 (12.36) 86.79 (11.29) 96.58 (10.44)
VABS-II Motor 83.93 (11.27) 86.11 (11.17) 88.44 (13.67) 94.96 (9.82)
ADOS-2, Autism Diagnostic Observation Schedule, Second Edition; CARS2, Childhood Autism Rating Scale, Second Edition;
DL, Daily Living Skills; EL, expressive language; FM, �ne motor; MSEL, Mullen Scales of Early Learning; RL, receptive language;
VABS-II, Vineland Adaptive Behavior Scales, Second Edition; VR, visual reception.
a
ADOS-2 comparison score indicates severity of ASD-related symptoms.
b
CARS2 range:15–60; threshold for autism = 30.
c
MSEL T scores (mean = 50, SD = 10).
d
VABS-II standard scores (mean = 100, SD = 15).
42 ROBINS et al
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may bypass the follow-up. On the basis
of initial screening only, the total sam-
ple of screen-positive children have a
27% risk of any developmental delay or
concern (95% CI: 0.20–0.32), whereas
all cases in the high-risk range were
diagnosed with delays or concerns, jus-
tifying immediate referrals for evalua-
tion and possible early intervention.
Children who screened positive on M-
CHAT-R/F were 114 times more likely
to receive an ASD diagnosis than chil-
dren who screened negative. In addi-
tion, 94.6%of childrenevaluated forASD
risk on the 2-stage M-CHAT-R/F showed
developmental delay or concern that
warranted referrals to early interven-
tion (95% CI: 0.92–0.98). Although one
might interpret this �nding to mean
that the M-CHAT-R/F may be screening
more broadly than for ASD, it is not
justi�ed to use the screener for that
purpose, given that the sensitivity of the
tool for non-ASD delays is not known.
One study directly comparing M-CHAT
to the Parents’ Evaluation of Devel-
opmental Status (PEDS)
24
found that
25% of children demonstrated risk for
a broad range of developmental con-
cerns on the PEDS, far exceeding the
screen-positive rate of the M-CHAT.
25
An
important �nding from the study is that
the average age of diagnosis was just
after the second birthday, which is 2
years earlier than the median age of
diagnosis
2
; this �nding suggests that
implementing standardized screening
and expeditious evaluation for positive
cases can greatly increase the time
that children are eligible for early-
intervention services and therefore
improve the outcome. However, it is
important to note that ASD screening
continues to be challenging. Because
no screening tool can have perfect
sensitivity and speci�city, providers
should continue to perform develop-
mental surveillance in addition to us-
ing validated screening tools.
The performance of theM-CHAT-R/Fwas
compared with the published studies
using the M-CHAT/F in low-risk sam-
ples.
12
Overall, the revision signi�cantly
reduced the initial screen-positive rate,
which means that fewer children re-
quire follow-up. Also indicating im-
provement of the tool, the rate of ASD
detection increased for M-CHAT-R/F.
Although it is impossible to rule out
increasing ASD prevalence as contrib-
uting to this �nding, this �nding sug-
gests that the reduction in the initial
screen-positive rate is not negatively
affecting sensitivity. When M-CHAT-R/F
was compared with physician clinical
judgment, sensitivity was signi�cantly
higher for M-CHAT-R/F; when these
methods were combined, ASD detection
was very high, indicating that stan-
dardized screening in conjunction with
routine developmental surveillance
optimizes early detection for ASD.
It is important to examine the preva-
lence of ASD detected in the current
sample to evaluate utility of the
screening tool. TheM-CHAT-R/Fdetected
ASData rateof 1per149cases. This rate
is notably below the published preva-
lence of ASD as 1 in 88
2
; however, the
Centers for Disease Control and Pre-
vention’s prevalence data were ascer-
tained on the basis of review of school
and health records for 8-year-old chil-
dren, and it is not expected that all ASD
cases will be detectable in toddlers.
Furthermore, with enhanced methods
to detect missed cases, such as fol-
lowing up on physician concern and
sampling screen-negative cases, 123
ASD cases were detected in the sample,
which is 1 in 127. It is likely that many of
the remaining children who will later
be diagnosed with ASD, such as those
with Asperger disorder without early
developmental delays, are not showing
signi�cant symptoms at this young
age
26
; in addition, later detection may
occur in mild cases only in the school
setting where peer interactions can be
seen. Therefore, the rate of detection of
1 in 127 may not be far off from the
actual prevalence in 2-year-olds.
Limitations and Future Directions
One limitation of level 1 screening re-
search is that it is impossible to eval-
uate all screen-negative cases to identify
misses and calculate true sensitivity.
An additional challenge is that many
parentsof childrenwho initially screened
positive did not complete additional
steps in the study.
27
The current study
had a disproportionately high number
of African-American families who did
not complete the study (eg, follow-up
or evaluation), indicating that barriers
continue to exist even under stan-
dardized protocols. In addition, mater-
nal education was signi�cantly higher
in the GSU sample (mean: 14.93 years;
SD: 2.53 years) than the UConn sample
(mean: 14.57 years; SD: 2.46 years) (t
[13 938] = 28.37; P , .001), although
the effect size was very small (h
2
=
0.005). These variables are complex
and are addressed in other articles.
28
The current study used multiple ap-
proaches to detect possible false-
negative cases, improving accuracy of
sensitivity estimates. Both sites asked
physicians to identify cases of possible
ASD, and these families were offered
evaluation regardless of M-CHAT-R/F
score. In some cases, when physicians
hadASDconcernsbut thechild screened
negative on the M-CHAT-R/F, the children
were found to have other develop-
mental delays; however, 9 ASD cases
were detected with physician concern
but had negative M-CHAT-R/F. Not all
physicians applied this surveillance
component equally in their practices,
and further research may identify fac-
tors that predict use of surveillance,
screening, and their integration. A sec-
ond approach to �nd false negatives
conducted at 1 site (GSU) invited a
sample of screen-negative cases for
play-based screening. The sample was
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PEDIATRICS Volume 133, Number 1, January 2014 43
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strati�ed to oversample cases who just
missed screening positive. A barrier to
this approach was that many families
declined to schedule or attend this
session. However, of the 375 completed,
7 ASD cases were detected, suggesting
that this is a successful strategy for
�nding casesmissed by theM-CHAT-R/F.
In fact, these cases contributed to the
change in threshold for the follow-up. A
�nal approach to �nding missed cases
is under way, rescreening participants
bymail when they are 3.5 to 4 years old.
Future research should validate the M-
CHAT-R/F in high-risk samples. Our
group is screening children with older
siblings already diagnosed with ASD,
but additional high-risk groups include
children referred for early intervention
but not yet diagnosed and children with
risk factors for developmental delay,
such as prematurity. It will be essential
for such validationstudies todetermine
diagnosis, to evaluate the utility of the
M-CHAT-R/F in these high-risk samples,
and to assess whether the published
thresholds for low-risk, or level 1,
samples are the same or different in
these high-risk groups.
Additional examination of thresholds
for low-, medium-, and high-risk scores
on the M-CHAT-R will also be fruitful. As
the threshold for bypassing the follow-
up and referring immediately is low-
ered, the risk of unnecessary referrals
increases. A risk-bene�t analysis may
help balance the cost of unnecessary
referrals against the bene�t of imme-
diate referral for those who need in-
tensive early intervention.
Conclusions
The M-CHAT-R/F is an effective tool to
screen for ASDs in low-risk pediatric
samples. Integration of screening and
surveillance strategies reduces the age
of ASD diagnosis by 2 years, facilitating
early intervention and optimizing long-
term prognosis. The simpli�ed scoring
of the M-CHAT-R/F, paired with speci�c
algorithms based on outcome, should
ease implementation.
ACKNOWLEDGMENTS
We thank all of the toddlers and their
families for participating in the
screening study. In addition, we thank
the pediatricians and health care pro-
viders for distributing the M-CHAT-R
during well-child care visits and all
of the members of the research team
who participated in data collection. We
also thank our funding source, the
Eunice Kennedy Shriver National Insti-
tute of Child Health and Human Devel-
opment.
REFERENCES
1. Autism Spectrum Disorder. American Psy-
chiatric Association. Diagnostic and Sta-
tistical Manual of Mental Disorders. 5th ed.
Arlington, VA: American Psychiatric Pub-
lishing; 2013:50–59
2. Autism and Developmental Disabilities
Monitoring Network Surveillance Year 2008
Principal Investigators; Centers for Disease
Control and Prevention. Prevalence of au-
tism spectrum disorders—Autism and
Developmental Disabilities Monitoring Net-
work, 14 sites, United States, 2008. MMWR
Surveill Summ. 2012;61(3):1–19
3. Myers SM, Johnson CP; American Academy
of Pediatrics Council on Children With
Disabilities. Management of children with
autism spectrum disorders. Pediatrics.
2007;120(5):1162–1182
4. Johnson CP, Myers SM; American Academy
of Pediatrics Council on Children With
Disabilities. Identi�cation and evaluation of
children with autism spectrum disorders.
Pediatrics. 2007;120(5):1183–1215
5. Mandell DS, Listerud J, Levy SE, Pinto-
Martin JA. Race differences in the age at
diagnosis among Medicaid-eligible chil-
dren with autism. J Am Acad Child Adolesc
Psychiatry. 2002;41(12):1447–1453
6. Robins DL, Fein D, Barton M. The Modi�ed
Checklist for Autism in Toddlers (M-CHAT).
Self-published; 1999
7. Canal-Bedia R, García-Primo P, Martín-
Cilleros MV, et al. Modi�ed Checklist for
Autism in Toddlers: cross-cultural adapta-
tion and validation in Spain. J Autism Dev
Disord. 2011;41(10):1342–1351
8. Inada N, Koyama T, Inokuchi E, et al. Re-
liability and validity of the Japanese ver-
sion of the Modi�ed Checklist for Autism in
Toddlers (M-CHAT). Res Autism Spectr Dis-
ord. 2011;5(1):330–336
9. Gura GF, Champagne MT, Blood-Siegfried JE.
Autism spectrum disorder screening in
primary care. J Dev Behav Pediatr. 2011;32
(1):48–51
10. Dumont-Mathieu T, Fein D. Screening for
autism in young children: the Modi�ed
Checklist for Autism in Toddlers (M-CHAT)
and other measures. Ment Retard Dev
Disabil Res Rev. 2005;11(3):253–262
11. Kleinman JM, Robins DL, Ventola PE, et al.
The Modi�ed Checklist for Autism in Tod-
dlers: a follow-up study investigating the
early detection of autism spectrum disor-
ders. J Autism Dev Disord. 2008;38(5):827–
839
12. Chlebowski C, Robins DL, Barton ML, Fein D.
Large-scale use of the Modi�ed Checklist
for Autism in low-risk toddlers. Pediatrics.
2013;131(4):e1121–e1127
13. Nygren G, Sandberg E, Gillstedt F, Ekeroth G,
Arvidsson T, Gillberg C. A new screening
programme for autism in a general pop-
ulation of Swedish toddlers. Res Dev Dis-
abil. 2012;33(4):1200–1210
14. Robins DL, Fein D, Barton M. The Modi�ed
Checklist for Autism in Toddlers, Revised
with Follow-Up (M-CHAT-R/F). Self-published;
2009
15. Robins DL, Fein D, Barton ML, Green JA. The
Modi�ed Checklist for Autism in Toddlers:
an initial study investigating the early de-
tection of autism and pervasive develop-
mental disorders. J Autism Dev Disord.
2001;31(2):131–144
16. Lord C, Risi S, Lambrecht L, et al. The
Autism Diagnostic Observation Schedule-
Generic: a standard measure of social and
communication de�cits associated with the
spectrum of autism. J Autism Dev Disord.
2000;30(3):205–223
17. Schopler E, Reichler RJ, Renner BR. The
Childhood Autism Rating Scale-2.Los
44 ROBINS et al
at University of Wisconsin-Madison on February 4, 2014pediatrics.aappublications.orgDownloaded from

Angeles, CA: Western Psychological Ser-
vices; 2010
18. Barton M, Boorstein H, Herlihy L, Dumont-
Mathieu T, Fein D. Toddler ASD Symptom
Interview. Self-published; 2012
19. Mullen EM. Mullen Scales of Early Learning.
Circle Pines, MN: American Guidance Ser-
vice, Inc; 1995
20. Sparrow SS, Cicchetti DV, Balla DA. Vineland
Adaptive Behavior Scales. 2nd ed. (Vineland
II) Survey Interview Form/Caregiver Rating
Form. Livonia, MN: Pearson Assessments;
2005
21. Reynolds CR, Kamphaus RW. Behavior As-
sessment System for Children (BASC-2).
2nd ed. Bloomington, MN: Pearson Assess-
ments; 2004
22. American Psychiatric Association. Di-
agnostic and Statistical Manual of Mental
Disorders. 4th ed, text revision. Wash-
ington, DC: American Psychiatric Associa-
tion; 2000
23. Stone WL, Coonrod EE, Ousley OY. Brief re-
port: Screening Tool for Autism in Two-year-
olds (STAT): development and preliminary
data. J Autism Dev Disord. 2000;30(6):607–
612
24. Glascoe FP. Parents’ Evaluation of De-
velopmental Status (PEDS). Nolensville, TN:
PEDSTest.com, LLC; 2010. Available at: www.
pedstest.com. Accessed September 9, 2013
25. Wiggins LD, Piazza V, Robins DL. Compari-
son of a broad-band screen versus disorder-
speci�c screen in detecting young children
with an autism spectrum disorder [published
online December 21, 2012]. Autism. 2012.
Available at: http://aut.sagepub.com/content/
early/2012/12/21/1362361312466962.full.pdf.
(Accessed September 4, 2013)
26. Marks K, Glascoe FP, Aylward GP, Shevell MI,
Lipkin PH, Squires JK. The thorny nature of
predictive validity studies on screening
tests for developmental-behavioral prob-
lems. Pediatrics. 2008;122(4):866–868
27. Pierce K, Carter C, Gallagher N, et al.
Detecting, studying, and treating autism
early: the one-year well-baby check-up ap-
proach. J Pediatr. 2011;159(3):458–465
28. Herlihy L, Brooks B, Dumont-Mathieu T,
et al. Standardized screening facilitates
timely diagnosis of autism spectrum dis-
order in a diverse sample of low-risk tod-
dlers. J Dev Behav Pediatr. 2013, In press
(Continued from �rst page)
www.pediatrics.org/cgi/doi/10.1542/peds.2013-1813
doi:10.1542/peds.2013-1813
Accepted for publication Oct 21, 2013
Address correspondence to Diana L. Robins, PhD, Department of Psychology, Georgia State University, PO Box 5010, Atlanta, GA 30302-5010. E-mail: drobins@gsu.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright ? 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Robins is co-owner of M-CHAT LLC, which receives royalties from parties that license use of the M-CHAT in electronic products. Drs Fein
and Barton are co-owners of M-CHAT LLC; they receive royalties, which are entirely allocated to research and clinical training expenditures. No royalties were
received for any of the data presented in the current study. The other authors have indicated they have no �nancial relationships relevant to this article to disclose.
FUNDING: This study was supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development grant R01HD039961. Funded by the
National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: Dr Robins is co-owner of M-CHAT LLC, which licenses use of the M-CHAT in electronic products. The other authors have indicated
they have no potential con�icts of interest to disclose.
ARTICLE
PEDIATRICS Volume 133, Number 1, January 2014 45
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DOI: 10.1542/peds.2013-1813
; originally published online December 23, 2013;Pediatrics
Dumont-Mathieu and Deborah Fein
Diana L. Robins, Kar s Casagrande, Marianne Barton, Chi-Ming A. Chen, Thyde
Follow-up (M-CHAT-R/F)
Validation of the Modified Checklist for Autism in Toddlers, Revised With


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