Toddler Screening for Autism Spectrum Disorders:

The Modified Checklist for Autism in Toddlers

(M-CHAT)Diana L. Robins, Ph.D.Georgia State University

drobins@gsu.eduwww.mchatscreen.com

Pervasive Developmental

DisordersAutistic Disorder (autism)Asperger’s DisorderRett’s DisorderChildhood Disintegrative DisorderPervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)Collectively called the autism spectrum or the PDD spectrum

DSM-IV Diagnostic Criteria for Autism

Early Deficits in Language & Communication

Impairments in Reciprocal Social Interaction

Restrictive, Repetitive, Stereotyped Behavior

Autism Criteria: Social Impairment

Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction Failure to develop peer relationships appropriate to developmental level Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) Lack of social or emotional reciprocity

Red Flags in Toddlers: Social

Lack of pointing (esp. to declare interest)

Reduced joint attention

Failure to orient to parent’s face

Reduced response to name or voice

Lack of interest in peers

Failure to brings things to show parent

Reduced eye contact

Autism Criteria: Communication Deficits

Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others Stereotyped and repetitive use of language or idiosyncratic language Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

Red Flags in Toddlers: Communication

Delay in, or total lack of, the development of spoken language is theMOST COMMON PRESENTING CONCERN, but not specific to ASD

Stereotyped and repetitive use of language or idiosyncratic language

Red Flags in Toddlers: Play

Limited play skills

•Reduced or absent pretend play

•Reduced or absent imitative

play

Autism Criteria: Restricted, Repetitive, Stereotyped Behaviors, Interests, &

Activities

Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus Apparently inflexible adherence to specific, nonfunctional routines or rituals Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) Persistent preoccupation with parts of objects

Red Flags in Toddlers: Restricted, Repetitive, Stereotyped Behaviors,

Interests, & Activities

Often emerge later than symptoms in the social and communication domains

When present in toddlers, generally the lower-order, or less sophisticated behaviors, rather than preoccupations and rituals, which may require more cognitive skills

Diagnostic Criteria for Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)

Impairment(s) in Reciprocal Social Interaction

AND one of the following:

Early Deficit in Language &

Communication OR

Restrictive, Repetitive, Stereotyped Behavior

Motivation for Early Detection

Severity of diagnosis

Outcome improved by early intervention (Baird et al., 2001; Bryson, Rogers, & Fombonne, 2003; Dawson, Ashman, & Carver, 2000; Lord, 1995; Prizant & Wetherby, 1988)

Practice Parameters (Filipek et al., 1999, 2000) emphasized need for improved early detection

Delay in DiagnosisBirth 12 mos 24 mos 36 mos

Parents first concerned (15-22 mos){ {

Child seen by specialist (20-27 mos)

?Often further delay until definitive diagnosis

ASD-specific factors that influence the success of early

detectionHeterogeneity in presentation

Physicians’ time with children is briefAbsence of typical behavior is

challenging to detect

Motor milestones are usually preserved

Positive signs of ASD may develop later than social and communication deficits

AAP Screening Guidelines 2006 AAP Policy Statement (Pediatrics 118, 405-420)

• Surveillance at all well-child visits• Broad developmental screening at 9, 18, and 24/30 months

• ASD-specific screening at 18 months Gupta et al. (2007) comment on Policy Statement (Pediatrics, 119, 152-153)• ASD-specific screening at 18 and 24 months

2007 AAP Clinical Report (Johnson et al., Pediatrics 120, 1183-1215)

• recap of ASD screening recommendations

Need for Screening Tools

StandardizedSupplement professional observation or surveillanceClinical impressions are not sufficient (Johnson, 2007)Clear algorithms for referral to specialists for diagnostic evaluation are expected to reduce age of diagnosis, and facilitate onset of early intervention services

Available English-Language Toddler Screening

InstrumentsChecklist for Autism in Toddlers (CHAT; Baron-Cohen et al., 1992, 1996)

Pervasive Developmental Disorders Screening Test-II (PDDST-II; Siegel, 2004)Screening Tool for Autism in Two-Year-Olds (STAT; Stone et al., 2000, 2004)Social Communication Questionnaire (Rutter, Bailey, & Lord, 2003)

Available English-Language Toddler Screening Instruments,

cont.Autism Observation Scale for Infants (Zwaigenbaum et al., 2008)Systematic Observation of Red Flags (Wetherby et al. 2004)Developmental Behavior Checklist, Early Screen (Gray et al., 2005)Quantitative Checklist for Autism in Toddlers (Allison et al., 2008)

Modified Checklist for Autism in Toddlers (M-CHAT; Robins et al., 1999, 2001)

M-CHAT (Robins, Fein, & Barton, 1999)

Eliminated CHAT observation sectionExpanded CHAT parent report section• Literature• Clinical judgment

Age range: 16-30 months

Administration time: 5-10 minutes

Goal: Identify all ASD, not just autism2nd goal after Baird et al., 2000 CHAT paper published: improve sensitivity

9 CHAT items

Follow-Up Interview Sample

How to Score the M-CHATFor all items except 11, 18, 20, & 22 a response of NO is a screen positive responseItems 2, 7, 9, 13, 14, 15 are criticalA child screens positive if the critical score is 2 or more OR if the total score is 3 or moreScoring instructions, template, and Excel scoring program available for download from www.mchatscreen.com

Overview of the M-CHAT Research in Multiple

Low-Risk (Primary Care) Samples

Total Screened (N=10,837)

Need Interview (N=899)Need Interview (N=899)

AT RISKAT RISK

AT RISKAT RISK

EvaluationEvaluation(N=132 +29*)(N=132 +29*)

Not at Risk

Pass (N=9938)

Declined/Excluded (N=169)

ASD ASD (N=50)(N=50)

Not at Risk

Non-ASD (N=54)

Pass (N=598)

Declined (N=57)

= 6-10%= 6-10%

= 16-24%= 16-24%

Kleinman et al., 2008; Pandey et al., 2008; Robins, 2008

Comparison between UConn and GSU Low-Risk Samples

UConn N=6050

Pandey et al., 2008

GSUN=4797

Robins, 2008

Failed M-CHAT 6.74% 9.71%Of those interviewed, failed interview

19.83% 16.85%

Of those evaluated based on M-CHAT and interview, diagnosed with ASD

43.28% 56.76%PPV

Psychometric Properties: Sensitivity

Ability to detect illness when truly presentTrue positives/all ASD in sample True positives/True positives + missesTP/(TP+FN)

Screen +

Screen -

ASD TP FN

nonASD FP TN

Psychometric Properties: Positive Predictive Value

Likelihood that positive result is a true positive case; Confidence that screen positive means significant risk of ASDTrue positives/all screen positivesTP/(TP+FP)

Screen +

Screen -

ASD TP FN

nonASD FP TN

Other Findings

Prevalence in this sample: 1 in 217Most of the remaining 54 children flagged by M-CHAT + Interview had significant language or global developmental delays (6 typically developing)Cases who passed the M-CHAT but were flagged by the pediatrician did not improve detection of ASD

15.77.6

0

20

40

60

80

100

Low Education High Education

Failing M-CHAT

< Bachelor’s deg

(n=376)

≥ Bachelor’s deg

(n=380)

% Failed M-CHAT

Effects of Maternal Education on M-CHAT

Screening

Zaj et al., 2007

p=.001

11.9

51.7

0

20

40

60

80

100

Low Education High Education

Failing Follow-up Interview% Failed Follow-up Interview

Zaj et al., 2007

Maternal Education, cont.

p=.000

< Bachelor’s deg

(n=376)

≥ Bachelor’s deg

(n=380)

Follow-up at age 4

1416 re-screened to dateOnly two possible missed cases detected so far75% ASD cases retain diagnosis25% no longer have ASD, although 60% of the “recovered” cases continue to have other mental health problems

(Kleinman, Robins et al., 2008)

Psychometric Properties of the M-

CHATSensitivity high, estimated in the 80-90% rangeSpecificity mid-high 90sPPV of M-CHAT alone is low (.1-.4)PPV of M-CHAT + Interview is moderate (.5-.6)

Kleinman et al., 2008; Pandey et al., 2008; Robins, 2008

Goals of the Ongoing M-CHAT Study

Screen an additional 20,000 children over the next 4-5 years (half in metro-Atlanta, half in Connecticut)Refine the M-CHATBetter characterize ASD in toddlers to facilitate early detection of ASDs & early intervention

Practical Issues in Screening for ASD

Who to screen: everyoneWhen to screen: 18 and 24-month well-child visits, PLUS other ages when surveillance indicates ASD concernsHow to screen: use a standardized, validated instrument

Incorporate Screening in the Primary Care Setting

Parents complete screen prior to, or at beginning of, well-child check-up

Physician or other healthcare professional reviews results during visit

Respond immediately to screen positive cases

How to Respond to a Screen Positive Case

Refer to a specialist for diagnosis• Psychologist• Developmental pediatrician• Autism centers

Refer to early intervention• Babies Can’t Wait• Private providers

Coordinate care

Georgia State University

Current Undergrads: Rebecca Bosch, April Coignard,Lora Henderson, Mirjana Ivanisevic, Amy Lasher, Molly Locklear, Robert Rivera, Janice Taylor, Sheniece Willis, Amber Wimsatt, Shelly ZodyPrevious lab members who contributed to the M-CHAT study: Assata Abayomi, Lyntovia Ashe, Nicolle Angeli, Jasmine Brigham, Laura Burch, Esther Choi, Leo Eng, Lama Farran, Wendy Greenway, Shelley Hinkle, Sean Hirt, Margaret Jones, Puja Joshi, Amy Lasher, Cassie Lovett, Melissa Nikolic, Christina Parfene, Ashley Proctor, Corey Reed, Ali Scott, Catherine Shelton, Gina Vanegas, Lisa Wiggins Center for Behavioral Neuroscience, NSF Agreement # Center for Behavioral Neuroscience, NSF Agreement #

IBN-9876754IBN-98767542R01HD 035612, R01HD 039961, GSU-CDC Seed Grant

Current postdocs, grad students and postbacs: Sharlet Anderson Margaret Banks Julia Juechter Meena Khowaja Susan McManus Kimberly Oliver Vivian Piazza Agata Rozga Noelle Santorelli Jamie Zaj

Diana L. Robins, Ph.D.

UConn Acknowledgements

National Institute of Child Health and Development

Maternal and Child Health Bureau

National Alliance for Autism Research/Autism Speaks

National Institute of Mental Health

U.S. Department of Education

UConn Research

Foundation

Deborah Fein, Ph.D.Marianne Barton, Ph.D.

James Green, Ph.D.

Thyde Dumont-Mathieu, M.D.Hilary C. Boorstein, B.A.

Pamela Ventola, Ph.D.

Emma L. Esser, M.A.

Sarah Hodgson, Ph.D.Jamie Kleinman, Ph.D.Gail Marshia, M.S.W.

Juhi Pandey, Ph.D.

Michael A. Rosenthal, M.A.

Saasha Sutera, M.A.

Alyssa D. Verbalis, M.A.

Leandra B. Wilson, M.A.

Eva Troyb, B.A.

Katelin Carr, B.A.