Validation of the modified checklist for autism in toddlers, revised with follow-up in Taiwanese toddlers

Validity and feasibility of using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) in primary care clinics in Singapore

LAY ABSTRACT

Systematic screening for autism in early childhood has been suggested to improve eventual outcomes by facilitating earlier diagnosis and access to intervention. However, clinical implementation of screening has to take into account effectiveness and feasibility of use within a healthcare setting for accurate diagnosis of autism. In Singapore, autism screening using a structured screening tool is not currently employed as a part of routine well-child visits for children in primary care clinics. In this study, 5336 children (aged 17-20 months) were screened for autism using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by nursing staff at each clinic. Children screened positive and a portion of those screened negative then underwent diagnostic assessments to determine whether they met the diagnostic criteria for autism. In total, 113 (2.1%) were screened positive, of which 54 (1.0%) met the criteria for autism. Children who screened positive and received a diagnosis accessed autism-specific intervention at an average age of 22 months. Nurses and physicians rated the acceptability and practicality of the M-CHAT-R/F highly. Therefore, the M-CHAT-R/F questionnaire was an effective and feasible tool for autism screening among 18-month-old children in this study. Future studies will be designed to determine the optimal age of screening and role of repeated screening in Singapore, as well as to better understand any potential improved outcomes nationwide compared with pre-implementation of autism screening.

Comparison between the Clancy Behavior Scale and the Modified Checklist for Autism in Toddlers in Taiwan

(1) Background: Precise diagnosis and early intervention are crucial for toddlers with autism spectrum disorder (ASD) to achieve a better prognosis. This study investigated the efficacy of the Clancy Behavior Scale (CBS) and Modified Checklist for Autism in Toddlers (M-CHAT) in detecting ASD among toddlers under 30 months of age. (2) Methods: A total of 215 toddlers (117 with ASD and 98 with development delays) aged between 18 and 29 months participated in this study. All the primary caregivers of these toddlers were recruited to complete the CBS and M-CHAT. (3) Results: The findings indicated that the accuracy of the CBS and M-CHAT was promising, and the short forms of these two instruments performed better than their full versions. The CBS:9 critical items presented a sensitivity of 0.75 and a specificity of 0.74, while the M-CHAT:14 brief items showed a sensitivity of 0.72 and a specificity of 0.85. (4) Conclusions: The diagnostic accuracy of high-risk ASD toddlers improved via the combination of CBS and M-CHAT, particularly when the information gathered from these two instruments were consistent. The findings may provide implications for enhancing the early detection of ASD.

Screening for Autism: A Review of the Current State, Ongoing Challenges, and Novel Approaches on the Horizon

Screening for autism is recommended in pediatric primary care. However, the median age of autism spectrum disorder (ASD) diagnosis is substantially higher than the age at which autism can reliably be identified, suggesting room for improvements in autism recognition at young ages, especially for children from minoritized racial and ethnic groups, low-income families, and families who prefer a language other than English. Novel approaches are being developed to utilize new technologies in aiding in autism recognition. However, attention to equity is needed to minimize bias. Additional research on the benefits and potential harms of universal autism screening is needed. The authors provide suggestions for pediatricians who are considering implementing autism-screening programs.

Early detection of neurodevelopmental disorders in African children living in informal settlements in Nairobi

BACKGROUND

Children in low-income and middle-income countries (LMICs) are at a substantially increased risk of delayed physical, emotional and sociocognitive outcomes, with consequential neurodevelopmental disorders. Evidence based, cost-effective and culturally appropriate screening tools are recommended for early identification of developmental disorders.

METHODS

The present study aims to assess the feasibility of early screening for neurodevelopmental disorders in children living in informal settlements in Nairobi, Kenya (Korogocho). The selected tools (ie, the CDC checklist and the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)), widely used in high-income countries, are applied in two different populations: one from Kenya (LMIC) and one from Italy, to compare the different scores.

RESULTS

Of 509 children screened, 8.6% were classified at-risk based on the results of the screening tools. Significant risk factors are history of low birth weight and Apgar score, presence of neurological disorders, malnutrition and/or rickets, younger age of the child and older age of the mother. Caesarean section delivery, first pregnancy and mothers' older age were common risk factors among the Kenyan and the Italian samples. The Italian sample had a significantly greater rate of missed milestones.

CONCLUSIONS

Our data demonstrate the feasibility of using the CDC and M-CHAT-R tools in informal settlement dwellers. Further studies are needed to explore the opportunity for early diagnosis of developmental disorders in LMICs.

Meta-analysis of the Modified Checklist for Autism in Toddlers, Revised/Follow-up for Screening

CONTEXT

The Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F) is used worldwide to screen for autism spectrum disorder (ASD).

OBJECTIVE

To calculate psychometric properties of the M-CHAT-R/F for subsequent diagnosis of ASD.

DATA SOURCES

Systematic searches of Medline, Embase, SCOPUS, and Trip Pro databases from January 2014 to November 2021.

STUDY SELECTION

Studies were included if they (1) used the M-CHAT-R/F (2) applied standard scoring protocol, (3) used a diagnostic assessment for ASD, and (4) reported at least 1 psychometric property of the M-CHAT-R/F.

DATA EXTRACTION

Two independent reviewers completed screening, full-text review, data extraction, and quality assessment, following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A random-effects model was used to derive pooled estimates and assess for between-study heterogeneity.

RESULTS

Of 667 studies identified, 15 with 18 distinct samples from 10 countries (49 841 children) were used in the meta-analysis. Pooled positive predictive value (PPV), was 57.7% (95% confidence interval [CI] 48.6-66.8, τ2 = 0.031). PPV was higher among high-risk (75.6% [95% CI 66.0-85.2]) than low-risk samples (51.2% [95% CI 43.0-59.5]). Pooled negative predictive value was 72.5% (95% CI 62.5-82.4 τ2 = 0.031), sensitivity was 82.6% (95% CI 76.2-88.9) and specificity 45.7% (95% CI 25.0-66.4).

LIMITATIONS

Negative predictive value, sensitivity, and specificity were calculated based on small sample sizes because of limited or no evaluation of screen-negative children.

CONCLUSIONS

These results support use of the M-CHAT-R/F as a screening tool for ASD. Caregiver counseling regarding likelihood of an ASD diagnosis after positive screen should acknowledge the moderate PPV.

Sensitivity and Specificity of the Modified Checklist for Autism in Toddlers (Original and Revised): A Systematic Review and Meta-analysis

Importance

The Modified Checklist for Autism in Toddlers (M-CHAT) and the M-CHAT, Revised With Follow-up (M-CHAT-R/F)-henceforth referred to as M-CHAT(-R/F)-are the most commonly used toddler screeners for autism spectrum disorder (ASD). Their use often differs from that in the original validation studies, resulting in a range of estimates of sensitivity and specificity. Also, given the variability in reports of the clinical utility of the M-CHAT(-R/F), researchers and practitioners lack guidance to inform autism screening protocols.

Objective

To synthesize variability in sensitivity and specificity of M-CHAT(-R/F) across multiple factors, including procedures for identifying missed cases, likelihood level, screening age, and single compared with repeated screenings.

Data Sources

A literature search was conducted with PubMed, Web of Science, and Scopus to identify studies published between January 1, 2001, and August 31, 2022.

Study Selection

Articles were included if the studies used the M-CHAT(-R/F) (ie, original or revised version) to identify new ASD cases, were published in English-language peer-reviewed journals, included at least 10 ASD cases, reported procedures for false-negative case identification, screened children by 48 months, and included information (or had information provided by authors when contacted) needed to conduct the meta-analysis.

Data Extraction and Synthesis

The systematic review and meta-analysis was conducted within the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. The Quality Assessment of Diagnostic Accuracy Studies-2 tool evaluated bias in sample selection. Data extraction and quality assessment were performed by 2 authors independently. The overall diagnostic accuracy of the M-CHAT(-R/F) was assessed with the hierarchic summary receiver operating characteristic (HSROC) model.

Main Outcomes and Measures

Sensitivity, specificity, diagnostic odds ratios, and HSROC curves of M-CHAT(-R/F).

Results

The review included 50 studies with 51 samples. The pooled sensitivity of M-CHAT(-R/F) was 0.83 (95% CI, 0.77-0.88), and the pooled specificity was 0.94 (95% CI, 0.89-0.97). Heterogeneity analyses revealed greater diagnostic accuracy for low- vs high-likelihood samples, a concurrent vs prospective case confirmation strategy, a large vs small sample size, use of M-CHAT(-R/F) Follow-up, and non-English vs English only.

Conclusions and Relevance

Overall, results of this study suggest the utility of the M-CHAT(-R/F) as an ASD screener. The wide variability in psychometric properties of M-CHAT(-R/F) highlights differences in screener use that should be considered in research and practice.

Cultural Adaptation and Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up in Moroccan Arabic dialect

BACKGROUND

The prevalence of autism spectrum disorder is increasing worldwide, making screening and early intervention necessary. Several screening instruments have been developed in recent years. The Modified Checklist for Autism in Toddlers Revised with Follow-up (M-CHAT-R/F) is considered to be one of the specific measures designed to identify toddlers at risk for autistic spectrum disorder.

OBJECTIVE

The aim of the study was to translate and adapt the original version of M-CHAT-R/F from the English to the Moroccan Arabic language.

STUDY DESIGN

Specialized translators and clinicians ensured forward and backward translation of the scale into Moroccan Arabic. Then, a two-stage screening of the M-CHAT-R/F-T was applied to a study sample comprised of 56 toddlers with autistic spectrum disorder (category I) and 96 toddlers with normal development (category II). "Kappa test", "Cronbach's alpha" test, the intra class correlation coefficient, and the area under the curve were determined.

RESULT

The average score results of M-CHAT-R/F were 13.12 for category I, while it was 2.24 for category II. The Cronbach's alpha coefficient of the checklist was 0.929. The kappa values ranged from k=0.78 to k=0.97 with a confidence interval of 95% indicating good convergence. The intra-class correlation coefficient ranged from 0.97 to 0.99, which is excellent. The area under the curve in our study was 0.988, an excellent result.

CONCLUSION

Efficiency of the Moroccan Arabic version of the MCHAT was demonstrated for screening in the general population.

Psychometric properties of the Mandarin version of the autism diagnostic observation Schedule-Generic

BACKGROUND/PURPOSE

The diagnosis of autism spectrum disorder (ASD), involving multiple components of clinical assessments, is challenging. The Autism Diagnostic Observation Schedule-Generic (ADOS-G), one of the standardized and validated instruments for ASD diagnostic evaluation, has been widely used in many countries. With the preparation of the Mandarin version of the ADOS-G (Mandarin-ADOS-G), this study aims to examine its psychometric properties, including reliability and validity.

METHODS

The sample included 554 individuals clinically diagnosed with ASD (477 males, 86.1%) and 50 typically developing (TD) individuals (29 males, 58.0%) who were assessed with different modules of the Mandarin-ADOS-G between 4.1 and 34.0 years old with a mean age of 13.0 years (Module 1, n = 40; Module 2, n = 46; Module 3, n = 275; Module 4, n = 243). We evaluated the inter-rater reliability, test-retest reliability, internal consistency, and concurrent validity with the Chinese Autism Diagnostic Interview-Revised (ADI-R) and Social Responsiveness Scale (SRS) caregiver-report and self-report forms. The discriminative validity of Mandarin-ADOS-G was also examined.

RESULTS

The Mandarin-ADOS-G demonstrated good inter-rater reliability (agreement of ADOS classification 0.91), good test-retest reliability (intraclass correlations 0.55-0.73), and low to high good internal consistency (Cronbach's alpha 0.27-0.86). The concurrent validity showed significant correlations with ADI-R (Pearson correlations 0.22-0.37) and the SRS caregiver-report form (Pearson correlations 0.15-0.23). Moreover, all Mandarin-ADOS-G domains successfully differentiated autistic individuals from TD individuals (all p-values <0.001).

CONCLUSION

The Mandarin-ADOS-G is a reliable and valid instrument for assisting the diagnosis of ASD in the Mandarin-speaking population.

Cultural Adaptation and Validation of Mullen Scales of Early Learning in Taiwanese children with Autism Spectrum Disorder, Global Developmental Delay, and Typically Developing Children

BACKGROUND

The Mullen Scales of Early Learning (MSEL) is a standardized comprehensive developmental assessment tool for children aged 0-68 months. However, few Asia-based studies have explored cultural and linguistic adaptations of the MSEL or investigated its psychometric properties in populations with autism spectrum disorder (ASD).

AIMS

This study evaluated the reliability and validity of the MSEL-Taiwan version (MSEL-T) for Taiwanese children with ASD, global developmental delay (GDD), and typical development (TD).

METHODS AND PROCEDURES

The MSEL items were translated and modified according to the language and culture in Taiwan. In total, 191 children (ASD, 69; GDD, 36; and TD, 86) aged 19-68 months were assessed using the MSEL-T and Peabody Developmental Motor Scales 2 (PDMS-2) at enrollment, followed by the assessments of Vineland Adaptive Behavior Scale-Chinese version (VABS-C) at the age of 36 months or later.

OUTCOMES AND RESULTS

All subscales were verified to have good interrater reliability and internal consistency, and subscale scores indicated moderate to high correlations with PDMS-2 and VABS-C scores. Significant differences in MSEL-T scores were observed between same-aged pairs of children with TD and GDD and between pairs of children with TD and ASD.

CONCLUSIONS AND IMPLICATIONS

The findings provide evidence of validity and reliability of the MSEL-T. And it is suggested that the culturally and linguistically adapted MSEL-T is a good tool for the clinical assessment of children with and without ASD.

Psychometric Comparison of the English and Spanish Western-Hemisphere Versions of the Modified Checklist for Autism in Toddlers-Revised

OBJECTIVES

Parent-report screening tools for autism spectrum disorder (ASD) are widely used to promote early identification of children with or at risk for ASD. Most screening tools have been developed in English in the United States or United Kingdom; thus, translated versions are needed for use with culturally and linguistically diverse populations. Traditional translation methods include a forward translation, back translation, and review. However, when used in new cultural and linguistic contexts, this "forward-back" approach may have limitations, including differing psychometric properties compared with original instruments. This study presents a psychometric analysis of the forward-back translation methodology of an ASD screening tool.

METHODS

A retrospective chart review design was used to examine Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R; Robins et al.) records from 2974 toddlers. Data were compared between caregivers who completed the original English M-CHAT-R and caregivers who completed its forward-back "Spanish-Western Hemisphere" translation to compare select psychometric properties of the 2 instruments.

RESULTS

Significant differences were observed between the 2 versions, including a higher overall risk score, higher initial screen-positive rate, and increased likelihood of leaving items blank among Spanish-speaking respondents.

CONCLUSION

Traditional translation methods seemed to affect select psychometric properties between translations of the M-CHAT-R. A more rigorous cultural adaptation approach may be necessary to maintain equivalence with the original instrument. Until new rigorous translations are available, it is recommended that language-specific screening tools continue to be used, along with recommended follow-up interviews, to avoid exacerbating existing health disparities.

Get SET Early to Identify and Treatment Refer Autism Spectrum Disorder at 1 Year and Discover Factors That Influence Early Diagnosis

OBJECTIVES

To examine the impact of a new approach, Get SET Early, on the rates of early autism spectrum disorder (ASD) detection and factors that influence the screen-evaluate-treat chain.

STUDY DESIGN

After attending Get SET Early training, 203 pediatricians administered 57 603 total screens using the Communication and Symbolic Behavior Scales Infant-Toddler Checklist at 12-, 18-, and 24-month well-baby examinations, and parents designated presence or absence of concern. For screen-positive toddlers, pediatricians specified if the child was being referred for evaluation, and if not, why not.

RESULTS

Collapsed across ages, toddlers were evaluated and referred for treatment at a median age of 19 months, and those screened at 12 months (59.4% of sample) by 15 months. Pediatricians referred one-third of screen-positive toddlers for evaluation, citing lack of confidence in the accuracy of screen-positive results as the primary reason for nonreferral. If a parent expressed concerns, referral probability doubled, and the rate of an ASD diagnosis increased by 37%. Of 897 toddlers evaluated, almost one-half were diagnosed as ASD, translating into an ASD prevalence of 1%.

CONCLUSIONS

The Get SET Early model was effective at detecting ASD and initiating very early treatment. Results also underscored the need for change in early identification approaches to formally operationalize and incorporate pediatrician judgment and level of parent concern into the process.

Cognitive development of children with Kawasaki disease and the parenting stress of their caregivers in Taiwan: a case-control study

OBJECTIVE

Kawasaki disease (KD) is an acute form of febrile vasculitis that occurs in early childhood. The multisystemic vasculitis common in patients with KD may influence blood perfusion in the brain, and thus caregivers of children with KD may feel stress with regard to caring for them. Intravenous immunoglobulin (IVIG) infusion is the standard treatment for acute KD, and the most serious complication of KD is coronary artery aneurysms (coronary artery lesion (CAL)). This study aimed to investigate the relationships between KD heterogeneity and the risk of patients' cognitive impairment or caregivers' parenting stress.

DESIGN

A case-control study with consecutive sampling.

SETTING

A medical centre (Kaohsiung Chang Gung Memorial Hospital, Taiwan).

PARTICIPANTS

This study consisted of 176 patients with KD (mean age: 5.5 years, 60.8% boys) and 85 healthy children (mean age: 6.4 years, 54.1% boys).

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on the children's age, each patient with KD and control subject was administered an assessment using the Mullen Scales of Early Learning or the Wechsler Intelligence Scale, and parenting function of their caregivers was assessed using the Parenting Stress Index (PSI)-Short Form.

RESULTS

We observed no significant differences in any developmental index, cognitive function or parenting stress between patients with KD and controls. Among the children with KD, IVIG administration nor CAL was associated with children's cognitive scores. However, the caregivers of patients who had CAL suffered from greater PSI total scores than those of patients without CAL. Furthermore, the caregivers who had education levels of a master's degree or above showed less parenting stress than those who had an education level of college or lower.

CONCLUSION

Caregivers' education is associated to parenting stress, and caregivers of patients with KD who developed CAL may feel stress about the unpredictable sequela caused by CAL for their children. Such caregivers may require support to fulfil their parenting roles.

Relationship Between Motor Skills and Language Abilities in Children With Autism Spectrum Disorder

OBJECTIVES

Few studies have examined the relationship between language abilities and specific motor skills in toddlers with autism spectrum disorder (ASD). The aim of this study was to compare the relationship of receptive language (RL) and expressive language (EL) abilities with motor functioning in toddlers with ASD aged 24 to 36 months and their peers with typical development (TD). Furthermore, the study compared multidimensional motor functioning in toddlers with ASD with delayed RL and EL development and toddlers with ASD and typical RL and EL development. The predictive powers of the motor skills were examined for the group with delayed RL and EL development.

METHODS

The language abilities of 38 toddlers with ASD and 38 age-matched toddlers with TD were evaluated using the Receptive and Expressive Language Subscales of the Mullen Scale of Early Learning, and their motor skills were assessed using the Peabody Developmental Motor Scales, Second Edition.

RESULTS

Significant correlations between language ability and motor functioning were observed in the ASD and TD groups. The ASD group with delayed RL and EL development had lower scores for multidimensional motor functioning than the ASD group with typical RL and EL development and the TD group. Moreover, the risks of delayed EL and RL development could be predicted by the lower motor scores in toddlers with ASD.

CONCLUSIONS

The positive correlation between language abilities and motor functioning in toddlers with ASD indicated potential connections between the early onsets of motor and speech-language impairments in these toddlers.

IMPACT

The results may have implications for the development of motor-based interventions targeting language development in young children with ASD.

Comparison of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) Positive Predictive Value by Race

The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) is the most widely used screener for ASD. Despite the comparable rate of ASD in Black and White children, the M-CHAT-R/F was validated on a primarily White, Non-Hispanic sample. Few studies have assessed whether the screener performs adequately with racial minorities. This study compared the M-CHAT-R/F Positive Predictive Value (PPV), for ASD, and for any developmental condition, in Black and White children. We also examined M-CHAT-R/F item-level PPV by race. The PPVs for ASD and other developmental disorders were similar in both racial groups for total score and individual items. Therefore, our findings support the use of the M-CHAT-R/F with Black and White children.

Modified Checklist for Autism in Toddlers Revised (MCHAT-R/F) in an Urban Metropolitan Sample of Young Children in Turkey

The study assessed the feasibility of using a Turkish-version of the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R/F) as a screening tool for an urban low risk population of young children. M-CHAT-R/F was completed for 6712 children between ages 16 and 36 months living in Istanbul, Turkey. Autism Diagnostic Observation Schedule-2 was served as the main measure for diagnosis. M-CHAT-R/F screen was positive for 9.8% of children. At follow up interview, 39.7% of initial screen-positive children met criteria for ASD. The study identified 57 (1 in 117) children with ASD (0.8%; 95% CI 0.063-1.05%). M-CHAT-R/F performed comparably in Turkey as in United States. Implications of the study for future universal screening for autism in Turkey is also discussed.

Multidimensional Developments and Free-Play Movement Tracking in 30- to 36-Month-Old Toddlers With Autism Spectrum Disorder Who Were Full Term

BACKGROUND

Few studies have investigated multidimensional developments and free-play movement performance in toddlers with an early diagnosis of autism spectrum disorder (ASD).

OBJECTIVE

This study compared cognitive, motor, and behavioral developments and free-play movement performance in toddlers with ASD who were full term (FT-ASD), toddlers who were full term and are typically developing (FT-TD), and toddlers who were born preterm and had a very low birth weight (VLBW-PT).

DESIGN

This was a prospective cross-sectional study.

METHODS

Forty-five 30- to 36-month-old age-matched toddlers were recruited and divided into FT-ASD, FT-TD, and VLBW-PT groups. Their developments were examined using the Mullen Scales of Early Learning; the Peabody Developmental Motor Scales, Second Edition; the Child Behavior Checklist for Ages 1.5 to 5; and the Repetitive Behavior Scale-Revised. In addition, the toddlers' free-play movements were tracked in laboratory settings using an automatic movement tracking system.

RESULTS

Toddlers with FT-ASD exhibited lower cognitive and motor scores and a higher degree of behavioral problems compared with toddlers with FT-TD or VLBW-PT. Furthermore, the movement tracking data in a free-play setting revealed that toddlers with FT-ASD displayed a higher degree of turning velocity, a higher moving time, and a higher frequency of moving toward the peripheral region compared with toddlers with FT-TD or VLBW-PT. Moreover, several motor developmental and movement-tracking indicators were found to correlate with behavioral problems and cognitive scores in toddlers with FT-ASD.

LIMITATIONS

The study results may have been affected by the small sample size, the cross-sectional design, and tracking only the whole body without subtle movements or segmental motions.

CONCLUSIONS

The findings suggest varied aspects of co-occurring developmental conditions and movement-based problems in toddlers with FT-ASD. Using standardized and sensitive measures for the early assessment of perceptuo-motor impairments is necessary for timely early intervention for such toddlers.