Journal of Autism and Developmental Disorders

, Volume 47, Issue 10, pp 3180–3188 | Cite as

Comparison of Autism Screening in Younger and Older Toddlers

  • Raymond Sturner
  • Barbara Howard
  • Paul Bergmann
  • Lydia Stewart
  • Talin E. Afarian
Original Paper


This study examined the effect of age at completion of an autism screening test on item failure rates contrasting older (>20 months) with younger (<20 months) toddlers in a community primary care sample of 73,564 children. Items related to social development were categorized into one of three age sets per criteria from Inada et al. (Research in Autism Spectrum Disorders 4(4):605–611, 2010). Younger toddlers produced higher rates of item failure than older toddlers and items in both of the later acquired item sets had higher probability rates for failure than the earliest acquired item set (prior to 8 months). Use of the same items and the same scoring throughout the target age range for autism screening may not be the best strategy for identifying the youngest toddlers at risk for autism.


Autism screening M-CHAT Developmental screening Test development 



We are grateful to all of the participating practices using CHADIS for clinical care. This project was funded in part by a grant from the NIMH Grant No. R44MH085399.

Author Contributions

RS and BH conceived of the study, participated in its design and coordination and drafted the manuscript; LS and TEA participated in the design and interpretation of the data; PB participated in the design of the study and performed the statistical analysis. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Conflict of interest

This study was conducted by the Center for Promotion of Child Development through Primary Care and its for-profit subsidiary, Total Child Health (TCH), Inc. CHADIS, the web-tool used in the study, was developed by Dr. Sturner and his spouse, Dr. Howard. Dr Sturner is Director of the Center and Dr. Howard is President of TCH. Both are members of the Board of Directors of both entities and are paid consultants to both entities.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. American Academy of Pediatrics. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics, 118(1), 405–420.CrossRefGoogle Scholar
  2. Araceli, R. C., Pablo, M. M. J., & Penélope, G. H. (2016). Maturational changes of the auditory system in normal preschool children assessed by brainstem auditory evoked potentials (BAEPs). Clinical Neurophysiology, 127(9), e320–e321. doi: 10.1016/j.clinph.2016.05.351.CrossRefGoogle Scholar
  3. Autism Speaks. (2016). Modified checklist for autism in toddlers, revised (M-CHAT-R). Retrieved August 3, 2016, from
  4. Baird, G., Charman, T., Baron-Cohen, S., Cox, A., Swettenham, J., Wheelwright, S., & Drew, A. (2000). A screening instrument for autism at 18 months of age: A 6-year follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 39(6), 694–702. doi: 10.1097/00004583-200006000-00007.CrossRefGoogle Scholar
  5. Barbaro, J., & Dissanayake, C. (2010). Prospective identification of autism spectrum disorders in infancy and toddlerhood using developmental surveillance: The social attention and communication study. Journal of Developmental & Behavioral Pediatrics, 31(5), 376–385. doi: 10.1097/DBP.0b013e3181df7f3c.CrossRefGoogle Scholar
  6. Barger, B. D., Campbell, J. M., & McDonough, J. D. (2013). Prevalence and onset of regression within autism spectrum disorders: A meta-analytic review. Journal of Autism and Developmental Disorders, 43(4), 817–828. doi: 10.1007/s10803-012-1621-x.CrossRefPubMedGoogle Scholar
  7. Baron-Cohen, S., Allen, J., & Giliberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161, 839–843.CrossRefPubMedGoogle Scholar
  8. Baron-Cohen, S., Cox, A., Baird, G., Swettenham, J., Nightingale, N. A. T. A. S. H. A., Morgan, K. A. T. E., ... Charman, T. (1996). Psychological markers in the detection of autism in infancy in a large population. The British Journal of Psychiatry, 168(2), 158–163.CrossRefPubMedGoogle Scholar
  9. Centers for Disease Control and Prevention (CDC). (2015). Autism spectrum disorder: Screening and diagnosis for health care providers. Retrieved August 8, 2016, from
  10. CHADIS—Comprehensive Health & Development Interactive System. Accessed 15 July 2017.
  11. Chlebowski, C., Robins, D. L., Barton, M. L., & Fein, D. (2013). Large-scale use of the modified checklist for autism in low-risk toddlers. Pediatrics, 131(4), e1121–e1127. doi: 10.1542/peds.2012-1525.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Christensen, D. L., et al. (2016). Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. MMWR Surveill Summ.Google Scholar
  13. Dudova, I., Markova, D., Kasparova, M., Zemankova, J., Beranova, S., Urbanek, T., & Hrdlicka, M. (2014). Comparison of three screening tests for autism in preterm children with birth weights less than 1,500 grams. Neuropsychiatric Disease and Treatment, 10, 2201–2208. doi: 10.2147/NDT.S72921.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Guy, A., Seaton, S. E., Boyle, E. M., Draper, E. S., Field, D. J., Manktelow, B. N., … Johnson, S. (2015). Infants born late/moderately preterm are at increased risk for a positive autism screen at 2 years of age. The Journal of Pediatrics, 166(2), 269–275. doi: 10.1016/j.jpeds.2014.10.053.CrossRefPubMedGoogle Scholar
  15. Howlin, P., Magiati, I., & Charman, T. (2009). Systematic review of early intensive behavioral interventions for children with autism. American Journal on Intellectual and Developmental Disabilities, 114(1), 23–41. doi: 10.1352/2009.114:23;nd41.CrossRefPubMedGoogle Scholar
  16. Inada, N., Kamio, Y., & Koyama, T. (2010). Developmental chronology of preverbal social behaviors in infancy using the M-CHAT: Baseline for early detection of atypical social development. Research in Autism Spectrum Disorders, 4(4), 605–611. doi: 10.1016/j.rasd.2009.12.003.CrossRefGoogle Scholar
  17. Kamio, Y., Inada, N., Koyama, T., Inokuchi, E., Tsuchiya, K., & Kuroda, M. (2014). Effectiveness of using the Modified Checklist for Autism in Toddlers in two-stage screening of autism spectrum disorder at the 18-month health check-up in Japan. Journal of Autism and Developmental Disorders, 44(1), 194–203. doi: 10.1007/s10803-013-1864-1.CrossRefPubMedGoogle Scholar
  18. Kim, S. H., Joseph, R. M., Frazier, J. A., O’Shea, T. M., Chawarska, K., Alfred, E. N., Leviton, A., & Kuban, K. K. (2016). Predictive validity of the Modified Checklist for Autism in Toddlers (M-CHAT) born very preterm. The Journal of Pediatrics, 178, 101–107.CrossRefPubMedGoogle Scholar
  19. Kleinman, J. M., Robins, D. L., Ventola, P. E., Pandey, J., Boorstein, H. C., Esser, E. L., & Barton, M. (2008). The modified checklist for autism in toddlers: A follow-up study investigating the early detection of autism spectrum disorders. Journal of Autism and Developmental Disorders, 38(5), 827–839. doi: 10.1007/s10803-007-0450-9.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Kuzniewicz, M. W., Wi, S., Qian, Y., Walsh, E. M., Armstrong, M. A., & Croen, L. A. (2014). Prevalence and neonatal factors associated with autism spectrum disorders in preterm infants. The Journal of Pediatrics, 164(1), 20–25. doi: 10.1016/j.jpeds.2013.09.021.CrossRefPubMedGoogle Scholar
  21. Mahoney, A. D., Minter, B., Burch, K., & Stapel-Wax, J. (2013). Autism spectrum disorders and prematurity: A review across gestational age subgroups. Advances in Neonatal Care, 13(4), 247–251. doi: 10.1097/ANC.0b013e31828d02a1.CrossRefPubMedGoogle Scholar
  22. National Autism Association. (2015). Signs and symptoms of autism. Retrieved August 8, 2016, from
  23. National Research Council. (2001). Educating children with autism. Washington, DC: National Academies Press.Google Scholar
  24. Ozonoff, S., Heung, K., Byrd, R., Hansen, R., & Hertz-Picciotto, I. (2008). The onset of autism: Patterns of symptom emergence in the first years of life. Autism Research, 1(6), 320–328. doi: 10.1002/aur.53.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Pandey, J., Verbalis, A., Robins, D. L., Boorstein, H., Klin, A., Babitz, T., & Fein, D. (2008). Screening for autism in older and younger toddlers with the Modified Checklist for Autism in Toddlers. Autism: The International Journal of Research and Practice, 12(5), 513–535. doi: 10.1177/1362361308094503.CrossRefGoogle Scholar
  26. Robins, D. L., Casagrande, K., Barton, M., Chen, C. M., Dumont-Mathieu, T., & Fein, D. (2014). Validation of the modified checklist for autism in toddlers, revised with follow-up (M-CHAT-R/F). Pediatrics, 133(1), 37–45. doi: 10.1542/peds.2013-1813.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (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(2), 131–144.CrossRefPubMedGoogle Scholar
  28. Siegel, B. (2004). Pervasive developmental disorders screening test-ii (pddst-ii). San Antonio, TX: Harcourt.Google Scholar
  29. Stenberg, N., Bresnahan, M., Gunnes, N., Hirtz, D., Hornig, M., Lie, K. K., & Schjølberg, S. (2014). Identifying children with autism spectrum disorder at 18 months in a general population sample. Paediatric and Perinatal Epidemiology, 28(3), 255–262. doi: 10.1111/ppe.12114.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Srisinghasongkram, P., Pruksananonda, C., Chonchaiya, W. (2016). Two-step screening of the modified checklist for autism in toddlers in Thai children with language delay and typically developing children. Journal of Autism and Developmental Disorders, 46, 3317–3329.CrossRefPubMedGoogle Scholar
  31. Størvold, G. V., Aarethun, K., & Bratberg, G. H. (2013). Age for onset of walking and prewalking strategies. Early Human Development, 89(9), 655–659. doi: 10.1016/j.earlhumdev.2013.04.010.CrossRefPubMedGoogle Scholar
  32. Sturner, R., Howard, B., Bergmann, P., Morrel, T., Andon, L., Marks, D., Rao, P., & Landa, R. (2016) Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics, 138(3), e20153036.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Sturner, R. A., Howard, B., Morrel, T., Bergmann, P., Walton, K., Marks, D., & Landa, R. (2013). Accurate autism screening at the 18 month visit requires different strategies than at 24 months. Presented at the Pediatric Academic Societies annual meeting, Washington, D. C.Google Scholar
  34. U.S. Preventive Services Task Force. (2016). Final Recommendation Statement: Autism spectrum disorder in young children: Screening. Accessed March 14, 2017, from
  35. Wetherby, A. M., Brosnan-Maddox, S., Peace, V., & Newton, L. (2008). Validation of the infant-toddler checklist as a broadband screener for autism spectrum disorders from 9 to 24 months of age. Autism: The International Journal of Research and Practice, 12(5), 487–511. doi: 10.1177/1362361308094501.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Raymond Sturner
    • 1
  • Barbara Howard
    • 1
  • Paul Bergmann
    • 2
    • 3
  • Lydia Stewart
    • 4
  • Talin E. Afarian
    • 5
  1. 1.PediatricsJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Foresight Logic, Inc.Saint PaulUSA
  3. 3.PrairieCare InstituteMinneapolisUSA
  4. 4.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  5. 5.Loyola UniversityBaltimoreUSA

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