Accurate Autism Screening at the 18-Month Well-Child Visit Requires Different Strategies than at 24 Months
Accuracy of autism screening using M-CHAT plus the follow-up interview (M-CHAT/F) for children screened positive at 18-months was compared to screening at 24-months. Formal ASD testing was criterion for a community sample of M-CHAT positive children (n = 98), positive predictive value (PPV) was 0.40 for the M-CHAT and 0.58 for the M-CHAT/F. MCHAT/F PPV was 0.69 among children 20+ months compared to 0.36 for <20 months. Multivariate analyses incorporating data from the Ages and Stages Questionnaire, MacArthur-Bates Communicative Development Inventory, M-CHAT and M-CHAT/F results, and M-CHAT items suggest language variables carry greatest relative importance in contributing to an age-based algorithm with potential to improve PPV for toddlers <20 months to the same level as observed in older toddlers.
KeywordAutism screening Developmental screening M-CHAT Toddler development
This project was funded by a grant from the NIMH Grant No. R44MH085399. The participating primary care pediatricians and their office staffs in the state of Maryland are acknowledged for their cooperation during the project and continuing implementation of the screenings described after the conclusion of the project.
RS and BH conceived of the study, participated in its design and coordination and drafted the manuscript; RL participated in the design and interpretation of the data; TM participated in the design and coordination of the study. KW and DM participated in the coordination of the study and assisted with the measurement; 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
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. The terms of the arrangement were managed by The Johns Hopkins University in accordance with its conflict of interest policies.
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.
- Allison, C., Baron-Cohen, S., Wheelwright, S., Charman, T., Richler, J., Pasco, G., & Brayne, C. (2008). The Q-CHAT (Quantitative Checklist for Autism in Toddlers): A normally distributed quantitative measure of autistic traits at 18–24 months of age: Preliminary report. Journal of Autism and Developmental Disorders, 38(8), 1414–1425.CrossRefPubMedGoogle Scholar
- American Academy of Pediatrics, Committee on Children With Disabilities (1994). Developmental surveillance and screening of infants and young children. Pediatrics, 93, 863.Google Scholar
- Autism Speaks (2016). Modified checklist for autism in toddlers, revised (M-CHAT-R). Retrieved August 3, 2016, from http://www.autismspeaks.org/what-autism/diagnosis/screen-your-child.
- 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
- 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
- Breiman, L., Friedman, J. H., Olshen, R. A., & Stone, C. J. (1984). Classification and regression trees. Belmont, CA: Wadsworth Statistical Press.Google Scholar
- CHADIS (2017). CHADIS (Child Health and Development Interactive System). http://www.chadis.com/site/. Accessed 15 July 2017.
- Chawarska, K., Shic, F., Macari, S., Campbell, D. J., Brian, J., Landa, R., Hutman, T., Nelson, C. A., Ozonoff, S., Tager-Flusberg, H., Young, G. S., Zwaigenbaum, L., Cohen, I. L., Charman, T., Messinger, D. S., Klin, A., Johnson, S., Bryson, S. (2014). 18-Month predictors of later outcomes in younger siblings of children with autism spectrum disorder: A baby siblings research consortium study. Journal of the American Academy of Child & Adolescent Psychiatry, 53(12), 1317–1327. doi: 10.1016/j.jaac.2014.09.015.CrossRefGoogle Scholar
- Christensen, D. L., Baio, J., Van Naarden Braun, K., Bilder, D., Charles, J., Constantino, J. N., Daniels, J., Durkin, M. S., Fitzgerald, R. T., Kurzius-Spencer, M., Lee, L. C., Pettygrove, S., Robinson, C., Schulz, E., Wells, C., Wingate, M. S., Zahorodny, W., & Yeargin-Allsopp, M. (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 Surveillance Summaries, 65(3), 1–23. doi: 10.15585/mmwr.ss6503a1.
- Core Team (2015). R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing. http://www.R-project.org/.
- Fenson, L., Marchman, V. A., Dale, P. S., Reznick, S., Thal, D., & Bates, E. (2007). The MacArthur Communicative Development Inventories: User’s guide and technical manual (2nd ed.). Baltimore: Paul H. Brookes Publishing Co.Google Scholar
- Halladay, A. K., Bishop, S., Constantino, J. N., Daniels, A. M., Koenig, K., Palmer, K., Messinger, D., Pelphrey, K., Sanders, S. J., Singer, A. T., Taylor, J. L., Szatmari, P. (2015). Sex and gender differences in autism spectrum disorder: summarizing evidence gaps and identifying emerging areas of priority. Molecular Autism, 6, 36. doi: 10.1186/s13229-015-0019-y.CrossRefPubMedPubMedCentralGoogle Scholar
- 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
- 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
- Luyster, R., Gotham, K., Guthrie, W., Coffing, M., Petrak, R., Pierce, K., Bishop, S., Esler, A., Hus, V., Oti, R., Richler, J., Risi, S., & Lord, C. (2009). The Autism Diagnostic Observation Schedule—Toddler Module: A new module of a standardized diagnostic measure for autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(9), 1305–1320.CrossRefPubMedPubMedCentralGoogle Scholar
- Mullen, E. M. (1995). The Mullen Scales of Early Learning: AGS edition. Circle Pines, MN: American Guidance Service, Inc.Google Scholar
- National Research Council (2001). Educating children with autism. Washington, DC: National Academies Press.Google Scholar
- Nectac (2016). States and territories’ definitions of/criteria for IDEA Part C eligibility. Updated March 4, 2015; Accessed September 29, 2016, from http://nectac.org/-pdfs/topics/earlyid/partc_elig_table.pdf.Nectac.org.
- 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
- Reznick, J. S., Baranek, G. T., Reavis, S., Watson, L. R., & Crais, E. R. (2007). A parent-report instrument for identifying one-year-olds at risk for an eventual diagnosis of autism: the first year inventory. Journal of autism and developmental disorders, 37(9), 1691–1710.CrossRefPubMedGoogle Scholar
- 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. DOI: 10.1177/1362361308094502.CrossRefPubMedGoogle Scholar
- Siu, A. L., & The US Preventive Services Task Force (USPSTF). (2016). Screening for autism spectrum disorder in young children. US preventive services task force recommendation statement. JAMA: The Journal of the American Medical Association, 315(7), 691–696. doi: 10.1001/jama.2016.0018.CrossRefPubMedGoogle Scholar
- Squires, J., & Bricker, D. (2009). Ages & Stages Questionnaires, Third Edition (ASQ-3). Baltimore: Brookes Publishing. http://www.agesandstages.com.
- StataCorp (2015). Stata statistical software: Release 14. College Station, TX: StataCorp LP.Google Scholar
- 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
- Therneau, T., Atkinson, B., & Ripley, B. (2015). rpart: Recursive partitioning and regression trees. R package version 4.1–9. https://cran.r-project.org/web/packages/rpart/rpart.pdf.