M-CHAT Screening: 7 Points Parents Need to Know

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Pediatric healthcare professionals routinely screen for developmental delays at 9-month, 18-month, and 24-month wellness visits. However, they should also be specifically screening for autism spectrum disorder (ASD) at the 18-month and 24-month wellness visits. Several screening tools can be used to determine if children are at risk for developing ASD. One of those tools is the Modified Checklist for Autism in Toddlers (M-CHAT).

This article will serve as a guide to help parents understand the M-CHAT, its purpose, the process involved, and how to interpret the results accurately.

What is the M-CHAT?

The M-CHAT is a parent-report, screening tool that was developed and validated for children between 16 and 30 months old. It is used to identify children who are at risk of developing ASD. The tool contains 23 items that ask questions about a child’s behavior. For example, “Does your child take an interest in other children?”. In addition, it contains a follow-up interview that is conducted by healthcare professionals if children receive a positive result on the parent questionnaire.

The instrument was introduced by Robins et. al. in 2001 as an extension of the Checklist for Autism in Toddlers (CHAT). The original CHAT was developed by Baron-Cohen, Allen, and Gillberg in 1992, but was not widely adopted in the United States because of the demand it placed on the professional’s time to complete.

However, the M-CHAT has 23 items and is designed to be completed by parents in just a few minutes. In 2009, the M-CHAT was further revised by Robins et. al. to improve psychometric properties and simplify the reading level. This means items were removed due to poor performance and the remaining items were reorganized to remove agreement bias.

The latest version, the M-CHAT-R/F contains 20 items and includes examples to clarify those items and add developmental context. For instance, “Does your child respond to his or her name?” was changed to “Does your child respond when you call his or her name? (For example, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)”.

Despite the revision in 2009, the M-CHAT remains the most commonly used screening tool implemented at 18-month and 24-month wellness checkups. Data suggests that the actual screening performance of the M-CHAT-R/F is not significantly different from the M-CHAT if the follow-up interview is used as directed. The M-CHAT is copyrighted but is freely available for clinical and research purposes.

How the M-CHAT Works

The M-CHAT consists of 20 yes or no questions completed by parents during their child’s 18-month and 24-month wellness check-ups. Parents respond to items on the tool based on their children’s usual behavior patterns. If a child has exhibited a behavior a few times, but it is not a usual response, the parent is instructed to indicate no for that item.  

The questionnaire covers key developmental areas and behavior patterns related to ASD, such as social interaction, communication skills, and repetitive behaviors or restricted interests.  Social interaction questions determine if the child is interested in interacting with others, responds to social cues, and enjoys partaking in activities with their caregivers.

The M-CHAT examines communication skills by asking questions about the child’s ability to use verbal and nonverbal communication and to use language for social purposes. For example, do they make comments or request preferred toys or activities? Lastly, the M-CHAT includes questions about repetitive or stereotypical behaviors such as hand flapping, flexibility, and interests in specific topics.

In addition to the questionnaire, there is a follow-up interview which is used to further explore the answers on the M-CHAT that were indicative of ASD. Follow-up questions are asked only for items where the parent’s response indicates ASD and not all 23 items. It is used to clarify points and provide more detailed information on the child’s behavior and developmental characteristics. The follow-up interview is conducted by the healthcare provider and takes 10 to 15 minutes. This interview was created due to the high rate of false positives in the M-CHAT.

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The Significance of Early Autism Screening

M-CHAT screening for toddlers

Early screening and diagnosis of ASD can pave the way for early intervention services. Early signs of ASD are typically delays in social communication, such as no eye contact, limited engagement with parents and caregivers, limited or lack of gestures, and lack of reciprocal smiles or babbles.

Early intervention encompasses therapies that are specifically designed to improve a child’s communication and social skills, which in turn, can improve a child’s quality of life. These treatment options can and should begin as early as ASD is suspected.

Furthermore, many early intervention options have a parent or caregiver component wherein parents are taught how to incorporate techniques into daily life and play interactions.

The first three years of life are incredibly important because brain plasticity is at its peak making it the ideal time for social and communication intervention services. Treatment is more likely to have a significant impact at these early ages than treatment that starts later.

Who Should Use the M-CHAT?

The M-CHAT was developed and validated for children between 16 and 30 months old. The American Academy of Pediatrics (AAP) recommends that all children should be screened at their 18-month and 24-month wellness visits to determine their risk for ASD.

If parents or caregivers are concerned about their child’s development due to a family history of ASD, missed milestones, delayed speech, repetitive movements, or restricted behavior patterns they should request screening for ASD. If your primary healthcare provider does not agree or take you seriously, get a second opinion.

Understanding M-CHAT Results

The M-CHAT consists of 23 items. For all items, except items 2, 5, and 12, the response “NO” indicates an ASD risk. For these items “YES” indicates an ASD risk. The current recommended scoring algorithm is as follows:

  • M-CHAT total score 0-2: No follow-up is necessary, however, if the child is less than 24 months, a second screening should be conducted at the 2-year check-up or after 3 months have elapsed. There should be continuous developmental surveillance.
  • M-CHAT total score 3-6: A score within this range warrants a follow-up interview. If the child continues to score at least 3, a referral should be made for a clinical evaluation and to determine early intervention eligibility. If the follow-up score is 2, the child should be more carefully monitored since they may need to be referred.
  • M-CHAT total score 7-23: The child is at high risk for ASD or other developmental disorders. In this case, it is acceptable to immediately refer the child for a clinical evaluation without conducting the follow-up interview.

Screening is not diagnosing. A positive screening result does not mean he or she will receive an Autism diagnosis. Conversely, if your child screens normally, it does not mean the absence of ASD. If you have concerns after a normal screening, speak with your healthcare provider about additional assessments available. The M-CHAT is not 100% accurate in detecting ASD.

However, following a positive screening result, parents must schedule a more in-depth, formal evaluation of their child’s development. The diagnostic assessment will determine the child’s specific needs and most suitable treatment options.

The M-CHAT and Professional Evaluation

While parents are responsible for completing the 23-item M-CHAT questionnaire, the healthcare providers are responsible for scoring the results, conducting the follow-up interview where necessary, and referring children for professional evaluations when positive screening results are noted.

Even though the M-CHAT is readily available for anyone to use, it is vital to work with trained healthcare providers and other specialists who have experience identifying ASD. An experienced professional, who understands the subtilities of ASD will be able to distinguish if behaviors exhibited, such as no eye contact, are due to shyness or are consistent with the typical presentation of someone with ASD.

Screening tools such as the M-CHAT are considered the first step in learning if a child is at risk for ASD. A professional evaluation from a specialist is immediately recommended when children receive a score of 3 or higher on the M-CHAT and the subsequent follow-up interview.

However, the M-CHAT should not be used in isolation. The results must be considered in the context of other information. Many healthcare providers are also simultaneously tracking the child’s milestone achievements and observing the child-parent interaction during the visit which can impact the interpretation of the M-CHAT results. For example, if a child receives a score of 2, but the healthcare professional has noted several delayed or missed milestones, this may warrant a referral for a professional evaluation.

While screenings can identify children at risk for ASD, they cannot provide a diagnosis. A professional evaluation is necessary to determine if a child is on the spectrum. Not everyone who receives a positive screening result is diagnosed with ASD and some who were not identified as at risk for ASD later received an Autism diagnosis following a professional evaluation.

Advantages and Limitations of the M-CHAT

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The goal of the M-CHAT is to detect as many cases of ASD as early as possible. Early identification is critical because it allows for early intervention services leading to improved outcomes for children with ASD. The tool has cultural adaptability and has been translated into many languages, making it suitable for use around the world.

It is a cost-effective way to screen a large number of children at risk for Autism. It can be used by childcare centers or early intervention programs without causing financial strain. The M-CHAT is also quick to administer with the questionnaire taking less than 5 minutes and the follow-up interview taking approximately 10 to 15 minutes.

However, the M-CHAT does have limitations and scores should not be taken at face value. It is designed to maximize sensitivity and detect as many cases of ASD as possible. This produces a high false positive rate, meaning children are being identified as at risk for ASD but do not receive an ASD diagnosis.

It is important for healthcare providers to fully explain to parents that screening results are not a diagnosis and that further evaluation is necessary. Even though there is a high rate of false positives, children who fail the M-CHAT are still typically at risk for other developmental disorders.

Tips for Parents Considering the M-CHAT

Parents who are considering using the M-CHAT screening tool to determine their child’s risk for ASD should consider the following:

  • ASD is a lifelong condition seen in 1 of 54 children.
  • Children as young as 12 months old can show signs of ASD.
  • Early identification and intervention can significantly impact the outcome of treatment.
  • The M-CHAT will only identify if your child is at risk for ASD and not provide a clinical diagnosis.
  • Your child does not have to be present for the assessment. Rather it is based on parent responses to 23 items.
  • The questionnaire can be done during the wellness checkup or it can be taken home if the parent would like time to observe their child before responding to the questions.
  • Ensure you are open and honest with your responses. If you are unsure, ask the healthcare provider for clarification.
  • After a positive result, do not wait for the professional evaluation to receive early intervention services.
  • If after a negative result, you still have concerns regarding ASD, advocate for your child to receive additional screening or a second opinion.
  • Remember a diagnosis of ASD will not change who your child is, it will only better enable you to provide the support and care they need.

Conclusion

The M-CHAT is a screening tool used to identify children at risk for ASD between 16 and 30 months of age. Early detection of ASD leads to early intervention services which greatly increases the likelihood of a better quality of life for children diagnosed with Autism.

Parents need to track developmental milestones, advocate for their healthcare providers to conduct screenings at the recommended ages of 18 and 24 months, and follow up on the results of screening tools by continuing to monitor their child’s development or by undergoing a professional evaluation.

FAQs

At what age do you do an M-CHAT?

The M-CHAT screening tool is administered between the ages of 16 and 30 months. Pediatric healthcare providers should do the M-CHAT during 18-month and 24-month wellness visits.

What is a normal M-CHAT score?

A normal M-CHAT score is 0 to 2, which indicates a low risk for ASD.

How accurate is the M-CHAT?

The predictive value or accuracy of the M-CHAT is 57.7%. This means 57.7% of positive screens went on to receive an ASD diagnosis. It is most accurate for those who have severe symptoms.

What is a failing M-CHAT score?

A failing M-Chat score is 7 points or higher, which indicates a high risk for ASD.

Does the M-CHAT rule out autism?

The M-CHAT cannot rule out autism. It is not a diagnostic tool and even children with negative screens should still be closely monitored for signs and symptoms.

References

Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161, 839–843.

Robins, D., Fein, D., Barton, M., & Green, J. (2001). The modified checklist for autism in toddlers (M-CHAT): An initial investigation in the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31(2), 131–144.

Robins, D. L., Casagrande, K., Barton, M. L., Chen, C., 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.

Robins, D. L., Fein, D., & Barton, M. (2009). The modified checklist for autism in toddlers, revised, with follow-up (M-CHAT-R/F) (Self-published, www.mchatscreen.com).

UC Davis MIND Institute. (2023, May 20). M-CHAT-R/F Autism Screening Tool Effective But Has Limitations. Disabled World. Retrieved February 15, 2024, from www.disabled-world.com/health/neurology/autism/m-chat-rf.php

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