The Influence of Culture on Caregiver Response When Completing the Modified Checklist for Autism in Toddlers (M-CHAT)

Background:

Autism spectrum disorders (ASD) affect approximately 1 in 150 children in the United States (Centers for Disease Control, 2008). The behavioral expression of ASD symptoms may be associated with behavior phenotypes, which may be expressed differently between ethnic groups (Mandell, & Novak, 2005). Mandell and Novak suggest that parental interpretation of behavior may impact the professional attention given to certain behaviors.

Objectives:

The purpose of this study was to identify items that may be susceptible to cultural biases and misinterpretation. Pediatrician offices in the Metro Atlanta area were invited to participate in the research study. M-CHAT forms were offered to all caregivers at their toddler’s 18- and 24-month well-child visit. Completed M-CHATs were scored at Georgia State University, data was entered into a secured data analysis system, and a follow-up interview was used to clarify responses.

Methods:

For this study, M-CHAT scores were compared across children whose ethnicity was reported to be African American or Caucasian. The sample included M-CHAT forms for African American toddlers (n= 682; male= 355, female= 317, no data= 10; mean age= 21 months, SD= 3.5, range= 14.9 – 37.5) and Caucasian toddlers (n= 2477; male= 1243, female= 1204, no data= 30; mean age= 20 months, SD= 3.1, range= 14.0- 49.2). There was no significant difference in age between groups. Maternal education was reported, and found to be significantly different between ethnicities t(2845)= 15.54, p= .000, with the maternal education of Caucasian caregivers being higher. Maternal education was found to be statistically predictive of parental response on 14 of the 23 M-CHAT items; therefore, a binary logistic regression was performed to measure variance attributable unique to ethnicity and not maternal education.

Results:

The results indicated that African American caregivers were significantly more likely than Caucasian caregivers to endorse failing responses on 4 items: plays with toys without mouthing or fiddling them (No), Odds Ratio (OR)= 4.497, p=.000, Confidence Interval (CI)=2.49 – 8.10; makes unusual finger movements near the face (Yes), OR=2.465 , p=.000, CI= 1.92 – 3.15; tries to attract caregiver’s attention to own activity (No), OR= 1.516, p=.041, CI= 1.01 – 2.26; sometimes stares or wanders with no purpose (Yes), OR= 1.960, p= .000, CI= 1.50 – 2.55. There were no significant ethnicity differences for toddlers diagnosed with ASD, indicating that the false positive rate appears to be higher in African-American children.

Conclusions:

This study raises attention to specific items on the M-CHAT that may be susceptible to cultural biases or misinterpretation. Results indicate that there may be differences in the interpretation of questions by caregivers based on cultural background, and suggest that some questions operate differently in specific cultural groups. Future research in this area will be important to understand why screening tools may work differently in different ethnic and socioeconomic groups, as usage of screeners becomes more popular and widely dispersed.  The follow-up interview for the M-CHAT, used to clarify item responses, may also need to be revisited with an eye towards providing culturally sensitive clarification for certain items.