The Clinical Utility of the Chinese Version Modified Checklist for Detecting Children with Autism Spectrum Disorders before Age 4 in Taiwan

Background:  Autism spectrum disorders (ASDs) are characterized by impairment in social interaction, communication and restricted and repetitive patterns of behaviors (APA, 2000). However, the DSM-5 defined a single autism spectrum disorder (ASD), which changed the corresponding symptom structures from three to two dimensions, including deficits in social interaction/ communication, and repetitive interests/ stereotyped behaviors (APA, 2013).Children with ASDs will show symptoms before age 3 (APA, 2000) or early childhood (APA, 2013). Recently, the prevalence of ASDs increases significantly since 2007(CDC, 2014). However, the diagnosis of children with ASDs is usually delayed. Hence, the screening measures are very crucial to identify individual who has high risk for ASDs. Earlier detection usually promises a better prognosis. Among the numerous screening tools, the Modified Checklist for Autism in Toddlers (M-CHAT; Robins et al., 2001) is one of the most widely-used and well-researched, it consists of 23 yes/no items and can be finished in a short time by the caregivers. 

Objectives:  Therefore, this study aims to examine clinical utility of the M-CHAT for detecting children with ASDs before age 4 years in low-socioeconomic area of Southern Taiwan. Chia-Yi area was chosen because it belongs to one of the low-socioeconomic area in Taiwan and there are much indigenous people who is relatively disadvantage. 

Methods:  The Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1999) was used to divide the children into ASDs and non-ASDs group, and M-CHAT was filled in by their caregiver. We would later see whether the classification of M-CHAT consistent with the result of ADOS. There were 236 children aged from 18 to 47 months old, including 113 children with ASDs and 123 children with developmental delay. 

Results:  The cutoff score of failing any 4 of the 23 M-CHAT items showed sensitivity of .77 and specificity of .72. Using cutoff score of failing any 3 of the 14 new critical items, which is called Brief 14 and was selected by using discriminant analysis, yielded the sensitivity of .71 and specificity of .82. 

Conclusions:  Inconsistence with previous studies, there is no item that children with ASDs showed failure rate beyond 50%.It might be due to the cultural issue in Chinese parents, they might underreported or deny their kids’ symptoms as they want to save their face. Being unfamiliar with ASDs symptoms, they might normalize and misinterpret their kids’ abnormal behavior. Even so, the validity of using the M-CHAT to screen clinical samples less than age of 4 years seemed acceptable in low-socioeconomic area of Southern Taiwan. This study also showed that there is cultural universality for children with ASDs in the domain of joint attention and imitation. Furthermore, this study replicated previous findings which children with ASDs showed impairments in social-communicative skill. Results suggest the need for increased education and detail information about childhood development. Furthermore, Brief 14 is suggested to use in the population in Taiwan to gain a better validity.