Validation of the Electronic 2-Stage Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R/F)

Background: Currently, the AAP recommends universal screening for ASD in toddlers. However, barriers have limited implementation, and median age of diagnosis remains after the fourth birthday (CDC, 2014). Simplifying procedures for administration and scoring of tools like the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) may improve uptake and sustained use in community settings.

Objectives:   Although the M-CHAT-R/F has been validated (Robins et al., 2014), it is important to examine validity when changing mode of delivery. The goal of the current study was to validate the adaptation of M-CHAT-R/F for electronic delivery.

Methods:   Four private practices and one urban public clinic offered electronic M-CHAT-R/F screening during routine toddler check-ups at 18 and 24 months. Parents completed screening on a Chromebook in the office or using an at-home portal prior to the check-up. All participants completed consent, demographics, and the initial 20 M-CHAT-R items; when children scored in the moderate risk range (total score 3-7), the appropriate Follow-Up items were launched automatically during the same screening session. Follow-Up items were adapted for self-report by converting open-ended questions to forced-choice. Children who screened positive (initial score ≥8, or Follow-Up score ≥2) or had physician concerns about ASD were invited for diagnostic evaluation. The screening sample was divided based on clinic type, considering the effect of maternal education, which is a marker for socioeconomic status, on screening (e.g., Khowaja et al., 2015). The sample included 1719 children from private practices (49.2% male; 75.2% Caucasian, 10.6% African-American; 83.3% mothers had a college degree) and 687 children from an urban public clinic (53.4% male; 2.8% Caucasian, 88.1% African-American; 13.0% mothers had a college degree). Results were compared to published M-CHAT-R/F data (Robins et al., 2014), in which parents completed the initial M-CHAT-R on paper, and the Follow-Up via phone interview with research staff.

Results:   The screen positive rate on the initial electronic M-CHAT-R was commensurate between the paper sample (7.2%) and the private practices (7.6%), but notably higher in the public clinic (14.7%). Drop-out at the Follow-Up stage was eradicated (1 family (<1%) failed to complete needed Follow-Up, compared to 18% dropout in the paper sample). A higher percentage of children who completed electronic Follow-Up continued to screen positive (4.3% private, 7.9% public) compared to phone Follow-Up (2.2%). The ASD detection rate was comparable across electronic and paper samples (7.9  and 6.7 per 1,000, respectively). Nineteen children were diagnosed with ASD (13 private; 6 public); 18 were detected by M-CHAT-R/F, one from physician concern.

Conclusions:   Initial screen positive results are consistent across mode of delivery (electronic vs. paper), when participants using the electronic assessment in private practices were compared to published norms for the paper version. The elevated screen positive rate after Follow-Up using the electronic version may indicate differences in parent responses during an interview vs. on computer, interviewer deviation from the Follow-Up script, or differences in findings due to eradication of the dropout at the Follow-Up phase of screening. Commensurate ASD detection rate supports the validity of the electronic M-CHAT-R/F.