Diana L. Robins

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

OBJECTIVE: This study validates the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F), a screening tool for low-risk toddlers, and demonstrates improved utility compared with the original M-CHAT. METHODS: Toddlers (N = 16 071) were screened during 18- and 24-month well-child care visits in metropolitan Atlanta and Connecticut. Parents of toddlers at risk on M-CHAT-R completed follow-up; those who continued to show risk were evaluated. RESULTS: The reliability and validity of the M-CHAT-R/F were demonstrated, and optimal scoring was determined by using receiver operating characteristic curves. Children whose total score was ≥3 initially and ≥2 after follow-up had a 47.5% risk of being diagnosed with autism spectrum disorder (ASD; confidence interval [95% CI]: 0.41–0.54) and a 94.6% risk of any developmental delay or concern (95% CI: 0.92–0.98). Total score was more effective than alternative scores. An algorithm based on 3 risk levels is recommended to maximize clinical utility and to reduce age of diagnosis and onset of early intervention. The M-CHAT-R detects ASD at a higher rate compared with the M-CHAT while also reducing the number of children needing the follow-up. Children in the current study were diagnosed 2 years younger than the national median age of diagnosis. CONCLUSIONS: The M-CHAT-R/F detects many cases of ASD in toddlers; physicians using the 2-stage screener can be confident that most screen-positive cases warrant evaluation and referral for early intervention. Widespread implementation of universal screening can lower the age of ASD diagnosis by 2 years compared with recent surveillance findings, increasing time available for early intervention.

Screening for autism spectrum disorders in primary care settings

The need for autism-specific screening during pediatric well-child visits has been established. However, additional support for specific screening instruments is needed. The current study used the Modified Checklist for Autism in Toddlers (M—CHAT) and the M—CHAT Follow-Up Interview to screen 4797 children during toddler checkups. Of the 4797 cases, 466 screened positive on the M—CHAT; of the 362 who completed the follow-up interview, 61 continued to show risk for autism spectrum disorders (ASDs). A total of 41 children have been evaluated; 21 children have been diagnosed with ASD, 17 were classified with non-ASD delays, and three were typically developing. The PPV of M—CHAT plus interview was .57. It is notable that only four of the 21 cases of ASD were flagged by their pediatrician. These findings suggest that the M—CHAT is effective in identifying ASD in primary care settings. Future research will follow this sample longitudinally.

Breif Report: Sensory Abnormalities as Distinguishing Symptoms of Autism Spectrum Disorders in Young Children

The purpose of this study was to explore the sensory profile of young children with ASD compared to young children with other developmental delays (DD) at first ASD assessment. Results found that young children with ASD had more tactile and taste/smell sensitivities and difficulties with auditory filtering than young children with other DD. Moreover, sensory scores were significantly correlated with stereotyped interests and behaviors. These findings support the hypotheses that young children with ASD show more sensory impairments than young children with other DD and that sensory symptoms are significantly related to stereotyped interests and behaviors. Results also suggest that sensory abnormalities are distinguishing symptoms of ASD that should be considered in diagnostic algorithms for younger cohorts.

Large-Scale Use of the Modified Checklist for Autism in Low-Risk Toddlers

OBJECTIVE: The purpose of the study was to examine use of the Modified Checklist for Autism in Toddlers (M-CHAT) as an autism-specific screening instrument in a large, geographically diverse pediatrics-based sample. METHODS: The M-CHAT and the M-CHAT Follow-Up (M-CHAT/F) were used to screen 18 989 toddlers at pediatric well-child visits in 2 US geographic regions. Pediatricians directly referred children to ascertain potential missed screening cases. Screen-positive children received the M-CHAT/F; children who continued to screen positive after the M-CHAT/F received a diagnostic evaluation. RESULTS: Results indicated that 54% of children who screened positive on the M-CHAT and M-CHAT/F presented with an autism spectrum disorder (ASD), and 98% presented with clinically significant developmental concerns warranting intervention. An M-CHAT total score cutoff of ≥3 identifies nearly all screen-positive cases, and for ease of scoring the use of only the M-CHAT total score cutoff is recommended. An M-CHAT total score of 7 serves as an appropriate clinical cutoff, and providers can bypass the M-CHAT/F and refer immediately to evaluation and intervention if a child obtains a score of ≥7. CONCLUSIONS: This study provides empirical support for the utility of population screening for ASD with the use of the M-CHAT in a primary care setting. Results suggest that the M-CHAT continues to be an effective screening instrument for ASD when the 2-step screening process is used. The M-CHAT is widely used at pediatric offices, and this study provides updated results to facilitate use and scoring of the M-CHAT by clinical providers.

Screening for autism in older and younger toddlers with the Modified Checklist for Autism in Toddlers

The Modified Checklist for Autism in Toddlers (M—CHAT) was used to screen younger (16—23 months) versus older (24—30 months) high- and low-risk toddlers. Refusal rates for follow-up interview showed no group differences, but parents of younger/low-risk children were more likely to refuse evaluation than parents of high-risk children. PPP for an ASD diagnosis was: younger/high-risk 0.79, older/high-risk 0.74, younger/low-risk 0.28, and older/low-risk 0.61, with PPP differing by age within the low-risk group. Most of the children in all groups, however, were diagnosed with a developmental disorder. Symptom severity generally did not differ among groups. Cognitive and adaptive measures showed minimal group differences. Therefore, older and younger toddlers had similar symptomatology and developmental delays; PPP for ASD is better at 24 than 18 months for low-risk children; however, these children are still highly likely to show a developmental disorder. Clinical decision making should balance early identification against the lower specificity of M—CHAT screening for the younger/low-risk group.

The Utility of the Social Communication Questionnaire in Screening for Autism in Children Referred for Early Intervention.

The Social Communication Questionnaire (SCQ) is a brief parental screening instrument used to identify children With autism spectrum disorders (ASD). Screening validity for the SCQ has been supported in children 4 years of age and older, but ongoing studies indicate that the SCQ may not be effective in identifying very young children With ASD. The purpose of the current investigation Was to determine Whether the SCQ could distinguish children With ASD from children With other developmental delays in a sample of very young children referred for early intervention. Results found that the recommended cutoff score of 15 yielded a sensitivity value of .47 and a specificity value of .89. Maximum sensitivity and specificity rates Were achieved When the SCQ cutoff score Was reduced to 11 (.89 and .89, respectively). Implications of the findings are discussed.

Superior temporal activation in response to dynamic audio-visual emotional cues ☆

Perception of emotion is critical for successful social interaction, yet the neural mechanisms underlying the perception of dynamic, audio-visual emotional cues are poorly understood. Evidence from language and sensory paradigms suggests that the superior temporal sulcus and gyrus (STS/STG) play a key role in the integration of auditory and visual cues. Emotion perception research has focused on static facial cues; however, dynamic audio-visual (AV) cues mimic real-world social cues more accurately than static and/or unimodal stimuli. Novel dynamic AV stimuli were presented using a block design in two fMRI studies, comparing bimodal stimuli to unimodal conditions, and emotional to neutral stimuli. Results suggest that the bilateral superior temporal region plays distinct roles in the perception of emotion and in the integration of auditory and visual cues. Given the greater ecological validity of the stimuli developed for this study, this paradigm may be helpful in elucidating the deficits in emotion perception experienced by clinical populations.

Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research

This article reviews current evidence for autism spectrum disorder (ASD) interventions for children aged <3 years, based on peer-reviewed articles published up to December 2013. Several groups have adapted treatments initially designed for older, preschool-aged children with ASD, integrating best practice in behavioral teaching methods into a developmental framework based on current scientific understanding of how infants and toddlers learn. The central role of parents has been emphasized, and interventions are designed to incorporate learning opportunities into everyday activities, capitalize on “teachable moments,” and facilitate the generalization of skills beyond the familiar home setting. Our review identified several comprehensive and targeted treatment models with evidence of clear benefits. Although some trials were limited to 8- to 12-week outcome data, enhanced outcomes associated with some interventions were evaluated over periods as long as 2 years. Based on this review, recommendations are proposed for clinical practice and future research.

Early identification of autism spectrum disorder: Recommendations for practice and research

Early identification of autism spectrum disorder (ASD) is essential to ensure that children can access specialized evidence-based interventions that can help to optimize long-term outcomes. Early identification also helps shorten the stressful “diagnostic odyssey” that many families experience before diagnosis. There have been important advances in research into the early development of ASDs, incorporating prospective designs and new technologies aimed at more precisely delineating the early emergence of ASD. Thus, an updated review of the state of the science of early identification of ASD was needed to inform best practice. These issues were the focus of a multidisciplinary panel of clinical practitioners and researchers who completed a literature review and reached consensus on current evidence addressing the question “What are the earliest signs and symptoms of ASD in children aged ≤24 months that can be used for early identification?” Summary statements address current knowledge on early signs of ASD, potential contributions and limitations of prospective research with high-risk infants, and priorities for promoting the incorporation of this knowledge into clinical practice and future research.

Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research.

This article reviews current evidence for autism spectrum disorder (ASD) screening based on peer-reviewed articles published to December 2013. Screening provides a standardized process to ensure that children are systematically monitored for early signs of ASD to promote earlier diagnosis. The current review indicates that screening in children aged 18 to 24 months can assist in early detection, consistent with current American Academy of Pediatrics’ recommendations. We identify ASD-specific and broadband screening tools that have been ev-aluated in large community samples which show particular promise in terms of accurate classification and clinical utility. We also suggest strategies to help overcome challenges to implementing ASD screening in community practice, as well as priorities for future research.