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Developmental characteristics and accuracy of autism screening among two-year-old toddlers in the ECHO program

Pediatric Research (2024)Cite this article

Abstract

Background

The Modified Checklist for Autism in Toddlers (M-CHAT) is a common pediatric screening tool with mixed accuracy findings. Prior evidence supports M-CHAT screening for developmental concerns, especially in toddlers born preterm. This study examined M-CHAT accuracy in a large, nationwide sample.

Methods

3393 participants from the Environmental influences on Child Health Outcomes (ECHO) program were included. Harmonized M-CHAT (M-CHAT-H) results were compared with parent-reported autism diagnosis and autism-related characteristics to assess accuracy for term and preterm children, together and separately. Generalized estimating equations, clustering for ECHO cohort and controlling for demographic covariates, were used to examine associations between developmental and behavioral characteristics with M-CHAT-H accuracy.

Results

Sensitivity of the M-CHAT-H ranged from 36 to 60%; specificity ranged from 88 to 99%. Positive M-CHAT-H was associated with more developmental delays and behavior problems. Children with severe motor delays and more autism-related problems were more likely to have a false-negative M-CHAT-H. Children with fewer behavior problems and fewer autism-related concerns were more likely to have a false-positive screen.

Conclusion

The M-CHAT-H accurately detects children at low risk for autism and children at increased risk with moderate accuracy. These findings support use of the M-CHAT-H in assessing autism risk and developmental and behavioral concerns in children.

Impact

  • Previous literature regarding accuracy of the Modified Checklist for Autism in Toddlers (M-CHAT) is mixed but this study provides evidence that the M-CHAT performs well in detecting children at low risk for autism and consistently detects children with developmental delays and behavioral problems. The M-CHAT moderately detects children at increased risk for autism and remains a useful screening tool.

  • This study examines M-CHAT accuracy in a large-scale, nationwide sample, examining associations between screening accuracy and developmental outcomes.

  • These findings impact pediatric screening for autism, supporting continued use of the M-CHAT while further elucidating the factors associated with inaccurate screens.

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Fig. 1: Selection criteria flowchart.

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Data availability

Select de-identified data from the ECHO Program are available through NICHD’s Data and Specimen Hub (DASH). Information on study data not available on DASH, such as some Indigenous datasets, can be found on the ECHO study DASH webpage.

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Acknowledgements

The authors wish to thank our ECHO Colleagues; the medical, nursing, and program staff; and the children and families participating in the ECHO cohorts. We also acknowledge the contribution of the ECHO Program collaborators. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding

Research reported in this publication was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health, under Award Numbers U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center), U24OD023319 with co-funding from the Office of Behavioral and Social Science Research (PRO Core), UH3OD023251 (Alshawabkeh), UH3OD023320 (Aschner), UH3OD023313 (Koinis Mitchell), UH3OD023318 (Dunlop), UH3OD023271 (Karr), UH3OD023347 (Lester), UH3OD023349 (O’Connor), UH3OD023348 (O’Shea), UH3OD023290 (Herbstman), UH3OD023249 (Stanford), UH3OD023279 (Elliott).

Author information

Authors and Affiliations

  1. Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA

    Coral L. Shuster & Barry M. Lester

  2. Department of Psychology, Emory University School of Medicine, Atlanta, GA, USA

    Patricia A. Brennan

  3. Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO, USA

    Brian S. Carter

  4. Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Jennifer Check & Jennifer Helderman

  5. Division of Developmental and Behavioral Pediatrics, Hasbro Children’s Hospital, Providence, RI, USA

    Viren D’Sa

  6. University of Tennessee Health Science Center, Memphis, TN, USA

    Joyce C. Graff, F. Tylavsky, A. Mason & Q. Zhao

  7. Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Julie A. Hofheimer & T. Michael O’Shea

  8. Department of Anatomy and Neurobiology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA

    Robert M. Joseph

  9. Department of Psychiatry, University of Tennessee Health Science Center, Memphis, TN, USA

    Laura E. Murphy

  10. Department of Psychiatry, University of Rochester, Rochester, NY, USA

    Thomas G. O’Connor

  11. Department of Psychiatry and Human Behavior, Hasbro Children’s Hospital, Lifespan, Providence, RI, USA

    Michelle Pievsky

  12. Thompson Center for Autism & Neurodevelopment, University of Missouri, Columbia, MO, USA

    Stephen J. Sheinkopf

  13. Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY, USA

    Lauren C. Shuffrey

  14. Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA

    Lynne M. Smith

  15. Developmental Behavioral Pediatrics, Children’s Neurodevelopment Center, Lifespan, Providence, RI, USA

    Pei-Chi Wu

  16. Department of Pediatrics, Brown Alpert Medical School, Providence, RI, USA

    Barry M. Lester

  17. Coordinating Center Duke Clinical Research Institute, Durham, NC, USA

    P. B. Smith & L. K. Newby

  18. Data Analysis Center: Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA

    L. P. Jacobson

  19. Research Triangle Institute, Durham, NC, USA

    D. J. Catellier

  20. Person-Reported Outcomes Core: Northwestern University, Evanston, IL, USA

    R. Gershon & D. Cella

  21. Northeastern University, Boston, MA, USA

    A. N. Alshawabkeh

  22. University of Georgia, Athens, GA, USA

    J. Cordero

  23. University of Michigan, Ann Arbor, MI, USA

    J. Meeker

  24. Albert Einstein College of Medicine, Bronx, NY, USA

    J. Aschner

  25. Icahn School of Medicine at Mount Sinai, New York, NY, USA

    S. L. Teitelbaum & A. Stroustrup

  26. Cohen Children’s Medical Center, Northwell Health, New Hyde Park, NY, USA

    A. Stroustrup

  27. Children’s Hospital Medical Center, Cincinnati, OH, USA

    S. Merhar

  28. Children’s Hospital and Clinic Minnesota, Minneapolis, MN, USA

    A. Lampland

  29. University of Buffalo, Buffalo, NY, USA

    A. Reynolds

  30. University of Florida, College of Medicine, Jacksonville, FL, USA

    M. Hudak

  31. University of Rochester Medical Center, Rochester, NY, USA

    G. Pryhuber & R. K. Miller

  32. Vanderbilt Children’s Hospital, Nashville, TN, USA

    P. Moore

  33. Wake Forest University School of Medicine, Winston Salem, NC, USA

    L. Washburn

  34. Rhode Island Hospital, Providence, RI, USA

    D. Koinis Mitchell & S. Deoni

  35. Emory University, Atlanta, GA, USA

    A. L. Dunlop

  36. University of Washington, Department of Environmental and Occupational Health Sciences, Seattle, WA, USA

    C. Karr

  37. Seattle Children’s Research Institute, Seattle, WA, USA

    S. Sathyanarayana

  38. University of California, San Francisco, San Francisco, CA, USA

    N. Bush & K. Z. LeWinn

  39. Women & Infants Hospital of Rhode Island, Providence, RI, USA

    B. Lester

  40. Children’s Mercy, Kansas City, MO, USA

    B. Carter

  41. Corewell Health, Helen DeVos Children’s Hospital, Grand Rapids, MI, USA

    S. Pastyrnak

  42. Kapiolani Medical Center for Women and Children, Honolulu, HI, USA

    C. Neal

  43. University of Pittsburgh Medical Center, Magee Women’s Hospital, Pittsburgh, PA, USA

    H. Simhan

  44. Magee Women’s Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    C. Buss & P. Wadhwa

  45. University of North Carolina, Chapel Hill, NC, USA

    K. Huff

  46. Baystate Children’s Hospital, Springfield, MA, USA

    R. Vaidya

  47. Beaumont Children’s Hospital, Royal Oak, MI, USA

    R. Obeid

  48. Boston Children’s Hospital, Boston, MA, USA

    C. Rollins

  49. East Carolina University, Brody School of Medicine, Greenville, NC, USA

    K. Bear

  50. Michigan State University College of Human Medicine, East Lansing, MI, USA

    M. Lenski

  51. Tufts University School of Medicine, Boston, MA, USA

    R. Singh

  52. University of Chicago Comer Medicine, Chicago, IL, USA

    M. Msall

  53. University of Massachusetts Chan Medical School, Worcester, MA, USA

    J. Frazier

  54. Atrium Health Wake Forest Baptist, Winston Salem, NC, USA

    S. Gogcu

  55. Yale School of Medicine, New Haven, CT, USA

    A. Montgomery

  56. Boston Medical Center, Boston, MA, USA

    K. Kuban, L. Douglass & H. Jara

  57. Columbia University Medical Center, New York, NY, USA

    J. Herbstman

  58. University of Utah, Salt Lake City, UT, USA

    J. Stanford, C. Porucznik & A. Giardino

Authors
  1. Coral L. Shuster
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  2. Patricia A. Brennan
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  3. Brian S. Carter
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  4. Jennifer Check
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  5. Viren D’Sa
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  6. Joyce C. Graff
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  7. Jennifer Helderman
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  8. Julie A. Hofheimer
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  9. Robert M. Joseph
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  10. Laura E. Murphy
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  11. Thomas G. O’Connor
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  12. T. Michael O’Shea
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  13. Michelle Pievsky
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  14. Stephen J. Sheinkopf
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  15. Lauren C. Shuffrey
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  16. Lynne M. Smith
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  17. Pei-Chi Wu
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  18. Barry M. Lester
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Consortia

on behalf of program collaborators for Environmental influences on Child Health Outcomes

  • ECHO Components—Coordinating Center

    • P. B. Smith
    • , L. K. Newby
    • , L. P. Jacobson
    • , D. J. Catellier
    • , R. Gershon
    •  & D. Cella

  • ECHO Awardees and Cohorts

    • A. N. Alshawabkeh
    • , J. Cordero
    • , J. Meeker
    • , J. Aschner
    • , S. L. Teitelbaum
    • , A. Stroustrup
    • , S. Merhar
    • , A. Lampland
    • , A. Reynolds
    • , M. Hudak
    • , G. Pryhuber
    • , P. Moore
    • , L. Washburn
    • , D. Koinis Mitchell
    • , S. Deoni
    • , A. L. Dunlop
    • , C. Karr
    • , F. Tylavsky
    • , A. Mason
    • , Q. Zhao
    • , S. Sathyanarayana
    • , N. Bush
    • , K. Z. LeWinn
    • , B. Lester
    • , B. Carter
    • , S. Pastyrnak
    • , C. Neal
    • , R. K. Miller
    • , H. Simhan
    • , C. Buss
    • , P. Wadhwa
    • , K. Huff
    • , R. Vaidya
    • , R. Obeid
    • , C. Rollins
    • , K. Bear
    • , M. Lenski
    • , R. Singh
    • , M. Msall
    • , J. Frazier
    • , S. Gogcu
    • , A. Montgomery
    • , K. Kuban
    • , L. Douglass
    • , H. Jara
    • , J. Herbstman
    • , J. Stanford
    • , C. Porucznik
    •  & A. Giardino

Contributions

C.S., B.C., J.A.H., R.J., T.O., M.O., S.S., L.C.S., L.M.S. contributed significantly to study design. C.S. conducted data analysis and interpretation of results. C.S., P.B., B.C., J.C., V.D., J.G., J.H., J.A.H., R.J., L.M., T.O., M.O., M.P., S.S., L.C.S., L.M.S., P.C.W., B.L. assisted with critical revisions for important intellectual content and approved of the final version.

Corresponding author

Correspondence to Coral L. Shuster.

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The authors declare no competing interests.

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All participants provided consent to their respective institutions and all study protocols were approved by each respective Institutional Review Board.

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Shuster, C.L., Brennan, P.A., Carter, B.S. et al. Developmental characteristics and accuracy of autism screening among two-year-old toddlers in the ECHO program. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03193-5

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