A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

Early Identification of Autism Spectrum Disorder: A Critical Review of Parent-Report and

Clinician-Administered Screening Measures for Toddlers.

Advanced Psychological Assessments

3rd May 2021

A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

The early detection of developmental delays, including Autism Spectrum Disorder

(ASD), is crucial for integration into early intervention as this is a key prognostic indicator for

optimising positive outcomes (Levy & Perry, 2011; Nowell et al., 2015). A crucial limitation

though, is the delay or failure in identifying the disorder in early childhood. ASD is a

complex, multifactorial, neurodevelopmental disorder that can cause impairment in three

areas; social-emotional interaction, communicative intent, and restricted and repetitive

behaviours (American Psychiatric Association [APA], 2013). In 2013, the DSM-5 combined

four independent diagnoses; Childhood Disintegrative Disorder, Asperger’s Syndrome,

Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), and Autism, into a

single disorder, yet, on a wide ‘spectrum’ (APA, 2013; Park et al., 2016). To meet diagnostic

criteria, there must be persistent functional impairment in social communication and social

interaction’ and show restrictive and repetitive behaviours (APA, 2013).

In the past decade, prevalence rates have almost doubled. According to the World

Health Organisation (WHO), approximately 1 in 270 people worldwide, and 1 in 150

Australians are living with ASD (Australian Bureau Statistics, 2018). The Centre for Disease

Control and Prevention (CDC) reveal ASD is four times more common in males, though, the

exact cause remains unknown as currently there is no medical test to diagnose. The increase

in prevalence is thought to be, at least partially, due to the DSM-IV broadening the definition

of ASD and therefore increasing the opportunity for many cases to be identified that would

have previously been undiagnosed (Neggers, 2014).

Consequently, as prevalence has increased, so has the need for valid, efficient, and

effective standardised screening measures. Despite the ability to reliably diagnose ASD as

early as 24 months, the median age of diagnosis is generally delayed until 48, 53, and 78

months (CDC, 2016). Two primary sources of information are typically employed when
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

assessing developmental delays; parent-reports and direct assessment

(clinician-administered). However, both have advantages and unique challenges associated

with measuring development in childhood (Thabtah & Peebles, 2019). For example, Robins

et al., (2014) claims utilising a parent-screening tool at population level would help identify a

larger pool of children at-risk of ASD or other developmental disorders and therefore

reducing the gap to much needed early intervention. In contrast, Fein & Baby Sibs Research

Consortium, (2016) claims parent-report screening tools at population level may be highly

bias and would produce too many false positives. Trained clinician screening is needed as

the potential effect of subjecting children to ASD treatment when they do not have the

disorder would significantly drain family and healthcare resources.

To address concerns with both approaches, efforts to determine the most effective

approach at identifying ASD, is contingent on analysing the psychometric strengths of the

instruments utilised (Matson et al., 2007). Validity and reliability are considered the central

measurement properties. Validity refers to the degree to which an instrument accurately

measures what it intends to measures and reliability refers to the extent to which an

instrument produces consistent results that could be replicated and generalised (Matson et

al., 2007).

Thus, in an attempt to determine a preferred approach, this paper will critically

analyse and compare the evidence for a screening parent-report; Modified Checklist for

Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F), and a clinician-administered;

Screening Tool for Autism in Toddlers and Young Children (STAT). The psychometrics

properties of each tool will be discussed and any cultural and ethical considerations will be

explored. Given the brevity and significance in which an early ASD diagnosis is most
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

beneficial, it is imperative to assess the available screening methods to determine which is

most feasible, appropriate, and effective.

Screening Measures for Population Levels:

The American Academy of Paediatrics (AAP) recommends screening all children

between the ages of 18 and 24 months and suggests the universal practice is optional to

reduce the age of diagnosis for ASD (CDC, 2016). Currently, there are two levels of ASD

screening; level 1: intended for the ‘unselected’, to help identify any developmental

disorders in the general population, and level 2: intended for children at increased risk for

ASD either from familial predisposition, genetic risk factors, or from demonstrating

developmental concerns such as language impairment or global development delay (GDD)

(Petrocchi et al., 2020; Stone et al., 2004).

The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F):

The M-CHAT-R/F is a level 1 and 2 population screener. It is a two stage psychological

parent-report questionnaire checklist, designed to assess the risk of ASD in children aged 16

and 30 months. For the initial stage, the parents complete a binary 20-item questionnaire to

help determine the child’s current behaviours using a yes/no format. In approximately 5-10

minutes, parents can answer and complete domain specific questions regarding; pretend

play, following a point, pretending, producing a point, and proto-declarative pointing, and

receive a score to see if further assessment is necessary (Weitlauf et al., 2015). Three items

are reversed scored, three are distractor items, and all items were reorganised in the

modified version to reduce bias. Scores between the moderate-risk range of 3-7 means a

follow-up interview (FUI) is needed with a professional to gather further information (second

stage). If score remains at two or higher at FUI, the child has screened positive. Higher

scores are indicative of more ASD-related concerns with 8-20 indicating a FUI can be
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

bypassed, instead, it is recommended to refer the child for a diagnostic evaluation (Robins et

al., (2014)

The Screening Tool for Autism in Toddlers and Young Children (STAT):

The STAT is a level 2, clinician-administered, semi structured, interactive play-based

screening tool to identify toddlers between the ages of 24 and 36 months. The tool assesses

behaviours in the areas of early social and communicative behaviours including: play,

directing attention, requesting, and imitation, and takes approximately 20 minutes to

administer (Stone et al., 2004). The tool consists of 12-items that are derived from three

measures: the Motor Imitation Scale, the Play Assessment Scale, and the Prelinguistic

Communication Assessment (Stone et al., 2004). The STAT consists of four imitation items,

four directing attention items, two play items, and two requesting items for facilitating

interaction. However, the two requesting items are not included in the scoring system. Each

item is scored as a pass or fail, and the number of passes in each area is summed to obtain

an area score (Stones et al., 2000). It is noted, because the domains contain an unequal

number of items, equal weighting is achieved by expressing domain scores as the proportion

of failed items to total items (i.e., domain with two items can be 0, .5, or 1) . The total score

is achieved by summing the four domain scores and can range from 0 to 4, with higher

scores signifying greater impairment (Stones et al., 2000).

Comparison of Psychometric Properties:

Screening instruments can be evaluated by sensitivity; the ability of a test to correctly

identify when a disorder is present, specificity; how well a test identifies those who do not

have the disease, positive predictive value (PPV); the probability that children with a positive

screening have the disorder, and negative predictive value (NPV); the probability that
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

children with a negative screening truly do not have the disease (Parikh et al., 2008; Thabtah

& Peebles, 2019). An adequate balance between sensitivity and specificity is ideal, though,

sensitivity is noted as the most salient for early ASD screeners (Barton et al., 2012).

Retrospective parent-reports are considered valuable when acquiring information

regarding a child’s development and behaviour. The history of a child and observations in a

naturalistic setting is information that could otherwise not be measured in a clinical setting

(Nordahl-Hansen et al., 2014). The M-CHAT-R/F is currently one of the most worldwide used

level 1 population ASD screening instruments as it is quick to administer, cost-effective,

accessible in multiple languages, and specific knowledge or training is not needed to

administer or to interpret scores (Weitlauf et al., 2015). In an attempt to detect as many

children with ASD as possible, while also significantly reducing false positives rates, the

M-CHAT was revised from its initial 23 questions to 20 questions and a second follow-up

stage was added to confirm results (Chlebowski et al., 2013).

In an effort to validate the revised version, Robins et al., (2014) conducted a

longitude study with a sample of 16,071 low-risk toddlers in the United States. To determine

optimal cut-off scores, Receiver Operator Characteristic (ROC) analysis was applied to

establish the score >3 as ideal. At the initial stage, sensitivity and specificity were high .911

and .955, however, at FUI sensitivity decreased and specificity increased .833 and .992

respectively. The tool had excellent criterion validity (the degree to which the measure

correlates with a gold-standard measure), yet, across all items, internal consistency was poor

(α = .63). Considering the items do not assess a unitary dimension, motor items were

created to be distractors, and Cronbach Alpha was calculated as a total scale instead of each

domain/subscale separately, it is not surprising internal consistency was below the

A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

threshold. Among those who had positive-screening in both the first stage (18 months) and

FUI (24 months), 47% (PPV) had a risk of being diagnosed with ASD (95% CI: 0.41–0.54) and

a 94.6% risk for developmental delay concerns (95% CI: 0.92–0.98). Though, this could be

interpreted as the tool screening more broadly than just for ASD, although, given the

unknown sensitivity for such purposes it cannot be justified. When compared with published

studies using the previous version in low-risk samples, there is a significant reduction in the

initial screen-positive rate (from 9.15% to 7.17% p < .001). This implies the tool is successful

as fewer children required a FUI, the rate of detection had significantly increased, while also

maintaining high sensitivity (Chlebowski et al., 2013; Robins et al., 2001). It is not certain

however, if the increase in detection is due to increased ASD prevalence or from improved

parent awareness of ASD.

A meta-analysis by Sanchez-Garcia, (2019) further validated the M-CHAT-R/F as an

effective screening tool in low risk children under the age of 36 months. A Bayesian model

which is established as a strong method of analysis, was used to estimate the screening

accuracy in population based studies demonstrating a pooled sensitivity of 0.72 and

specificity 0.98 (95% CI). However only 66.6% of the studies showed all the primary

outcomes required to populate a PPV (Sanchez-Garcia, 2019). In contrast, findings from a

meta-analysis by Yuen et al., (2018) analysing 13 M-CHAT-R/F studies, found a lack of

evidence for the tool being effective for identifying ASD in low risk children aged between 18

to 24. Though, considering the authors aim was to assess the M-CHAT-R/F as a universal

screening tool for ASD, there was only one low risk study, and PPV was calculated for only

high risk studies 0.53 (95% CI: 0.43–0.63), possibly suggesting selection bias. Additionally,

studies have found at the initial 18 month screen, only about a third of children were

identified of the cases ultimately recognised, in younger low risk toddlers PPV was lower
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

(0.28) compared to older (0.61), ASD symptoms were more likely to emerge gradually,

hence, more noticeable after 18 months ( i.e., repetitive behaviours), and many high risk

siblings not diagnosed at 18 months were eventually diagnosed at 36 months revealing poor

sensitivity and increased false negatives (Chlebowski et al., 2013; Ozonoff et al., 2015;

Robins et al., 2014; Stenberg et al., 2014; Sturner et al., 2013). These findings suggest that

18 months old’s who do not score high enough for FUI should still be monitored.

Despite the low-cost and feasibility of the M-CHAT-R/F, concerns have been raised

surrounding the accuracy of parent-reporting. Parents may be unaware of developmental

milestones and likely to attend to unusual or challenging behaviours (Zapolski & Smith,

2013). In addition, report and recall bias is likely to occur as parents perception of a child’s

functioning may be overestimated as a result of reluctance to acknowledge any

developmental delays (Ozonoff et al., 2015). On the contrary, trained clinicians are expected

to offer an unbiased, objective, and standardised assessment. Interactive screening tools like

the STAT have the advantage of providing clinicians with the opportunity to detect any subtle

communication or behavioural impairments that may not be readily recognised by parents

(Stones et al., 2000).

So far, the STAT is the only level 2 screener comprised of interactive items and

numerous studies have revealed strong psychometric properties. For instance, in an attempt

to screen for Autism in children aged 24 to 36 months, Stones et al., (2004) provided the

STAT to fifty-two participants; toddlers clinically diagnosed with autism (n = 26) and

developmental delay and/or language impairment (DD/LI) (n = 26). The authors went to

great measures to validate the screening tool. In study 1, matched pairs were used to

establish the optimal cut-off of 2 and as a result the STAT had high sensitivity 0.92, specificity

0.85, PPV 0.86, and NPV 0.92, indicating a respectable rate for identifying children with or
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

without a clinical autism diagnosis. In study 2, children with a clinical autism diagnosis (n =

50), PDD-NOS (n = 15), and DD/LI (n = 39) were evaluated by administers blind to referral or

diagnosis. Using Cohen’s Kappa; STAT risk interrater agreement was 1.00 an almost perfect

agreement, STAT risk test-retest reliability was 0.90, and concurrent validity comparing STAT

with Autism Diagnostic Observation Schedule-Generic (ADOS-G) was high 0.95. Although the

STAT demonstrated high PPV in identifying children at risk for autism, it was less accurate at

identifying PDD-NOS and other milder ASD symptoms. This could be a potential issue

considering the DSM-5 modified the diagnosis of autism to a spectrum with milder

symptoms .

In their subsequent study using the STAT in children younger than 24 months,

children with PDD-NOS were included. However, the non-ASD sample contained a high

number of children with siblings already diagnosed with ASD (Stones et al., 2008). It is not

clear though if administers were blind to this information so clinician bias needs to be

considered. Additionally, the cut-off score of 2 resulted in an increase of false-positives in

the youngest children of 12 to 13 months. Removing the youngest children resulted in

substantially better specificity 0.83 and PPV 0.68. Although the PPV at a young age needs to

be considered when evaluating ASD screening instruments, the average lag in this study

between screen and diagnosis was 15 months (Stones et al., 2008). Hence, based on the

screening information provided, it is still unclear if a child will continue to meet diagnostic

criteria or severity of symptoms (Brewer et al., 2020). The clinical-setting, small sample size,

and outcome diagnosis of ASD (n = 19) needs to be acknowledged as a limitation for future

replication.
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

Cultural and Ethical Considerations:

Most of the documented knowledge of prevalence and interventions has come from

research conducted in developed, westernised countries with readily available support

services (Canal-Bedia et al., 2011; Koh et al., 2014; Nygren et al., 2012). However, studies

have confirmed ASD is not limited to affluent, English-speaking countries (Samadi &

McConkey, 2011). Mandell, Novak, and Zubritsky (2005) found diagnosis of ASD on average,

is 11 months later for those in low income families, low parental education, and from

ethnic/race minority. Differences in prevalence are associated with factors such as limited

access to healthcare, stigma, and cultural differences in behaviours for ASD diagnosis. For

example, the M-CHAT-R/F considers limited eye contact as an ASD characteristic, however,

countries like Japan and Ghana consider this as a sign of respect (Akechi et al., 2013).

Therefore it is vital to examine the validity and reliability of the M-CHAT-R/F and STAT in

different SES, cultures, and languages.

The M-CHAT-R/F has been translated into over 50 languages and the modification to

use illustrations and simple language is suggested to improve comprehension in both English

and non-English speaking languages when translated (Robins et al., 2014). The M-CHAT-R/F

has been successful across countries such as Albania, Serbia, Indonesia, China, and West

Africa. Recording high sensitivity and specificity (Brennan et al., 2016; Carakovac et al., 2016;

Guo et al., 2019; Petrocchi et al., 2020). However several concerns need to be considered

when it comes to psychological test and the conduct of assessment for cultural differences.

First, pilot-testing of the translated M-CHAT-R/F is needed to strengthen both semantic and

content equivalence (AI Maskari et al., 2018). A longitudinal Chinese study by Guo et al.,

(2019) found the M-CHAT-R/F was successful in differentiating children at risk of ASD from

developmental delays, however, no pilot test was conducted, possibly affecting research
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

findings. Further, an Albanian study by Brennan et al., (2016) found the M-CHAT-R/F has the

advantage of being adaptive. To increase internal consistency, problematic or less predictive

items such as the three reverse-scored sensory symptom items (have you ever wondered if

your child was deaf?, does your child make unusual finger movements near their eyes?, does

your child get upset by everyday noises?) were removed. As a result, internal consistency at

the initial stage increased from (α = .737) to (α = .886), follow up remained stable (α = .931),

and out of all the children screened, 9.75% screened positive (PPV 0.16), and at follow-up,

20% continued to screen positive for ASD (PPV 0.895).

Second, cultural background may influence attitudes and knowledge of ASD which

can influence willingness to interact (Samadi & McConkey, 2011). Several studies have found

attrition rates were higher in those of race/ethnic minorities and low parental education and

SES. The M-CHAT-R/F has the advantage of being able to screen from home (private setting)

without fear of stigma while also providing information of ASD symptoms. However, this is

only beneficial if the parent has knowledge and awareness of abnormal developmental

delays to detect (Dawson, G., & Bernier, 2013).

Clinician-administered assessments like the STAT have the advantage of having

trained professionals with knowledge of ASD symptoms that parents may not have. However

this would need valid consent from the parent to be ethical, which may be a barrier in some

cultures that fear stigmatisation (cite). Furthermore, children may be reluctant to talk to an

adult, especially from a cultural group. Hence, the clinician’s cultural perspective and biases

matters in assigning a diagnosis (Ennis-Cole et al., 2013).

Discussion:

Screening tools are a vital for the early identification of ASD. Numerous studies have

revealed early interventions are correlated with optimal outcomes in children with ASD
A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

(Levy & Perry, 2011; Nowell et al., 2015). Two primary approaches to screening tools are

currently utilised; level 1 for the general population level and level 2 for children already

considered at risk. The M-CHAT-R/F is a cost-effective and feasible parent-report

questionnaire that be used to assess risk of ASD (Petrocchi et al., 2020; Stone et al., 2004).

The STAT is a clinician-administered screening tool for referred children. Both tools have

advantages and disadvantages. For example, both the M-CHAT-R/F and STAT have

demonstrated strong psychometric properties with adequate sensitivity, specificity, and PPV

in nearly all studies (Robins et al., 2014). The modified M-CHAT-R/F has two stages and is

able to detect more screen-positives with the second stage beneficial for identifying any

false-positives (Robins et al., 2014). However, parent-reporting may be considered as bias as

parents answers are through their perspectives (Ozonoff et al., 2015). Alternatively, the STAT

is considered to be an unbiased and objective screening tool with the advantage of having a

trained clinician to pick up on abnormal social and behavioural problems parents may

otherwise miss (Stones et al., 2000).

Based on the evidence, the M-CHAT-R/F and its two stage parent-report and FUI is

the chosen preferred screening method. The two stages not only allows early detection, it

also offers a FUI to gain more information for an accurate diagnosis. The M-CHAT-R/F is

cost-effective and feasible and therefore beneficial to low SES and race/ethnic minorities

who may be limited to healthcare. Furthermore, the tool can be translated into over 50

languages making to accessible to those where English is not the first language. Finally, the

M-CHAT-R/F can be used in a natural setting to screen and gather information on symptoms

without fear of stigma, especially for those in diverse cultures.

A COMPARISON OF STANDARDISED SCREENING MEASURES IN ASD

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