Pediatrics. 2016 Sep;138(3). pii: e20153036. doi: 10.1542/peds.2015-3036.

Autism Screening With Online Decision Support by Primary Care Pediatricians Aided by M-CHAT/F.

Sturner R1, Howard B2, Bergmann P3, Morrel T4, Andon L5, Marks D6, Rao P7, Landa R7.
  • 1Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Center for Promotion of Child Development through Primary Care, Baltimore, Maryland;
  • 2Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Total Child Health, Baltimore, Maryland;
  • 3PrairieCare Institute, Minneapolis, Minnesota; Foresight Logic, Inc, St Paul, Minnesota;
  • 4Total Child Health, Baltimore, Maryland;
  • 5Population Health Research, Johns Hopkins HealthCare, Baltimore, Maryland;
  • 6Woman and Infant Health Program, Wyoming Department of Health, Cheyenne, Wyoming; and.
  • 7Kennedy Krieger Institute, Baltimore, Maryland.



Autism spectrum disorders (ASDs) often go undetected in toddlers. The Modified Checklist for Autism in Toddlers (M-CHAT) With Follow-up Interview (M-CHAT/F) has been shown to improve detection and reduce over-referral. However, there is little evidence supporting the administration of the interview by a primary care pediatrician (PCP) during typical checkups. The goal of this study was to evaluate the feasibility, validity, and reliability of the M-CHAT/F by PCPs with online prompts at the time of a positive M-CHAT screen.


Forty-seven PCPs from 22 clinics completed 197 M-CHAT/Fs triggered by positive M-CHAT screens via the same secure Web-based platform that parents used to complete M-CHATs before an 18- or 24-month well-child visit. A second M-CHAT/F was administered live or by telephone by trained research assistants (RAs) at the Kennedy Krieger Institute Center for Autism and Related Disorders. The Autism Diagnostic Observation Schedule, Second Edition, and the Mullen Scales of Early Learning were administered as criterion measures. Measures of agreement between PCPs and RAs were calculated, and measures of test performance compared.


There was 86.6% agreement between PCPs and RAs, with a Cohen’s κ of 0.72. Comparison of sensitivity, specificity, positive predictive value (PPV), and overall accuracy for M-CHAT/F between PCPs and RAs showed significant equivalence for all measures. Use of the M-CHAT/F by PCPs resulted in significant improvement in PPV compared with the M-CHAT alone.


Minimally trained PCPs can administer the M-CHAT/F reliably and efficiently during regular well-child visits, increasing PPV without compromising detection.

PMID: 27542847



One of the barriers to implementation of the American Academy of Pediatrics guideline for routine autism screening for all toddlers in pediatric practice is that the most commonly used screening test (M-CHAT) requires a two step process, but the second step had never been adapted and validated for use in routine practice. While the first step of implementing and scoring a parent-administered questionnaire is gaining wide usage in pediatric practice, the second stage is not. The second stage of conducting a standard “follow-up interview” was originally validated using trained interviewers on the telephone after the first stage in the pediatric office. What we did is to make the M-CHAT available for online completion by the parent, and made a scored result available to the doctor with an alert for screens requiring the interview. This follow-up interview was “teleprompted” on the usual web-enabled computer normally used during healthcare visits so the doctor could register the parent’s response to the specific questions required by the parent’s pattern of results. The doctors’ answers to the follow up items triggered instant rescoring in the background until the initial failure result was confirmed or refuted. The study showed that doctors results using this electronic decision support tool predicted autism diagnostic evaluations as well as those of trained assistants from the autism center. The doctors incorporated the follow up interview process into their regular check-ups taking less time than it would have to tell parents that their child needs further evaluation for possible autism. Reducing the over-referral rate by an estimated 90% lowers the burden of evaluations required of the generally scarce community resources and avoids unnecessary anguish for families.




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