ORIGINAL ARTICLE

Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 311-315

P-ISSN.2089-1180, E-ISSN.2302-2914

Indonesian Modified Checklist for Autism in Toddler,

Revised with Follow-Up (M-CHAT-R/F) for autism
screening in children at Sanglah General Hospital, CrossMark
Bali-Indonesia
Published by DiscoverSys

I Gusti Ayu Trisna Windiani,1 Soetjiningsih,2 I Gusti Agung Sugitha Adnyana,3

Kadek Apik Lestari4*

ABSTRACT

Background: Autism Spectrum Disorder (ASD) is a developmental Sanglah Hospital were asked to fill out the Indonesian M-CHAT-
disorder characterized by impaired reciprocal social interaction and R/F form. In the same visit, the Autism Spectrum Disorder (ASD)
communication, and by a restricted, repetitive or stereotyped behavior. assessment according to the DSM-5 as a gold standard was done
Early detection of autism is recommended on all toddlers from the by the researchers, without knowing the M-CHAT-R/F result. The
ages of 9 months because of increasing in prevalence. The Modified assessment comparison based on M-CHAT-R/F and DSM-5 was
Checklist for Autism (M-CHAT) in Toddlers, a Revised with Follow-Up analyzed to obtain the AUC intersection on ROC curve that gives the
(M-CHAT-R/F) is a 2-stage parent-report screening tool to assess a risk best sensitivity and specificity.
for ASD and it demonstrates an improvement compared to the original Results: We found 10.71% of our outpatient was diagnosed with
M-CHAT. It is translated to Indonesian language by Soetjiningsih and autism according to DSM 5, when they are 18-24 months old. The
colleagues, and it needs to be validated. Indonesian version of M-CHAT-R/F as an ASD screening tool has 88.9%
Methods: This is a diagnostic accuracy study conducted at Sanglah in sensitivity and 94.6% in specificity.
Hospital, Bali, conducted from March 2015 to December 2016. Conclusion: Our results suggest that the Indonesian translation of the
We included children 18-48 months in this study. The parents of M-CHAT-R/F is an effective screening instrument for ASD, particularly
the outpatient children in the growth and development clinic of when a two-step screening process is used.

Keywords: M-CHAT-R/F, Modified Checklist for Autism, Autism Spectrum Disorder, Validity Test
Cite This Article: Windiani, T., Soetjiningsih, S., Adnyana, S., Apik Lestari, K. 2016. Indonesian Modified Checklist for Autism in Toddler, Revised
with Follow-Up (M-CHAT-R/F) for autism screening in children at Sanglah General Hospital, Bali-Indonesia. Bali Medical Journal 5(2): 311-315.
DOI:10.15562/bmj.v5i2.240

1-3
4
Lecturer, INTRODUCTION
Resident, Department of Child
Health, School of Medicine, Autism spectrum disorder (ASD) is a syndrome pediatric outpatient.5 An early detection is essential
Udayana University/Sanglah with a wide clinical phenotype, characterized by for children with ASD. Clinical studies that have
General Hospital, Denpasar, Bali, impairments in social interaction and reciprocal shown that an early intervention subsequent to
Indonesia
communication, and by patterns of stereotyped early detection can enhance their potential and lead
behaviours. The term ASD is used here to define a to an optimal outcome.4,6
broad concept of autism, manifested as a spectrum The original Modified Checklist for Autism in
of behavioural, cognitive, and linguistic problems Toddlers (M-CHAT) is currently one of the most
that include autistic disorder, Asperger syndrome, widely used ASD screening instruments both in
and pervasive developmental disorder not other- the United States and internationally, providing
wise specified (PDDNOS). ASD is a chronic and an accessible and a low-cost option for universal
severe neurodevelopmental disorder with a signif- toddler screening.6,7 A paper by Robins in 2014,
icant social impact.1 reported the first published data for a revised
Recent epidemiologic studies have confirmed version of the M-CHAT screening instrument and
that ASD is more common than previously follow-up interview, and so called the Modified
thought, with a rate of approximately 6 to 7 per Checklist for Autism in Toddlers, a Revised with
1,000 children.1-3 The most recent estimation in the Follow-Up (M-CHAT-R/F).8 The purpose of
*
Correspondence to: Kadek Apik United States in children of 8 years old was as high revising the M-CHAT was to reduce the number
Lestari, MD, Department of Child
Health, Udayana University/Sanglah
as 6.5 per 1,000 in 2002, to 10.2 per 1,000 in 2006 of cases who initially screen positive and need a
General Hospital, Denpasar, Bali and 13.0 per 1,000 in 2008.4 Autism in aged 18-48- follow-up, while maintaining a high sensitivity.
kadekapiklestari@gmail.com month old constitutes 9.7% of all Sanglah Hospital The overall rate of detection of ASD was higher

Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj 311

ORIGINAL ARTICLE

for the M-CHAT-R/F, which detected 67 cases per First stage using M-CHAT-R form:
10,000, compared with the original M-CHAT/F, A total score of 0-2 is considered as low risk. A total
which detected 45 cases per 10,000. The M-CHAT- score of 3-7 is considered medium risk and the
R/F has been shown to have an adequate sensitivity evaluation proceeds to the second stage using the
and specificity, 47.5% of children screen-positive M-CHAT-R/F. If the M-CHAT-R/F score remains
cases on the basis of the M-CHAT-R/F were diag- at 2 or higher, the child is positive. If the score is
nosed with ASD and 35.7% presented with devel- 0-1, child has screened negative. A total score of
opmental delay or concerns.8 We have not found M-CHAT-R of 8-20 shows a need to bypass the
any research done regarding the M-CHAT-R/F use second stage and a need torefer immediately for
in Indonesia. The aim of this study is to update diagnostic evaluation and eligibility evaluation for
the findings regarding the use of the Indonesian an early intervention.
version of M-CHAT-R/F as an ASD screening
instrument. Second Stage using the M-CHAT-R/F form:
The follow-up items are selected based on which
items the child failed on the M-CHAT-R. Only
METHODS
those items that were originally failed need to be
This is a diagnostic accuracy study to evaluate the administered for a complete interview. The inter-
validity of the Indonesian version of M-CHAT- view is considered positive if the child fails any two
R/F. The study was conducted at the children items on the follow-up.
growth and development outpatient clinic, The reliability of the instrument is done through
Sanglah General Hospital, from March 2015 to a process of translation of the M-CHAT-R/F into
December 2015. The subjects were 110 patients Indonesian by Soetjiningsih and colleagues, with
who fulfilled the inclusion and exclusion criteria. Diana Robins permission. The original is available
We used a consecutive sampling method. The at www.mchatscreen.com. The reliability test was
inclusion criteria are: (1) the age of the patient performed by calculating the coefficient of test-re-
who visit the clinic within the study time frame test reliability. Fifteen parents of children who
is between 18 and 48 months, (2) the parents are joined the study were asked to fill out the form two
willing to participate in the study and signed an times, first in their first visit, and the next within 3
informed consent form. The exclusion criteria are: weeks to a month after the initial visit. The Bland-
(1) the patient was diagnosed with ASD before Altman plot was used to measure the reability of
the visit, (2) the patient has a severe sensory and the translated M-CHAT-R/F. Pediatric residents
communication disability (eg. blindness or deaf- who were stationed in the clinic helped the parents
ness) or severe motoric disability (eg. cerebral filling the M-CHAT-R form, if the parents has any
palsy or hydrochepalus) which prevents them question in filling out the form. In the same visit,
from completing study assessment. the researchers conducted a n examination using
The gold standard of the diagnosis of ASD is The DSM-5 criteria. The diagnosis is made based on the
American Psychiatric Association’s Diagnostic and DSM-5 as the gold standard. The researchers did
Statistical Manual, Fifth Edition (DSM-5). The age not know the M-CHAT-R/F result while conduct-
was determined by checking the patient birth date ing the examination using the DSM-5.
against the date of the visit. The sex was determined The data were analyzed using Stata E 15.
based on the phenotype appearance; divided into Descriptive statistics were used to evaluate the
male and female. data distribution based on the characteristics and
The M-CHAT-R/F is a 2-stage parent-report the frequency of the disorders. An analysis was
screening tool to assess the risk of ASD.8 It is free performed to calculate the sensitivity, specificity,
for a clinical, a research, and an educational use, positive predictive value (PPV), negative predictive
and it requires little or no training for health care value (NPV), positive likelihood ratio (LR+), nega-
professionals. The instruments were available at tive likelihood ratio (LR-). The study was approved
www.mchatscreen.com. Initially, the parents have by the Ethics Committee of Udayana University
to answer 20 yes/no questions using the M-CHAT School of Medicine in conjunction with Sanglah
form, which takes 5 minutes. If the child is screened General Hospital, the university teaching hospital.
positive, the parent is asked a structured follow-up
questions, using the M-CHAT-R/F form, to obtain
RESULTS
an additional information and examples of at risk
behaviors. It takes approximately 5 to 10 minutes The Bland-Altman plot showed the limit of agree-
with a professional. The scoring algorithm of M ment between the first and second M-CHAT-R/F
CHAT-R/F. scores. The scores of M-CHAT-R/F as measured in

312 Published by DiscoverSys | Bali Med J 2016; 5 (2): 311-315 | doi: 10.15562/bmj.v5i2.240
 ORIGINAL ARTICLE

different time periods has a not statistically signifi- male: female ratio of 2.05:1. The median age was
cant mean difference, 0.067 (-0.964-0.830, 95% CI) 30.6 months, SD 9.55 months, range 18-48 months.
with p=0.118. Based on their nutritional status, 23 (20.91%) were
A total of 168 children were studied from underweight, 66 (60%) were normal, 18 (16.36%)
March to December 2015. Fifty-eight children were were overweight, and 3 (2.73%) were obese. Most
excluded due to suffering a global developmental of the respondence was the mother 93 (84.55%).
delay. The remaining 110 children were screened Among the pediatric outpatient of the Sanglah
with the M-CHAT-R/F (see Table 1). They are 74 Hospital, autism aged 18-48 months was found
males (67.27%) and 36 females (32.73%), with as much as 10.71%, and became 16.36% when the
global developmental delay was excluded.
Table 1  The Subject Characteristics
First-Stage M-CHAT-R Scoring
Autism From 110 children screened with the first stage
(DSM-5) Total
n = 18 n = 110 M-CHAT-R, 83 (75.45%) was negative (low risk),
Variables f (%) f (%) 15 (13.64%) was medium risk and required an
Sex additional follow-up, and 12 (10.90%) was positive
Male 15 (83.33) 74 (67.27) (high risk) and required no additional follow-up.
Female 3 (16.67) 36 (32.73) Area under the curve was 0.990 (Figure 1). The
Age in months 34.33 (20-48) 30.6 (18-48) threshold for which both sensitivity and specificity
mean (min-max) exceeding 0.80 was 6 (Table 2).
Nutritional Status
Underweight 4 (22.22) 23 (20.91)
Two-Stage M-CHAT-R/F Scoring
Normal 9 (50.00) 66 (60.00) Fifteen children in medium risk completed the
Overweight 4 (22.22) 18 (16.36) second stage M-CHAT-R/F, 9 (60%) was positive
Obese 1 (5.56) 3 (2.73) and 6 (40%) was negative. A total of 89 children was
Responden screened negative, 21 children was positive using the
Mother 17 (94.44) 93 (84.55) M-CHAT-R/F. The DSM-5 examination showed 92
Father 1 (5.56) 14 (12.73) children non-ASD and 18 children diagnosed with
Others 0 (0.00) 3 (2.73) ASD. Five children who screened positive using
Father’s Education M-CHAT-R/F was diagnosed with non-ASD using
Elementary School 0 (0.00) 2 (1.82) DSM-5. Two children who was screened negative
Junior High School 2 (11.11) 17 (15.45) using M-CHAT-R/F was diagnosed with ASD using
Senior High School 8 (44.44) 53 (48.18) DSM-5. The Indonesian version of M-CHAT-R/F
Undergraduate 8 (44.44) 38 (34.55) has a sensitivity of 88.9% and specificity of 94.6%
Mother’s Education
Elementary School 1 (5.56) 6 (5.45) Table 2  S
 ensitivity and Specificity for Each
Junior High School 3 (16.67) 24 (21.82) M-CHAT-R Total Score.
Senior High School 7 (38.89) 54 (49.09)
Undergraduate 7 (38.89) 26 (23.64) AUC = 0.990
Cutoff on
M-CHAT-R
Total Score Sensitivity (%) Specificity (%)
0 100 0.00
1 100 75.00
2 100 88.04
3 100 90.22
4 83.33 97.83
5 83.33 98.91
6 83.33 100
7 72.22 100
8 66.67 100
9 55.56 100
10 44.44 100
11 33.33 100
12 27.78 100
14 11.11 100
16 5.56 100
Figure 1 ROC curve for first-stage M-CHAT-R. AUC, area under the curve;
>16 0.00 100
ROC, receiver operating characteristic.

Published by DiscoverSys | Bali Med J 2016; 5 (2): 311-315 | doi: 10.15562/bmj.v5i2.240 313
ORIGINAL ARTICLE

Table 3  Psychometric Properties of M-CHAT-R/F Scores

DSM-5
Sen (%) Spe (%) PPV (%) NPV (%)
M-CHAT-R/F ASD Non-ASD (95% CI) (95% CI) (95% CI) (95% CI) LR+ LR-
Positive 16 5 88.9 94.6 76.2 97.8 16.4 0.117
Negative 2 87 (65.3-98.6) (87.8-98.2) (52.8-91.8) (92.1–99.7)

with PPV of 76.2% and NPV of 97.8% to predict (E-S) theory of typical sex differences proposes that
ASD (Table 3). females on average have a stronger drive to empa-
thize while males on average have a stronger drive
to systemize.14
DISCUSSION
The best age for autism screening is an ongo-
Our study analyzed the validity of the Indonesian ing debate, and the AAP currently recommends
version of the M-CHAT-R/F as a screening tool autism-specific screening at both 18 and 24 months
for early detection of ASD. We found a proportion of age.10 An important findings in our study is that
of autism patient aged 18-48 months was 10.71% the average age of diagnosis was just before the
among overall Sanglah Hospital outpatient. The third birthday, which is 1 years earlier than the
previous study in the same hospital reported a lower median age of diagnosis.10 This finding suggests
rate of 9.7%.5 The reported prevalence of ASD has that implementing a standardized screening and an
increased in recent decades. For example, data from expeditious evaluation for positive cases can greatly
the Centers for Disease Control and Prevention’s increase the time that children are eligible for early
(CDC) National Health Interview Survey (NHIS) intervention services, and therefore improve the
revealed a nearly fourfold increase in parent-re- outcome.
ported ASD between the 1997–1999 and 2006– The recommended algorithm classifies children
2008 surveillance periods.9 The CDC’s Autism and into 3 ranges of risk, on the basis of the initial
Developmental Disabilities Monitoring (ADDM) questionnaire. The children who score in the
Network revealed a 78% increase in ASD preva- low-risk range (75.45% of cases) are not in need of
lence between 2002 and 2008.10 Various communi- M-CHAT-R follow-up or an additional evaluation.
ty-based studies showed different results about the Children should be rescreened if they are younger
prevalence of autism. A study in the United States than 24 months, as recommended by the American
reported the prevalence of autism among children Academy of Pediatrics.15 The children whose scores
age 3 to 5 years was 8.5 per 1000 children.2 A study are in the medium-risk range (13.64% of cases)
in 14 states in the U.S. found the prevalence of require administration of the follow-up, which
autism has increased from 6.5 per 1,000 children gathers additional detail about at-risk items. The
aged 8 years in 2002, to 10.2 per 1,000 in 2006 and children who score in the high-risk range (10.9 %
13.0 per 1,000 in 2008.10 A community-based study of cases) may bypass the follow-up. This result a
in South Korea showed the autism prevalence in consistency with a validation study of M-CHAT-
children aged 7-12 years was 2.64% (1.91-3.37, 95% R/F that showed 93%, 6%, and 1% of children who
CI).11 Another two-stage community-based study score low-risk range, medium-risk range, and high-
in Spain reported a prevalence of 0.92% and 0.29% risk range, respectively.8
respectively.12 The first stage result in this study indicates an
In this study, we found that the male female optimal sensitivity and specificity, and demon-
was 5:1 for all ASD cases. This finding is consistent strates an area under the curve of 0.990 were
with previous study in Sanglah Hospital that have achieved using the cutoff score of 6 items on the
demonstrated a higher proportion of male, with a M-CHAT-R. This cutoff score was lower than the
ratio of 4.7:1.5 A sex difference in the prevalence of previous recommended algorithm, which use score
ASDs has been well documented in epidemiologic ≥ 8 as high risk range.8 Our study recommends
studies since the 1960s, and boys with an ASD children with a M-CHAT-R score of ≥ 7 can bypass
outnumbered the girls by a ratio of about 4 to 5.13 the follow up, because approximately 60% of the
A study in the U.S. showed the prevalence of ASD children whose parents completed the second stage
was significantly higher among boys than among of M-CHAT-R/F continue to show ASD risk and
girls, with ratios ranging from 3.6 to 5.1 (p<0.01).10 require referrals for an evaluation and a possible
The specific factors responsible for the higher male early intervention.
prevalence in ASD remain unclear. The extreme The sensitivity and specificity of M-CHAT-R/F
male brain (EMB) theory, first proposed in 1997, in this study were 88.9% (65.3%-98.6%, 95% CI)
is an extension of the Empathizing-Systemizing and 94.6% (87.8%-98.2%,95% CI), respectively.

314 Published by DiscoverSys | Bali Med J 2016; 5 (2): 311-315 | doi: 10.15562/bmj.v5i2.240
 ORIGINAL ARTICLE

This finding is consistent with the previous study 2. Kogan MD, Blumberg SJ, Schieve LA, Boyle CA, Perrin JM,
Ghandour RM, et al. Prevalence of parent-reported diag-
using the original English version of M-CHAT-R/F nosis of autism spectrum disorder among children in the
demonstrating the sensitivity of 85.4% (79%-92%, US. Pediatrics. 2009; 124:1395-403.
95% CI) and specificity of 99.3% (99%-99%, 95% 3. Fombonne E, Zakarian R, Bennett A, Meng L, McLean-
Heywood D. Pervasive developmental disorders in
CI).8 This study showed a good PPV 76.2%, which Montreal, Quebec, Canada: prevalence and links with
supported the purpose of revising the M-CHAT to immunizations. Pediatrics. 2006; 118:139-50.

M-CHAT-R/F: to reduce the number of cases who 4. Dawson G, Rogers S, Munson J, Smith M, Winter J,
Greenson J, et al. Randomized, controlled trial of an inter-
initially screen positive and need the follow-up, vention for toddlers with autism: the early start Denver
while maintaining a high sensitivity. A good diag- model. Pediatrics. 2010;125: e17–e23.

nostic test has LR+ >10, LR- <0.1 and their positive 5. Hendra. MCHAT (Modified Checklist for Autism in
Toodlers) valid untuk skrining autisme pada anak usia
result has a significant contribution to the diagno- 18-48 bulan: suatu uji diagnostic (Thesis). Thesis. Fakultas
sis. Our Indonesian translation of M-CHAT-R/F Kedokteran Udayana; 2013. 

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for children with autism: four-year outcome and predic-
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The limitation of our is the small sample size 7. Sutera S, Pandey J, Esser EL, Rosenthal MA, Wilson LB,
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the follow-up and the ones using DSM 5, was Disord. 2007; 37:98-107.
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Published by DiscoverSys | Bali Med J 2016; 5 (2): 311-315 | doi: 10.15562/bmj.v5i2.240 315