The Checklist for Autism in Toddlers (CHAT) is a screening tool developed in 1992 to identify toddlers aged 18 months who may be at risk for autism or other social-communication disorders. The CHAT consists of questions for parents about behaviors like pretend play, pointing, and bringing objects to show others, as well as observations by a healthcare provider. The Modified Checklist for Autism in Toddlers (M-CHAT) was later developed to screen children at 24 months and add additional questions, screening for a broader range of disorders. Both checklists aim to identify children in need of further evaluation rather than diagnose autism and have limitations but provide an objective, quick way for pediatricians to assess early signs of social

1. Checklist for Autism
in Toddlers (Chat)
Claudia Betancourt
Angela Bonner
Breona Smith

2. Common Level 1 Checklists
for Autism in Children
These test are usually 5-15 minutes typically filled out
by the parent and the pediatrician answers some
questions
 Checklist for Autism in Toddlers (CHAT)
 CHAT - Denver Modifications
 Checklist for Autism in Toddlers-23 (China tested)
 Modified Checklist for Autism in Toddlers (M-CHAT)
 PDD Screening Test II, Primary Care Screener

3. CHAT
 Developed in England in 1992 by Dr. Simon Baron-
Cohen and colleagues
 A screening instrument which identifies children at 18
months who are at risk of having social-communication
disorders
 A short questionnaire with 14 checklist items which is
filled out by the parents and a primary health care worker
at the 18 month developmental check-up

4. Administering CHAT
 It consists of two sections: the first nine items are questions asked
to the parents and the last five items are observations made by the
primary health care worker
 The key items look at behaviors which, if absent at 18 months, put a
child at risk for a social-communication disorder
 Includes 14 items measuring:
(a) joint attention (pointing to show and gaze-monitoring, looking to
where a parent is pointing)
(b) pretend play (pretending to pour tea from a teapot)
(c) Imitation (copying actions or words)

5. Creating the Checklist
 Pediatricians generated a list of symptoms thought to be
present in very young children with autism
 Items were created based on hypotheses in the
literature, clinical instruments used to evaluate older
children and their own clinical experience.
 Some items were generated based on findings from
home videos of children later found to have autism

6. Test Questions
Section A - Parents
1. Does your child enjoy being swung, bounced on your knee, etc?
2. Does your child take an interest in other children?
3. Does your child like climbing on things, such as upstairs?
4. Does your child enjoy playing peek-a-boo/hide-and-seek?
5. Does your child ever PRETEND, for example, to make a cup of tea using a toy cup and teapot,
or pretend other things?
6. Does your child ever use his/her index finger to point, to ASK for something?
7. Does your child ever use his/her index finger to point, to indicate INTEREST in something?
8. Can your child play properly with small toys (eg cars or bricks) without just mouthing, fiddling or
dropping them?
9. Does your child ever bring objects over to you (parent) to SHOW you something?

7. Test Questions
Section B – Observer
 During the appointment, has the child made eye contact with you?
 Get child's attention, then point across the room at an interesting object and say
'Oh look! There's a (name of toy!)' Watch child's face. Does the child look across
to see what you are pointing at?
 Get the child's attention, then give child a miniature toy cup and teapot and say
'Can you make a cup of tea? ' Does the child pretend to pour out tea, drink it,
etc.?
 Say to the child 'Where's the light?', or 'Show me the light'. Does the child point
with his/her index finger at the light?
 Can the child build a tower of bricks? (If so how many?)
(Number of bricks:.............)

8. Modified Checklist for Autism
in Toddlers (M-CHAT)
 Developed in 2001 by Robins, Fein, Barton and Green
 Screens at 24 months instead of 18 months to catch regression
between 18-24 months
 14 new items were added to the 9 parent-report items from the
original CHAT creating 23 parent-report items checklist
 Broadens the design to identify greater range of children with
pervasive developmental disorders (PDD) and eliminate the home
health visitor observation

9. M-CHAT Additional Questions
for Parents
10. Does your child look you in the eye for more than a second or two?
11. Does your child ever seem oversensitive to noise? (e.g., plugging ears)
(REVERSE)
12. Does your child smile in response to your face or your smile?
13. Does your child imitate you? (e.g., you make a face-will your child imitate it?)
14. Does your child respond to his/her name when you call?
15. If you point at a toy across the room, does your child look at it?
16. Does your child walk?
17. Does your child look at things you are looking at?
18. Does your child make unusual finger movements near his/her face?
(REVERSE)
19. Does your child try to attract your attention to his/her own activity?
20. Have you ever wondered if your child is deaf? (REVERSE)
21. Does your child understand what people say?
22. Does your child sometimes stare at nothing or wander with no purpose?
(REVERSE)
23. Does your child look at your face to check your reaction when faced with
something unfamiliar?

10. Scoring
There are five key items:
 A5 (pretend play)
 A7 (protodeclarative pointing)
 Bii (following a point)
 Biii (pretending)
 Biv (producing a point)
If a child fails all five key items, they have a high risk of developing
autism. Children who fail items A7 and Biv have a medium risk of
developing autism.

11. Scoring
 Six items pertaining to social relatedness and communication were
found to best identify between children diagnosed with and without
autism
 Cutoff scores were created for the best items and the total checklist
 Critical items are marked in BOLD and reverse score items,
meaning those for which a score of “Yes” indicates risk for autism
(11, 18, 20, 22) are noted by the word REVERSE.
Results indicate that the M-CHAT is a promising instrument for the
early detection of autism

12. M-CHAT Scoring
 A child fails the checklist when 2 or more critical
items (11, 18, 20, 22) are failed OR when any
three items are failed.
 Yes/No answers convert to pass/fail responses.

13. Rescreening
 Any child who fails the CHAT should be re-screened approximately
one month later
 As with any screening instrument, a second CHAT is advisable so
that those children who are just slightly delayed are given time to
catch up
 Any child who fails the CHAT for a second time should be referred
to a specialist clinic for diagnosis since the CHAT is not a diagnostic
tool
 M-CHAT Follow-up Interview (addresses only the failed items)
Failure of two critical items (items 2, 7, 9, 13, 14, 15) or any three
total warrants referral to a specialist

14. Follow-Up

15. Pyschometrics
 Reliability
 Validity
 Usability

16. Advantages of CHAT
 There is no single known medical cause of social-communication
disorders, therefore it is very unlikely that there will be a medical test
available in the near future
 Regardless of the cause of these problems, the behavioral
characteristics have been identified and this is what the CHAT is
based on
 In addition, CHAT is cheap (usually free), quick and easy to
administer

17. More Advantages
 Given the pressures of the typical pediatrician’s office, such an
instrument must be objective, easy to administer, and brief
 Physicians cannot always reliably identify a developmental delay
based on a child’s behavior in one session in the doctor’s office
 Particularly for very young children, a potentially serious
communication and social delay may be confused with shyness in a
typically developing youngster and behavior in the doctor’s office
 Therefore, being able to administer the test in multiple settings
increases the reliability of the test

18. Weaknesses
 The presentation of autism changes depending on the child’s age
 Must be sensitive to developmental concerns
 Potentially serious communication and social delay may be
confused with shyness in a typically developing child
 Behavior in the doctor’s office may not represent the child’s typical
behavior. This makes parent report essential to any screening
instrument
 Must distinguish between developmental delays and legitimate
displays of autistic symptoms
 Therefore, screening positive on the test does not diagnose autism;
it simply indicates an increased risk
 Yes/No answer format

19. Weaknesses
 The M-CHAT’s primary goal is to detect as many cases of Autism as
possible. Therefore, there is a high false positive rate, meaning that
many children who score at risk for Autism will not be diagnosed
with it
 To address this, the authors developed a structured M-CHAT
Follow-up Interview (addresses only the failed items)

20. References
 Iannelli, V., (2011). Autism Checklists for Toddlers. Retrieved from
http://pediatrics.about.com/od/autism/a/autism-checklists.htm
 Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The
Modified Checklist for Autism in Toddlers: An Initial Study
Investigating the Early Detection of Autism and Pervasive
Developmental Disorders. Journal Of Autism & Developmental
Disorders, 31(2), 131.
 The Pediatrician's Role in the Diagnosis and Management of
Autistic Spectrum Disorder in Children. (2001). Pediatrics, 107(5),
1221.

21. Questions?