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Meta-Analysis
. 2023 Apr 1;177(4):373-383.
doi: 10.1001/jamapediatrics.2022.5975.

Sensitivity and Specificity of the Modified Checklist for Autism in Toddlers (Original and Revised): A Systematic Review and Meta-analysis

Andrea Trubanova Wieckowski  1 , Lashae N Williams  1 , Juliette Rando  1 , Kristen Lyall  1 , Diana L Robins  1
Affiliations
Meta-Analysis

Sensitivity and Specificity of the Modified Checklist for Autism in Toddlers (Original and Revised): A Systematic Review and Meta-analysis

Andrea Trubanova Wieckowski et al. JAMA Pediatr. .

Abstract

Importance: The Modified Checklist for Autism in Toddlers (M-CHAT) and the M-CHAT, Revised With Follow-up (M-CHAT-R/F)-henceforth referred to as M-CHAT(-R/F)-are the most commonly used toddler screeners for autism spectrum disorder (ASD). Their use often differs from that in the original validation studies, resulting in a range of estimates of sensitivity and specificity. Also, given the variability in reports of the clinical utility of the M-CHAT(-R/F), researchers and practitioners lack guidance to inform autism screening protocols.

Objective: To synthesize variability in sensitivity and specificity of M-CHAT(-R/F) across multiple factors, including procedures for identifying missed cases, likelihood level, screening age, and single compared with repeated screenings.

Data sources: A literature search was conducted with PubMed, Web of Science, and Scopus to identify studies published between January 1, 2001, and August 31, 2022.

Study selection: Articles were included if the studies used the M-CHAT(-R/F) (ie, original or revised version) to identify new ASD cases, were published in English-language peer-reviewed journals, included at least 10 ASD cases, reported procedures for false-negative case identification, screened children by 48 months, and included information (or had information provided by authors when contacted) needed to conduct the meta-analysis.

Data extraction and synthesis: The systematic review and meta-analysis was conducted within the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. The Quality Assessment of Diagnostic Accuracy Studies-2 tool evaluated bias in sample selection. Data extraction and quality assessment were performed by 2 authors independently. The overall diagnostic accuracy of the M-CHAT(-R/F) was assessed with the hierarchic summary receiver operating characteristic (HSROC) model.

Main outcomes and measures: Sensitivity, specificity, diagnostic odds ratios, and HSROC curves of M-CHAT(-R/F).

Results: The review included 50 studies with 51 samples. The pooled sensitivity of M-CHAT(-R/F) was 0.83 (95% CI, 0.77-0.88), and the pooled specificity was 0.94 (95% CI, 0.89-0.97). Heterogeneity analyses revealed greater diagnostic accuracy for low- vs high-likelihood samples, a concurrent vs prospective case confirmation strategy, a large vs small sample size, use of M-CHAT(-R/F) Follow-up, and non-English vs English only.

Conclusions and relevance: Overall, results of this study suggest the utility of the M-CHAT(-R/F) as an ASD screener. The wide variability in psychometric properties of M-CHAT(-R/F) highlights differences in screener use that should be considered in research and practice.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Wieckowski reported receiving grants from the Pennsylvania Medical Society and the Eagles Autism Foundation. Dr Lyall reported receiving grants from the Eagles Autism Foundation. Dr Robins reported receiving personal fees from M-CHAT LLC co-ownership, in which licensees pay royalties; receiving grants from the Eagles Autism Foundation, the National Institutes of Health, and the Pennsylvania Medical Society; having a contract to contribute to a Food and Drug Administration trial from Autism Speaks; receiving a gift to support pilot research from the Wawa Foundation; receiving personal fees from Quadrant Biosciences, Inc, for serving as a member of an advisory board; having a contract to collaborate on a toddler screening study in Monterrey, Mexico, from Autismo ABP outside the submitted work; and holding a copyright for M-CHAT, M-CHAT-R/F issued to M-CHAT, LLC (M-CHAT and M-CHAT-R/F are copyrighted instruments). No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Methodological Quality Graph Depicting the Cumulative Findings of the Methodological Quality Analysis
QUADAS-2 indicates Quality Assessment of Diagnostic Accuracy Studies–2.
Figure 2.
Figure 2.. Forest Plot of Modified Checklist for Autism in Toddlers and Modified Checklist for Autism in Toddlers, Revised With Follow-up (Original and Revised Versions Combined) Sorted by Sensitivity
FN indicates false negative; FP, false positive; TN, true negative; and TP, true positive. aRefers to sample 2 of Srisinghasongkram et al.
Figure 3.
Figure 3.. Sensitivity and Specificity Estimates Grouped by Strategy Used for Identifying Missed Cases, Likelihood Level, and Size of Study Sample
FN indicates false negative.
See this image and copyright information in PMC

Comment in

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