Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 133-137

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, Bali-Indonesia.

I Gusti Ayu Trisna Windiani1, Soetjiningsih2, I Gusti Agung Sugitha Adnyana3, Kadek Apik Lestari4*
1-3
Lecturer, 4Resident
Department of Child Health,
School of Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
*Corresponding: Email: kadekapiklestari@gmail.com
Background: Autism Spectrum Disorder (ASD) is a developmental disorder characterized by impaired
reciprocal social interaction and communication, and by a restricted, repetitive or stereotyped behavior.
Early detection of autism is recommended on all toddlers from the ages of 9 months because of
increasing in prevalence. The Modified Checklist for Autism (M-CHAT) in Toddlers, a Revised with
Follow-Up (M-CHAT-R/F) is a 2-stage parent-report screening tool to assess a risk for ASD and it
demonstrates an improvement compared to the original M-CHAT. It is translated to Indonesian
language by Soetjiningsih and colleagues, and it needs to be validated. Methods: This is a diagnostic
accuracy study conducted at Sanglah Hospital, Bali, conducted from March 2015 to December 2016.
We included children 18-48 months in this study. The parents of the outpatient children in the growth
and development clinic of Sanglah Hospital were asked to fill out the Indonesian M-CHAT-R/F form.
In the same visit, the Autism Spectrum Disorder (ASD) assessment according to the DSM-5 as a gold
standard was done by the researchers, without knowing the M-CHAT-R/F result. The assessment
comparison based on M-CHAT-R/F and DSM-5 was analyzed to obtain the AUC intersection on ROC
curve that gives the best sensitivity and specificity. Results: We found 10.71% of our outpatient was
diagnosed with autism according to DSM 5, when they are 18-24 months old. The Indonesian version
of M-CHAT-R/F as an ASD screening tool has 88.9% in sensitivity and 94.6% in specificity.
Conclusion: Our results suggest that the Indonesian translation of the M-CHAT-R/F is an effective
screening instrument for ASD, particularly when a two-step screening process is used.

Keywords: M-CHAT-R/F, Modified Checklist for Autism, Autism Spectrum Disorder, validity test

DOI: 10.15562/bmj.v5i2.240

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): 133-
138. DOI:10.15562/bmj.v5i2.240

INTRODUCTION Recent epidemiologic studies have

Autism spectrum disorder (ASD) is a confirmed that ASD is more common than
syndrome with a wide clinical phenotype, previously thought, with a rate of approximately 6
characterized by impairments in social interaction to 7 per 1,000 children.1-3 The most recent
and reciprocal communication, and by patterns of estimation in the United States in children of 8 years
stereotyped behaviours. The term ASD is used here old was as high as 6.5 per 1,000 in 2002, to 10.2 per
to define a broad concept of autism, manifested as a 1,000 in 2006 and 13.0 per 1,000 in 2008.4 Autism
spectrum of behavioural, cognitive, and linguistic in aged 18-48-month old constitutes 9.7% of all
problems that include autistic disorder, Asperger Sanglah Hospital pediatric outpatient.5 An early
syndrome, and pervasive developmental disorder detection is essential for children with ASD. Clinical
not otherwise specified (PDDNOS). ASD is a studies that have shown that an early intervention
chronic and severe neurodevelopmental disorder subsequent to early detection can enhance their
with a significant social impact.1 potential and lead to an optimal outcome.4,6
The original Modified Checklist for Autism
Corresponding author: in Toddlers (M-CHAT) is currently one of the most
Kadek Apik Lestari, MD widely used ASD screening instruments both in the
Address: Department of Child Health, Udayana United States and internationally, providing an
University/Sanglah General Hospital, Denpasar, accessible and a low-cost option for universal
Bali. Email: kadekapiklestari@gmail.com toddler screening.6,7 A paper by Robins in 2014,

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 Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 133-137
P-ISSN.2089-1180, E-ISSN.2302-2914

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

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 Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 133-137
P-ISSN.2089-1180, E-ISSN.2302-2914

statistically significant mean difference, 0.067 (- Two-Stage M-CHAT-R/F Scoring

0.964-0.830, 95% CI) with p=0.118. Fifteen children in medium risk completed
A total of 168 children were studied from the second stage M-CHAT-R/F, 9 (60%) was
March to December 2015. Fifty-eight children were positive and 6 (40%) was negative. A total of 89
excluded due to suffering a global developmental children was screened negative, 21 children was
delay. The remaining 110 children were screened positive using the M-CHAT-R/F. The DSM-5
with the M-CHAT-R/F (see Table 1). They are 74 examination showed 92 children non-ASD and 18
males (67.27%) and 36 females (32.73%), with children diagnosed with ASD. Five children who
male: female ratio of 2.05:1. The median age was screened positive using M-CHAT-R/F was
30.6 months, SD 9.55 months, range 18-48 months. diagnosed with non-ASD using DSM-5. Two
Based on their nutritional status, 23 (20.91%) were children who was screened negative using M-
underweight, 66 (60%) were normal, 18 (16.36%) CHAT-R/F was diagnosed with ASD using DSM-5.
were overweight, and 3 (2.73%) were obese. Most The Indonesian version of M-CHAT-R/F has a
of the respondence was the mother 93 (84.55%). sensitivity of 88.9% and specificity of 94.6% with
Among the pediatric outpatient of the Sanglah PPV of 76.2% and NPV of 97.8% to predict ASD
Hospital, autism aged 18-48 months was found as (Table 3).
much as 10.71%, and became 16.36% when the
global developmental delay was excluded.

Table 1. The Subject Characteristics

Autism
(DSM-5) Total
Variables
n = 18 n = 110
f (%) f (%)
Sex
Male 15 (83.33) 74 (67.27)
Female 3 (16.67) 36 (32.73)
Age in months 34.33 (20- 30.6 (18- Figure 1.
mean (min-max) 48) 48) ROC curve for first-stage M-CHAT-R. AUC, area
Nutritional Status under the curve; ROC, receiver operating
Underweight 4 (22.22) 23 (20.91) characteristic.
Normal 9 (50.00) 66 (60.00)
Overweight 4 (22.22) 18 (16.36) Table 2. Sensitivity and Specificity for Each M-
Obese 1 (5.56) 3 (2.73) CHAT-R Total Score.
Responden AUC = 0.990
Mother 17 (94.44) 93 (84.55) Cutoff on
Father 1 (5.56) 14 (12.73) M-CHAT-R Sensitivity Specificity
Others 0 (0.00) 3 (2.73) Total Score (%) (%)
Father’s Education 0 100 0.00
Elementary School 0 (0.00) 2 (1.82) 1 100 75.00
Junior High School 2 (11.11) 17 (15.45) 2 100 88.04
Senior High School 8 (44.44) 53 (48.18) 3 100 90.22
Undergraduate 8 (44.44) 38 (34.55) 4 83.33 97.83
Mother’s Education 5 83.33 98.91
Elementary School 1 (5.56) 6 (5.45) 6 83.33 100
Junior High School 3 (16.67) 24 (21.82) 7 72.22 100
Senior High School 7 (38.89) 54 (49.09) 8 66.67 100
Undergraduate 7 (38.89) 26 (23.64) 9 55.56 100
10 44.44 100
First-Stage M-CHAT-R Scoring 11 33.33 100
From 110 children screened with the first 12 27.78 100
stage M-CHAT-R, 83 (75.45%) was negative (low 14 11.11 100
risk), 15 (13.64%) was medium risk and required an 16 5.56 100
additional follow-up, and 12 (10.90%) was positive >16 0.00 100
(high risk) and required no additional follow-up.
Area under the curve was 0.990 (Figure 1). The DISCUSSION
threshold for which both sensitivity and specificity Our study analyzed the validity of the
exceeding 0.80 was 6 (Table 2). Indonesian version of the M-CHAT-R/F as a
screening tool for early detection of ASD. We found
a proportion of autism patient aged 18-48 months

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 Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 133-137
P-ISSN.2089-1180, E-ISSN.2302-2914

was 10.71% among overall Sanglah Hospital different results about the prevalence of autism. A
outpatient. The previous study in the same hospital study in the United States reported the prevalence of
reported a lower rate of 9.7%.5 The reported autism among children age 3 to 5 years was 8.5 per
prevalence of ASD has increased in recent decades. 1000 children.2 A study in 14 states in the U.S. found
For example, data from the Centers for Disease the prevalence of autism has increased from 6.5 per
Control and Prevention’s (CDC) National Health 1,000 children aged 8 years in 2002, to 10.2 per
Interview Survey (NHIS) revealed a nearly fourfold 1,000 in 2006 and 13.0 per 1,000 in 2008.10 A
increase in parent-reported ASD between the 1997– community-based study in South Korea showed the
1999 and 2006–2008 surveillance periods.9 The autism prevalence in children aged 7-12 years was
CDC’s Autism and Developmental Disabilities 2.64% (1.91-3.37, 95% CI).11 Another two-stage
Monitoring (ADDM) Network revealed a 78% community-based study in Spain reported a
increase in ASD prevalence between 2002 and prevalence of 0.92% and 0.29% respectively. 12
2008.10 Various community-based studies showed

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

M- DSM-5 Sen (%) Spe (%) PPV (%) NPV (%) LR+ LR-
CHAT- ASD Non- (95% CI) (95% CI) (95% CI) (95% CI)
R/F ASD
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)

In this study, we found that the male female are in the medium-risk range (13.64% of cases)
was 5:1 for all ASD cases. This finding is consistent require administration of the follow-up, which
with previous study in Sanglah Hospital that have gathers additional detail about at-risk items. The
demonstrated a higher proportion of male, with a children who score in the high-risk range (10.9 % of
ratio of 4.7:1.5 A sex difference in the prevalence of cases) may bypass the follow-up. This result a
ASDs has been well documented in epidemiologic consistency with a validation study of M-CHAT-
studies since the 1960s, and boys with an ASD R/F that showed 93%, 6%, and 1% of children who
outnumbered the girls by a ratio of about 4 to 5.13 A score low-risk range, medium-risk range, and high-
study in the U.S. showed the prevalence of ASD was risk range, respectively.8
significantly higher among boys than among girls, The first stage result in this study indicates an
with ratios ranging from 3.6 to 5.1 (p<0.01).10 The optimal sensitivity and specificity, and demonstrates
specific factors responsible for the higher male an area under the curve of 0.990 were achieved
prevalence in ASD remain unclear. The extreme using the cutoff score of 6 items on the M-CHAT-R.
male brain (EMB) theory, first proposed in 1997, is This cutoff score was lower than the previous
an extension of the Empathizing-Systemizing (E-S) recommended algorithm, which use score ≥ 8 as
theory of typical sex differences proposes that high risk range.8 Our study recommends children
females on average have a stronger drive to with a M-CHAT-R score of ≥ 7 can bypass the
empathize while males on average have a stronger follow up, because approximately 60% of the
drive to systemize.14 children whose parents completed the second stage
The best age for autism screening is an of M-CHAT-R/F continue to show ASD risk and
ongoing debate, and the AAP currently recommends require referrals for an evaluation and a possible
autism-specific screening at both 18 and 24 months early intervention.
of age.10 An important findings in our study is that The sensitivity and specificity of M-CHAT-
the average age of diagnosis was just before the third R/F in this study were 88.9% (65.3%-98.6%, 95%
birthday, which is 1 years earlier than the median CI) and 94.6% (87.8%-98.2%,95% CI),
age of diagnosis.10 This finding suggests that respectively. This finding is consistent with the
implementing a standardized screening and an previous study using the original English version of
expeditious evaluation for positive cases can greatly M-CHAT-R/F demonstrating the sensitivity of
increase the time that children are eligible for early 85.4% (79%-92% ,95% CI) and specificity of 99.3%
intervention services, and therefore improve the (99%-99%, 95% CI).8 This study showed a good
outcome. PPV 76.2%, which supported the purpose of
The recommended algorithm classifies revising the M-CHAT to M-CHAT-R/F: to reduce
children into 3 ranges of risk, on the basis of the the number of cases who initially screen positive and
initial questionnaire. The children who score in the need the follow-up, while maintaining a high
low-risk range (75.45% of cases) are not in need of sensitivity. A good diagnostic test has LR+ >10, LR-
M-CHAT-R follow-up or an additional evaluation. <0.1 and their positive result has a significant
Children should be rescreened if they are younger contribution to the diagnosis. Our Indonesian
than 24 months, as recommended by the American translation of M-CHAT-R/F can be classified as a
Academy of Pediatrics.15 The children whose scores good diagnostic test because the LR+ is 16.4 and

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 Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 133-137
P-ISSN.2089-1180, E-ISSN.2302-2914

LR- 0.117. 2005; 110:417-38.

The limitation of our is the small sample size 7. Sutera S, Pandey J, Esser EL, Rosenthal MA,
and all of the examination, the M-CHAT-R, the Wilson LB, Barton M. Predictors of optimal
follow-up and the ones using DSM 5, was performed outcome in toddlers diagnosed with autism
at the same visit time. In addition, this study was not spectrum disorders. J Autism Dev Disord. 2007;
done in a community setting. Thus, we should avoid 37:98-107.
over generalizing the findings of this study. Some 8. Robins DL, Casagrande K, Barton M, Chen CA,
modifications of the form may be necessary to cater Dumont-Mathieu T, Fein D. Validation of the
the age of children, different cultural attitudes and Modified Checklist for Autism in Toddlers,
values. Nonetheless, our Indonesian translation of Revised with Follow-up (M-CHAT-R/F).
the M-CHAT-R/F can be considered reliable and Pediatrics. 2014;133:37-45.
valid to be used as a first-level screening tool for 9. Boyle CA, Boulet S, Schieve LA, Cohen RA,
early detection of ASD. Blumberg SJ, Yeargin- Allsopp M, et al. Trends
in the prevalence of developmental disabilities in
CONCLUSION US children, 1997– 2008. Pediatrics. 2011;
Our study provides an empirical support for 127:1034-42.
the utility of screening for ASD by using the M- 10. Centers for Disease Control and Prevention.
CHAT-R/F in the primary care setting. The result Prevalence of Autism Spectrum Disorder
suggests that Indonesian translation of the M- Among Children Aged 8 Years - Autism and
CHAT-R/F continues to be an effective screening Developmental Disabilities Monitoring
instrument for ASD in our hospital, particularly Network, 11 Sites, United States, 2010. MMWR
when the two-step screening process is used. A Surveill. Summ. 2014; 63:1-13.
screening with the M-CHAT-R/F potentially 11. Kim YS, Leventhal BL, Koh Y, Fombonne E,
reduces greatly the age at diagnosis, facilitates an Laska E, Lim E, et al. Prevalence of autism
early intervention, and optimizes the long-term spectrum disorders in a total population sample.
prognosis. The simplified scoring of the M-CHAT- Am J Psychiatry. 2011; 168:904-12.
R/F, paired with specific algorithms based on the 12. Canal-Bedia R, García-Primo P, Martín-Cilleros
outcome, should simplified the implementation. MV. Modified Checklist for Autism in Toddlers:
cross-cultural adaptation and validation in Spain.
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