M CHAT English

Child's name*

Date*

Date

Age/DOB*

Relationship to child*

M-CHAT-R TM (Modified Checklist for Autism in Toddlers Revised)

Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no.

1. If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)*

YesNo

2. Have you ever wondered if your child might be deaf?*

YesNo

3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)*

YesNo

4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)*

YesNo

5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)*

YesNo

6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)*

YesNo

7. Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)*

YesNo

8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)*

YesNo

9. Does your child show you things by bringing them to you or holding them up for you to see - not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)*

YesNo

10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble; or stop what he or she is doing when you call his or her name?)*

YesNo

11. When you smile at your child, does he or she smile back at you?*

YesNo

12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)*

YesNo

13. Does your child walk?*

YesNo

14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?*

YesNo

15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)*

YesNo

16. If you turn your head to look at something, does your child look around to see what you are looking at?*

YesNo

17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say "look" or "watch me"?)*

YesNo

18. Does your child understand when you tell him or her to do something? (FOR EXAMPLE, if you don't point, can your child understand "put the book on the chair" or "bring me the blanket"?)*

YesNo

19. If something new happens, does your child look at your face to see how you feel about it? (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)*

YesNo

20. Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)*

YesNo

Permissions for Use of the M-CHAT-R/F^TM

The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F; Robins, Fein, & Barton, 2009) is a 2-stage parent-report screening tool to assess risk for Autism Spectrum Disorder (ASD The M-CHAT-R/F is available for free download for clinical, research, and educational purposes. Download of the M-CHAT-R/F and related material is authorized from www.mchatscreen.com.

The M-CHAT-R/F is a copyrighted instrument, and use of the M-CHAT-R/F must follow these guidelines:

(1) Reprints/reproductions of the M-CHAT-R must include the copyright at the bottom (© 2009 Robins, Fein, & Barton No modifications can be made to items, instructions, or item order without permission from the authors.

(2) The M-CHAT-R must be used in its entirety. Evidence indicates that any subsets of items do not demonstrate adequate psychometric properties.

(3) Parties interested in reproducing the M-CHAT-R/F in print (e.g., a book or journal article) or electronically for use by others (e.g., as part of digital medical record or other software packages) must contact Diana Robins to request permission (DianaLRobins@gmail.com

(4) If you are part of a medical practice, and you want to incorporate the first stage M-CHAT-R questions into your own practice's electronic medical record (EMR), you are welcome to do so. However, if you ever want to distribute your EMR page outside of your practice, please contact Diana Robins to request a licensing agreement.

Instructions for Use

The M-CHAT-R can be administered and scored as part of a well-child care visit, and also can be used by specialists or other professionals to assess risk for ASD. The primary goal of the M-CHAT-R is to maximize sensitivity, meaning to detect as many cases of ASD as possible. Therefore, there is a high false positive rate, meaning that not all children who score at risk will be diagnosed with ASD. To address this, we have developed the Follow-Up questions (M-CHAT-R/F Users should be aware that even with the Follow-Up, a significant number of the children who screen positive on the M-CHAT-R will not be diagnosed with ASD; however, these children are at high risk for other developmental disorders or delays, and therefore, evaluation is warranted for any child who screens positive. The M-CHAT-R can be scored in less than two minutes, Scoring instructions can be downloaded from http://www.mchatscreen.com. Associated documents will be available for download as well.

Scoring Algorithm

For all items except 2, 5, and 12, the response "NO" indicates ASD risk; for items 2, 5, and 12, "YES" indicates ASD risk. The following algorithm maximizes psychometric properties of the M-CHAT-R:

LOW-RISK: Total Score is 0-2; if child is younger than 24 months, screen again after second birthday. No further action required unless surveillance indicates risk for ASD.

MEDIUM-RISK: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or higher, the child has screened positive. Action required: refer child for diagnostic evaluation and eligibility evaluation for early intervention. If score on Follow-Up is 0-1, child has screened negative. No further action required unless surveillance indicates risk for ASD. Child should be rescreened at future well-child visits.

HIGH-RISK: Total Score is 8-20; It is acceptable to bypass the Follow-Up and refer immediately for diagnostic evaluation and eligibility evaluation for early intervention.