Screening tool may enable early detection of autism in young children

Published on 18 March 2024

A recent study has shown that the M-CHAT-R/F screening tool could be useful in early autism detection in the primary care setting.

About four years ago, Qaiser Fikri was diagnosed with autism during his routine developmental check at Bukit Batok Polyclinic at 18 months old.

The diagnosis came as a shock to Qaiser’s parents, with his mother in particular finding it difficult to accept that her son had the condition.

Autism is a neuro-developmental condition that can affect how children interact, behave, and learn.

As Qaiser began to display more symptoms – which included difficulties with communication, frequent tantrums, and an inability to follow instructions – his parents decided to heed their doctor's advice and send him for therapy at the National University Hospital’s (NUH) Child Development Unit @ Keat Hong.

Qaiser was subsequently enrolled in national intervention programmes – the Early Intervention Programme for Infants and Children (EIPIC) and Development Support (DS)-Plus – while his parents also regularly practised developmental and speech exercises with him.

These interventions proved to be invaluable to Qaiser’s development, and at two years old, he began communicating independently with words. Indeed, his development now aligns with his peers, and he no longer shows symptoms of autism.

Qaiser’s experience is a positive example of how early detection can lead to better developmental outcomes in young children with autism, which is what a screening tool – named the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) – aims to achieve. With early detection, parents can opt to enrol their child in early intervention programmes to allow for more positive progress in the child’s learning, development, and functioning skills.

According to a large-scale pilot study conducted between August 2020 and November 2022, the M-CHAT-R/F autism screening tool was shown to be effective in early autism detection in the primary care setting.

This new study was led by the Child Development Unit under the Khoo Teck Puat – National University Children’s Medical Institute (KTP-NUCMI) in collaboration with the National University Polyclinics (NUP).

In the study – which involved 5,336 multi-ethnic children aged between 17 to 20 months – those who were screened positive for autism with the M-CHAT-R/F tool were seen for a comprehensive evaluation by a mean age of 21.9 months, and began autism-specific therapy at a mean age of 22.1 months.

In contrast, a previous study that examined autism trends in Singapore – conducted between 2016 to 2018 – showed that the mean age of autism diagnosis was at 35.5 months of age, and the age of receiving intervention was 42 months. 

The findings of the latest study were published in the peer-reviewed academic journal Autism in October 2023.

While M-CHAT-R/F is already used to screen for autism in countries such as the United States, it is not as commonly used in Singapore. As such, the study was conducted to examine its feasibility and effectiveness when applied in a primary care setting.

The study’s senior author, Dr Aishworiya Ramkumar, Consultant, Child Development Unit, KTP-NUCMI, NUH, explained, “Cultural and contextual differences in each country may impact how effective the screening tool is… so the study was needed to actually see whether it works well in our population before we decide whether we want to use it.”

The M-CHAT-R/F involves parents and caregivers completing a questionnaire as part of their child’s routine 18-month-old childhood developmental screening visits. Screening and follow-up interviews were administered by trained nursing staff or research personnel.

Of the children who screened positive in the study, approximately 85.7 per cent were confirmed to have autism after undergoing further evaluation at the CDU.

Children identified with autism then received appropriate follow-up support and intervention to address their communication and behavioural difficulties.

Highlighting the importance of early detection and treatment for children with autism, Dr Ramkumar said, “Early treatment and intervention can make a big difference to children with autism spectrum disorder (ASD), as it can lead to better improvements in their skills and development, including improved language and cognitive skills.

“This, in turn can lead to better quality of life, and independent-living skills in future. There are also many effective treatment options for ASD in children.”

Dr Ruth Zheng Mingli, co-lead researcher of the study and Senior Consultant, Family Physician, NUP, emphasised the need to expand access to autism screening tools such as M-CHAT-R/F within the community.

She said, "The results of this study underscore the importance of early screening for ASD in young children in a primary care setting, bringing it upstream into the community and improving the outreach to families. The M-CHAT-R/F has proven to be a promising tool that enhances the capacity of healthcare professionals to identify children who may benefit from early interventions.”

However, though the results from the study of M-CHAT-R/F have so far been encouraging, Dr Ramkumar stressed that further studies are required to finetune the screening tool.

“This study is important for Singapore, being the first to explore systematic screening of well-children for presence of autism, using a quick, easy to use questionnaire,” Dr Ramkumar said.

“While this is a promising first step, further studies are essential to better understand the use of the M-CHAT-R/F, including the most appropriate age to screen and caregivers’ acceptance of such screening.”

The M-CHAT-R/F was also widely welcomed by most nurses involved in the study, with 98 per cent finding it practical and suitable to be used in Singapore primary care clinics.

One advantage of the M-CHAT-R/F that was cited was its short completion time, with families and caregivers able to complete the questionnaire in approximately five to 10 minutes with minimal guidance and support.

Ms Ong Li Ping, Nurse Manager at Pioneer Polyclinic and one of the nursing leads for the pilot study, believes that since its introduction in August 2022, the M-CHAT-R/F has become an integral component of the routine 18-month-old check-ups for children at NUP. 

She added, “This proactive approach to early intervention and screening holds promise of not only significantly enhancing the immediate wellbeing of the child but also positively impacting their future functional outcomes and overall quality of life.”

The research team for M-CHAT-R/F intends to embark on further studies to better understand the long-term outcomes and benefits following the screening.

In consultation with Dr Aishworiya Ramkumar, Consultant, Child Development Unit, KTP-NUCMI, NUH, Dr Ruth Zheng Mingli, Senior Consultant, Family Physician, NUP, Ms Ong Li Ping, Nurse Manager, NUP.