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Screening for Autism Spectrum Disorder

Profiles of Children Who Are Missed

Beacham, Chloe, BS*; Reid, Morganne, BA*; Bradshaw, Jessica, PhD*,†; Lambha, Meena, PhD*; Evans, Lindsey, BA*; Gillespie, Scott, MS*,†; Klaiman, Cheryl, PhD*,†; Richardson, Shana S., PhD*,†

Journal of Developmental & Behavioral Pediatrics: December 2018 - Volume 39 - Issue 9 - p 673–682
doi: 10.1097/DBP.0000000000000607
Original Article
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Objective: To characterize children presenting with concerns for autism spectrum disorder (ASD) missed by parent-report screeners and to examine benefits of a combined screening approach with the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) and the Ages and Stages Questionnaire, Third Edition (ASQ-3).

Methods: Participants included were 154 children aged 16 to 42 months presenting for an evaluation at an autism center. Caregivers completed the M-CHAT-R, ASQ-3, and a demographic questionnaire. Children participated in an autism diagnostic evaluation consisting of the Mullen Scales of Early Learning (Mullen) and Autism Diagnostic Observation Schedule, Second Edition (ADOS-2).

Results: A total of 124 children (81%) were diagnosed with ASD. The M-CHAT-R identified 85% (n = 105) of these children. Children with ASD missed by the M-CHAT-R had significantly higher scores on the Mullen and significantly lower scores on the ADOS-2. Of the ASQ-3 domains, the majority (n = 102, 82%) of children with ASD failed the communication domain; missed cases showed similar patterns of higher Mullen scores and lower ADOS-2 scores. When adopting a combined screening approach, using a failed screen from either the M-CHAT-R or ASQ-3 communication domain, 93% of children were identified. Parent-reported concerns on an open-ended questionnaire revealed ASD red flags for many missed cases.

Conclusion: Children with ASD missed by screeners had higher scores on developmental testing and lower scores on the ADOS-2; however, children still performed below average on developmental tests. Our findings suggest that a combined screening approach was most effective for identifying children with ASD from a sample group referred for an ASD evaluation.

*Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, GA;

Division of Autism and Related Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.

Address for reprints: Shana S. Richardson, PhD, Marcus Autism Center, 1920 Briarcliff Rd NE, Atlanta, GA 30329; e-mail:

Supported by the Marcus Foundation, JB Whitehead Foundation, Georgia Research Alliance.

Disclosure: The authors declare no conflict of interest.

See the Video Abstract at

Received November 21, 2017

Accepted June 15, 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.