CHecklist for Autism in Toddlers (CHAT)   by Dr Avril Brereton

What is the CHAT?

The CHAT is not a diagnostic instrument. It is a screening instrument that can identify children at risk for autism who are 18 months old and who require further comprehensive assessment.  Early identification of autism is important but is not an end in itself. How service providers respond to very young children with autism and their families is critical. Early identification is only useful if followed up by access to early intervention programmes, parent education and support and a range of health, education and welfare services for each child and family.

Background

The CHAT was developed by researchers at Guy's Hospital London, the University of Cambridge and University College London. Their aim was to establish if autism could be detected at 18 months of age. The first study by Baron-Cohen, Allen and Gillberg was published in 1992 (Baron-Cohen et al., 1992). At that time autism was usually detected at about three years of age. The study focussed on impairments in early social communication; in particular, joint attention and pretend play. These are usually present in typically developing children by 18 months of age. Problems with joint attention and pretend play at 18 months were considered likely precursors to the later impairments of children diagnosed with autism - impaired language, social and communication skills. Initially, 91 toddlers took part. General Practitioners (GPs) and health visitors administered the checklist. Four children failed two or more of the items and at 30 months of age were diagnosed with autism. The other 87 toddlers passed four or more items and continued to develop normally when followed up at 30 months of age.

In a later study, a large population of 16,000 children aged 18 months was screened using the CHAT (Baron-Cohen et al., 1996). This study concluded that consistent failure of the three key CHAT items (protodeclarative pointing, pretend play and gaze monitoring) at 18 months carried an 83.3% risk of autism.

Administration & Scoring

The CHAT (see below) has two sections.  Section A has 9 questions that are answered by parents. Section B has 5 items that are observations made by the GP or primary health care worker. There are five key items: A5 (pretend play), A7 (protodeclarative pointing), Bii (following a point), Biii (pretending) and Biv (producing a point). If a child fails all five key items, they have a high risk of developing autism.

Further Reading

Baron-Cohen et al. (1992) Can autism be detected at 18 months? the needle, the haystack and the CHAT. British Journal of Psychiatry, 161, pp. 839-843.

Baron-Cohen et al. (1996) Psychological markers in the detection of autism in infancy in a large population. British Journal of Psychiatry, 168, pp. 158-163.

Baron-Cohen et al. (2000) Early identification of autism by the CHecklist for Autism in Toddlers (CHAT). Journal of the Royal Society of Medicine, 93, pp. 521-525.

CHAT     

Section A - Ask Parent:

Yes or No?

____ 1) Does your child enjoy being swung, bounced on your knee, etc?

____ 2) Does your child take an interest in other children?

____ 3) Does your child like climbing on things, such as up stairs?

____ 4) Does your child enjoy playing peek-a-boo/hide-and-seek?

____ *5) Does your child ever pretend, for example, to make a cup of tea using a toy cup and teapot, or pretend other things?

____ 6) Does your child ever use his/her index finger to point, to ask for something?

____ *7) Does your child ever use his/her index finger to point, to indicate interest in something?

____ 8) Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them?

____ 9) Does your child ever bring objects over to you, to show you something?

Section B - GP's observation

Yes or No?

 * Indicates critical question most indicative of autistic characteristics

____ i) During the appointment, has the child made eye contact with you?

____ *ii) Get child's attention, then point across the room at an interesting object and say "Oh look! There's a (name a toy)!" Watch child's face. Does the child look across to see what you are pointing at?

NOTE - to record yes on this item, ensure the child has not simply looked at your hand, but has actually looked at the object you are pointing at.

____ *iii) Get the child's attention, then give child a miniature toy cup and teapot and say "Can you make a cup of tea?" Does the child pretend to pour out the tea, drink it etc?

NOTE - if you can elicit an example of pretending in some other game, score a yes on this item.

____ *iv) Say to the child "Where's the light?" or "Show me the light". Does the child point with his/her index finger at the light?

NOTE - Repeat this with "Where's the teddy?" or some other unreachable object, if child does not understand the word "light". To record yes on this item, the child must have looked up at your face around the time of pointing.

____ v) Can the child build a tower of bricks? (If so, how many?) (Number of bricks...)