NUH and NUP study on M-CHAT-R/F autism screening tool involving 5,336 multi-ethnic children shows promising results that may enable early detection and intervention
Singapore — A pilot study on a screening tool has demonstrated effectiveness in early autism detection in the primary care setting, which may facilitate systematic screening and pave the way for earlier interventions that can lead to better developmental outcomes in young children with the condition. The large-scale study, published in leading international journal Autism1 in October 2023, showed promise for the early detection of autism spectrum disorder (ASD) among toddlers who attended their routine developmental checks at the National University Polyclinics (NUP). Positive feedback from staff who administered the screening highlighted the tool’s efficacy and feasibility.
Led by the Child Development Unit under the National University Hospital's (NUH) Khoo Teck Puat – National University Children’s Medical Institute (KTP-NUCMI) in collaboration with NUP, the large-scale study involved 5,336 children aged between 17 to 20 months.
Systematic screening for autism has potential for earlier intervention
ASD is a life-long neuro-developmental condition that can affect learning, development as well as social communication skills of children. Signs of autism are usually seen in early childhood and can be detected as young as between one to two years of age in many children2.
A prior study that examined autism trends in Singapore3 from 2016 to 2018 led by Dr Aishworiya Ramkumar, Consultant, Child Development Unit, KTP-NUCMI, NUH, showed that the mean age of autism diagnosis was 35.5 months of age, and age of receiving intervention was 42 months.
In this latest study conducted between August 2020 and November 2022, children who screened positive 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.
Dr Ramkumar who is the senior author of the study said: "Early treatment and intervention can make a big difference to children with ASD as it can lead to better improvements in their skills and development, including improved language and cognitive skills, which in turn can lead to better quality of life, and independent-living skills in future. There are many effective treatment options for ASD in children.”
Screening tool shows good performance and feasibility consistent with international studies
Primarily, the study assessed the performance of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) questionnaire and its practical implementation in seven polyclinics4 under NUP.
Parents and caregivers were asked to complete the questionnaire as part of the routine 18-month-old childhood developmental screening visits. Screening and follow-up interviews were administered by trained nursing staff or research personnel.
Results of this initial pilot study suggested that the M-CHAT-R/F is able to identify children who are at a higher likelihood for autism spectrum and need further assessment, accurately. Approximately two per cent of children were screened positive, and among those who had further evaluation at the Child Development Unit, the majority (85.7%) were confirmed to have autism5.
Children identified with autism received appropriate follow-up support and intervention to address their communication and behavioural difficulties.
A large majority of nurses who administered the study were in favour of the practicality of the M-CHAT-R/F screening tool, with 98 per cent agreeing that it is a good and suitable tool to be used in Singapore primary care clinics. Advantages of the M-CHATR/F include the short time taken to complete it (approximately five to 10 minutes) by families and caregivers with minimal guidance and support.
Plans for further studies to support autism screening in Singapore
Dr Ramkumar shared: “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. 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’ acceptability to such screening.”
Dr Ruth Zheng Mingli, co-lead researcher of the study and Senior Consultant, Family Physician, NUP, 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."
Dr Ramkumar cautioned that while the M-CHAT-R/F is valuable for screening, a positive screen does not equate to an autism diagnosis, and definitive assessment is necessary. It is recommended to be administered by trained healthcare professionals, ensuring appropriate counselling for parents and caregivers after completion.
The M-CHAT-R/F questionnaire is currently offered as part of the routine 18-month childhood developmental screening in all the seven polyclinics under NUP.
Said Ms Ong Li Ping, Nurse Manager at Pioneer Polyclinic and one of the nursing leads for the pilot study at NUP: “The M-CHAT-R/F has become an integral component of the routine well-child check with nurses for children at 18 months old since August 2022. 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 intends to embark on further studies to better understand the longterm outcomes and benefits following the screening.
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