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Early identification of autism by the Checklist for Autism in Toddlers (CHAT)
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Short Description: The CHecklist for Autism in Toddlers (CHAT) is a screening instrument that identi®es children
aged 18 months who are at risk for autism. This article explains how the CHAT was developed
and how it should be used.
Content Inside: JOURNAL
OF
THE ROYAL SOCIETY
OF
MEDICINE
Volume 93
October 2000
Early identi®cation of autism by the CHecklist for Autism in Toddlers (CHAT)
Simon Baron-Cohen PhD Sally Wheelwright MSc Antony Cox FRCPsych 1 Gillian Baird FRCPCH 1 Tony Charman PhD 2 John Swettenham PhD 3 Auriol Drew MA 1 Peter Doehring PhD 4
J R Soc Med 2000;93:521±525
The CHecklist for Autism in Toddlers (CHAT) is a screening instrument that identi®es children aged 18 months who are at risk for autism. This article explains how the CHAT was developed and how it should be used. First we offer a brief introduction to autism.
WHAT IS AUTISM?
syndrome are present, together with a history of language delay (de®ned as not using single words by two years old or phrase speech by three years old).
EARLY DETECTION
Autism, ®rst described by Kanner in 19431, is one of a family of `pervasive developmental disorders2. The most severe of the childhood psychiatric conditions, it is characterized by a triad of impairmentsÐin socialization, communication and ¯exible behaviour. The exact cause is unclear but family and twin studies suggest a genetic basis3±5; molecular genetic studies are underway6. Altered central nervous system function is evident in several different brain regions including the medial prefrontal cortex7 and the amygdala8±10. Autism occurs in about 1 per 1000 children11. The general view is that autistic conditions exist in a spectrum, with classic autism at the extreme. In DSM±IV this is referred to as autistic disorder, and in ICD±10 as childhood autism. To qualify for this diagnosis, the dif®culties in social interaction, communication, and ¯exible behaviour must have begun before the age of three years. Atypical autism and `pervasive developmental disorder not otherwise speci®ed' (PDD-NOS) also lie on the autistic spectrum, but children with these conditions do not meet criteria for autism because of late age of onset, atypical symptoms, symptoms which are not very severe, or all of these. Asperger's syndrome is thought to be another condition on the autistic spectrum: individuals with this syndrome have the social interaction dif®culties and restricted patterns of behaviour and interests but their IQ is normal and there is no general delay in language. A ®nal subtype are individuals with `high functioning autism' (HFA), who are diagnosed when all the signs of Asperger's
University of Cambridge, Departments of Experimental Psychology and Psychiatry, Downing Street, Cambridge CB2 3EB; 1Newcomen Centre, UMDS, Guy's Hospital, London SE1 9RT; 2Behavioural Sciences Unit, Institute of Child Health, London WC1N 1EH; 3Department of Human Communication and Science, University College London, London WC1N 1PG, UK; 4Delaware Autistic Program, 144 Brennan Drive, Newark DE 19713, USA Correspondence to: Simon Baron-Cohen. E-mail: sb205@cus.cam.ac.uk
Until recently, autism was seldom detected before the age of three years. This is not surprising since it is a relatively uncommon condition and can have subtle manifestations. No specialized screening tool exists and most primary healthcare professionals have little training in the detection of autism in toddlers. However, the earlier a diagnosis can be made, the sooner family stress can be reduced; moreover, intervention can improve outcome12. In addition, early professional recognition of parental concerns may prevent secondary dif®culties developing. The challenge is to identify a cost-effective method of detecting the early signs.
Which behaviours might be important?
Parents of children with autism often report that they ®rst suspected that their child was not developing normally around the age of eighteen months13. At this age, certain behaviours are present in the normally developing child that are lacking or limited in older children with autism. Two of these are joint attention14,15 and pretend play11,16. Joint attention refers to the ability to establish a shared focus of attention with another person via pointing, showing or gaze monitoring (e.g. glancing back and forth between an adult's face and an object of interest or an event)17. Joint attention allows children to learn through othersÐboth learning what words refer to18,19, and what to pay attention to in the environment (`social referencing')20. Joint attention is seen as the earliest expression of the infant's `mind-reading' capacity, in that the child shows a sensitivity to what another person is interested in or attending to21. Pointing to share interest (or declarative pointing) can be distinguished from a simpler form of pointing (pointing to request, or imperative pointing). This distinction comes from child language research22. It is the declarative form which is of particular importance simply because in this type of pointing mind-reading may be the driving force (`Look at
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