Journal of Child Language Acquisition and Development – JCLAD

Vol: 8 Issue: 4 136-143, 2020, December

ISSN: 2148-1997

Translation and validation of modified checklist for autism in

toddlers-revised version in Tamil (T-MCHAT-R)
Perumal Santhanam Divya1
MERF- Institute of Speech and Hearing (P) Ltd
Jasmine Lydia Selvaraj2
Received : 22.05.2020 MERF- Institute of Speech and Hearing (P) Ltd
Accepted : 08.11.2020
Published : 30.12.2020 Priscilla P3
MERF- Institute of Speech and Hearing (P) Ltd
Sai Sreya R4
MERF- Institute of Speech and Hearing (P) Ltd

Abstract
The Modified Checklist for autism in toddlers - revised (MCHAT-R) (Robin et al
2001) is a simple questionnaire for parents which improves discrimination
between autism and other developmental disorders. This screening tool is
currently available in more than 20 languages of the World. The aim of the
current study is adaptation and validation of the Modified Checklist for Autism
in Toddlers (M-CHAT-R) in the Tamil language. A total of 450 children from both
sexes between 16 to 30 months of age were taken, and those who have any
comorbid serve chronic diseases were excluded. For the reliability of T-MCHAT-
R, statistical analysis was done by using SPSS version 20.0. The Cronbach's
Alpha test found out that the T- MCHAT- R has an alpha score of 0.894 on a
standardized item, which is categorized as excellent reliability. Pearson's two-
tailed correlation was performed to compare T-MCHAT-R scores with ISAA scores
which reveal a positive correlation (r=0.01). The ‘p’ value for T-MCHAT-R and
ISAA for both the normal and abnormal groups was >0.001 indicating that the
results are highly significant. Our results yielded reliability and validity
estimates similar to the values of the original M-CHAT validity study (Robins et
al. 2001). We have shown that the Tamil version of M-CHAT-R has divergent
Validity. The Tamil version of M-CHAT-R has shown satisfactory reliability.
Hence it is an effective tool for screening for ASD in medium and high-risk
children and should be regarded as the first official Tamil version of the M-
CHAT-R to be applied in Tamil Nadu.

Keywords: Tamil, Screener, MCHAT-R, Autism Spectrum Disorder

1. Introduction
Autism Spectrum Disorder is a complex developmental disorder. It is most
often a lifelong disorder, though there are more and more cases of children
with ASD who eventually function independently, leading full lives. Autism
differs from person to person in severity and combinations of symptoms. It
usually begins in early childhood and eventually causes problems

1 Bio: Clinical supervisor P. S. Divya’s area of interest covers child language disorder,
neurogenic language disorder, motor speech disorders. C. A: [email protected]
Phone: +91 9566910570
2 Bio: Assist. Prof. Dr. Selvaraj carries out research on fluency disorders, neurogenic
language disorders, motor speech disorders.
3 Bio: BASLP, Area of interest – fluency disorders, child language disorders)
4 Bio: BASLP, Area of interest – child language disorders.

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Checklist for autism in toddlers-revised for Tamil Divya, Selvaraj, Priscilla P., Sreya R.

functioning in society – socially, in school and at work. Diagnostic and

Statistical Manual of Mental Disorder contains revised diagnostic criteria for
autism spectrum disorder (ASD). The DSM-V have 12 diagnostic criteria for
PDD divided in to 3 domains of impairment: Social Interaction;
Communication and Repetitive Behavior or Restricted interest. The onset of
impairment must have occurred before age 3 years. Diagnosing autism
spectrum disorder (ASD) can be difficult, since there is no medical test, like a
blood test, to diagnose the disorders. Doctors look at the child’s behavior
and development to make a diagnosis. Diagnosing an ASD takes two steps;
Developmental screening and comprehensive diagnostic evaluation.
Screening plays a major role especially for those who are at a higher risk for
developmental problems due to preterm birth, low birth weight, or having a
brother or sister with ASD. If a problem is suspected, a comprehensive
diagnostic evaluation is needed. The increased prevalence of autism
spectrum disorder (ASD) and its detection during the first 3 years of life have
substantial relevance for early intervention. Autism is found in every country
(Diagnosed in one in every 115 people) (Matthew J et al at September-12,
2012) and region of the world and in families of all racial, ethnic, regions,
and economic backgrounds, making up roughly 1percent of the world
population. Diagnosing this wide range of prevalence points to a need for
earlier and more accurate screening for the symptoms of ASD. In 2010,
overall estimated ASD prevalence was 14.7 per 1000 (1 in 68) children age 8
years (U.S. centers for disease control and Prevention [CDC], 2014). It is well
known that delayed diagnosis and treatment of Autistic Spectrum Disorders
(ASDs) can worsen the prognosis (Corsello 2005; Dawson and Osterling
1997; Kasari et al. 2006). Current U.S estimates suggest that 1out of 68
children carry an ASD diagnosis (Center for Disease control, 2014). Recent
Global ASD Prevalence estimates indicate 62 out of 10000 children meet
criteria for ASD. American Academy of Pediatrics (AAP) recommends that
ASD –Specific standardize screening should be performed at 18 – 24-month
preventive check-ups; even though a 2009 survey among pediatricians found
that only 28% routinely used it and most common barrier included lack of
time and lack of familiarity with screening tools.
The M-CHAT which stands for Modified Checklist for Autism in toddlers –
Revised with follow up, is a screening tool for parents to assess their child is
at risk of Autism Spectrum Disorder (ASD). This unique diagnostic tool was
first developed in USA as a tool for detecting ASD in children aged under 2
years in low-risk population, and does not require specialized direct
observation. This tool was developed by Diana Robins, PhD. M-CHAT-R tool
may be administered as part of a child wellness visit with a health care
provider, or it may be used by other professionals, such as a school
psychologist or counselor. The ultimate goal of the M-CHAT-R is to
accurately detect as many causes of Autism Spectrum Disorder as possible
in a timely manner. All M-CHAT studies have yield similar results and
indicate that M-CHAT could be effective tool for early ASD screening. (Inada
et al. 2010; Pandey et al. 2008; Robins et al. 2001; Robins and Dumont-
Mathieu 2006; Ventola et al. 2007). As Tamil pediatricians have no detection
tool for developmental screening in ASD, The Modified Checklist for Autism
in Toddlers (M-CHAT-R) was first translated in to and culturally adapted to

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 Journal of Child Language Acquisition and Development – JCLAD
Vol: 8 Issue: 4 136-143, 2020, December
ISSN: 2148-1997

Tamil. Validity and reliability studies were carried out in two different
geographical areas of Tamil Nadu.
The aim of the current study is adaptation and validation of the Modified
Checklist for Autism in Toddlers (M-CHAT-R) in the Tamil language.

2. Methodology
2.1. M-CHAT-R (Robins et al., 2001)
The M-CHAT-R is a parent-report screening tool to assess the risk of ASD.
Initially, the parents have to answer 20 yes/no questions using the M-CHAT-
R form, which takes 5 minutes. If the child is screened positive, the parent is
asked to follow-up for detailed evaluation. A total score of 0-2 is considered
as low risk, 3-7 is considered as medium risk and 8-20 is considered as high
risk. If the M-CHAT –R score remains at 2 or higher, the child is positive and
if the score is 0-1, the child has screened negative. A total score of M-
CHART-R of 8-20 shows a need to refer immediately for diagnostic
evaluation. The T-MCHAT-R can be administered and scored and also can be
used by other professionals to assess risk for ASD. For all items except 2, 5
and 12 the response “no” indicates ASD risk; for items 2, 5 and 12, “yes”
indicates ASD risk.

2.2. ISAA (National Institute for Mentally Handicapped. 2009)

The Indian Scale for Assessment of Autism (ISAA) is also another tool used
for diagnosing and measuring the severity of autism. This tool was developed
and was standardized in the Indian population to diagnose the severity of
autism. The Ministry of Social Justice & Empowerment, Government of India
constitute an Expert Committee comprising of professionals working in the
field of autism and related developmental disabilities to standardize an
Indian tool for assessment of autism. ISAA is an objective assessment tool
for a person with autism which uses observation, clinical evaluation of
behavior, testing by interaction with the subject and also information
supplemented by parents or caretakers to diagnose autism. ISAA consist of
40 items rated on a 5-point scale ranging from 1 (never) to 5(always). The 40
items ISAA are divided into six domains. The domains are Social
Relationship and Reciprocity, Emotional Responsiveness, Speech-Language
and Communication, Behavior Patterns, Sensory Aspects, and Cognitive
Components. A score of < 70 indicates no autism, 70- 106 (mild autism),
107-153 (moderate autism) and > 153 (severe autism).

2.3. Study framework

The Tamil MCHAT-R study was undertaken in the following three phases:
(i) translation and back translation
(ii) the validity of the study itself and
(iii) the reliability of the study

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Checklist for autism in toddlers-revised for Tamil Divya, Selvaraj, Priscilla P., Sreya R.

M-CHAT original version

Study Framework

Translation Validity Relability

Figure 1. M-CHAT study framework

2.4. Translation and Adaptation of MCHAT-R to MCHAT-R in Tamil

MCHAT-R was translated into the Tamil language by one bilingual Speech
Language Pathologist (SLP) who is proficient in Tamil as well as the English
language. This version was given to three SLPs and one linguist. Then back-
translated by a native English speaker who was bilingual, who is fluent in
English as well as Tamil and the revised version was compared to the
original M-CHAT-R. Finally, the Tamil M-CHAT-R was prepared. A slight
adaptation of wordings was required, to match the cultural differences. [6]

2.5. Participants
This is a study to evaluate the validity of the Tamil version of MCHAT–R. The
study was conducted in Tamil Nadu. 420 children who fulfilled the inclusion
and exclusion criteria were included for the study. The data was collected
from kindergarten schools and day care centres. The inclusion criteria were
children from both genders between 12 months to 46 months of age.
Children were excluded if they had known co-morbid conditions that had the
potential to bias the M- CHAT scores, such as Hearing impairment,
Intellectual disability, Downs's syndrome, and ADHD. Participants’ parents
were required to sign an informed consent form.

2.6. Procedure
Tamil-Modified Checklist for Autism in Toddlers - Revised (T-MCHAT-R) was
Prepared. This T-MCHAT-R was administered for 420 children. The children
were divided based on their scores obtained in T-MCHAT-R. Based on the
scores, the children were categorized into 2 groups, group-A and Group-B.
Group-A consists of the children who passed the criteria, and Group-B
included the children who fell into the ASD criterion. We administered ISAA
for both of the groups to find the reliability of the T-MCHAT-R.

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 Journal of Child Language Acquisition and Development – JCLAD
Vol: 8 Issue: 4 136-143, 2020, December
ISSN: 2148-1997

PASS(N=350)(nor
mal group-A) ISAA
T-M-CHAT-R
(N=420) Fail(N=70)(At
risk for ISAA
ASD,Group-B)
Figure 2. The categories in T-MCHAT-R

3. Findings and discussion

T-MCHAT-R was administered to 420 children. Among the 420, 350 children
(Group-A) passed the criteria and 70 (Group-B) had failed the M-CHAT-R
criteria.

Table 1
Mean, Standard Deviation and Cronbach’s alpha values for T-MCHAT-R
Std. Corrected Item- Cronbach's Alpha if
Mean Deviation Total Correlation Item Deleted
1 .08 .269 .559 .882
2 .02 .137 .260 .890
3 .25 .436 .295 .898
4 .04 .203 .374 .887
5 .05 .228 .541 .883
6 .07 .254 .631 .880
7 .08 .269 .683 .878
8 .09 .291 .662 .879
9 .09 .287 .732 .876
10 .05 .218 .448 .886
11 .04 .203 .548 .883
12 .05 .223 .519 .884
13 .01 .084 .215 .890
14 .04 .186 .511 .885
15 .06 .241 .634 .880
16 .11 .313 .798 .873
17 .13 .332 .327 .891
18 .07 .254 .606 .881
19 .16 .364 .575 .882
20 .05 .223 .387 .887

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Checklist for autism in toddlers-revised for Tamil Divya, Selvaraj, Priscilla P., Sreya R.

Table 2
Mean, standard deviation and p value for T-MCHAT-R and ISAA for both the
groups.
Group A Group B P value
Normal ASD
Mean SD Mean SD >0.001
T-MCHAT-R 0.39 .547 7.27 3.438 >0.001
ISAA 41.33 2.744 124.44 33.137 >0.001

The Group-B children passed the critical items, which indicates the risk for
ASD. In Group-A for children who fall on low risk for ASD, ISAA was
administered, which reveals no autism for Group-A children. Group B shows
55% of children in T-M-CHAT-R showed medium risk and ISAA scores reveal
47% of those children have autism and 41% of children in M-CHAT-R
showed high risk and ISAA scores reveals 79% of those children got greater
than 70. In T- MCHAT-R the children who failed and fall in the medium and
high risk they got greater than 70 scores in ISAA.
To check the internal consistency of the items, Cronbach's Alpha scores were
calculated for the whole 20 items in the questionnaire. The Cronbach's
Alpha test found out that the T- MCHAT- R has an alpha score of 0.894 on a
standardized item, which is categorized as excellent reliability. Each item of
the questionnaire obtained an alpha value ≥ 0.6, thereby confirming higher
internal consistency. An item-total correlation was also carried out and
results are depicted in Table 3.

Table 3
Cronbach's Alpha test scores.
Cronbach's Alpha Cronbach's Alpha Based N of Items
on Standardized Items
.889 .894 20

For the reliability of T-MCHAT-R, statistical analysis was done by using

SPSS version 20.0. Pearson's two-tailed correlation was performed to
compare T-MCHAT-R scores with ISAA scores which reveal a positive
correlation (r=0.01) and results are depicted in Table 4.

Table 4
Pearson two-tailed correlation
GROUP A GROUP B
M-CHAT-R ISAA M-CHAT-R ISAA
Pearson Correlation 1 .191** 1 -.085
Sig. (2-tailed) .000 .483
N 350 350 70 70

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 Journal of Child Language Acquisition and Development – JCLAD
Vol: 8 Issue: 4 136-143, 2020, December
ISSN: 2148-1997

4. Conclusion
A The increased prevalence of autism spectrum disorder (ASD) and its
detection during the first 3 years of life have substantial relevance for early
intervention. Autism is found in every country (Diagnosed in one in every
115 people) (Matthew J et al at September-12, 2012) and region of the world
and in families of all racial, ethnic, regions, and economic backgrounds,
making up roughly 1 percent of the world population. Diagnosing this wide
range of prevalence points to a need for earlier and more accurate screening
for the symptoms of ASD. The M-CHAT-R is currently available in more than
20 languages of the world including many Asian languages. Tamil is a
Dravidian language spoken by the people of Tamil Nadu in South India and
there is a need for a screening tool in this language to detect the presence of
ASD among the population of the state. This is the first study to validate the
M-CHAT-R in the Tamil language and the process involved were translation;
validity and reliability analysis. The Tamil version of M-CHAT-R has shown
satisfactory reliability. Children who fall under the medium and high risk
category when M-CHAT- R was administered on them, were also diagnosed
to fall under the autism spectrum when assessed using the Indian Scale for
Assessment of Autism (ISAA). Hence it is an effective screening tool to
identify individuals who fall under the autism spectrum disorder in medium
and high-risk children and should be regarded as the first official Tamil
version of the M-CHAT-R to be applied in Tamil Nadu.

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