Checklist for Autism in Toddlers (CHAT)

The Checklist for Autism in Toddlers (CHAT) is a screening instrument which identifies children aged 18 months who are at risk of having social-communication disorders. This article outlines the process and provides a set of CHAT questions for you to use.

Questions and answers about the CHAT

1. What is the CHAT?
   The Checklist for Autism in Toddlers is a short questionnaire which is filled out by the parents and a primary health care worker at the 18 month developmental check-up. It aims to identify children who are risk for social-communication disorders.
2. How is the CHAT administered?
   The CHAT can be found below. It consists of two sections: the first nine items are questions asked to the parents, and the last five items are observations made by the primary health care worker. The key items look at behaviours which, if absent at 18 months, put a child at risk for a social-communication disorder. These behaviours are (a) joint attention, including pointing to show and gaze-monitoring (eg looking to where a parent is pointing), and (b) pretend play (eg pretending to pour tea from a toy teapot).
3. How is the CHAT scored?
   The CHAT is very easy to score. 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. Children who fail items A7 and Biv have a medium risk of developing autism.
4. What happens if a child fails the CHAT?
   Any child who fails the CHAT should be re-screened approximately one month later. As with any screening instrument, a second CHAT is advisable so that those children who are just slightly delayed are given time to catch up and also to focus efforts on children who are failing consistently. Any child who fails the CHAT for a second time should be referred to a specialist clinic for diagnosis since the CHAT is not a diagnostic tool.
5. What happens if a child passes the CHAT?
   If a child passes the CHAT during the first administration, no further action needs to be taken. However, passing the CHAT does not guarantee that a child will not go on to develop a social-communication problem of some form and if parents are worried they should seek referral.
6. What are the advantages of the CHAT?
   Because there is no single known medical cause of social-communication disorders, it is very unlikely that there will be a medical test available in the near future. Whatever the cause of these problems, the behavioural characteristics have been identified and this is what the CHAT is based on. In addition, the CHAT is cheap, quick and easy to administer. Currently, autism is rarely detected before the age of three and for the other social-communication disorders, age of detection can be even later. The CHAT, however, is administered when the child is 18 months old. The earlier a diagnosis can be made, the earlier intervention methods can be implemented and family stress reduced.
7. How can further information be obtained?
   If you have any questions about the CHAT, please contact:

   Sally Wheelwright
   Autism Research Centre
   Cambridge University
   Douglas House
   18b Trumpington Road
   Cambridge CB2 2AH, UK

   Tel: 01223 746057
   Fax: 01223 746033
   Email: sjw18@cam.ac.uk

To be used by GPs or Health Visitors during the 18-month developmental check-up.

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

YES/NO

2. Does your child take an interest in other children?

YES/NO

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

YES/NO

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

YES/NO

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

YES/NO

6. Does your child ever use his/her index finger to point, to ASK for something?

YES/NO

7. Does your child ever use his/her index finger to point, to indicate INTEREST in something?

YES/NO

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

YES/NO

9. Does your child ever bring objects over to you (parent) to SHOW you something?

YES/NO

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

YES/NO

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

YES/NO*

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 tea, drink it, etc.?

YES/NO**

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?

YES/NO***

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

YES/NO

* (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.)

** (If you can elicit an example of pretending in some other game, score a YES on this item.)

*** (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.) Copyright of MRC/SBC 1995

The CHAT research team

Guy's Hospital
Newcomen Centre, UMDS, Guy's Hospital, St. Thomas Street, London SE1 9RT, UK
Tony Cox, Gillian Baird, Auriol Drew, Kate Morgan, Natasha Nightingale and Mary Marden

University of Cambridge
Department of Experimental Psychology, Downing Street, Cambridge, CB2 3EB, UK
Simon Baron-Cohen, Sally Wheelwright

Behavioural Sciences Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
Tony Charman

Department of Human Communication and Science, Chandler House, 2 Wakefield Street, London, WC1N 1PG, UK
John Swettenham

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.

This information was supplied by Sally Wheelwright, based at the University of Cambridge. For information on permission to reproduce this page (or any other material on the NAS website) please see the link in 'Related resources' at the bottom of this page. 

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