ARI’s Autism Treatment Evaluation Checklist (ATEC): Its Development and Application
EDITORIAL: Stephen M. Edelson, Ph.D.
The Autism Treatment Evaluation Checklist, or ATEC, is one of the most widely used assessment tools in the autism community. The checklist is designed to evaluate the efficacy of treatments as well as to monitor how an individual progresses over time. The ATEC is used by parents and researchers as well as by schools, medical and behavioral clinics, and insurance companies. Over a half million ATECs have been completed over the past two decades.
The ATEC contains a total of 77 questions that are classified into four subscales: Speech/Language/Communication, Sociability, Sensory/Cognitive Awareness, and Physical/Health/Behavior. The ATEC is available free of charge online; you can download it at www.AutismTreatmentEvaluationChecklist.com. Besides English, the ATEC is available in 20 different languages, such as Chinese, Czech, Japanese, French, Italian, and Spanish.
History / Background
Dr. Rimland and I developed the ATEC in the mid 1990s. During this time, the Autism Research Institute (ARI) was conducting a series of research studies on the efficacy of various sensory interventions. In addition, we were encouraging the autism research community to evaluate various biomedical and nutritional interventions, and we wanted to recommend a set of valid and reliable assessment tools.
When searching for appropriate assessment measures, I realized that the results of countless studies relied on checklists designed to diagnose autism rather than to evaluate treatment efficacy. Given that the goal of these studies was to investigate the effectiveness of interventions as objectively as possible, we realized that many if not most of these results could be considered questionable.
Dr. Rimland and I wrote to the authors of many diagnostic checklists and soon confirmed what we had suspected: Those diagnostic checklists were not validated to evaluate changes in medical co-morbidities or behavior. Although our resources were limited, we decided to develop a checklist to properly evaluate changes in individuals with autism.
At that time, we were aware of the Aberrant Behavior Checklist (ABC). Although the checklist was created to assess behaviors in those who were intellectually challenged, some researchers used it to evaluate behaviors in those with autism. Given its original intent, the ABC lacks many questions that would be considered autism-specific, such as “avoids contact with others,” “anxious/fearful,” and “sleep problems.”
Several years after the ATEC was released, the Pervasive Developmental Disorder Inventory (PDD-BI) was published (2003). This checklist was validated to assess treatment efficacy in children with autism between 1 1/2 years and 12 years, 5 months of age. The parent form contains 188 questions, and the teacher form contains 180 questions as compared to the 77 questions in the ATEC. In addition, there is a charge to use the PDD-BI.
Development of the ATEC
When developing the ATEC, I first gathered as many autism-related questions as possible from many different sources. Dr. Rimland had written several autism surveys during the previous 30 years, such as the E-2 and the E-3 (109 and 216 questions, respectively); I also collected questions from numerous autism checklists and questionnaires in the public domain. Overall, I compiled more than 1,000 questions.
Dr. Rimland and I then spent several weeks discussing the questions. We removed redundant ones as well as those that would not typically be used to evaluate changes in behavior (e.g., pregnancy and birth complications, child’s eye and hair color). We also reworded almost all of them. We then mailed a rough draft to over a dozen researchers and clinicians and asked them to indicate whether each question was clinically relevant and whether the wording was as clear as possible. Based on this input, we felt confident that the questionnaire had face validity, i.e., the questions assessed what they appeared to be evaluating.
Throughout the development of the ATEC, Dr. Rimland would often stress that the final version should fit on a single page; otherwise, he felt that people would not take the time to complete it. After much effort, I was able to format all 77 questions on one sheet.
We then sent out a preliminary draft of the ATEC to parents and professionals who had contacted ARI in the past, and asked them to complete and return the checklist. In the cover letter, we stressed that we were pilot testing the checklist, and we appreciated their taking the time and effort to respond as accurately as possible. We also asked for feedback regarding the wording of the questions and any other thoughts they wanted to share with us.
A total of 1,358 ATECs were returned to ARI over a six-month period. We then analyzed the data to examine whether the questions within each of the four subscales were assessing the same issue. This was accomplished by calculating a Pearson split-half (internal consistency) coefficient in which the responses to the odd-numbered questions were compared to the even-numbered questions within each subscale and between subscales. For this analysis, one would expect relatively high association between questions within each subscale, and relatively low association between the subscales. For example, questions within the Sociability subscale should be highly correlated with one another, and these questions should have a lower correlation with those in the Sensory/Cognitive Awareness subscale. The results were quite impressive, with correlation coefficients ranging from 0.815 to 0.920.
We then publicized the availability of the ATEC through ARI’s e-newsletters, conferences, and websites. Initially, the checklist was available in hardcopy only, and eventually, it was uploaded to ARI’s autism.com website.
Published research studies
Over the years, a number of researchers have used the ATEC and have commented on its usefulness. Klaveness et al. (2013) employed the ATEC to investigate the effectiveness of dietary interventions and noted the checklist’s high level of reliability. In a study examining the usefulness of iPad intervention, Whitehouse (2017) stated that the scores of the ATEC had “internal consistency and adequate predictive validity.” In a five-year study, Magiati et al. (2011) monitored the progress of 22 school children and found that the ATEC had high internal consistency and was comparable to other standardized measures.
More recently, I have been working with Dr. Andrey Vyshedskiy and his colleagues on a series of studies on the usefulness of the ATEC. In a recent study involving 2,649 cases, we were able to develop a “growth” chart for autism which maps out, on average, the trajectory of expected ATEC scores given one’s age and current ATEC scores (Mahapatra et al., 2018).
Additional Comments on the ATEC
I have several helpful suggestions for parents or professionals completing the ATEC. One is to consider the individual’s behavior during the past three days rather than in a general sense. In this way, the rater does not need to rely too much on memory. An example would be the question on hyperactivity. If the person was hyperactive anytime during the previous three days, then this behavior should be rated as a minor, moderate, or serious problem. However, if there were no signs of hyperactivity during the past three days, then this behavior would be rated as “Not a problem.”
When evaluating the effectiveness of a treatment, I suggest completing the ATEC at least twice prior to administering the treatment. The time interval could be a few days or a week or more apart. Since a person’s behavior varies from day to day, two or more baseline assessments will likely provide a much more accurate representation of the individual’s overall behavior status.
It is important to mention that the ATEC is not a diagnostic tool, although research in the future may find that the ATEC, or a subset of its questions, can be used to diagnose autism or possibly a subtype of autism.
Occasionally, someone will write to ARI and urge that we translate the ATEC into his or her language. Unfortunately, we do not have the resources to translate the checklist into additional languages. However, we do encourage the autism community worldwide to consider translating the ATEC. If the accuracy of the translation is confirmed by an independent source, we will be more than happy to upload it and make it available on ARI’s website.
For nearly 20 years, the ATEC has been a popular and easy-to-use online assessment tool. Monitoring an individual’s behavior from time to time can provide assurance that he or she is moving in a forward direction. The scores may also signal if the individual is regressing or may be suffering from a medical and/or behavior issue that may not be obvious to others. And finally, when trying a new intervention, the results can provide a clear and objective indication as to whether the intervention is truly helpful.