Use of M-CHAT for Autism Screening in Well-Baby Clinics of a Primary Health Care Center in Dhahran, Saudi Arabia: A Retrospective Cross-Sectional Study

Use of M-CHAT for Autism Screening in Well-Baby Clinics of a Primary Health Care Center in Dhahran, Saudi Arabia: A Retrospective Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of M-CHAT for Autism Screening in Well-Baby Clinics of a Primary Health Care Center in Dhahran, Saudi Arabia: A Retrospective Cross-Sectional Study Maha A. Almuraisel, Razan Z. AlShammari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8491807/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Background Autism Spectrum Disorder (ASD) is a neurodevelopmental condition in which early identification and intervention significantly improve developmental outcomes. The Modified Checklist for Autism in Toddlers (M-CHAT) is commonly used in primary care settings for early screening; however, real-world data on its performance in Saudi primary care, particularly within military healthcare systems, remain limited. The purpose of this study is to evaluate the outcomes of ASD screening using M-CHAT among toddlers attending the Well-Baby Clinics (WBCs) at the Armed Forces Hospital in Dhahran, including the prevalence of positive screening, confirmed ASD diagnoses, associated demographic factors, and monthly trends in screening yield. Methods A retrospective cross-sectional study was conducted at the Family Medicine Department WBCs of the Armed Forces Hospital in Dhahran. All toddlers aged 16–30 months who underwent ASD screening between January 2024 and July 2025 were included. Demographic data and M-CHAT results were extracted from electronic medical records. Screen-positive children were followed to determine confirmed ASD diagnosis by specialists. Data were analyzed using SPSS version 22.0. Chi-square and independent t-tests were used to assess associations, with significance set at p < 0.05. Results A total of 742 toddlers were screened (51.9% females, 48.1% males), with a mean age of 19.3 ± 2.2 months. Forty-nine children screened positive on M-CHAT, yielding a screening prevalence of 6.6%. Of these, 12 were confirmed to have ASD, resulting in a confirmed prevalence of 1.6% and a positive predictive value of 24.5%. No significant associations were found between screening outcomes and sex (p = 0.145), age group (p = 0.551), or parental age (p > 0.05). Monthly screening positivity ranged from 0% to 14.6%, while confirmed ASD prevalence ranged from 0% to 3.4%, with no consistent temporal trend. Conclusions ASD screening using M-CHAT in primary care Well-Baby Clinics (WBCs) demonstrated low confirmed ASD prevalence with moderate positive predictive value. Screening outcomes showed variability over time and were not significantly influenced by demographic factors. These findings highlight the importance of continuous evaluation of screening practices and strengthening referral and diagnostic pathways to optimize early ASD detection in Saudi primary care settings. Autism Spectrum Disorder M-CHAT developmental screening toddlers primary health care Well-Baby Clinics Figures Figure 1 BACKGROUND Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted or repetitive patterns of behavior or interests. Early diagnosis and intervention have been shown to substantially improve outcomes in affected children, including language acquisition, adaptive functioning, and long-term quality of life ( 1 ). The Modified Checklist for Autism in Toddlers (M-CHAT) is a widely used parent-completed screening instrument designed for toddlers aged approximately 16–30 months ( 2 ). As part of routine well-child care, it aims to identify children at risk for ASD who should be referred for specialist diagnostic assessment. While M-CHAT has demonstrated good sensitivity in multiple settings, its specificity and positive predictive value may vary according to population characteristics, cultural context, and follow-up procedures ( 2 , 8 ). In Saudi Arabia and other Arab-speaking countries, data on ASD screening in primary care remain limited. A study from a Saudi primary care setting demonstrated that although the Arabic version of M-CHAT was feasible and acceptable, only a small proportion of toddlers who screened positive were ultimately confirmed to have ASD ( 3 ). Furthermore, expert consensus guidelines for ASD assessment and management in Saudi Arabia emphasize the need for locally generated evidence regarding screening yield, referral pathways, and diagnostic outcomes ( 4 ). The Armed Forces Hospital in Dhahran (AFHD), Saudi Arabia, under the Family Medicine Department, provides well-baby clinic (WBC) services that include routine developmental screening for eligible beneficiaries. Although M-CHAT screening has been incorporated into standard well-child visits in this setting, a formal evaluation of screening outcomes, confirmed diagnoses, and temporal trends has not previously been conducted. Understanding the prevalence of positive screening results, confirmed ASD diagnoses, and their associations with demographic factors is essential for quality improvement, resource allocation, and early childhood service planning. METHODS This study employed a retrospective cross-sectional design to assess the outcomes of Autism Spectrum Disorder (ASD) screening among toddlers attending the WBCs at the Armed Forces Hospital in Dhahran (AFHD), Saudi Arabia, under the Family Medicine Department. The hospital is a military facility providing comprehensive preventive and developmental services for eligible beneficiaries in the Eastern Region. The study population included all male and female toddlers aged 16–30 months who attended the WBCs and underwent ASD screening during the study period. Sample size was calculated using EpiInfo™ version 7.0, yielding a minimum required sample of 480 toddlers at a 95% confidence level and a 5% margin of error. All eligible children within the study timeframe were included, resulting in a final sample of 742 toddlers, which exceeded the calculated requirement. A retrospective review of electronic medical records was undertaken for toddlers who visited the WBCs between January 2024 and July 2025. Data were extracted using a standardized data collection sheet and included demographic characteristics (age, sex, parental age), date of screening, and results of the M-CHAT. Screening results recorded in the system were categorized as normal (screen-negative) or abnormal (screen-positive). Toddlers who screened positive and were referred to specialist clinics were followed up through hospital records and, where required, by contacting the primary caregiver to confirm their ASD diagnostic status. The dependent variables were M-CHAT screening outcome and confirmed ASD diagnosis following specialist assessment. Independent variables included toddler age, sex, and parental age. Age at screening was calculated in months and further categorized into approximately 18-month (< 21 months) and 24-month (≥ 21 months) groups for comparative analysis. Data were coded, organized, and entered into a secure database for processing. Statistical analysis was conducted using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 22.0. Continuous variables were summarized as means and standard deviations, while categorical variables were presented as frequencies and percentages. Associations between categorical variables were assessed using the chi-square test, and differences in mean parental age between screen-positive and screen-negative groups were evaluated using independent samples t-tests. Screening performance indicators were calculated, including screening prevalence, confirmed ASD prevalence, positive predictive value (PPV), and false positive rate. A p-value of < 0.05 was considered statistically significant. A pilot study was not conducted due to the retrospective nature of the study and the availability of complete electronic medical records. Ethical approval was obtained from the Institutional Review Board of the Armed Forces Hospitals in the Eastern Region, Saudi Arabia. Informed consent was not required as anonymized medical records were used, and all data were handled with strict confidentiality to protect participants’ rights and welfare. RESULTS A total of 742 toddlers attended the WBC and were screened for ASD using M-CHAT. The mean age at screening was 19.3 ± 2.2 months (range 16.4–24.6), and 385 (51.9%) were girls while 357 (48.1%) were boys. Mean paternal age at the child’s birth was 40.5 ± 7.4 years and mean maternal age was 35.0 ± 4.6 years (Table 1 ). Overall, 49 children screened positive on M-CHAT, giving a positive screening prevalence of 6.6% (49/742). Among the 49 screen-positive children, 12 were diagnosed with ASD after specialist referral and assessment, corresponding to a confirmed ASD prevalence of 1.6% among all screened toddlers. The positive predictive value (PPV) of a positive M-CHAT result was 24.5% (12/49), and the false positive rate was 75.5% (37/49) (Table 2 ). Male toddlers had a higher proportion of positive M-CHAT results than females (8.1% vs 5.2%), but this difference was not statistically significant (χ² = 2.12, p = 0.145). Among screen-positive children, confirmed ASD was more frequent in boys than in girls (10/29 [34.5%] vs 2/20 [10.0%]), although this association also did not reach statistical significance (χ² = 2.63, p = 0.105). When age at screening was grouped as approximately 18 months (< 21 months) versus approximately 24 months (≥ 21 months), the proportion of positive screens was 6.9% (43/621) and 5.0% (6/121), respectively, with no significant difference between age groups (χ² = 0.36, p = 0.551) (Table 2 ). Parental age was not significantly associated with screening outcome. Fathers of screen-positive children had a mean age of 41.1 ± 7.4 years compared with 40.4 ± 7.4 years in the screen-negative group (t = 0.59, p = 0.559), while mothers’ ages were 35.5 ± 4.7 and 35.0 ± 4.6 years, respectively (t = 0.81, p = 0.422) (Table 1 ). Monthly variation in screening outcomes was observed across the study period (January 2024–July 2025). The proportion of toddlers screening positive on M-CHAT ranged from 0% to 14.6%, with the highest rate recorded in June 2024 (14.6%), while confirmed ASD prevalence remained consistently low, varying between 0% and 3.4% per month. Several months in 2025 showed no positive or confirmed cases despite ongoing screening activity. Overall, rates fluctuated over time without a consistent increasing or decreasing pattern (Fig. 1). Table 1 Baseline characteristics of the study population by screening outcome. Variable Total (n = 742) Screen positive (n = 49) Screen negative (n = 693) Male, n (%) 357 (48.1%) 29 (59.2%) 328 (47.3%) Female, n (%) 385 (51.9%) 20 (40.8%) 365 (52.7%) Toddler age (months), mean ± SD 19.3 ± 2.2 19.0 ± 1.9 19.3 ± 2.2 Maternal age (years), mean ± SD 35.0 ± 4.6 35.5 ± 4.7 35.0 ± 4.6 Paternal age (years), mean ± SD 40.5 ± 7.4 41.1 ± 7.4 40.4 ± 7.4 Table 2 Prevalence of positive M-CHAT screening and confirmed ASD diagnosis. Category Screen positive n (%) Confirmed ASD n (%) Overall 49 (6.6%) 12 (1.6%) Male 29 (8.1%) 10 (2.8%) Female 20 (5.2%) 2 (0.5%) 18 months group (< 21 months) 43 (6.9%) 11 (1.8%) 24 months group (≥ 21 months) 6 (5.0%) 1 (0.8%) DISCUSSION This study provides real-world evidence on the performance of the M-CHAT when implemented as part of routine developmental surveillance in WBCs within a Saudi Arabian military primary health care setting. Among 742 screened toddlers, 6.6% screened positive, while 1.6% were ultimately diagnosed with ASD following specialist evaluation. These findings provide important insight into the yield, predictive value, and operational implications of ASD screening in primary care. The confirmed ASD prevalence of 1.6% observed in this cohort is consistent with international estimates, which generally range between 1% and 2% in many populations worldwide ( 5 , 6 ). Although national epidemiological data on ASD in Saudi Arabia remain limited, available regional studies suggest comparable prevalence rates, with underdiagnosis likely contributing to observed variability across settings ( 7 ). The alignment of confirmed prevalence in this study with global figures supports the external validity of the screening outcomes. The positive screening rate of 6.6% is consistent with reports from other primary care and community-based studies using M-CHAT, where positivity rates typically range from 5% to 10% ( 8 , 9 ). This finding supports the feasibility of incorporating ASD screening into routine WBC services without generating an excessive referral burden. The positive predictive value of M-CHAT in the present study was 24.5%, indicating that approximately one in four toddlers who screened positive received a confirmed ASD diagnosis. This finding is comparable to previous real-world studies reporting positive predictive values between 20% and 40% when M-CHAT is used as a first-stage screening tool in unselected populations ( 10 , 11 ). The relatively high false-positive rate reflects the intentional design of M-CHAT to prioritize sensitivity over specificity, thereby minimizing missed cases during critical early developmental periods. False-positive screening results may be influenced by parental interpretation of questionnaire items, cultural perceptions of child behavior, and variability in diagnostic follow-up processes ( 12 ). In Middle Eastern and Arab contexts, cultural norms related to social interaction and communication may further influence parental responses, potentially increasing false-positive rates ( 7 , 14 ). These findings highlight the importance of structured follow-up procedures and clear referral pathways to optimize screening efficiency and reduce unnecessary parental anxiety. No significant associations were observed between M-CHAT outcomes or confirmed ASD diagnosis and child sex, age at screening, or parental age. Although male toddlers demonstrated higher proportions of both positive screening results and confirmed diagnoses, these differences did not reach statistical significance. This contrasts with established epidemiological data reporting a male predominance in ASD, with male-to-female ratios of approximately 3–4:1 ( 5 , 6 ), and is likely attributable to the relatively small number of confirmed cases in this cohort. Similarly, parental age was not significantly associated with screening outcomes, despite evidence from larger population-based studies suggesting associations between advanced maternal or paternal age and ASD risk ( 15 , 16 ). These findings suggest that demographic characteristics alone are insufficient predictors of screening outcomes in primary care and support the use of universal rather than risk-based developmental screening approaches. Monthly analysis revealed variability in M-CHAT positivity and confirmed ASD prevalence without a consistent temporal trend. Such fluctuations are commonly reported in screening programs and may reflect changes in clinic attendance, staff experience, parental awareness, or documentation practices over time ( 17 ). This underscores the importance of sustained screening efforts and ongoing program evaluation. The findings of this study support the integration of ASD screening into routine WBC services within Saudi primary care. While M-CHAT effectively identifies children at increased risk, its moderate PPV highlights the necessity of robust referral systems, timely specialist access, and clear communication with families. Family physicians play a pivotal role in interpreting screening results, counseling caregivers, and coordinating follow-up care. At a system level, these results underscore the need for ongoing evaluation of screening pathways, potential incorporation of structured second-stage screening tools, and strengthening collaboration between primary care and developmental services. Locally generated evidence such as this study is essential for informing national guidelines, resource allocation, and workforce planning for early childhood developmental services in Saudi Arabia. This study benefits from a large sample size, inclusion of all eligible toddlers over an extended period, and the use of real-world electronic medical record data from routine primary care practice. However, several limitations should be acknowledged. The retrospective design limited control over follow-up standardization, and not all screen-positive children may have undergone uniform diagnostic assessment. In addition, ASD diagnoses made outside the hospital system may not have been captured. Despite these limitations, the study provides valuable insight into ASD screening performance in Saudi primary care and addresses a notable gap in the local literature. Conclusion Routine ASD screening using M-CHAT in WBCs within a PHC setting demonstrated a low prevalence of confirmed ASD and a moderate PPV. Although a proportion of toddlers screened positive, only one quarter were diagnosed with ASD following specialist evaluation, highlighting the need for structured referral and diagnostic pathways after initial screening. Screening outcomes were not significantly associated with child sex, age at screening, or parental age, supporting the use of universal rather than risk-based screening approaches in PHC. Variability in monthly screening positivity underscores the importance of continuous monitoring and QI initiatives to optimize early ASD detection and follow-up. Abbreviations ASD Autism Spectrum Disorder M-CHAT Modified Checklist for Autism in Toddlers WBC Well-Baby Clinic PHC Primary Health Care AFHD Armed Forces Hospital, Dhahran SPSS Statistical Package for the Social Sciences PPV Positive Predictive Value QI Quality Improvement IRB Institutional Review Board Declarations Ethics approval and consent to participate: The study was held in accordance with the World Medical Association Declaration of Helsinki 1975 (revised in 2000). Ethical approval for this study was obtained from the Armed Forces Hospitals Eastern Province Institutional Review Board (IRB), vide letter No. AFHER-IRB-2024-042. Consent for publication: not applicable. Clinical trial number not applicable. Competing interests: the authors have no conflicts of interest to declare. Funding: This study was not supported by any sponsor or funder. Author Contribution MAM contributed to study conception and data collection. RZS contributed to study design, data analysis, manuscript drafting, and final approval of the version to be published. Both authors approved the final manuscript. Acknowledgement The authors sincerely thank Dr. Sana A. Alharbi for her kind support and cooperation during the conduct of this research. Data Availability the data supporting the findings of this study are not publicly available, as they contain information that could compromise the privacy of research participants. However, they are available from the corresponding author, RZS, upon reasonable request. References National Institute of Child Health and Human Development. Early intervention for autism. Available from: https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/early-intervention Robins DL, Fein D, Barton ML, Green JA. The Modified Checklist for Autism in Toddlers (M-CHAT): an initial study investigating the early detection of autism and pervasive developmental disorders. J Autism Dev Disord. 2001;31(2):131–44. Rashad M, Razek G, Reffat G. Validity of the Modified Checklist for Autism in Toddlers (M-CHAT): preliminary study in the Eastern Province of Saudi Arabia. Open Access Libr J. 2015;2:e1945. Saudi Expert Consensus-Based Autism Spectrum Disorder Statement. Child (Basel). 2022;9(9):1269. Maenner MJ, Shaw KA, Bakian AV, Bilder DA, Durkin MS, Esler A, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, United States, 2020. MMWR Surveill Summ. 2023;72(2):1–14. Lord C, Brugha TS, Charman T, Cusack J, Dumas G, Frazier T, et al. Autism spectrum disorder. Nat Rev Dis Primers. 2020;6(1):5. Alnemary FM, Aldhalaan HM, Simon-Cereijido G, Alnemary FM. Services for children with autism in Saudi Arabia: perspectives of parents and professionals. J Autism Dev Disord. 2017;47(9):2759–71. Robins DL, Casagrande K, Barton M, Chen CM, Dumont-Mathieu T, Fein D. Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics. 2014;133(1):37–45. Sturner R, Howard B, Bergmann P, Stewart L, Afarian T, Messina M, et al. Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics. 2016;138(3):e20153036. Carbone PS, Campbell K, Wilkes J, Stoddard G, Huynh K, Gabrielsen TP, et al. Primary care autism screening and later autism diagnosis. Pediatrics. 2020;146(2):e20192314. Guthrie W, Wallis K, Bennett A, Brooks E, Dudley J, Gerdes M, et al. Accuracy of autism screening in a large pediatric network. Pediatrics. 2019;144(4):e20183963. Zwaigenbaum L, Bauman ML, Fein D, Pierce K, Buie T, Davis PA, et al. Early screening of autism spectrum disorder: recommendations for practice and research. Pediatrics. 2015;136(Suppl 1):S41–59. Daniels AM, Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: a critical review. Autism. 2014;18(5):583–97. Scarpa A, Reyes NM, Patriquin MA, Lorenzi J. Cultural issues in autism spectrum disorder: diagnostic and intervention considerations. Curr Psychiatry Rep. 2016;18(8):66. Sandin S, Hultman CM, Kolevzon A, Gross R, MacCabe JH, Reichenberg A. Advancing maternal age is associated with increasing risk for autism: a review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2012;51(5):477–e4861. Wu S, Wu F, Ding Y, Hou J, Bi J, Zhang Z. Advanced parental age and autism risk in children: a systematic review and meta-analysis. Acta Psychiatr Scand. 2017;135(1):29–41. Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Screening for autism spectrum disorder in young children: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 11 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviews received at journal 15 Jan, 2026 Reviewers agreed at journal 09 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor invited by journal 05 Jan, 2026 Editor assigned by journal 02 Jan, 2026 Submission checks completed at journal 02 Jan, 2026 First submitted to journal 31 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8491807","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570941631,"identity":"29218296-6301-4bb1-ac3b-951ed4a9af80","order_by":0,"name":"Maha A. 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Early diagnosis and intervention have been shown to substantially improve outcomes in affected children, including language acquisition, adaptive functioning, and long-term quality of life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Modified Checklist for Autism in Toddlers (M-CHAT) is a widely used parent-completed screening instrument designed for toddlers aged approximately 16\u0026ndash;30 months (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As part of routine well-child care, it aims to identify children at risk for ASD who should be referred for specialist diagnostic assessment.\u003c/p\u003e \u003cp\u003eWhile M-CHAT has demonstrated good sensitivity in multiple settings, its specificity and positive predictive value may vary according to population characteristics, cultural context, and follow-up procedures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Saudi Arabia and other Arab-speaking countries, data on ASD screening in primary care remain limited. A study from a Saudi primary care setting demonstrated that although the Arabic version of M-CHAT was feasible and acceptable, only a small proportion of toddlers who screened positive were ultimately confirmed to have ASD (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, expert consensus guidelines for ASD assessment and management in Saudi Arabia emphasize the need for locally generated evidence regarding screening yield, referral pathways, and diagnostic outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Armed Forces Hospital in Dhahran (AFHD), Saudi Arabia, under the Family Medicine Department, provides well-baby clinic (WBC) services that include routine developmental screening for eligible beneficiaries. Although M-CHAT screening has been incorporated into standard well-child visits in this setting, a formal evaluation of screening outcomes, confirmed diagnoses, and temporal trends has not previously been conducted. Understanding the prevalence of positive screening results, confirmed ASD diagnoses, and their associations with demographic factors is essential for quality improvement, resource allocation, and early childhood service planning.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study employed a retrospective cross-sectional design to assess the outcomes of Autism Spectrum Disorder (ASD) screening among toddlers attending the WBCs at the Armed Forces Hospital in Dhahran (AFHD), Saudi Arabia, under the Family Medicine Department. The hospital is a military facility providing comprehensive preventive and developmental services for eligible beneficiaries in the Eastern Region.\u003c/p\u003e \u003cp\u003eThe study population included all male and female toddlers aged 16\u0026ndash;30 months who attended the WBCs and underwent ASD screening during the study period. Sample size was calculated using EpiInfo\u0026trade; version 7.0, yielding a minimum required sample of 480 toddlers at a 95% confidence level and a 5% margin of error. All eligible children within the study timeframe were included, resulting in a final sample of 742 toddlers, which exceeded the calculated requirement.\u003c/p\u003e \u003cp\u003eA retrospective review of electronic medical records was undertaken for toddlers who visited the WBCs between January 2024 and July 2025. Data were extracted using a standardized data collection sheet and included demographic characteristics (age, sex, parental age), date of screening, and results of the M-CHAT. Screening results recorded in the system were categorized as normal (screen-negative) or abnormal (screen-positive). Toddlers who screened positive and were referred to specialist clinics were followed up through hospital records and, where required, by contacting the primary caregiver to confirm their ASD diagnostic status.\u003c/p\u003e \u003cp\u003eThe dependent variables were M-CHAT screening outcome and confirmed ASD diagnosis following specialist assessment. Independent variables included toddler age, sex, and parental age. Age at screening was calculated in months and further categorized into approximately 18-month (\u0026lt;\u0026thinsp;21 months) and 24-month (\u0026ge;\u0026thinsp;21 months) groups for comparative analysis. Data were coded, organized, and entered into a secure database for processing.\u003c/p\u003e \u003cp\u003eStatistical analysis was conducted using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 22.0. Continuous variables were summarized as means and standard deviations, while categorical variables were presented as frequencies and percentages. Associations between categorical variables were assessed using the chi-square test, and differences in mean parental age between screen-positive and screen-negative groups were evaluated using independent samples t-tests. Screening performance indicators were calculated, including screening prevalence, confirmed ASD prevalence, positive predictive value (PPV), and false positive rate. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eA pilot study was not conducted due to the retrospective nature of the study and the availability of complete electronic medical records. Ethical approval was obtained from the Institutional Review Board of the Armed Forces Hospitals in the Eastern Region, Saudi Arabia. Informed consent was not required as anonymized medical records were used, and all data were handled with strict confidentiality to protect participants\u0026rsquo; rights and welfare.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 742 toddlers attended the WBC and were screened for ASD using M-CHAT. The mean age at screening was 19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 months (range 16.4\u0026ndash;24.6), and 385 (51.9%) were girls while 357 (48.1%) were boys. Mean paternal age at the child\u0026rsquo;s birth was 40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 years and mean maternal age was 35.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, 49 children screened positive on M-CHAT, giving a positive screening prevalence of 6.6% (49/742). Among the 49 screen-positive children, 12 were diagnosed with ASD after specialist referral and assessment, corresponding to a confirmed ASD prevalence of 1.6% among all screened toddlers. The positive predictive value (PPV) of a positive M-CHAT result was 24.5% (12/49), and the false positive rate was 75.5% (37/49) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMale toddlers had a higher proportion of positive M-CHAT results than females (8.1% vs 5.2%), but this difference was not statistically significant (χ\u0026sup2; = 2.12, p\u0026thinsp;=\u0026thinsp;0.145). Among screen-positive children, confirmed ASD was more frequent in boys than in girls (10/29 [34.5%] vs 2/20 [10.0%]), although this association also did not reach statistical significance (χ\u0026sup2; = 2.63, p\u0026thinsp;=\u0026thinsp;0.105). When age at screening was grouped as approximately 18 months (\u0026lt;\u0026thinsp;21 months) versus approximately 24 months (\u0026ge;\u0026thinsp;21 months), the proportion of positive screens was 6.9% (43/621) and 5.0% (6/121), respectively, with no significant difference between age groups (χ\u0026sup2; = 0.36, p\u0026thinsp;=\u0026thinsp;0.551) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParental age was not significantly associated with screening outcome. Fathers of screen-positive children had a mean age of 41.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 years compared with 40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 years in the screen-negative group (t\u0026thinsp;=\u0026thinsp;0.59, p\u0026thinsp;=\u0026thinsp;0.559), while mothers\u0026rsquo; ages were 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 and 35.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 years, respectively (t\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;=\u0026thinsp;0.422) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMonthly variation in screening outcomes was observed across the study period (January 2024\u0026ndash;July 2025). The proportion of toddlers screening positive on M-CHAT ranged from 0% to 14.6%, with the highest rate recorded in June 2024 (14.6%), while confirmed ASD prevalence remained consistently low, varying between 0% and 3.4% per month. Several months in 2025 showed no positive or confirmed cases despite ongoing screening activity. Overall, rates fluctuated over time without a consistent increasing or decreasing pattern (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study population by screening outcome.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;742)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScreen positive (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScreen negative (n\u0026thinsp;=\u0026thinsp;693)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e357 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (59.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e328 (47.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e385 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (40.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e365 (52.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToddler age (months), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaternal age (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of positive M-CHAT screening and confirmed ASD diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreen positive n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfirmed ASD n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18 months group (\u0026lt;\u0026thinsp;21 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months group (\u0026ge;\u0026thinsp;21 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study provides real-world evidence on the performance of the M-CHAT when implemented as part of routine developmental surveillance in WBCs within a Saudi Arabian military primary health care setting. Among 742 screened toddlers, 6.6% screened positive, while 1.6% were ultimately diagnosed with ASD following specialist evaluation. These findings provide important insight into the yield, predictive value, and operational implications of ASD screening in primary care.\u003c/p\u003e \u003cp\u003eThe confirmed ASD prevalence of 1.6% observed in this cohort is consistent with international estimates, which generally range between 1% and 2% in many populations worldwide (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Although national epidemiological data on ASD in Saudi Arabia remain limited, available regional studies suggest comparable prevalence rates, with underdiagnosis likely contributing to observed variability across settings (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The alignment of confirmed prevalence in this study with global figures supports the external validity of the screening outcomes.\u003c/p\u003e \u003cp\u003eThe positive screening rate of 6.6% is consistent with reports from other primary care and community-based studies using M-CHAT, where positivity rates typically range from 5% to 10% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This finding supports the feasibility of incorporating ASD screening into routine WBC services without generating an excessive referral burden.\u003c/p\u003e \u003cp\u003eThe positive predictive value of M-CHAT in the present study was 24.5%, indicating that approximately one in four toddlers who screened positive received a confirmed ASD diagnosis. This finding is comparable to previous real-world studies reporting positive predictive values between 20% and 40% when M-CHAT is used as a first-stage screening tool in unselected populations (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The relatively high false-positive rate reflects the intentional design of M-CHAT to prioritize sensitivity over specificity, thereby minimizing missed cases during critical early developmental periods.\u003c/p\u003e \u003cp\u003eFalse-positive screening results may be influenced by parental interpretation of questionnaire items, cultural perceptions of child behavior, and variability in diagnostic follow-up processes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Middle Eastern and Arab contexts, cultural norms related to social interaction and communication may further influence parental responses, potentially increasing false-positive rates (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These findings highlight the importance of structured follow-up procedures and clear referral pathways to optimize screening efficiency and reduce unnecessary parental anxiety.\u003c/p\u003e \u003cp\u003eNo significant associations were observed between M-CHAT outcomes or confirmed ASD diagnosis and child sex, age at screening, or parental age. Although male toddlers demonstrated higher proportions of both positive screening results and confirmed diagnoses, these differences did not reach statistical significance. This contrasts with established epidemiological data reporting a male predominance in ASD, with male-to-female ratios of approximately 3\u0026ndash;4:1 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and is likely attributable to the relatively small number of confirmed cases in this cohort.\u003c/p\u003e \u003cp\u003eSimilarly, parental age was not significantly associated with screening outcomes, despite evidence from larger population-based studies suggesting associations between advanced maternal or paternal age and ASD risk (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These findings suggest that demographic characteristics alone are insufficient predictors of screening outcomes in primary care and support the use of universal rather than risk-based developmental screening approaches.\u003c/p\u003e \u003cp\u003eMonthly analysis revealed variability in M-CHAT positivity and confirmed ASD prevalence without a consistent temporal trend. Such fluctuations are commonly reported in screening programs and may reflect changes in clinic attendance, staff experience, parental awareness, or documentation practices over time (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This underscores the importance of sustained screening efforts and ongoing program evaluation.\u003c/p\u003e \u003cp\u003eThe findings of this study support the integration of ASD screening into routine WBC services within Saudi primary care. While M-CHAT effectively identifies children at increased risk, its moderate PPV highlights the necessity of robust referral systems, timely specialist access, and clear communication with families. Family physicians play a pivotal role in interpreting screening results, counseling caregivers, and coordinating follow-up care.\u003c/p\u003e \u003cp\u003eAt a system level, these results underscore the need for ongoing evaluation of screening pathways, potential incorporation of structured second-stage screening tools, and strengthening collaboration between primary care and developmental services. Locally generated evidence such as this study is essential for informing national guidelines, resource allocation, and workforce planning for early childhood developmental services in Saudi Arabia.\u003c/p\u003e \u003cp\u003eThis study benefits from a large sample size, inclusion of all eligible toddlers over an extended period, and the use of real-world electronic medical record data from routine primary care practice. However, several limitations should be acknowledged. The retrospective design limited control over follow-up standardization, and not all screen-positive children may have undergone uniform diagnostic assessment. In addition, ASD diagnoses made outside the hospital system may not have been captured. Despite these limitations, the study provides valuable insight into ASD screening performance in Saudi primary care and addresses a notable gap in the local literature.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRoutine ASD screening using M-CHAT in WBCs within a PHC setting demonstrated a low prevalence of confirmed ASD and a moderate PPV. Although a proportion of toddlers screened positive, only one quarter were diagnosed with ASD following specialist evaluation, highlighting the need for structured referral and diagnostic pathways after initial screening. Screening outcomes were not significantly associated with child sex, age at screening, or parental age, supporting the use of universal rather than risk-based screening approaches in PHC. Variability in monthly screening positivity underscores the importance of continuous monitoring and QI initiatives to optimize early ASD detection and follow-up.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eM-CHAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModified Checklist for Autism in Toddlers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWell-Baby Clinic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArmed Forces Hospital, Dhahran\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePositive Predictive Value\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality Improvement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e The study was held in accordance with the World Medical Association Declaration of Helsinki 1975 (revised in 2000). Ethical approval for this study was obtained from the Armed Forces Hospitals Eastern Province Institutional Review Board (IRB), vide letter No. AFHER-IRB-2024-042.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical trial number\u003c/strong\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003ethe authors have no conflicts of interest to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMAM contributed to study conception and data collection. RZS contributed to study design, data analysis, manuscript drafting, and final approval of the version to be published. Both authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors sincerely thank Dr. Sana A. Alharbi for her kind support and cooperation during the conduct of this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003ethe data supporting the findings of this study are not publicly available, as they contain information that could compromise the privacy of research participants. However, they are available from the corresponding author, RZS, upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Child Health and Human Development. Early intervention for autism. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/early-intervention\u003c/span\u003e\u003cspan address=\"https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/early-intervention\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobins DL, Fein D, Barton ML, Green JA. The Modified Checklist for Autism in Toddlers (M-CHAT): an initial study investigating the early detection of autism and pervasive developmental disorders. J Autism Dev Disord. 2001;31(2):131\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRashad M, Razek G, Reffat G. Validity of the Modified Checklist for Autism in Toddlers (M-CHAT): preliminary study in the Eastern Province of Saudi Arabia. Open Access Libr J. 2015;2:e1945.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaudi Expert Consensus-Based Autism Spectrum Disorder Statement. Child (Basel). 2022;9(9):1269.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaenner MJ, Shaw KA, Bakian AV, Bilder DA, Durkin MS, Esler A, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years \u0026mdash; Autism and Developmental Disabilities Monitoring Network, United States, 2020. MMWR Surveill Summ. 2023;72(2):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLord C, Brugha TS, Charman T, Cusack J, Dumas G, Frazier T, et al. Autism spectrum disorder. Nat Rev Dis Primers. 2020;6(1):5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlnemary FM, Aldhalaan HM, Simon-Cereijido G, Alnemary FM. Services for children with autism in Saudi Arabia: perspectives of parents and professionals. J Autism Dev Disord. 2017;47(9):2759\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobins DL, Casagrande K, Barton M, Chen CM, Dumont-Mathieu T, Fein D. Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics. 2014;133(1):37\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSturner R, Howard B, Bergmann P, Stewart L, Afarian T, Messina M, et al. Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics. 2016;138(3):e20153036.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarbone PS, Campbell K, Wilkes J, Stoddard G, Huynh K, Gabrielsen TP, et al. Primary care autism screening and later autism diagnosis. Pediatrics. 2020;146(2):e20192314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuthrie W, Wallis K, Bennett A, Brooks E, Dudley J, Gerdes M, et al. Accuracy of autism screening in a large pediatric network. Pediatrics. 2019;144(4):e20183963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZwaigenbaum L, Bauman ML, Fein D, Pierce K, Buie T, Davis PA, et al. Early screening of autism spectrum disorder: recommendations for practice and research. Pediatrics. 2015;136(Suppl 1):S41\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels AM, Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: a critical review. Autism. 2014;18(5):583\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScarpa A, Reyes NM, Patriquin MA, Lorenzi J. Cultural issues in autism spectrum disorder: diagnostic and intervention considerations. Curr Psychiatry Rep. 2016;18(8):66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandin S, Hultman CM, Kolevzon A, Gross R, MacCabe JH, Reichenberg A. Advancing maternal age is associated with increasing risk for autism: a review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2012;51(5):477\u0026ndash;e4861.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu S, Wu F, Ding Y, Hou J, Bi J, Zhang Z. Advanced parental age and autism risk in children: a systematic review and meta-analysis. Acta Psychiatr Scand. 2017;135(1):29\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Screening for autism spectrum disorder in young children: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Autism Spectrum Disorder, M-CHAT, developmental screening, toddlers, primary health care, Well-Baby Clinics","lastPublishedDoi":"10.21203/rs.3.rs-8491807/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8491807/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAutism Spectrum Disorder (ASD) is a neurodevelopmental condition in which early identification and intervention significantly improve developmental outcomes. The Modified Checklist for Autism in Toddlers (M-CHAT) is commonly used in primary care settings for early screening; however, real-world data on its performance in Saudi primary care, particularly within military healthcare systems, remain limited. The purpose of this study is to evaluate the outcomes of ASD screening using M-CHAT among toddlers attending the Well-Baby Clinics (WBCs) at the Armed Forces Hospital in Dhahran, including the prevalence of positive screening, confirmed ASD diagnoses, associated demographic factors, and monthly trends in screening yield.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cross-sectional study was conducted at the Family Medicine Department WBCs of the Armed Forces Hospital in Dhahran. All toddlers aged 16\u0026ndash;30 months who underwent ASD screening between January 2024 and July 2025 were included. Demographic data and M-CHAT results were extracted from electronic medical records. Screen-positive children were followed to determine confirmed ASD diagnosis by specialists. Data were analyzed using SPSS version 22.0. Chi-square and independent t-tests were used to assess associations, with significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 742 toddlers were screened (51.9% females, 48.1% males), with a mean age of 19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 months. Forty-nine children screened positive on M-CHAT, yielding a screening prevalence of 6.6%. Of these, 12 were confirmed to have ASD, resulting in a confirmed prevalence of 1.6% and a positive predictive value of 24.5%. No significant associations were found between screening outcomes and sex (p\u0026thinsp;=\u0026thinsp;0.145), age group (p\u0026thinsp;=\u0026thinsp;0.551), or parental age (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Monthly screening positivity ranged from 0% to 14.6%, while confirmed ASD prevalence ranged from 0% to 3.4%, with no consistent temporal trend.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eASD screening using M-CHAT in primary care Well-Baby Clinics (WBCs) demonstrated low confirmed ASD prevalence with moderate positive predictive value. Screening outcomes showed variability over time and were not significantly influenced by demographic factors. These findings highlight the importance of continuous evaluation of screening practices and strengthening referral and diagnostic pathways to optimize early ASD detection in Saudi primary care settings.\u003c/p\u003e","manuscriptTitle":"Use of M-CHAT for Autism Screening in Well-Baby Clinics of a Primary Health Care Center in Dhahran, Saudi Arabia: A Retrospective Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:19:29","doi":"10.21203/rs.3.rs-8491807/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-11T05:19:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T14:57:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296677104797184950947418223401326363728","date":"2026-02-02T15:40:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T10:08:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316858812521248684091310822480907487881","date":"2026-01-09T17:33:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T15:02:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-05T05:29:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-03T02:52:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-03T02:51:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-31T18:50:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff8f3769-f08b-48b8-ac9c-b9f562a6ed1c","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:03:39+00:00","versionOfRecord":{"articleIdentity":"rs-8491807","link":"https://doi.org/10.1186/s12887-026-06721-w","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-03-11 15:59:49","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2026-01-12 06:19:29","video":"","vorDoi":"10.1186/s12887-026-06721-w","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06721-w","workflowStages":[]},"version":"v1","identity":"rs-8491807","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8491807","identity":"rs-8491807","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}