Implementation of Social Attention and Communication Surveillance in Gunma, Japan (SACS-J)

Background: Autism Spectrum Disorders (ASDs) emerge over the first two years of life, and early signs of ASDs are recognizable during this period. In Japan, over 90% of children have health check-ups at around 18 months and 36 months in compliance with the Maternal and Child Health Act. The 18-month check-up, in particular, is expected to play a role in early identification of developmental disorders, including ASDs. Public health centres provide the check-ups, and nurses are responsible for screening infants to identify developmental risk. The Japanese M-CHAT is utilized in some community health check-ups, but it’s still the case that old-fashioned questionnaires and/or behavior observation lists, which are not adequate for screening for ASDs, are commonly used at many health centres in Gunma.

Objectives: The goal in this study was to confirm the feasibility and effectiveness of Social Attention and Communication Surveillance (SACS) as a Level 1 screening tool within two health centres in Gunma, Japan.

Methods: The original SACS items were used and modified to adapt to the mass check-ups undertaken in Gunma. The number of items were reduced to enable implementation within 10 minutes. Fine and gross motor items were also added and some items adapted to take into account cultural differences. In Gunma, the SACS-J was first implemented in Tamamura (270 births/year) and then in Shibukawa (500 births/year). As there were slight differences in the age at which checkups were undertaken across the two settings (Tamamura: 15-, 20-, 27-, and 38-months; Shibukawa: 10-, 18-, 24-, and 36-months), the SACS-J items were appropriately modified to suit each age.

Results: In Tamamura, a total of 166 infants were monitored longitudinally (2012 – 2015; the first cohort born in 2011), and attended the 15- and 20-month check-ups. Infants were classified into 4 groups at 20 months, depending on their failure on more than 2 items at each age. 12 infants (7.2%) failed more than 2 items at both 15 and 20 months, and their low pass rates lasted through to 27 months. In this group, 4 infants were diagnosed with ASD (around 2%), and the other 8 infants comprised: 1 severe Developmental Delay, 1 ASD suspected, 1 ADHD suspected, and 5 infants who had caught up developmentally by 38 months. In Shibukawa, a total of 271 infants were monitored (2015 – 2017; the first cohort born in 2014), and attended the 18- and 24-months check-ups. 23 infants (8.5%) failed more than 2 items at both 18 and 24 months. 69.6% of these infants were considered to be at risk for ASD and 30.4% were not considered to be at risk by clinical psychologists.

Conclusions: Successive failure (at two ages) in SACS-J items indicates serious risk for ASD indicating that continuous developmental surveillance within the first 2 years of life is successful in identifying ASD in young children in two low resource community settings. The feasibility and effectiveness of implementing the SACS in a different cultural context was confirmed.