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A Pilot Investigation of the Social Attention and Communication Surveillance (SACS) Tool for the Early Identification of Autism in Tianjin, China (SACS-C)

journal contribution
posted on 2021-01-04, 04:23 authored by Josephine BarbaroJosephine Barbaro, C Wang, J Wang, G Liu, Y Liang, Ifrah AbdullahiIfrah Abdullahi, Cheryl DissanayakeCheryl Dissanayake
© Copyright © 2020 Barbaro, Wang, Wang, Liu, Liang, Wang, Abdullahi and Dissanayake. Introduction: Autism spectrum disorder (ASD) comprises difficulties in social communication and restrictive and repetitive behaviors. Despite an increased global prevalence, little remains known about early detection and diagnosis of autism in Mainland China. Our aim was to conduct a pilot investigation of the implementation of an Australian tool, Social Attention and Communication Surveillance (SACS), in Tianjin, China (SACS-C) by trained professionals to identify autism early compared to the Checklist for Autism in Toddlers-23 (CHAT-23) completed by parents and professionals. Materials and Methods: A total of 10,514 children were monitored across 61 Community Health Service Centres in six Tianjin districts on the SACS-C at 12, 18, and 24 months of age following a half-day training of 225 child health practitioners. Children deemed at “high likelihood” for autism on either the SACS, CHAT-23, or both, were referred for developmental assessments at the Tianjin Women and Children's Health Centre (TWCHC). Results: A total of 87 children (0.8%) were identified at “high likelihood” on the SACS-C, of whom 57 (66%) were assessed for autism; 24 children were subsequently diagnosed with autism (42.1%), and the remaining 33 (57.9%) were diagnosed with developmental and/or language delays. The SACS-C had a positive predictive value (PPV) of 42.1%, a negative predictive value (NPV) of 99.8%, and sensitivity and specificity of 53.3 and 99.7%, respectively. Only 21 children were identified at “high risk” for autism on the CHAT-23 (0.2%), over four times fewer children than the SACS-C, with 14 children assessed for autism (66%); nine were diagnosed with autism (64.3%) and the remaining five children were diagnosed with developmental and/or language delays. The CHAT-23 had an overall PPV of 64.3%, NPV of 99.6%, sensitivity of 27.3%, and specificity of 99.9%. Conclusion: This was the first large-scale study identifying autism in 12–24-month-old children in China. We ascertained the feasibility of training community health practitioners to monitor infants and toddlers for the early signs of autism, and determined the effectiveness of their use of SACS-C which had a better balance between accuracy and sensitivity in detecting autism in contrast to the CHAT-23 which missed the majority of children with autism (72.7%) vs. the SACS-C (46.7%). Given the emphasis on identifying as many children with autism as possible in Mainland China, SACS-C was identified as the tool of choice by the TWCHC. However, more work is needed to improve the psychometric properties in using the SACS-C in Mainland China so that it is comparable to its use in Australia.


This research received funding from the projects of the National Key Research and Development Program of China (2016YFC0900600/2016YFC0900602), Tianjin Women's and Children's Health Centre, and Tianjin Public Health Bureau of Science and Technology Fund (Grant no. 12KG130). JB and CD was supported by funding from the Australian Government's Department of Innovation, Industry, Science, and Research, through its Australia-China Science and Research Fund Group Mission, and JB was supported by a La Trobe Asia Grant through La Trobe University.


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Frontiers in Neurology



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Frontiers Media S.A.



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