Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal.
A 12-item volunteer checklist in Nepal caught all developmental delays and nearly half of autism cases among 1,926 toddlers.
01Research in Context
What this study did
Shrestha et al. (2021) taught local female health volunteers in Nepal to use a short checklist called SACS-N.
They watched 1,926 toddlers at home and in clinics.
The goal was to spot autism and other delays early, before age three.
What they found
Every child the volunteers flagged for any delay truly had one.
About four in ten kids they flagged for autism later got an autism diagnosis.
The checklist worked in a low-income setting without doctors or fancy gear.
How this fits with other research
Shaban et al. (2026) push the same idea further. They cut an eye-tracking test from ten minutes to four and still caught autism across a wide age range.
Snijder et al. (2021) show the flip side. Dutch doctors often skip the formal autism screen, even with guidelines. Nepal proves lay volunteers can finish a simple tool and get kids to help faster.
Feldman et al. (1999) set the old two-step surveillance rules. Rena’s team shows one community-ready step can work where resources are thin.
Why it matters
You can borrow the SACS-N items or the volunteer model for rural clinics, home-based programs, or global tele-health sites. Train staff once, give them the 12-point list, and you have an evidence-based way to find toddlers who need full evaluation. Start small: add the checklist to your intake packet and track how many flagged kids confirm delay within three months.
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02At a glance
03Original abstract
BACKGROUND: Although Autism Spectrum Disorder (ASD) can be identified as early as 12 months and diagnosed by 24 months, the mean age of diagnosis of ASD in Nepal is ∼58 months, with children missing the opportunity for early intervention. AIMS: This study implemented and evaluated a Nepali version of the Social Attention and Communication Surveillance (SACS-N) tool, to identify children between 11-30 months who are at "high likelihood" of ASD in a local community in Nepal. METHODS: Sixty Female Community Health Volunteers (FCHVs) were trained to monitor and identify the early signs of ASD using SACS-N. RESULTS: Overall, 1926 children were monitored with the SACS-N, with 11 children (0.57 %) referred for further assessments at 11-15 months (n = 4), 16-21 months (n = 4), and 22-30 months (n = 3). Of these children, 10 children had a developmental disorder, including ASD and Global Developmental Delay; no information was available on one child who migrated. Hence, the positive predictive value (PPV) of SACS-N for all developmental disorders was 100 %. Of seven children attending a gold standard diagnostic/ developmental assessment, three had ASD (43 % PPV for ASD). The estimated prevalence of ASD ranged between 0.16 % to 0.26 %. CONCLUSION: Community-based developmental monitoring of ASD and other developmental delays by FCHVs is a feasible, cost-effective and sustainable approach to promoting early identification of ASD in Nepal. Further training and awareness of autism is needed for more accurate and increased referral rates using the SACS-N, including regular supervision of FCHVs.
Research in developmental disabilities, 2021 · doi:10.1016/j.ridd.2021.104013