The Social Attention and Communication Surveillance (SACS) tool
For early Autism detection
Associate Professor Josephine Barbaro, Principal Research Fellow at the Olga Tennison Autism Research Centre, has been working on the early signs of autism in babies and toddlers for more than 18 years. The SACS method identifies a set of behaviours or 'early signs' that are characteristic of Autistic children, from as young as 12 months old.
Originally implemented in Maternal and Child Health services in Victoria, the SACS method is now used across more than 15 countries.
We now offer training in the SACS Revised and SACS Pre-school tools.
View our training courses
Our research impact and outreach
This program is developed by Associate Professor Josephine Barbaro, Principal Research Fellow and Registered Psychologist at La Trobe University's Olga Tennison Autism Research Centre, and co-founder and lead clinician in Australia's first 'Early Assessment Clinic' for autism - The Victorian Early Assessment Clinic.
The Social Attention and Communication Surveillance (SACS) approach, developed during her PhD, has been translated into 8 languages and disseminated across more than 15 countries. In Australia, the SACS has been used to monitor over 45,000 infants and toddlers in the Victorian and Tasmanian Maternal and Child Health (MCH) systems alone.
The SACS is the most effective autism screening tool in the world - read the open access article
IMPACT TIMELINE
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2013
Incorporated into the 7-year Tianjin Women and Child Health plan, China’s 4th largest city, where we trained 600 early childhood medical professionals in 2013 to monitor every baby born from 2013-2020 (700,000 in total).
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2015
- The Minister for Human Services in Tasmania (The Hon. Jacquie Petrusma) announced in Parliament that Tasmania was implementing SACS across the State.
- The SACS tool was translated and adapted for use in Nepal and used to train Nepalese Female Community Health Volunteers. All children seen by the Nepalese female community health volunteers are monitored for the early behavioural signs of Autism as part of regular child health visits, enabling access to earlier diagnosis and intervention.
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2016
The SACS was translated into telehealth, the ASDetect mobile application. The world’s first, empirically based, Autism surveillance mobile application (based on the SACS) is freely available in four languages (English, Spanish, Mandarin, Slovak).
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2018
The Victorian Government announced that all 1250 Victorian Maternal and Child Health (MCH) nurses will be trained using the SACS method to monitor babies for Autism at their routine health checks between 12- and 24-months-of-age.
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2024
- China has screened 1 Million babies using the SACS
- SACS is recommended in the Guideline for Growth, Health and Developmental Follow-up for Children Born Very Preterm
- 320+ professionals trained in SACS in Aotearoa/New Zealand.
Research papers – developmental surveillance
Barbaro, J., Masi, A., Gilbert, M., Nair, R., Abdullahi, I., et al. (2021). A Multistate Trial of an Early Surveillance Program for Autism Within General Practices in Australia [Study Protocol]. Frontiers in Pediatrics, 9(260).
Mozolic-Staunton, B., Barbaro, J., Yoxall, J., & Donelly, M. (2021). Monitoring children’s development in early childhood education settings to promote early detection of autism. Australasian Journal for Early Childhood.
Mozolic-Staunton, B., Donelly, M., Yoxall, J., & Barbaro, J. (2020). Early detection for better outcomes: universal developmental surveillance for autism across health and early childhood education settings. Research in Autism Spectrum Disorders. 71, 101496.
Mozolic-Staunton, B., Donelly, M., Yoxall, J. & Barbaro, J. (2017). Interrater reliability of early childhood education professionals involved in developmental surveillance for autism spectrum disorder and related conditions. Australian Journal of Early Childhood, 42(2), 61-68.
Barbaro, J. & Dissanayake, C. (2013). Early markers of Autism Spectrum Disorders in infants and toddlers prospectively identified in the Social Attention and Communication Study (SACS). Autism: International Journal of Research and Practice, 17, 64-86.
Barbaro, J., Ridgway, L., & Dissanayake, C. (2011). Developmental surveillance of infants and toddlers by Maternal and Child Health nurses in an Australian community-based setting: Promoting the early identification of Autism. Journal of Pediatric Nursing, 26, 334-347.
Barbaro, J., & Dissanayake C. (2010). Prospective identification of Autism in infancy and toddlerhood using developmental surveillance: The Social Attention and Communication Study (SACS). Journal of Developmental and Behavioral Pediatrics, 31, 376-385.
SACS training evaluation papers
Gilbert, M., Gore, K., Hawke, M., & Barbaro, J. (2023). Development, delivery, and evaluation of a training program for the early identification of autism: Monitoring of Social Attention, Interaction, and Communication [Original Research]. Front Neurol, 14, 1201265.
Gore, K., Gilbert, M., Hawke, M., & Barbaro, J. (2023). Investigating autism knowledge, self-efficacy, and confidence following maternal and child health nurse training for the early identification of autism. Front Neurol, 14, 1201292.
ASDetect papers
Barbaro, J. & Yaari, M. (2020). Study Protocol for an Evaluation of ASDetect - A Mobile Application for the Early Detection of Autism. 20(1), 21.
Intervention studies and outcomes of SACS identified children
Ke, C., Carter, L.-A., Green, J., Whitehouse, A. J. O., Hudry, K., Barbaro, J., Dissanayake, C., Maybery, M., Vicky, S., Segal, L., Varcin, K., & Wan, M. W. (2025). Which emerging autism features at 12 months of age are associated with later parent-child interaction? Research in Autism Spectrum Disorders, 119, 102525.
Whitehouse, A. J. O. Varcin, K. J., Pillar, S., Billingham, W., Alvares, G. A., et al. (2021). Pre-emptive intervention for infants showing early behavioral signs of autism. JAMA Pediatrics.
Luu, J., Jellett, R., Yaari, M., Gilbert, M., & Barbaro, J. (2020). A Comparison of Children Born Preterm and Full-Term on the Autism Spectrum in a Prospective Community Sample. Frontiers in Neurology: Pediatric Neurology, 11, 597505.
Whitehouse, A. J. O., Varcin, K. J., Alvares, G. A., Barbaro, J., Bent, C., et al. (2019). A randomised-controlled trial of a pre-emptive intervention for infants showing early behavioural risk signs of autism spectrum disorder. The Lancet Child and Adolescent Health. 3(9), 605-615.
Clark, M. L., Vinen, Z., Barbaro, J., & Dissanayake, C. (2018). School age outcomes of children diagnosed early and later with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 48, 92-102.
Clark, M. L., Barbaro, J., & Dissanayake, C. (2017). Continuity and Change in Cognition and Autism Severity from Toddlerhood to School Age. Journal of Autism and Developmental Disorders, 47, 328-339.
Barbaro, J. & Dissanayake, C. (2012). Developmental profiles of infants and toddlers with Autism Spectrum Disorders identified prospectively in a community-based setting. Journal of Autism and Developmental Disorders, 42, 1939-1948.
Gender differences of SACS identified children
Hollier, L. P., Joshi, R., Barbaro, J., Dissanayake, C (2018). Gender Differences during Toddlerhood in Autism Spectrum Disorder: A Prospective Community-Based Longitudinal Follow-Up Study. Journal of Autism and Developmental Disorders, 48, 2619-2628.
Barbaro, J., & Freeman, N. (2021). Investigating gender differences in the early markers of Autism Spectrum Conditions (ASC) in infants and toddlers. Research in Autism Spectrum Disorders, 83, 101745.
Ethnicity and the SACS
Abdullahi, I., Sadka, N., Gilbert, M., & Barbaro, J. (2023). Who Is Attending? The Role of Child Ethnicity and Maternal Demographics in Research Engagement and Early Identification of Autism. Brain Sciences, 13(6).
International implementation of the SACS
Waddington, H., Shepherd, D., van der Meer, L., Powell-Hector, N., Wilson, E., & Barbaro, J. (2022). Brief Report: Training New Zealand Well Child/Tamariki Ora Nurses on Early Autism Signs Using the Social Attention and Communication Surveillance-Revised. J Autism Dev Disord, 52(11), 5050-5057.
Shrestha, R., Barbaro, J. & Dissanayake, C. (2021). Changes in knowledge on the signs of autism in young children (11-30 Months) among Female Community Health Volunteers in Nepal. Journal of Autism and Developmental Disorders.
Shrestha, R., Dissanayake, C., & Barbaro, J. (2021). Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal. Research in Developmental Disabilities.
Barbaro, J., Wang, C., Wang, J., Liu, G., Liang, Y., et al. (2020). A pilot investigation of the Social Attention and Communication Surveillance (SACS) tool for the early identification of autism in Tianjin, China (SACS-C). Frontier in Neurology, Paediatrics, 11, 1389.
Mohd Zambri, N., Lau LHS., Koh, HC., Yeleswarapu, SP., Daniel, LM., et al. (2019). Screening for Autism in Younger Siblings of Children with Autism: Preliminary Findings. Asia Pacific Autism Conference; Resorts World Convention Centre Singapore.
Okuno, M., & Uehara, T. (2018). Early childhood behavioral features that discriminate autism from other developmental problems in Japan. Journal of Child and Adolescent Psychiatric Nursing 31(1):23-9.
ASDetect
Based on the SACS method, ASDetect is a free mobile app that guides parents through age-appropriate assessments, using videos of Autistic and non-autistic children to illustrate questions about social communication milestones. Parents receive an on-screen result of either 'low' or 'high' likelihood of Autism, and a comprehensive formal assessment results email, which they can take to their family doctor.
With over 120,000 downloads since launch in February 2016, ASDetect has been translated into Mandarin Chinese and Spanish, bringing this ground-breaking early detection research to parents and caregivers around the world.
Here is one of the 30 videos in ASDetect that highlights some of the important social and communication behaviours of developing children
Visit https://asdetect.org for more information about the application.
In children under 2 years old, the ‘early markers’ include infrequent or inconsistent use of:
- eye contact
- gestures, like pointing at objects
- response to being called by name
- imitation or copying others' activities
These and other social communication milestones have been incorporated into 3 SACS assessments for children aged 12 months,18 months and 24 months, and used by trained Victorian Maternal and Child Health Nurses.
The SACS method currently has the best psychometric properties of any Autism identification tool, with an accuracy of 83%.
In March 2024, Associate Professor Josephine Barbaro conducted a comprehensive training program in New Zealand to educate over 320 professionals in early autism detection using the Social Attention and Communication Surveillance (SACS) tool.
Conducted in partnership with Te Herenga Waka—Victoria University of Wellington, over 320 education and healthcare professionals were trained through a combination of in-person workshops and online courses.
This marked Olga Tennison Autism Research Centre’s (OTARC) largest investment in SACS training to date and the biggest implementation of the tool in the southern hemisphere outside of Australia.
The training was part of a collaborative research project led by Dr. Hannah Waddington of Victoria University of Wellington, with training in the SACS tool coordinated and provided by La Trobe University. The initiative involved four full-day workshops in various locations around Wellington, and online training components tailored to accommodate participants who were unable to attend in person. This blended approach ensured wide accessibility and participation across the region.
The SACS tool has demonstrated exceptional diagnostic accuracy in early autism detection. According to a comprehensive OTARC study published in 2022, the SACS-Revised (SACS-R) and SACS-Preschool (SACS-PR) tools showed greater accuracy compared with other commonly used autism screening tools for community-based samples.
In the 2022 study, maternal and child health nurses conducted screenings during routine checkups for children aged 11 to 42 months, evaluating 13,511 children. Those identified as being at high likelihood for autism subsequently underwent diagnostic assessments.
The results were compelling: the SACS (R+PR) programs exhibited very high diagnostic accuracy for early autism detection. This population-based developmental surveillance program has shown promise not only for national application, but has potential to transform early autism identification and detection globally.
A unique aspect of the New Zealand training was the creation of a bespoke online learning management system by OTARC staff. This was specially designed to incorporate Māori perspectives, language, and culturally responsive supports, ensuring that the training was not only effective but also culturally appropriate and sensitive to local contexts.
"It was important for us to integrate Māori specific knowledge, needs, and perspectives into the training,” says A/Prof Barbaro. “This was done through a lived experience engagement co-production and was essential for the trainings success in New Zealand.”
The training should inform New Zealand autism diagnostic pathways for decades to come across the country and sets a benchmark for international best practices in autism care. The New Zealand training initiative has been the second-largest global training effort outside of China.
The SACS tool, a cornerstone of early autism detection, has been implemented in 16 countries and is available to complete online. This training is suited to a wide variety of professionals who engage with children in an environment where screening would be appropriate.
For more information about the SACS tool and our ongoing research, visit the SACS training page on our website or email the SACS team at sacs.training@latrobe.edu.au