Autism

http://aut.sagepub.com/ Early Intervention System for Preschool Children with Autism in the Community : The Discovery Approach in Yokohama, Japan
Hideo Honda and Yasuo Shimizu Autism 2002 6: 239 DOI: 10.1177/1362361302006003003 The online version of this article can be found at: http://aut.sagepub.com/content/6/3/239

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Early intervention system for preschool children with autism in the community
The DISCOVERY approach in Yokohama, Japan
HIDEO HONDA YA S U O S H I M I Z U
Yokohama Rehabilitation Center, Japan Yokohama Rehabilitation Center, Japan

autism 2002 SAGE Publications and The National Autistic Society Vol 6(3) 239257; 026185 1362-3613(200209)6:3

A B S T R AC T

The article reports on DISCOVERY, a conceptual model for a clinical system of early detection and early intervention in cases of autism that has been implemented in Yokohama, Japan.The minimal requirements for this system are subsystems dealing with detection, diagnosis and intervention. Specic issues involving early diagnosis that complicate the design of the system are the seemingly contradictory considerations of early versus precise diagnosis, the undifferentiated recognition of a childs disorder on the part of the parents, and the difculty of establishing cooperative working relationships among related facilities. To overcome these issues, an interface linking consecutive subsystems is emphasized in the DISCOVERY model. A clinical system based on this model has been developed in Yokohama. This system not only benets clinical performance, but will also add signicantly to research on autism.

K E Y WO R D S

autism; community services; early detection; early diagnosis; early intervention

ADDRESS Correspondence should be addressed to: H I D E O H O N DA , MD, Yokohama Rehabilitation Center, 1770 Toriyama-cho, Kohoku-ku, Yokohama 2220035, Japan. e-mail: honda@yokohama.email.ne.jp

Introduction
Decades of research have thus far produced no single treatment method for the cure of autism, but they have served to justify a comprehensive and interdisciplinary approach for providing services in the community (Schopler, 1989; 1997). The efcacy of programs offering structured educational experiences in school settings to children and adolescents with autism has been emphasized (Bartak and Rutter, 1973; Rutter and Bartak, 1973; Schopler, 1997).The controversy among researchers today is focused more on the potential efcacy of early intervention (Dawson and Osterling, 1997; Erba, 2000; Shields, 2001). Although a consensus has not been 239

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6(3) reached on whether early intervention will cure autism (Lovaas, 1987; Schopler et al., 1989), at least researchers may agree that early intervention can somewhat improve the outcome. A body of solid scientic evidence, obtained using rigorous methodologies, is needed on early intervention for children with autism (Rogers, 1996). In this article, the authors present a model of a community-oriented clinical system designed to guarantee early intervention for all children with developmental disorders, including autism, and their families. The DISCOVERY model (Detection and Intervention System in the COmmunity for VERy Young children with developmental disorders) is important clinically because intervention for children with autism must be implemented in the context of the daily lives of children and their families, rather than in an institutional setting, especially given the difculty for people with autism to generalize experiences to other situations. The model can also benet research because it provides both large-scale and longitudinal databases of clinical pictures of autism beginning with the preschool period. Theoretical issues to be overcome specic to early intervention, and practical solutions employed in the DISCOVERY model, are described. The authors introduce an example of the DISCOVERY model as it has been applied and developed in Yokohama, Japan, together with data on how effectively the model functions to guarantee early intervention for children with autism and their families. Note that the theory and practice described in this article are applicable to all diagnoses of pervasive developmental disorders (PDDs: American Psychiatric Association, 1994; World Health Organization, 1993) and the autistic spectrum (Wing, 1996). The term autism in this article refers to PDDs and the autistic spectrum generally, except when the term childhood autism is used according to ICD-10 (World Health Organization, 1993).
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Need for a systems approach encompassing the process from early detection to early intervention
Intervention for autism cannot be commenced until parents recognize the symptoms in their child and consult a psychiatrist or pediatrician, and a diagnosis is made. Early diagnosis can be facilitated most effectively if early detection is made possible.Thus, in order to ensure that preschool children with autism benet from an early intervention program, early detection and diagnosis are necessary. In planning early intervention services for autism with a community focus, a systems approach (von Bertalanffy, 1968) should be considered to integrate plans in an interdisciplinary manner beginning with early detection and proceeding rapidly to 240

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& S H I M I Z U : E A R LY I N T E RV E N T I O N S Y S T E M intervention. In this approach, subsystems dealing with early detection, early diagnosis and early intervention are regarded as the minimal requirements for a total community service system.The early detection subsystem is especially important in making the system work and is possible only if routine health checkups are conducted in the community.
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The uncertainty principle in early detection and early intervention for preschool children with autism
The uncertainties that must be dealt with when designing a community system of early detection and early intervention for preschool children with autism are those inherent in issues such as a diagnosis of autism, parental recognition of the disorder, and the boundaries of responsibility among facilities in charge of each phase of the process. It is impossible to eliminate these uncertain conditions completely; a parallel may be drawn with Heisenbergs (1927) uncertainty principle. The nature of these uncertainties will be outlined below.

In diagnosis The problem with early diagnosis lies in the apparent contradiction between diagnosing early and diagnosing precisely. The earlier the diagnosis, the less precise it becomes, thus yielding many false-negative and false-positive cases. In order for the diagnosis to be precise, it would have to be delayed, and intervention would likewise be deferred later in time. Thus, early diagnosis and diagnostic precision cannot be achieved simultaneously, just as precision of both position and momentum of a particle cannot coexist in Heisenbergs uncertainty principle. For some diseases, early detection is possible in the presymptomatic period when, although the affected individual remains free of symptoms, the mechanisms of the disease produce structural or functional changes that are detectable by using the appropriate test (Sackett et al., 1991). This may minimize uncertainty in the diagnosis. In the case of autism, however, which currently lacks biological markers for diagnosis and is dened operationally as a behavioral syndrome, early detection must depend solely on behavioral markers.Thus, the problem of uncertainty in diagnoses of autism may never be resolved. A recent report from a British research project provides an illustration of this (Baird et al., 2000). In the report, the Checklist for Autism in Toddlers (CHAT: Baron-Cohen et al., 1992) was used to screen children with autism at the age of 18 months, yielding a sensitivity of 38 percent. In other words, more than 60 percent of children with autism could not be diagnosed precisely at that early age. As long as the uncertainty of early diagnosis exists, development of better screening
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6(3) devices alone will not provide a satisfactory solution because of the difculty of relying on one-time judgments to identify cases of autism. Other strategies may be necessary.
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In parental recognition of the disorder It is reported that more than half the parents of children with autism noticed developmental abnormalities by the time their child had reached the age of 2 long before a denitive diagnosis of autism was made (Howlin and Moore, 1997; Ornitz, et al., 1977). However, noticing developmental abnormalities is not equivalent to suspecting that a child may suffer from a pervasive developmental disorder. Moreover, a specialist may be able to detect subtle symptoms of autism in a child whose parents suspect nothing. Even if parents are somehow aware, their recognition may still be undifferentiated; they may simply feel anxious, or they may only regard the symptoms in their child as the slightly delayed or transient developmental characteristics of infancy or childhood. This introduces another element of uncertainty that is highly specic to the early detection of autism. The problems giving rise to this uncertainty cannot be resolved in a hospital-based clinical system where patients or their families never consult physicians unless they have complaints about symptoms. Efforts to overcome this uncertainty should be integrated into the clinical system. These may consist of attempts to sensitize parents to the characteristics of autism and provide psychological support while parents struggle with the apprehension they feel about the possibility that their child may suffer from autism. In boundaries of responsibility among facilities The importance of creating a network among related facilities in the community to ensure an interdisciplinary approach to intervention for children with autism cannot be overemphasized. However, communication and cooperation among facilities specializing in different disciplines cannot always be well coordinated in the community under one coherent plan. Without a systematic approach to ensure coherence among related facilities, the power of early intervention in the context of a comprehensive system would be greatly reduced.

Philosophy of DISCOVERY
Here the authors present the philosophy of the DISCOVERY model which guarantees early intervention for all children with autism and their families in the community. This model offers practical strategies to deal with the issues described above. 242

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& S H I M I Z U : E A R LY I N T E RV E N T I O N S Y S T E M A community-oriented systems approach from early detection to early intervention DISCOVERY is a model of a completely community-oriented systems approach which acknowledges the fact that autism takes a chronic course throughout life, and that people with autism have difculty in generalizing what they have learned in a particular situation to other settings. The subsystems of early detection, early diagnosis and early intervention can all be offered in the community in accordance with the DISCOVERY model. It is often the case that all three subsystems cannot be supplied by a single facility. Early detection can be facilitated when infant and child health is promoted as a part of public health programs. Making denitive diagnoses of autism is a function of medical facilities. Intervention for autism is most effective when an educational approach is used in collaboration with medical and social services support. The conditions necessary to develop a system of early intervention in the community are viewed from the standpoint of three elements: hardware, software and human resources. Ideally, laws will be passed which ensure a rm public commitment to the construction and operation of facilities that permit early intervention programs to be offered on a community basis. Software must be adaptable over time for the system to develop. Human resources with specialized knowledge working within a team framework are essential to utilizing both hardware and software.
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Interface to deal with uncertainty An outstanding feature of the DISCOVERY philosophy is its way of dealing with the uncertainty principle. The most practical method now available to address the problem of uncertainty involves establishing independent mechanisms to deal directly with the uncertainty. These mechanisms form the interfaces linking the detection, diagnosis and intervention phases within the system. Two sites at which it is most advantageous to locate these interfaces are between the detection and diagnosis phases and the diagnosis and intervention phases of the system. The specic purpose of the interface is to deal with the problem of uncertainty, thereby enabling repeated longitudinal judgments instead of one-time judgments during the period in which the uncertainty exists. This approach is especially crucial in the case of disorders such as autism in which accurate methods of early diagnosis have not been established. The interface can also overcome issues of uncertainty arising from parental recognition of the disorder. In the period between detection and denitive diagnosis, parents may feel anxious and guilty about their childraising methods. At the time the denitive diagnosis is made, they may
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6(3) experience shock and despair. The interface covers this stressful period by ensuring that specialists are available to provide real-time psychological support to help parents overcome their anxiety and motivate them to participate in the subsequent steps of early intervention. The interface also addresses issues of uncertainty in the boundaries of responsibility between facilities. It can link the different facilities providing detection, diagnosis and intervention services in a longitudinal manner so that every child can be assured a seamless and consistent program, guided by a coherent plan, from detection to intervention.
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The DISCOVERY approach in Yokohama

Geographical background The city of Yokohama is located approximately in the center of Japan (Figure 1).The population of Yokohama exceeded 3,400,000 in 2000 and is second only to Tokyo. The number of newborns in 1999 was 33,676. Yokohama is divided into 18 wards, and each ward has its own public health center (PHC). Yokohama is fortunate to be able to offer an urban community-oriented clinical system for dealing with autism that is easily accessible and has specialized facilities that provide services to assist residents with disorders and their families to have fuller, more satisfying social lives. The Yokohama population is dense and the trafc network is highly developed, so all residents, wherever they live, are within one hour of a special services facility. Second, health checkups for 4-month-old (HC-4m), 18-month-old (HC18m) and 3-year-old infants and children (HC-3y) are mandated by the Maternal and Child Health Law and are routinely conducted free of charge at all of the 18 PHCs in the city. Third, regional habilitation centers for children (Yokohama Habilitation Centers for Children) are also provided for under the Child Welfare Law. In Yokohama, the PHCs are in charge of detection, and the habilitation centers for children are in charge of diagnosis and intervention for developmental disorders. Health checkups for children at PHCs The Japanese public health system is one of the worlds most highly developed in its provision of health checkups for infants and children.The health checkup participation rates in many Japanese cities, including Yokohama, are consistently high. The participation rates for child health checkups in Yokohama during the period from April 1999 to March 2000 were 94.2 percent for the HC-4m, 92.5 percent for the HC-18m and 89.4 percent for
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Figure 1 Yokohama. The city of Yokohama is located in approximately the center of Japan (left) and is divided into 18 wards (right). The Child Division of (1) the Yokohama Rehabilitation Center (YRC) plays a central role in supervising and assisting the six Yokohama Habilitation Centers for Children; (2) North Yokohama; (3) East Yokohama (opens in 2003); (4) West Yokohama; (5) Totsuka; (6) Central Yokohama; (7) South Yokohama

the HC-3y. For early detection of autism, the HC-18m may be the most useful. It is hypothesized from published research that at the age of 18 months, social interaction and communication have developed sufciently to be observed and may provide behavioral markers for the early detection of autism (Baron-Cohen et al., 1992; 1996; Filipek et al., 1999; Johnson et al., 1992). The set of items used to screen for autism in health checkups was drawn up by the Public Health Bureau of Yokohama and is called YACHT (Young Autism and other developmental disorders CHeckup Tool). It includes YACHT-18 which is used at the HC-18m and YACHT-36 which is used at the HC-3y.The YACHT consists of a questionnaire covering the development of motor function, communication and social interaction (see Appendix), interviews with caregivers on the topics of the questionnaire, and a specic examination of children by public health nurses. This is only a part of the whole checkup procedure to detect various diseases and disorders. Public 245

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6(3) health nurses in Yokohama are specically trained in mass screening methods and are experienced in screening for autism.
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The role of the Yokohama Habilitation Centers for Children The 1981 Yokohama city plan provided for the construction of six Yokohama Habilitation Centers for Children, i.e. one per every 500,000 people. Five of them have already been constructed and had started providing habilitation services prior to the beginning of the 2001 scal year, and the remaining facility (the East Yokohama Habilitation Center for Children) is scheduled to open in 2003. In addition, the Child Division of the Yokohama Rehabilitation Center (YRC) was constructed to play a central role in supervising and assisting the habilitation centers (Figure 1). Each center has its own geographical jurisdiction and has formed a network with PHCs in its service area.The YRC and the habilitation centers have both outpatient clinics providing medical services and day-care facilities to offer welfare-based services in intervention programs. The programs are provided for children with any kind of developmental disorder and vary according to the characteristics of the special needs presented by the children. In the early intervention programs of the YRC and the Yokohama Habilitation Centers for Children, both childrens therapy and support for parents are considered essential. Accordingly, all programs consist of childfocused classes as well as parent-focused educational sessions. In contrast, other early intervention programs tend to emphasize either therapy for children (Lovaas, 1987) or education for parents (Shields, 2001) and fail to deal adequately with the totality of the situation. The programs of the YRC and the Yokohama Habilitation Centers for Children place equal emphasis on addressing the needs of children and of their parents. Interface between the detection and diagnosis subsystems Interfaces are positioned at two points in the system: between the early detection and early diagnosis subsystems, and between the early diagnosis and early intervention subsystems. The interfaces used by the YRC and Yokohama Habilitation Centers for Children are multifaceted in nature, and therefore they differ in their specics. However, to provide an example of an interface as it articulates with its subsystems, the YRC interfaces shown in Figure 2 will be described. Within the area under YRC jurisdiction, early detection for autism takes place, rst of all, in the PHCs. Children with suspected disorders are then referred to the YRC outpatient clinic for diagnosis. Next, an early intervention program is provided which children may participate in throughout their preschool years. The interface established between the detection and diagnosis
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Yokohama Rehabilitation Center

Detection

Diagnosis

Intervention

HC-18m

Diagnosis

Main program

Follow-up Joint clinic Failsafe

Introductory program

Interface

Interface

Figure 2 The DISCOVERY approach consists of the three subsystems of detection, diagnosis, and intervention, with interfaces between consecutive stages. The HC-18m at the PHCs plays the major role in the detection component, and the YRC is in charge of the diagnosis and intervention components. The interface between the detection and diagnosis subsystems consists of the follow-up, joint clinic, and the fail safe mechanism, and the interface between the diagnosis and intervention subsystems consists of the introductory program

subsystems in the YRC service area include the follow-up after the HC-18m, the joint clinic, and the failsafe mechanism of the HC-18m to catch falsenegative cases. The items covered in the follow-up at PHCs after the HC-18m and the joint clinic are shown in Table 1. Follow-ups are planned for children who are suspected of having diseases and disorders difcult to detect in a onetime screening at the age of 18 months. For most children suspected of having disorders, including autism, public health nurses initiate the followup with either a telephone call or a home visit. Then, a weekly group program for mothers and children and individual psychological consultations are introduced. It should be noted that in addition to supplementing the mass screening program for children, the follow-up plays an important role in educating and assisting parents. Throughout the followup, public health nurses and clinical psychologists in the PHCs make a persistent effort to sensitize parents to their childs developmental abnormality, while at the same time providing psychological support for them. If necessary, mentoring relationships are encouraged by introducing parents to voluntary community groups which are supported by the Social Services Bureau of Yokohama and managed by parents whose children, ranging in age from infancy to adulthood, have developmental disorders. 247

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6(3) If it is strongly suspected that a child has a disorder such as autism, public health nurses refer the child to the YRC. Cases that require more specialized assessment than is offered at the PHCs are considered at a joint clinic, held once a month at each PHC. Participating in the joint clinic are YRC staff consisting of a child psychiatrist, a clinical psychologist and a social worker who team up with the public health nurses at the PHC. The team observes and assesses the child, interviews the parents and formulates a plan. The failsafe mechanism of the HC-18m is designed to catch falsenegative cases and refer them to YRC. This aspect of the system, consisting of a network of related facilities, has already been described elsewhere by the authors (Honda et al., 1996). Most children with autism are referred to YRC by the PHCs through the HC-18m. However, some children with autism are false-negatives or have not participated in the HC-18m. These children may be identied at the HC-3y which functions as another mass screening. Children may also be referred to YRC from kindergartens and nursery schools, other medical clinics and child guidance clinics. The YRC offers programs to support these related facilities, e.g. periodic supervision programs for kindergarten teachers to increase knowledge of autism and other developmental disorders.Thus, the network among these related facilities functions as a failsafe mechanism for the HC-18m.
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Interface between diagnosis and intervention subsystems The early intervention program at YRC is composed of an introductory program and the main program.The introductory program forms the interface between the diagnosis and intervention stages at the YRC. It focuses not only on intervention but also on assessment for the purpose of making a denitive diagnosis. At the rst consultation at the YRC, a child undergoes a preliminary diagnosis by a child psychiatrist. After this, in the introductory
Table 1 Follow-up at the PHCs after HC-18m and the joint clinic Description Staff

Mechanism Follow-up: Introduction Ongoing

Telephone call Home visit Weekly group Psychological consultation Assessment upon referral to YRC

Public health nurse Public health nurse Public health nurse, teacher Clinical psychologist Public health nurse Staff from YRC (child psychiatrist, clinical psychologist, social worker)

Joint clinic

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& S H I M I Z U : E A R LY I N T E RV E N T I O N S Y S T E M program, a more in-depth assessment of the child and an appropriate program of intervention are initiated, and the family is encouraged to go on to the next step, i.e. the main program. The introductory program is offered once a week for 3 months. Classes designed with a highly visual emphasis provide both highly structured situations and unstructured free play sessions in which repeated observations are conducted to obtain behavioral data to assist in making a denitive diagnosis regarding autism. Class size is limited to approximately six children and their parents. For very young children with autism, the program provides their rst opportunity to experience a structured situation in which they fully understand the instructions, feel at ease and are motivated to participate in the activities. It also gives parents their rst opportunity to learn about the characteristics of autism and how to cope with them in daily life. Parents are relieved to see their children participate spontaneously in the activities and to feel both competent and condent about rearing their children with the assistance of specialized services in the community. The introductory program also offers opportunities for peer counseling for participating parents. Individual assessments are made of each child and counseling is offered to the parents during this period. After the introductory program, a summary of the assessment is submitted to the child psychiatrist.Then, the child psychiatrist re-evaluates the child using his own observation data and the staffs summary, makes a denitive diagnosis and formulates a plan for the next step. After obtaining the informed consent of the parents regarding the diagnosis, assessment and intervention plan, the child and parents are introduced into the main program. In the main program, classes are offered weekly by two to three therapists (teachers and clinical psychologists) and last from 3 to 4 hours including lunch. Class size is limited to ve to eight families. Classes are offered continuously throughout the Japanese scal year, i.e. from April to March. Some classes are held 4 to 5 days a week for children for whom the program is the only opportunity to attend social activities, while other classes are held 1 to 3 days a week for children who also participate in integration programs in kindergartens or nursery schools. Classes for children with autism are highly visually structured, and main program objectives are acquisition of adequate communication skills and preventing the development of challenging behaviors, as well as acquisition of self-help skills useful in daily life. Periodic parent-focused programs include counseling on an individual as well as a group basis by child psychiatrists and clinical psychologists, lectures by staff therapists, peer counseling, and mentoring by parents of older children. Support to promote generalization is provided through home visits and by offering supervision to help kindergartens and nursery schools integrate children with special needs into their programs. Once
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6(3) children enter the main program, they are able to participate throughout their preschool years.
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Effect of DISCOVERY on clinical performance

The DISCOVERY clinical system for early detection and early intervention in Yokohama is based on a systems approach and is derived from the YRC system established in 1987. All components described above have been in existence since then, but the idea of establishing an interface was not present at the beginning. The original idea of the interface was rst introduced into the system by one of the authors (YS) in 1990. Since then, the conceptual model of DISCOVERY has evolved in parallel with the development of the actual clinical system.The DISCOVERY model in Yokohama has stimulated so much demand from parents that the number of classes offering the main program at the YRC have had to be greatly increased. Now, more and more children in Yokohama benet from the DISCOVERY system, then go on to the next step of their education in the school system, supported by follow-up activities at the YRC clinic. In the following, longitudinal data on how children utilize the YRC clinical system are presented. The data were collected, using ICD-10 research criteria, from 50 children with childhood autism who were selected from referrals to YRC. These children represent all referrals to the YRC for childhood autism who were born in years 1986 to 1988 and who participated in the HC-18m conducted at the PHCs in the YRC service area during the years 1987 to 1990. Minimal bias exists in data sampling because as many as 90 percent of children in the area participated in the HC-18m at the PHCs.

The sensitivity of the YACHT-18 for childhood autism The 50 children were divided into two groups based on their YACHT-18 results: 37 true-positive cases which were accurately suspected of a disorder, and 13 false-negative cases which were overlooked in the screening. The sensitivity of the YACHT-18 for detecting childhood autism was as high as 74 percent.The authors are preparing to publish newer data on the sensitivity and specicity of YACHT-18, yet it is nevertheless worth emphasizing that the sensitivity of the clinical screening routinely conducted at the regional PHCs in Yokohama more than 10 years ago was higher than the sensitivity of 38 percent recently reported in a British research study which used CHAT to screen for childhood autism (Baird et al., 2000).

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The age of referral The mean age of referral to the YRC was 2 years 8 months in the truepositive group and 3 years 7 months in the false-negative group (Figure 3). The early detection phase, making use of routine health checkups for children, led to a signicantly earlier age of referral. In addition, even the false-negative cases are referred to the YRC at the mean age of 3 by virtue of the failsafe mechanism in the system. Of the 13 false-negative children, the families of ve children consulted YRC on their own before the HC-3y. Seven children participated in the HC-3y, and four of them were identied and referred to the YRC. The other three were encouraged by the staff of either kindergartens or nursery schools to consult the YRC. The remaining false-negative child did not participate in the HC-3y, but consulted the child guidance clinic in the area and was referred to the YRC (Figure 4).
Years 6

5 Age of referral to YRC

F < 0.005
0
True-positive (mean = 2 years 8 months) False -negative (mean = 3 years 7 months)

Figure 3 YRC

Relation between the results of the HC-18m and the age of referral to

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50

negative
7

HC-18m

negative

HC-3y

positive
37

Medical clinics

Child guidance clinics

Kindergartens Nursery schools

positive
4

;4+
Figure 4 Referral pathways of the 50 children to YRC

Children with childhood autism who do not participate in the HC-18m may miss the opportunity for an early intervention program in their preschool years, but such cases are rare because of the high participation rate in the HC-18m. As seen in Figure 3, all 50 children, i.e. the great majority of children with childhood autism in the area, were referred to YRC by the age of 5 at the latest.

The route from referral to intervention Of the 50 children, 45 participated in the introductory program. Except for one child who moved out of Yokohama soon after the introductory program, 49 children participated in the main program throughout their preschool years. The proportion of children still being followed after reaching school age Of the 49 children who participated in the early intervention program at the YRC, 10 had moved out of Yokohama by the end of 1999. Of the remaining 39, 32 were still being followed by child psychiatrists and clinical psychologists at the end of 1999 at which time the age of the children ranged from 11 to 13. It must be emphasized that autism cannot be cured, even given the most benecial early intervention. It must be further emphasized that early intervention is just the beginning of lifelong
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& S H I M I Z U : E A R LY I N T E RV E N T I O N S Y S T E M support for the children and their families. In Yokohama, the DISCOVERY approach not only enables early intervention but also ensures that a high proportion of children will receive follow-up assistance through all stages of their lives.
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Effect of DISCOVERY on research

In addition to its contribution to clinical performance, another important effect of the DISCOVERY approach is in the area of research.The DISCOVERY model applied in Yokohama offers researchers the opportunity to observe directly all the cases in the area from infancy to adulthood. This enables large-scale clinical research studies on autism to be conducted. In the eld of epidemiological surveys of autism, the DISCOVERY model guarantees researchers the most rigorous methodology available to obtain reliable data from a birth cohort in the community. This is accomplished by virtue of the interface between the early detection and early diagnosis subsystems. Thus, accurate data on the incidence of autism, which are far more useful than prevalence data in biological investigations on the etiology of autism (such as in the eld of genetics), are obtainable for the rst time. In fact, the authors were the rst to publish data on the incidence of childhood autism (Honda et al., 1996). The clinical system based on the DISCOVERY model may also be crucial to tame some aspects of the wilderness of research on autism. On issues of early diagnosis, development of a valid screening tool to detect children with autism will be encouraged. In this article, the results of our pilot study on the sensitivity of YACHT-18 for the screening of childhood autism were discussed. The authors are now preparing recent data on the sensitivity and specicity of YACHT-18 in a larger population, which, together with the follow-up data, will clarify the potential and limitations of the candidate behavioral markers for early detection of autism, and contribute to the revision of YACHT-18. The DISCOVERY model will benet research on the clinical course of autism by providing researchers with more opportunities directly to observe children with autism from early childhood to adulthood. This will clarify the clinical picture of autism for the period from 18 months to 3 years of age a picture previously based mainly on retrospective descriptions from parents, and still an area veiled to researchers. Prospective direct observation of children with autism from early childhood to adulthood will also reveal the controversial relationship between symptoms and the clinical course throughout life, and may contribute to the reorganization of subcategories of PDDs and the autistic spectrum. Lastly, evidence on the efcacy of early intervention on longterm outcomes will accumulate, precisely because the clinical system, 253

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6(3) based on the DISCOVERY model, is designed to produce this kind of evidence.
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Conclusion
Early community-oriented intervention for autism is best implemented through an interdisciplinary approach in which the various professions participate by providing clinical care as well as by engaging in research activities. The idea of interface in the DISCOVERY model is essential for hardware, software and human resources to function in an interdisciplinary manner under a coherent plan. Preschool children with autism in Yokohama receive early intervention assistance most effectively with the DISCOVERY approach which ensures a smooth transition to special education programs in the schools.With the benet of a decade of clinical practice in Yokohama based on the DISCOVERY model, an acceleration of research activities can be expected in the twenty-rst century.

Appendix: questionnaires for autism and other developmental disorders at 18 months (YACHT-18) and 3 years (YACHT-36)
YACHT-18
1 2 3 4 5 6 7 8 9 10 11 12 13 Can your child walk? Well/Not well (less than 56 steps) Can your child climb stairs holding your hand? Yes/No Can your child scribble with a pencil? Yes/No Can your child eat by him/herself with a spoon or fork? Yes/No Can your child hold things between thumb and forenger? Yes/No Does your child point to pictures in a familiar picture book, when asked? Yes/No Can your child say words with meaning? Yes/No (List about 4 examples: ) Does your child follow simple commands? Yes/No Does your child imitate people? Yes/No Is your child interested in other children? Yes/No When you call your child, does he/she look at you? Yes/No Do you have any worries concerning your childs vision? Yes/No (List: ) Do you have any worries concerning your childs hearing? Yes/No (List: )

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& S H I M I Z U : E A R LY I N T E RV E N T I O N 14 Do you have any other worries or questions? Yes/No (List: )

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YACHT-36
1 Can your child stand on one foot without holding on to something? Yes/No 2 Can your child ride a tricycle? Yes/No 3 Can your child draw a circle when shown how to? Yes/No 4 Can your child put on his/her shoes by him/herself? Yes/No 5 Can your child now talk quite freely? Yes/No (List: ) 6 Can other people also understand what your child says? Yes/No 7 Does your child ask Whats this? and similar questions? Yes/No 8 When you ask your child Which one is bigger?, does he/she point to the correct object? Yes/No 9 When playing, does your child pretend that blocks represent meaningful things (e.g. cars, houses)? Yes/No 10 Does your child want to play with other children? Yes/No 11 When you tell your child, Later, okay?, can he/she wait? Yes/No 12 Do you have any worries concerning your childs vision or hearing? Yes/No (List: ) 13 Does your child have any problems in his/her everyday life (e.g. thumbsucking/stuttering/discharge)? Yes/No

Acknowledgement This study was funded by the Japanese Ministry of Health, Labour, and Welfare through a Research Grant for Nervous and Mental Disorders (11B10). References
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