2023 clinical practice guidelines on autism spectrum disorder in children and adolescents in Singapore.

Introduction: Autism is a neurodevelopmental condition that is increasing in prevalence worldwide. There has been an exponential increase in autism-related research since 2010, when the first Singapore Clinical Practice Guidelines (CPG) on autism was published. Understanding of autism has since evolved to adopt a lifespan approach beyond that of a childhood condition. The aim of this CPG was to provide an updated set of recommendations for children and adolescents to aid clinical practice for professionals. Method: A multidisciplinary workgroup that comprised representatives from various sectors worked on this CPG. Clinical questions were organised into 10 different sections, each with its own subgroup of members. Seventeen existing international guidelines were evaluated using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE-II) framework, of which 4 met criteria to act as references. Literature review across multiple databases was conducted between January 2011 to 2023; Grading of Recommendations, Assessment, Development and Evaluation (GRADE-like) methodology was used to synthesise evidence. Recommendation statements were derived, following Delphi-style consensus surveys among the workgroup. The draft guidelines underwent external review and public consultation before being formalised. Results: Recommendation and good practice statements pertaining to care of children and adolescents on the autism spectrum across 10 different sections were developed. Evidence matrices complement these recommendations and detail relevant evidence behind each recommendation statement. Conclusion: It is intended for these guidelines to promote effective management and healthcare services for children and adolescents on the autism spectrum, by reinforcing good and evidence-based clinical practice within our national context.

2023 clinical practice guidelines on autism spectrum disorder in children and adolescents in Singapore

Autism is a neurodevelopmental condition that is increasing in prevalence worldwide. There has been an exponential increase in autism-related research since 2010, when the first Singapore Clinical Practice Guidelines (CPG) on autism was published. Understanding of autism has since evolved to adopt a lifespan approach beyond that of a childhood condition. The aim of this CPG was to provide an updated set of recommendations for children and adolescents to aid clinical practice for professionals. A multidisciplinary workgroup that comprised representatives from various sectors worked on this CPG. Clinical questions were organised into 10 different sections, each with its own subgroup of members. Seventeen existing international guidelines were evaluated using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE-II) framework, of which 4 met criteria to act as references. Literature review across multiple databases was conducted between January 2011 to 2023; Grading of Recommendations, Assessment, Development and Evaluation (GRADE-like) methodology was used to synthesise evidence. Recommendation statements were derived, following Delphi-style consensus surveys among the workgroup. The draft guidelines underwent external review and public consultation before being formalised. Recommendation and good practice statements pertaining to care of children and adolescents on the autism spectrum across 10 different sections were developed. Evidence matrices complement these recommendations and detail relevant evidence behind each recommendation statement. It is intended for these guidelines to promote effective management and healthcare services for children and adolescents on the autism spectrum, by reinforcing good and evidence-based clinical practice within our national context.

Validity of the patient health questionnaire 9-item in autistic youths: a pilot study.

BACKGROUND: Autistic adolescents have greater predisposition to depression and suicidality than neurotypical adolescents. Early detection is essential for timely treatment. The Patient Health Questionnaire 9-item (PHQ-9) is a brief screen for depression. The study examines the validity of the PHQ-9 for detecting major depressive disorder (MDD) in autistic youths. METHODS: English speaking youths aged 10-18 years, with DSM-IV/DSM-5/ICD-10 diagnosis of Autism Spectrum Disorder (ASD), and their parents presenting to a child psychiatric service were invited to participate between May 2018 to August 2020. Participants completed the respective self- and parent-rated PHQ-9 independently. MDD was verified using the MINI-Kid (Mini-International Neuropsychiatric Interview, Kid version). RESULTS: One hundred one youth, mean (SD) age 14.6 (2.3), were enrolled. 27 (27%) met criteria for current MDD. Mean total PHQ-9 scores, percentage ratings for severity of symptoms of depression, functional impairment, dysthymia and suicidality were compared. Areas under the ROC curve and statistically optimal cutoffs were determined. Parents rated depressive symptoms severity lower than their children. The PHQ-9 displayed low sensitivity with high false negative rates at conventional, adjusted and proposed cutoffs. CONCLUSIONS: Future studies should improve on the validity and reliability of existing depression screening tools, or develop more appropriate screening methods of depression, for autistic youths.

Mental Resilience of Medical Practitioners in Singapore during COVID-19: Survey Results from a Webinar Course on Resilience.

Front-line doctors are at high risk of exposure to COVID-19. The mental resilience of general practitioners and their areas of concerns and support required are important during this COVID-19 period. A total of 403 general practitioners attending a webinar on resiliency, hosted by the College of Family Physicians, Singapore, participated in the survey anonymously. Participants provided responses to questions relating to COVID-19 in the domains of Family and friends, Myself, Practice, and Community. Responses are categorized into LEARNING, FEAR, and GROWTH zones. The majority of the doctors reported to be in the GROWTH zone in relation to Family and friends (39%) and Myself (38%) as compared to Practice and Community, aOR = 4.5 (95% CI 3.4 to 5.9), p < 0.001. 34% of the participants reported being in the FEAR zone in relation to Family and friends, aOR = 8.0 (95% CI = 5.6 to 11.2), p < 0.001; at least 81% reported being in the LEARNING zone in relation to Practice and Community, aOR = 7.5 (95% CI = 5.8 to 9.6), p < 0.001, compared to other domains. Supporting and protecting the doctors is important in strategic planning and management of the current pandemic and building preparedness and an effective response towards future crises.

Our children then and now: Changes in mental health symptoms among Singaporean children from 2003 to 2017.

In recent years, there appears to be a rise in the diagnosis and treatment of child mental health disorders in many countries, including Singapore. While this increase may be alarming, it could possibly be attributed to factors such as changes in diagnostic criteria, improved screening in schools and primary health settings, changes in clinical practices, and an increase in help-seeking behaviour. Hence, an examination of community-level trends in mental health symptoms can elucidate how child psychopathology has changed over the years. This study aimed to investigate differences in symptoms of mental health between two cohorts of young Asian children aged six to eight living in Singapore. Child Behaviour Checklist (CBCL) scores from a sample in 2003 (Cohort 1; n = 524) were compared to another sample taken in 2017 (Cohort 2; n = 655). Cohort 2 had lower externalizing scale scores as compared to Cohort 1, but there were no significant differences in total problem scores or internalizing scale scores. Among the CBCL subscales, Cohort 2 had comparatively lower levels of aggressive behaviour and withdrawn/depressed symptoms, but higher levels of thought problems and somatic complaints as compared to Cohort 1. Our findings suggest that children in Singapore are progressing as well as, or even better than, children 14 years ago on most aspects of mental well-being.

Clinical presentations of social communication disorder: A case series.

Social Communication Disorder (SCD) is a new DSM-5 diagnostic category poorly understood by clinicians. We describe a case series of four individuals diagnosed with SCD to identify common characteristics and differences in presentations of the disorder. All cases had deficits in the area of social communication, and sub-threshold level of restricted and repetitive behaviours, not sufficient to meet criteria for Autism Spectrum Disorder (ASD). All cases presented with at least one mental health co-morbid condition. There are significant overlaps in clinical presentation between SCD and ASD. It is imperative that accurate diagnostic tools and effective intervention approaches of SCD be developed.

Correlates of adaptive skills in children with autism spectrum disorder.

LAY ABSTRACT: Despite improving services and care for individuals with autism spectrum disorder, functional outcomes such as daily living skills tend to be suboptimal for many. This study wanted to identify modifiable early intervention factors that are associated with better outcomes and possible high-risk groups of children who are at risk of poorer outcomes. Participants included 193 children aged between 5 and 12 years of age whose parents provided information on their family background and early intervention characteristics. These children also had their adaptive behaviour skills examined by formal testing. Results indicated that shorter wait time for early intervention was associated with better adaptive behaviour scores. Children from families with financial difficulties and lower paternal education were also at risk of poorer adaptive skills. Designing services for children with autism such that wait times to enter early intervention services are minimised following initial diagnosis can improve their eventual functional outcomes. Changes in healthcare policy to allow expedited entry or targeted intervention to children from low socio-economic status families can also enhance their eventual adaptive skill gains.

Caregiver- and Child-Reported Anxiety Using an Autism-Specific Measure: Measurement Properties and Correlates of the Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD) in Verbal Young People with ASD.

Identifying and measuring anxiety in young people on the autism spectrum can be challenging. The present study investigated the use of the Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD), a self- and caregiver-rated screening tool in a Singaporean sample of ninety-one verbal autistic youths and their caregivers. Internal consistency ranged from satisfactory to desirable (α = .74-.92). Convergent validity with medium-large effect size was established using a structured diagnostic interview, the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). ASC-ASD scores were positively associated with autistic symptoms and response patterns indicated strong endorsement of autism-specific items. The findings are discussed in relation to existing literature on assessment of anxiety in ASD and in light of the study's strengths and limitations.

Comparison of DSM-IV-TR and DSM-5 Criteria in Diagnosing Autism Spectrum Disorders in Singapore.

Our study examines the Diagnostic and Statistical Manual-Fifth Edition (DSM-5) and Diagnostic and Statistical Manual-Fourth Edition, Text Revision (DSM-IV-TR) when applied concurrently against the best estimate clinical diagnoses for 110 children (5.1-19.6 years old) referred for diagnostic assessments of Autism Spectrum Disorder (ASD) in a Singaporean outpatient speciality clinic. DSM-IV-TR performed slightly better, yielding sensitivity of 0.946 and specificity of 0.889, compared to DSM-5 (sensitivity = 0.837; specificity = 0.833). When considering the ASD sub-categories, sensitivity ranged from 0.667 to 0.933, and specificity ranged from 0.900 to 0.975. More participants with a PDD-NOS best estimate clinical diagnosis (40%) were misclassified on DSM-5. Merits and weaknesses to both classification systems, and implications for access to services and policy changes are discussed.

Coping and Well-Being in Parents of Children with Autism Spectrum Disorders (ASD).

This study examined psychological well-being and coping in parents of children with ASD and parents of typically developing children. 73 parents of children with ASD and 63 parents of typically developing children completed a survey. Parents of children with ASD reported significantly more parenting stress symptoms (i.e., negative parental self-views, lower satisfaction with parent-child bond, and experiences of difficult child behaviors), more depression symptoms, and more frequent use of Active Avoidance coping, than parents of typically developing children. Parents of children with ASD did not differ significantly in psychological well-being and coping when compared as according to child's diagnosis. Study results reinforced the importance of addressing well-being and coping needs of parents of children with ASD.

Effects of cognitive-behavioral therapy on anxiety in children with autism spectrum disorders: a randomized controlled trial.

We compared the effects of a 16-week Cognitive-Behavioral Therapy (CBT) program and a Social Recreational (SR) program on anxiety in children with Autism Spectrum Disorders (ASD). Seventy children (9-16 years old) were randomly assigned to either of the programs (n (CBT) = 36; n (SR) = 34). Measures on child's anxiety using the Spence Child Anxiety Scale--Child (SCAS-C) and the Clinical Global Impression-Severity scale (CGI--S) were administered at pre-, post-treatment, and follow-ups (3- and 6-month). Children in both programs showed significantly lower levels of generalized anxiety and total anxiety symptoms at 6-month follow-up on SCAS-C. Clinician ratings on the CGI-S demonstrated an increase in the percentage of participants rated as "Normal" and "Borderline" for both programs. Findings from the present study suggest factors such as regular sessions in a structured setting, consistent therapists, social exposure and the use of autism-friendly strategies are important components of an effective framework in the management of anxiety in children and adolescents with ASD.

Prevalence of behavioural and emotional problems in children with high-functioning autism spectrum disorders.

OBJECTIVE: The goal of the present study was to examine the prevalence of behavioural and emotional problems among children with high-functioning autism spectrum disorders (ASD). METHOD: Archival data from a total of 71 children (Mage = 10.24, SD = 2.91) diagnosed by their clinicians to have high-functioning ASD were obtained. Information on demographics and behavioural and emotional problems from the Child Behavioural Checklist (CBCL) were entered. RESULTS: We found that between 72% and 86% of children with high-functioning ASD had at least one behavioural or emotional problem of clinical concerns as indicated by the CBCL syndromes and DSM-oriented scales. The most commonly reported problems were social problems (60.6%), thought problems (50.7%), attention problems (49.3%), and withdrawn/depressed (40.8%). Using the DSM-oriented scales, the most commonly reported problems were attention deficit/hyperactivity problems (35.2%), anxiety problems (33.8%) and affective problems (31%). CONCLUSIONS: Findings from the present study provide further evidence to support the high prevalence of behavioural and emotional problems, which could result in multiple psychiatric diagnoses among children with high-functioning ASD.