Quality of Life and Its Associated Correlates of Parents of Children on the Autism Spectrum in Singapore.

This cross-sectional study aimed to assess Quality of life (QoL) of parents of children on the autism spectrum in Singapore and identify its associated factors. Parents of children (age ≥ 5 years) completed the Quality of Life in Autism scale which measures parental self-rated QoL (higher scores denote greater QoL), and the perceived impact of the child's autism-related behaviors on parents (higher scores denote lesser impact). Information on the child's degree of autism (measured by the Social Responsiveness Scale, second edition [SRS-2]), community and social participation and cognitive and adaptive functioning were also obtained. Participants were 86 parents with mean child age 6.3 years (SD 1.0). Univariate analysis results revealed greater participation in community and social events to be two modifiable factors associated with higher parental QoL. However, these factors were not found to be significant in the multivariate model. Higher autism features (represented by higher parent-rated SRS scores) was associated with a greater perceived impact of the child's behaviors by parents in both univariate and multivariate analyses. Of note, child's cognitive or adaptive skills were not significantly associated with either QoL measure. Equipping parents to handle autism-related behaviors can be useful to reduce their impact on parental QoL. Facilitating community participation for these children may positively influence caregiver QoL as well.

Restricted and repetitive behaviors and association with cognition and adaptive functioning in children with autism spectrum disorder in Singapore.

Background: One of the core features of autism spectrum disorder (ASD) is restricted, repetitive patterns of behavior, interests and activities (RRBs). RRBs are known to adversely affect cognition and adaptive functioning. We explored the relationship of RRBs with cognition and adaptive functioning in children with ASD in an Asian setting. Methods: This cross-sectional study was conducted at a tertiary developmental pediatrics center in Singapore from September 2019 to October 2021. Parent-child dyads (parents and their children ≤7 years old diagnosed with ASD) were recruited. Parents completed the Repetitive Behavior Questionnaire-2 (RBQ-2), which reports total score and two subscales - Motor/Sensory Behaviors (RBQ-2 MS) and Rigidity/Routines/Preoccupation with Restricted Interests (RBQ-2 RRPRI). Standardized assessments included Mullen Scales of Early Learning (MSEL) and Vineland Adaptive Behavior Scales (VABS-II). Data analysis utilized descriptive statistics and Pearson's correlation. Results: Parents of 113 children [75.2% male, mean (SD) age 5.0 (1.2) years] participated. Median (IQR) RBQ-2 score was 29.0 (11.0). Significant negative correlations (adjusted for age, gender and family history of ASD) were observed for total RBQ-2 scores with MSEL ELC scores (r = -0.248, n = 101, p = 0.014) and VABS-II ABC scores (r = -0.281, n = 88, p = 0.009). Specifically, these correlations of fair strength were seen only with the RBQ-2 MS subscale for both ELC (r = -0.321, n = 101, p = 0.001) and ABC (r = -0.3478, n = 88, p = 0.001). Conclusion: In children with ASD, severity of RRBs correlated with adverse cognition and adaptive functioning measures in our study, consistent with Western literature. While our study does not show causality, it adds to literature serving as a foundation for further research for both clinicians and researchers to target RRBs in improving outcomes with children in ASD.

Validity and feasibility of using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) in primary care clinics in Singapore.

LAY ABSTRACT: Systematic screening for autism in early childhood has been suggested to improve eventual outcomes by facilitating earlier diagnosis and access to intervention. However, clinical implementation of screening has to take into account effectiveness and feasibility of use within a healthcare setting for accurate diagnosis of autism. In Singapore, autism screening using a structured screening tool is not currently employed as a part of routine well-child visits for children in primary care clinics. In this study, 5336 children (aged 17-20 months) were screened for autism using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by nursing staff at each clinic. Children screened positive and a portion of those screened negative then underwent diagnostic assessments to determine whether they met the diagnostic criteria for autism. In total, 113 (2.1%) were screened positive, of which 54 (1.0%) met the criteria for autism. Children who screened positive and received a diagnosis accessed autism-specific intervention at an average age of 22 months. Nurses and physicians rated the acceptability and practicality of the M-CHAT-R/F highly. Therefore, the M-CHAT-R/F questionnaire was an effective and feasible tool for autism screening among 18-month-old children in this study. Future studies will be designed to determine the optimal age of screening and role of repeated screening in Singapore, as well as to better understand any potential improved outcomes nationwide compared with pre-implementation of autism screening.

Parent coaching via telerehabilitation for young children with autism spectrum disorder (ASD): study protocol for a randomised controlled trial.

BACKGROUND: Early parent-implemented intervention enhances parent-child interaction and improves language skills in children with autism spectrum disorders (ASD). Parent coaching is often delivered as standard care for children with ASD, where parents are taught to apply strategies in their child's play activities and daily routines to achieve the prior stated goals. However, the ability to conduct parent coaching in physical in-clinic sessions is limited by resource constraints such as clinic space and therapist manpower. Furthermore, parents may experience difficulties with the generalisation of intervention strategies taught in the clinic to their natural home environments. In this study, telerehabilitation is evaluated as an alternative platform to deliver parent coaching for parent-implemented interventions to children with ASD in their homes. METHODS: This parallel-group, randomised, controlled, non-inferiority trial aims to evaluate the effectiveness of parent coaching delivered through video conferencing (telerehabilitation) versus in-clinic (standard care) delivery. Children aged 15 to 48 months (n = 200) who meet the cut-off score for ASD on the Autism Diagnostic Observation Schedule-2 are eligible. Parent-child dyads are randomly assigned to receive parent coaching either through weekly telerehabilitation or standard care. The primary outcome is the child's development as measured by the subscale and composite scores of a standardised developmental assessment. Primary analysis will determine if the lower boundary of the 95% confidence interval for the mean difference in pre-post change between groups exceeds -5 (the non-inferiority margin). Secondary outcomes are the child's adaptive behaviour, parent-child interaction, parental stress, and family quality of life. Outcomes will be measured pre-intervention, midterm, and post-intervention. Secondary analysis will determine if there is any between-group difference for the pre-post change in scores at the 5% significance level using two-sample t-test or Mann-Whitney U test. DISCUSSION: As a randomised controlled trial of a moderately large scale, this study will contribute to the limited existing literature on the effectiveness of parent coaching via telerehabilitation for early parent-implemented intervention for children with ASD. The results of this study will provide insights on whether telerehabilitation is comparable to conventional in-clinic parent coaching in enhancing parent-child interaction and improving language skills. TRIAL REGISTRATION: ClinicalTrials.gov NCT05792449. Registered (retrospectively) on 31 March 2023.

Exploring the perception of parents on children's screentime: a systematic review and meta-synthesis of qualitative studies.

BACKGROUND: Screentime (ST) has been increasingly pervasive in young children. Evidence suggests positive and negative effects of ST on children's development. Parents play a crucial role in influencing their children's ST. There is limited research consolidating the parental perceptions related to children's ST. This review consolidates the evidence on the perception of parents on their children's ST. METHODS: Six electronic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, and ProQuest) were searched from their inception to September 2022. Critical appraisal was conducted using the Critical Appraisal Skills Program (CASP) checklist. Data synthesis was performed using Sandelowski and Barroso's approach. RESULTS: Twenty studies were included in this review, encapsulating the experiences of 1,311 parents. Three main themes with corresponding subthemes were identified: (1) Varied reasons behind ST; (2) Attitudes toward ST; and (3) Strategies and approaches to managing ST. CONCLUSION: The findings highlighted the varied reasons parents promote ST. Parents reported their concerns and confusion about ST and shared some strategies and approaches for better ST. Future research is needed to develop and evaluate educational programs to ensure that parents understand the risks and benefits of ST and in turn, ensure the appropriate adoption of ST for their children. IMPACT: In the digital era, parents' attitudes towards screentime (ST) for their children are mixed. This review presents the dilemma parents face and their struggles with using optimal screen time for their children. This review provides up-to-date evidence on the parents' confusion and concerns about ST as well as strategies and approaches used by the parents for better ST. There is an urgent need for evidence-based educational programs to enhance parental knowledge about ST so that they can ensure appropriate ST among children. CLINICAL TRIAL REGISTRATION: PROSPERO Registration No. CRD42022356083.

Feeding difficulties in Asian children with autism spectrum disorder.

BACKGROUND: To characterize the nature and severity of feeding difficulties in Asian young children with Autism Spectrum Disorders (ASD) and identify potential predictors of poorer feeding outcomes. METHODS: Cross sectional study of children aged 1-7 years with ASD. Parents completed the following: demographic information, brief autism mealtime behavior inventory, aberrant behavior checklist (ABC), behavioral pediatrics feeding assessment scale (BPFAS) and caregiver feeding style questionnaire. Additional information (medical data, cognitive and developmental assessment results, e.g., Autism Diagnostic Observation Schedule Second Edition, Autism Diagnostic Interview, Revised, Vineland Adaptive Behaviour Scales, etc.) were subsequently obtained from electronic medical records retrospectively by one of the study team members. RESULTS: Of the 67 children, 28.4% had feeding difficulties (high BPFAS total frequency score). Caregiver feeding styles were authoritarian (34.8%) or indulgent (39.4%). Child characteristics did not significantly predict for the severity of feeding difficulties. Univariate analysis revealed that authoritarian feeding style (p = 0.001) and ABC hyperactivity score (p = 0.006) were significantly associated with BPFAS severity score. Multivariate analysis revealed that ABC hyperactivity score remained significantly associated with BPFAS severity score after controlling for all other ABC subscale scores. A final regression model including all child characteristics and ABC scores did not reveal any significant predictors of BPFAS total frequency score (R2 = 0.557). CONCLUSION: Our findings suggest an association between hyperactivity, authoritarian feeding style and feeding difficulties. Children with ASD who have significant hyperactivity behaviors in the context of parents with an authoritarian feeding style should be actively screened for problematic feeding behaviors.

Factors Contributing to Psychological Ill-Effects and Resilience of Caregivers of Children with Developmental Disabilities During a Nation-wide Lockdown During the COVID-19 Pandemic.

We evaluated factors affecting psychological ill-effects and resilience of caregivers of children with developmental disabilities during the coronavirus pandemic. Depression, Anxiety, and Stress Scales (DASS-21) and Connor-Davidson Resilience Scale 25-item were administered. Logistic regression was used to identify factors associated with psychological ill-effects and resilience. DASS-21 depression, anxiety and stress scores were high; these were associated with difficulties with infection control measures, autism diagnosis, and need for early intervention services. For caregivers of children with ASD, our DASS-21 scores were significantly higher than non-pandemic scores locally and in other Asian sites. Resilience scores correlated inversely with DASS-21 scores. Targeted support to selected at-risk caregivers and improving resilience can help their coping.

International Interprofessional Collaborative Office Rounds (iiCOR): Addressing Children's Developmental, Behavioral, and Emotional Health Using Distance Technology.

Developmental, behavioral, and emotional issues are highly prevalent among children across the globe. Among children living in low- and middle-income countries, these conditions are leading contributors to the global burden of disease. A lack of skilled professionals limits developmental and mental health care services to affected children globally. Collaborative Office Rounds are interprofessional groups that meet regularly to discuss actual cases from the participants' practices using a non-hierarchical, peer-mentoring approach. In 2017, International Interprofessional Collaborative Office Rounds was launched with several goals: to improve the knowledge and skills of practicing child health professionals in high and low resourced settings regarding developmental and mental health care, to support trainees and clinicians in caring for these children, and to promote best practice in diagnosis and management of these conditions. Five nodes, each comprised of 3-4 different sites with an interprofessional team, from 8 countries in North America, Africa, Asia, and South America met monthly via videoconferencing. This report describes and evaluates the first 2 years' experience. Baseline surveys from participants (N = 141) found that 13 disciplines were represented. Qualitative analysis of 51 discussed cases, revealed that all cases were highly complex. More than half of the cases (N = 26) discussed children with autism or traits of autism and almost all (N = 49) had three or more themes discussed. Frequently occurring themes included social determinants of health (N = 31), psychiatric co-morbidity (N = 31), aggression and self-injury (N = 25), differences with the healthcare provider (N = 17), cultural variation in accepting diagnosis or treatment (N = 19), and guidance on gender and sexuality issues (N = 8). Participants generally sought recommendations on next steps in clinical care or management. A survey of participants after year 1 (N = 47) revealed that 87% (N = 41) had expectations that were completely or mostly met by the program. Our experience of regular meetings of interprofessional groups from different countries using distance-learning technology allowed participants to share on overlapping challenges, meet continuing educational needs while learning about different approaches in high- and low-resourced settings. International Interprofessional Collaborative Office Rounds may prove a useful strategy for increasing the work force capacity for addressing developmental, behavioral, and emotional conditions worldwide. More systematic studies are needed.

Innovations in practice: Adaptation of developmental and behavioral pediatric service in a tertiary center in Singapore during the COVID-19 pandemic.

BACKGROUND: As the coronavirus 2019 pandemic continues, healthcare services need to adapt to continue providing optimal and safe services for patients. We detail our adaptive framework as a large Developmental and Behavioral Pediatrics service in a tertiary academic institution in Singapore. METHODS: The multidisciplinary team at our unit implemented various adaptations and workflow processes during this evolving pandemic in providing continued clinical care tailored to the challenges specific to our patient population. Services were continued via teleconsultation mode during the 'Circuit Breaker' (enhanced movement restriction) period. Specific workflow processes, IT infrastructure, and staff training were put in place to support smooth running of this service. Segregation of services into two teams based at two separate sites and implementation of stringent infection control measures surrounding the clinic visit by providers, patients and their families were incorporated to ensure safety. Measures were also taken to ensure providers' mental wellbeing. RESULTS: The clinical service was continued for the majority of our patients with a lowest reduction in patient consultations to half of baseline during the 'Circuit Breaker' period. We received positive feedback from families for teleconsultation services provided. CONCLUSION: We have been able to continue services in our DBP clinics due to our dynamic reassessment of workflow processes and their prompt implementation in conjunction with the hospital and national public health response to the pandemic. Given that this pandemic is likely to be long drawn, our unit remains ready to constantly adjust these workflows and make adaptations as we go along, together with the support for mental health of patients, parents and staff. Continual improvements in workflows will be helpful even beyond the pandemic to ensure good continuity of care for our patients and families.

Sleep Patterns and Dysfunctions in Children with Learning Problems.

INTRODUCTION: This study aimed to determine the sleep patterns and dysfunctions in children with learning problems in comparison against a local population-based sample. MATERIALS AND METHODS: Parents of 200 children with learning problems and 372 parents of a local population-based sample of typically developing (TD) children were recruited to complete a questionnaire on their child's sleep patterns and sleep problems. The Children's Sleep Habits Questionnaire (CSHQ) is a validated parent-reported sleep screening questionnaire that contains 54 items identifying sleep behaviours in children. RESULTS: The mean age of the sample was 4.2 years (SD: 1.4; range, 2 to 6 years). Sleep duration was similar between the 2 groups. The difference in mean CSHQ subscale scores between children with learning problems and TD children was significant for sleep-disordered breathing (1.3 vs 1.2, P = 0.001). Among children with learning problems, 36.5% snored (vs 26.6% of TD children), 30.5% had noisy breathing (vs 18.8%), and 9.0% (vs 4.6%) experienced difficulty breathing 2 or more times a week. Children with learning problems woke up in a more irritable mood (P = 0.01), had more difficulty in getting out of bed (P <0.001), and took a longer time to be alert (P <0.001). They exhibited fewer behaviours of daytime drowsiness (P = 0.009). Among this group of children, 15.0% of parents reported that their child had a sleep problem compared to 9.0% in the TD group. CONCLUSION: Sleep breathing disorders and symptoms of morning sleepiness are more prevalent in children with learning problems. Symptoms of daytime lethargy are similar between the 2 groups. We suggest that a simple outpatient screening targeted at these problems be instituted in the initial workup of any child with learning difficulties.

ANXIETY AND DEPRESSION DURING PREGNANCY AND TEMPERAMENT IN EARLY INFANCY: FINDINGS FROM A MULTI-ETHNIC, ASIAN, PROSPECTIVE BIRTH COHORT STUDY.

Maternal antenatal mood is associated with negative infant temperament. This link has not been substantiated in Asian populations. We evaluated the association between antenatal maternal mood and infant temperament among Asian mother-infant pairs. Antenatal maternal depression and anxiety were assessed using the Edinburgh Postnatal Depression Scale (J. Cox, J. Holden, & R. Sagovsky, 1987) and the State-Trait Anxiety Inventory (C. Spielberger, R. Gorsuch, R. Lushene, P. Vagg, & G. Jacobs, 1983), respectively, at 26 weeks of pregnancy and 3 months' postnatally. Infant temperament was evaluated with the Early Infant Temperament Questionnaire (B. Medoff-Cooper, W.B. Carey, & S.C. McDevitt, 1993) at 3 months. Factor analysis was performed to extract culturally relevant categories of temperamental traits. Linear regression was performed to examine the influences of antenatal maternal mood on the factor-model-derived infant temperament. Of the 609 mothers, 11% met risk criteria for depression, 17% for state-anxiety, and 19% for trait-anxiety during pregnancy. Factor analysis yielded three infant temperament factors: Emotionality and Attentional Regulation, Sensory Reactivity, and Regularity and Motor Expression, Cronbach's αs = 0.613, 0.712, and 0.752, respectively. Maternal antenatal state-anxiety, p < .001, and trait anxiety, p = .005, were associated with negative emotionality and poor attentional regulation, especially among Chinese, whereas depression was not, p = .090. There was an association between maternal antenatal anxiety and negative infant temperamental traits in this Asian sample.

Academy of Medicine-Ministry of Health clinical practice guidelines: attention deficit hyperactivity disorder.

The Academy of Medicine (AMS) and the Ministry of Health (MOH) have developed the clinical practice guidelines on Attention Deficit Hyperactivity Disorder (ADHD) to provide doctors and patients in Singapore with evidence-based treatment for ADHD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on ADHD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Sleep behaviour in a sample of preschool children in Singapore.

INTRODUCTION: Sleep problems are common in all ages, but may be particularly acute in urban Singapore. This study aims to describe the sleep behaviour of, and to identify any sleep problems in, preschool children. MATERIALS AND METHODS: This was a cross-sectional questionnaire survey of 372 children attending local childcare centers. The questionnaire was based on the Children's Sleep Habits Questionnaire (CSHQ), a validated parent-report sleep screening questionnaire that contains 54 items identifying sleep behaviours in children. RESULTS: A total of 372 (40.0%) children participated. The mean age was 4.1 (SD 1.3) years (range, 2 to 6 years). Average total sleep duration was 10.8 hours (SD 1.1) with average night-time sleep duration of 8.5 hours (SD 0.6) and average nap duration of 1.6 hours (SD 1.0). Co-sleeping was common; 80.9% of children shared a room with someone else. The most common sleep problems were in the domains of sleep resistance and morning behaviour; namely: requiring company to fall asleep (n = 272, 73.1%), being afraid to sleep alone (n = 228, 61.6%) and diffi culty in waking up (n = 165, 44.4%). Among parents, 84.1 % (n = 313) perceived that their child's sleep duration was adequate. CONCLUSION: The duration of sleep in the Singaporean preschool population sampled is signifi cantly lower than recommended values and that of previously described Caucasian populations. Parental perception of sleep adequacy deviates from current recommendations. Given the clear relation of sleep duration with cognitive functioning, learning, and physical growth, this sleep deprivation should be addressed with parental education and opportunistic screening of sleep in well-child follow-ups.

Diseases that Result in Disability in Infants and Children – An Update

Disability in children can be broadly classified into physical and mental disabilities, and there are many conditions that result in this. Physical disability is often present in children with cerebral palsy or neuromuscular disorders. With mental disability, the children are not able to learn self-help skills and remain dependent on their caregivers for most of the activities of daily living. An extension of this group would include those with moderate to severe autism. In paediatrics, many conditions result in both forms of disabilities, with greater consequence and burden to their families. Nevertheless, there had been some recent advances in the management of the spasticity in children with cerebral palsy and the beginning of pharmacological treatment for Duchenne muscular dystrophy. Long term care and rehabilitation remains the most challenging task for all involved in the care of disabled children.