Title Supporting individuals with autism spectrum disorder in Author(s) Yong-Hwee Nah, Mo Chen, and Kenneth Kin-Loong Poon

Copyright © 2021 SAGE Publications

This is the author’s accepted manuscript (post-print) and the final, definitive version of this paper has been published in Intervention in School and Clinic, July 2021. https://doi.org/10.1177/10534512211032911 by SAGE publishing. All rights reserved.

ASD in Singapore 1

Running Head: ASD in Singapore

Supporting Individuals with Autism Spectrum Disorder in Singapore

Yong-Hwee Nah, PhD., Mo Chen, PhD. and Kenneth Kin-Loong Poon, PhD.

National Institute of Education, Nanyang Technological University, Singapore.

Correspondence concerning this article should be addressed to Yong-Hwee Nah, National

Institute of Education NIE2-03-106, 1 Nanyang Walk, Singapore 637616, Nanyang

Technological University, Singapore 637616. Email: [email protected]

Mailing Address:

Mo Chen, National Institute of Education NIE5-B3-32, 1 Nanyang Walk, Singapore 637616,

Nanyang Technological University, Singapore 637616. Email: [email protected]

Kenneth Kin-Loong Poon, National Institute of Education NIE5-B3-35, 1 Nanyang Walk,

Singapore 637616, Nanyang Technological University, Singapore 637616. Email:

[email protected]

No research funding was involved and there was no conflict of interest.

ASD in Singapore 2

Abstract

It has been reported that there is a rise in the number of individuals being diagnosed with Autism Spectrum Disorder (ASD) in Singapore along with evolving changes in

public awareness, attitudes, and levels of financial support occurring in the field in

recent years. As such, this column presents the current status and issues related to the

identification, provision of early intervention services, education, and transition into

youth/adults for individuals with ASD in Singapore. Additional needs and future

recommendations are also included.

Key words: Autism Spectrum Disorder; Singapore; Identification; Education;

Intervention; Transition; Adulthood

ASD in Singapore 3

Supporting Individuals with Autism Spectrum Disorder (ASD) in Singapore

Singapore is a small nation in South East Asia with a population of about 5.7 million,

with ethnic Chinese constituting approximately 74% of the residents, followed by ethnic

Malays (13%), Indians (9%) and others (3%) (Singapore Department of Statistics, 2019).

English is the official language of business, administration and school instruction and

Singapore has been widely recognized as one of the high performing education systems in the

Programme for International Student Assessment (PISA) (Deng & Gopinathan, 2016).

In Singapore, 2.1% of the student population was reported to have a form of special

needs including sensory impairment, physical impairment, intellectual , and Autism

Spectrum Disorder (ASD) (Third Enabling Master Plan Steering Committee, 2016). The

figure of 2.1% is lower than the figure of 8.9% reported in the United States (Lauer, &

Houtenville, 2019). This is possibly at least partly due to different frameworks for disability

categories, the lack of test instruments that are validated and normed in the Singapore

context, and also the difficulty of obtaining accurate information from parents due to the

culturally-based social stigma of having a child with disability in Asia (Poon, 2015). There

have been no accurate studies conducted in Singapore to establish exact prevalence rate of

ASD, but it is likely that, based on prevalence rates worldwide, the figure would be in the

region of 1% of the total population of about 5 million (Autism Resource Center, 2016). In

2014, it was reported that there was a 76% increase in the number of children diagnosed with

ASD in the local hospitals when compared against the same period 4 years prior (Third

Enabling Master Plan Steering Committee, 2016).

Given the reported rise in the number of individuals being diagnosed with ASD in

Singapore and evolving changes in public awareness, attitudes, and levels of financial support

in the local landscape in terms of supporting individuals with ASD, it is pertinent and timely to examine the current status and issues of supporting individuals with ASD in Singapore, ASD in Singapore 4

primarily in four broad domains of (1) identification; (2) early intervention; (3) education;

and (4) transition and adulthood.

Identification of Individuals with ASD

At this point of writing, the identification process of ASD is guided by the

publications of: (1) the Academy of Medicine Singapore-Ministry of Health Singapore

Clinical Guidelines for Pre-school Children with ASD (AMS-MOH Clinical Practice

Guidelines, 2010), and (2) Professional Practice Guidelines for Psycho-educational

Assessment and Placement of Students with Special Educational Needs (Ministry of

Education [MOE], Singapore, 2018). These guidelines summarize pertinent findings from

internationally conducted research and synthesize these into a set of recommendations. In

terms of identification of ASD, it is recommended that the diagnostic evaluation should be

conducted by a multi-disciplinary team through direct observation of the child, the use of

ASD-specific instruments and gathering of ASD-specific developmental information.

Screening and Diagnostic Services

Currently there is no country-wide level practice of screening for ASD though parents

who are concerned about their child’s early development can seek services in the nationwide

Child Development Program which currently diagnoses the majority of children with

(including ASD) in Singapore. The Child Development units at the KK Women’s

and Children’s Hospital (KKWCH) and the National University Hospital form part of the

Child Development Program where parents can access a one-stop service provided by the pediatricians and allied health professionals such as psychologist, speech and language pathologist and occupational therapist. A smaller number may be referred to the Institute of

Mental Health (IMH), or Singapore General Hospital. Based on health records from 2003-

2004 from the KKWCH, it was reported that ASD is the most common clinical development

diagnosis among young children (Lian et al., 2012). A study by Moh and Magiati (2012) ASD in Singapore 5

found that the average age of ASD diagnosis in Singapore was earlier at 3 years of age as

compared to U.S. data from Sheldrick et al. (2017) which indicated a mean of between 3.7 to

8.6 years old. In fact, in that study, more than half of Singaporean parents were reported to be

concerned about their child’s early development by the age of two years.

As for parents with school-aged and older children, they have several avenues for

seeking diagnostic services: (1) the Singapore MOE’s psychologists who work with students

with special educational needs in regular primary and secondary schools; (2) the MOE

psychologists may also collaborate with the IMH’s REACH (Response, Early Intervention

and Assessment in Community Mental Health) team, a nationally provided multidisciplinary

mental healthcare service, to help regular schools in the identification and support of students

with emotional and behavioral concerns such as ASD (Magiati et al., 2015); and (3) a

specialist outpatient Neurobehavioral (Autism Services) Clinic set up at IMH that assesses 6-

19 year old children and adolescents with suspected ASD and intervention services for those

children and adolescents with ASD who have mental health or behavioral comorbidities.

Issues in Screening and Identification of ASD

Previous research has suggested that it may be challenging to apply

screening/diagnostic instruments developed in Western countries into non-Western cultures

(Wallis & Pinto-Martin, 2008). Some possible differences in features of ASD between

Western and Eastern cultures have been reported in terms of eye contact and early language

development (e.g., Bernier et al., 2010). Culturally, it is also less likely that the parents in

Singapore will highlight their child’s difficulties or diagnosis to others even though the child

has some form of developmental disabilities due to social stigma (Poon, 2015; Vanen, 2016).

Sporadic efforts have been taken to use the well-known screening instruments for ASD in

Singapore. For instance, Ooi et al. (2011) used the parent-report Child Behavior Checklist

(CBCL) to screen for ASD in Singaporean children aged between 4 and 18 years of age ASD in Singapore 6

(mean age = 9.06; SD = 2.45) and the findings provided strong support for the CBCL as a

screening tool for ASD. Koh et al. (2014) used the Modified Checklist for Autism in

Toddlers (M-CHAT; a parent report developed in the U.S.) to screen for ASD in Singaporean

toddlers aged between 18 and 48 months of age even though the original M-CHAT was

validated for children up till 36 months old (Robins et al., 2001). Koh et al. (2014) found that the M-CHAT performed adequately in screening for ASD in 173 Singaporean children aged

18–30 months old, providing support for its use.

Given the nuanced differences between different cultures, therefore, the use of assessment tools developed and validated in the Western countries should be used with caution in Singapore. In particular, there is generally limited evidence on the cross-cultural validity and norms of those frequently used screening/diagnostic instruments developed in the Western culture (Soto et al., 2015). These measures are also predominantly conducted via parent reports. To our best knowledge, there have been no teacher-rating tools developed or used to screen for ASD in preschool children aged 3 to 6 years in an Asian population.

Developing and validating screening instruments based on teacher report is of particular relevance in the Singapore context.

As mentioned earlier, the study by Moh and Magiati (2012) found that the average age of ASD diagnosis in Singapore was as early as at 3 years of age. Nevertheless, it may still be possible to miss out on children with milder ASD symptoms and higher cognitive functioning in the identification process (Sheldrick et al., 2017). A more effective identification process via the involvement of preschool teachers may be useful in Singapore context as the MOE reported that more than 99% of Singaporean children have attended at least one year of preschool before entering primary school (Tan, 2017). Singapore preschool teachers would therefore be an ideal source of gathering reliable and quantifiable teacher information as an integral and essential part of the identification of preschoolers with ASD. ASD in Singapore 7

Since the initial diagnosis of children with ASD in Singapore by Bernard-Opitz in

1987, the coverage and accessibility of screening and diagnosis services for children with

ASD in this country has gradually improved. However, epidemiology studies of ASD in

Singapore need to be updated, with the previous one conducted about two decades ago when

there were only 3 million population reported then (Bernard-Opitz et al., 2001). In addition,

cross culturally validating the existing screening and diagnosis tools, exploring more efficient

or sensitive approaches for diagnosis (e.g., seeking teachers’ input, utilizing neuroimaging

technology), and identifying potential risk factors for ASD in the Singapore context seem to

be important issues for researchers to address in near future.

Early Intervention of Young Children with ASD

After a formal diagnosis from the medical professionals or/and psychologists, parents

are recommended to have their young child with ASD receive early intervention. There is a

range of publicly available early support and intervention options for young children with

ASD. Specialized centers providing the government subsidized service have been termed as

Early Intervention Program for Infants and Children (or EIPIC) centers and there are more

than 20 such centers to date. EIPIC centers are characterized by low teacher-child ratios and

individualized goals for each child. These EIPIC centers seek to maximize these children’s

developmental growth potential and minimize the development of secondary disabilities by

providing both therapy and educational intervention services in a small group setting from the

point of diagnosis till the year they turn seven. Home-based early intervention services via

EIPIC for children under two years are also available. These services emphasize the training of parents and caregivers so that they can effectively carry out intervention strategies in the child’s daily routines within their home setting (SG Enable, 2020). Some EIPIC centers offer early intervention programs that serve both children with ASD and children with developmental delay, while others provide specialized programs only for children with ASD. ASD in Singapore 8

Whilst EIPIC centers represent a major pillar in early intervention for children with

ASD, time-limited itinerant support services provided by specially trained teachers or therapists such as speech and language pathologists are available to children with such needs in a large number of government supported preschools. Additionally, children with ASD needing higher levels of support in preschools can also access Developmental Support Plus

(DS-Plus) or the Integrated Child Care Program (ICCP). DS-Plus is a preschool-based program that is targeted at children who have made sufficient progress in the EIPIC centers.

The DS-Plus is set up with the aim of helping the child adapt to the regular preschool setting, so that they can continue learning and be equipped with skills within a larger class setting.

Likewise, ICCP centers are childcare centers that support young children aged 18 months to 7 years with mild to moderate disabilities within regular preschool educational settings. The children do not receive any intervention services in this program though the regular curriculum could be modified to accommodate the child with ASD. This is in contrast to the

DS-Plus where early intervention professionals from the EIPIC centers will work with the child in his or her preschool, and co-teach the child alongside the preschool teacher.

Despite the infrastructural readiness, one pertinent issue in the domain of early intervention for young children with ASD in Singapore is that the extent to which these early intervention programs implement evidence-based approaches (e.g., early intensive behavioural intervention [EIBI] grounded on applied behavior analysis) is at present not clear, with the exception of structured teaching which appears to be a component shared across most intervention settings (Magiati et al., 2015). Similarly, it remains unknown about the knowledge and skills of early intervention teachers in terms of different evidence-based practices and strategies in working with young children with ASD. Hence, more evidence needs to be accumulated to profile, evaluate, and strengthen the effectiveness and efficacy of these local early intervention services and programs. Last but not least, the transition services ASD in Singapore 9

from early intervention to schooling for young children with ASD are yet to be further

investigated.

Education of School-Aged Children with ASD

Educational provision for children with ASD in Singapore is characterized by the

presence of a dual education system with regular education at one end and with special

education at the other (Poon et al., 2013). School-aged children with ASD can be enrolled in

regular schools or special educational schools. The Compulsory Education Act was enacted

in 2001 to make education compulsory for children to access primary education. However,

children with special educational needs, those homeschooled, or those attending full-time

religious schools are exempted. In 2019, the Compulsory Education Act was amended to

make it compulsory for all children with special educational needs to attend a regular or a

school (MOE, 2017).

Regular Schools. In order to support students with special needs in regular schools,

the Singapore MOE introduced the Support for Special Needs Initiative in 2005 where all

primary and selected secondary schools have at least one Allied Educator – Learning and

Behavior Support professional who is trained in supporting the learning and behavioral needs

of students with special educational needs. In addition, 10% of teachers in all primary schools

and 20% of teachers in all secondary schools have completed a Certificate level training in

Special Needs from the National Institute of Education at Nanyang Technological University,

Singapore to support students with special educational needs in regular schools (Disabled

People’s Association, Singapore, 2016).

During the last few years, there has been increasing focus on providing opportunities

for students with special educational needs to be included in regular schools (MOE, 2018).

Despite the well-designed system, one of the main challenges is how to support the inclusion of these students with ASD in Singapore’s regular education, and to sustain the inclusion ASD in Singapore 10

effort over the long run. A study by Yeo et al. (2016) looking at teachers’ experience with

inclusive reported that training is not enough but creating successful

classroom experiences that influence teachers’ sense of efficacy and attitude towards

inclusion is more important. Yeo et al. (2016) also proposed exploring mentorship or

coaching models that would strengthen teachers’ practical skills in special education support

which in turn would enhance their sense of efficacy.

Special Schools. Formal services for children with disabilities in Singapore began in

1989 with the establishment of the first program catering for special education at Rainbow

Center (Rainbow Center, 2020). The number of special schools serving children with ASD

has since proliferated. Of the currently 19 special schools in Singapore (MOE, 2021), all of which are government funded and run by Social Service Organizations (SSOs), 17 special schools offer educational services for children with ASD. There are also three special schools that cater specifically to students with ASD. One of these special schools, Pathlight School, offers access to the Singapore national curriculum in addition to specialized supports for students with ASD and other social-communication disabilities. Each special school adopts a unique approach to teaching these students with ASD. However, there are some fundamental

features that are common in special schools or classes for students with ASD such as a

customized curriculum, smaller teacher-student ratio, teamwork with allied professionals

such as psychologist and speech pathologist, and a structured visual approach to learning

(Magiati et al., 2015). During the last few years, there has also been increasing focus on

vocational preparation for post-school employment (MOE, 2016).

Overall this dual education system presents parents with a choice that they need to

make if they would like their child with ASD to be educated in the regular or special schools.

Although the local education system is organized around the child’s ability to access the

national curriculum and the level of social support, this is a difficult decision that parents ASD in Singapore 11

need to make balancing between support provided in special school and the perceived social

stigma of education within special schools (Choo & Poon, in preparation). Furthermore, the

presence of this dual education system coupled by the increasing number of students with

ASD also raises higher requirements for teacher training and professional development in

both regular and special education school settings. In addition, examining the educational

practices in those special schools specialized for children with ASD would be of paramount

importance as inclusive education and inclusive society is increasingly advocated.

Transition into Youth/Adulthood and ASD in Adulthood

Transition out of school to post school environments is critical but can be challenging for youths and young adults with ASD. All special schools have programs in place for post school transitions while currently three special schools offer an extended special education until the age of 21 (as compared to the age of 16 or 17 in other schools). These schools also offer vocational certification programs that will enhance opportunities for competitive employment or further education, if they meet the eligibility criteria (MOE, 2016). For students with ASD who are not eligible for the vocational certification programs, they would have the opportunity to access the School-to-Work (S2W) Transition Program (MOE, 2016).

Students who enter the S2W Transition Program would receive more support in terms of various training and preparatory activities to acquire the skills for certain jobs. They will also receive employment services such as job referrals during or after the training, and students may also undergo internship programs based on their abilities and preferences and available internship opportunities. As for students who are on the vocational certification programs, they would be eligible to attain nationally recognized and accredited certification, which are the same as those awarded to students from the regular schools. The national certification courses take about two to three years to complete. With these qualifications, students are in a better position to look for jobs; they can also explore further training at other ASD in Singapore 12 vocational institutes. Notably, students who are in the S2W program and those in the vocational certification programs may work in the same work environment, for example in

Food and Beverage industry, but the type of work and responsibilities may differ. For instance, students in the S2W program may become a kitchen assistant or do simple food preparatory work but those in the vocational certification programs with a certificate in baking or cooking may work as an assistant baker or chef.

As individuals with ASD enter adulthood, some services are in place to support them.

St. Andrew’s Adult Autism Services (SAAAS) provides training and support for adults with

ASD, with the aim of enabling them to lead dignified and meaningful lives. The Eden Center for Adults (formerly known as the Autism Youth Center) was repositioned as an adult Day

Activity Center in 2020, in response to the changing landscape of needs in the post-age-18 service areas for individuals with ASD. The Adult Neurodevelopmental Service (ANDS) in

IMH also provides health and treatment support for adults with ASD aged from 19 to 64 years old.

Increasing attention are paid to the post-school transition issue of students with ASD in Singapore and worldwide, with the 2020 United Nations observance of the World Autism

Awareness Day announcing issues related to the transition to adulthood. However, locally there continues to be a dearth of research in this area. Poon (2013) found that most parents of adolescents with ASD expected their child to be working either in a sheltered workshop or be unemployed while none of the parents expected their child to independently have access to the community. Hence, more investigations by both researchers and practitioners are required to establish empirically supported strategies in assisting individuals with ASD with smooth transition into different life paths.

Challenges and Future Directions ASD in Singapore 13

Since its ratification of the United Nations (UN) Convention on the Rights of Persons

with Disabilities (CRPD) in 2013, Singapore being a small nation has come a long way in its

development and provision of support services for individuals with ASD, and their families.

Several important government regulations promulgated in recent years have witnessed the

fast evolving situation in the service delivery for this group of population in Singapore.

Through the latest Enabling Masterplan (Third Enabling Master Plan Steering Committee,

2016), the Singapore government endeavors to ensure that persons with disabilities are not

excluded from the education system on the basis of disability. This is evident from the

amendment of the Compulsory Education Act in 2019 that presents the Singapore

government’s effort in facilitating improved quality outcomes and inclusion practices for

students with disabilities including those with ASD.

It was also recently announced that from 2021 onwards, three new schools will be set up in Singapore that specifically cater to students with ASD – a significant acknowledgement

of the growing need for support and number of places in schools for students with ASD

(Channel NewsAsia, 2019). Furthermore, two of these schools will deliver the primary and

secondary national curriculum (i.e., regular curriculum), as well as a post-primary program for students who cannot access the secondary curriculum (Channel NewsAsia, 2019). In

addition, prevocational and vocational education in special education schools have been

enhanced where students with mild disabilities are able to obtain industry-recognized or

nationally certified skills to enhance their employability (MOE, 2017).

However, there are areas that we could do more. First, conducting nationwide

epidemiological studies to more accurately understand and track the prevalence and incidence

rates of individuals with ASD would be required. Of equal importance is the development of

more sensitive assessment tools or approaches for screening and diagnosing children with

ASD as early as possible. Also, we have to think about how to clearly document the empirical ASD in Singapore 14

evidence of services such as the EIPIC centers as the quality and impact of these services

remains under-investigated and unclear. At the backdrop of a dual education system in

Singapore, inclusion continues to be widely discussed and advocated. It is anticipated that we will have more students with ASD accessing the regular education system (Lindsay et al.,

2014), and thus we have to find ways to better include and support these individuals.

However, not all regular schools are resourced with facilities and/or programs to support students with ASD, and regular teachers find it difficult to cope with the needs of those who require more help, on top of their existing teaching duties (Disabled People’s Association,

Singapore, 2016). Given that inclusive education underscores the participation and learning of all students (Booth & Ainscow, 2011) and the fact that there are special education schools in Singapore that are specialized for students with ASD, exploring culturally and contextually relevant inclusion practices for students with ASD becomes an important future endeavor.

Certain critical questions could arise from exploring the culturally and contextually relevant inclusion practices. For instance, how do we conceptualize inclusive education for students with ASD who are educated in special schools specialized for them? While

Singapore being a small nation that relies heavily on intellectual talents and emphasizes academic achievements, how can we best support students with ASD who may not be academically talented but talented in other aspects such as aesthetics? Last but not least,

Singapore is a multi-cultural and multi-lingual nation and students in the regular schools have to learn both English and Mother Tongue language (Chinese, Malay, or Tamil) in schools; however, students with ASD in special schools are not offered an option of learning Mother

Tongue language. Given impairment in social communication is one of the key features for students with ASD, it remains unclear how the current language education in special schools may influence their development in different aspects. Relatedly, it remains unclear how to better balance the learning needs of these students with ASD and the need for them to be ASD in Singapore 15 included in our multi-lingual and multi-cultural society with a strong emphasis on ethnic and racial harmony.

Next, Singapore has created a system of identifying young children with ASD but there is emerging need for the provision of services for the identification and support of undiagnosed adolescents and adults with ASD. Since 2011, the ANDS in IMH has been set up to support those individuals and their families through providing comprehensive assessment reviews and interventions. Almost one decade has passed, however, to what extent these current services for adolescent and adults with ASD have met their needs remains little known. Similarly, investigating transition services for students with ASD including those who are eligible for higher education and documenting the effectiveness of support systems would be equally important at minimum. Finally, to ensure that we can continue to provide the best support to individuals with ASD, we have to consider how best to continue to promote strong research and clinical collaborations among various stakeholders (i.e., families, schools, professionals, researchers and even the individuals with

ASD themselves) in Singapore and across the world.

ASD in Singapore 16

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