2023 Clinical Practice Guidelines on Autism Spectrum Disorder in Children and Adolescents in Singapore

Annals of the Academy of Medicine, Singapore

Wong, C. M., Aljunied, M., et al. (2024).

Annals of the Academy of Medicine, Singapore, 53(4), 541-552.

<div>This evidence-based clinical practice guideline provides recommendations on the diagnosis and management of children and adolescents on the autism spectrum in Singapore. Only those recommendations within the scope of speech-language pathology will be included in this summary.</div>

College of Paediatrics and Child Health (Singapore)

<div>The following recommendations were relevant to screening and diagnosis:</div> <div> <ul> <li>Professionals should identify autism early to provide the opportunity for prompt referral and intervention, and improve long-term outcomes (GPP 1.1)</li> <li>Professionals should initiate early specialist referrals for preschool children with concerns related to social-communication or play (GPP 1.6)</li> <li>Children with clinical features such as regression or loss of language or social skills, no babbling, use of gestures, or response to name by 12 months, no single words, following directions or pretend play by 18 months, lack of eye-contact or social response, repetitive or sensory behaviors should be referred for developmental evaluation (GPP 1.7)</li> <li>Professionals should remain vigilant for possible autism in children or adolescents with ongoing social-communication or behavioral difficulty (GPP 1.8)</li> <li>Healthcare professionals should be aware of factors associated with an increased likelihood for developing autism, and may consider targeted screening for children presenting with these factors (GPP 1.9)</li> <li>Where there are concerns for developmental delay in children, an autism specific screening tool can supplement clinical judgement (R 1.11), but professionals should be aware of their performance characteristics (GPP 1.12) and use them within the age range for which they have been validated (R 1.13)</li> <li>Professionals involved in diagnosis of autism should be aware that some children may meet a diagnosis of Social Communication Disorder instead and may still need interventions (GPP 1.16)</li> <li>A multidisciplinary approach is recommended for autism diagnosis where possible (GPP 1.18)</li> <li>Information gathered in diagnosis should include observations of the child outside the clinic setting (GPP 1.21)</li> <li>Professionals should be aware of cultural and gender differences when assessing for autism (GPP 1.22 and GPP 1.23)</li> </ul> </div>

<div>The following were recommendations related to etiology:</div> <div> <ul> <li>Healthcare professionals should be aware of the genetic heritability of autism and monitor for features in children with first-degree relatives on the autism spectrum (GPP 2.1)</li> <li>Healthcare professionals should be aware that some genetic conditions or syndromes may be associated with autism and monitor these children for features of autism (GPP 2.2)</li> <li>Children who present with autism and have additional clinical features suggestive of an underlying genetic condition should be referred to a genetic specialist (GPP 2.10)</li> </ul> </div>

<div>The following were recommendations regarding treatment:</div> <div> <ul> <li>Augmentative and Alternative Communication (AAC) may be used to support communication. The AAC system should be customized to the individual (R 3.1)</li> <li>Communication interventions may be used to improve social communication outcomes, receptive and expressive language, and speech prosody outcomes (R 3.3)</li> <li>Developmental interventions may be used to improve difficulties in social communication and social interactions (R 3.4)</li> <li>Early Intensive Behavioral Intervention may be considered to improve skills and cognitive ability. It should be implemented by trained professionals and be based on the child and family's intended goals (R 3.5)</li> <li>Emotion Regulation Therapy may be used via a social pragmatic approach to improve emotion recognition and socio-communication skills (R 3.6)</li> <li>Naturalistic Developmental Behavioral Interventions may be used to improve social communication, language, cognitive, and play skills (R 3.7)</li> <li>Play-based intervention may be used to improve language, joint attention and social engagement skills (R 3.8)</li> <li>Social skills intervention is recommended to improve social communication and interaction skills. The social skills intervention should be customized to the individual's needs, preferences and environment (R 3.12)</li> <li>Visual supports should be used (R 3.13)</li> </ul> </div>

<div>The following were recommendations regarding education and interprofessional practice:</div> <div> <ul> <li>Educators should be provided with knowledge and skills to provide reasonable accommodations and supports for students on the autism spectrum in their classrooms (GPP 5.8)</li> <li>School-based educational provisions offered to students should be determined by educational professionals, in consultation with parents, schools, and allied health professionals as needed (GPP 5.10)</li> <li>Educational support for students on the autism spectrum with moderate-to-high support needs in specialized schools should involve a multi-disciplinary team (GPP 5.12)</li> </ul> </div>

<div>The following were recommendations regarding co-occurring conditions and autism:</div> <div> <ul> <li>Professionals should be aware of the higher incidence of attention-deficit hyperactivity disorder in children and adolescents on the autism spectrum. In the presence of symptoms of ADHD, screening and referral for a thorough diagnostic evaluation should be made (R 7.4)</li> <li>Professionals should be aware of the need to assess for language and other developmental disorders. Caregivers would benefit from counselling regarding these conditions and their potential impact (R 7.6)</li> <li>Professionals should be aware of an increased prevalence of feeding disorders among children and adolescents on the autism spectrum. These may be related to factors including feeding dysfunction, sensory sensitivity, behavioral issues, and cognitive difficulties (R 7.11)</li> <li>A complete audiological assessment is recommended so as not to delay the diagnosis and management as needed in the event that hearing loss and autism co-exist (R 7.16)</li> </ul> </div>

<div>The following were recommendations regarding follow-up:</div> <div> <ul> <li>Transition planning should be encouraged for predictable major transitions. Such planning should be proactive and person-centric. The need for early transition planning for adolescents ahead of their graduation is important (GPP 8.3)</li> </ul> </div>

<div>The following were recommendations regarding caregiver support:</div> <div> <ul> <li>Professionals should provide caregivers with information tailored to the child's developmental age and needs and also support them in accessing appropriate services (GPP 9.2)</li> <li>Professionals should adopt a collaborative and family-centered approach in supporting caregivers (GPP 9.3)</li> <li>Caregiver education and training programs should be incorporated in intervention when possible (R 9.6)</li> </ul> </div>

<div>The following was recommended regarding professional training:</div> <div> <ul> <li>Access to autism-related information should be provided for staff who interact with children and adolescents on the autism spectrum. The extent and depth of the information should be tailored to the specific professional's needs (GPP 10.1)</li> </ul> </div>

<div>The following were recommendations regarding post-secondary transition:</div> <div> <ul> <li>Professionals should ensure that transition support is planned systematically, is holistic, and person-centric (GPP 5.14)</li> <li>Professionals should provide families information about recommended support groups, organizations, and sources of information (GPP 5.16)</li> <li>During post-secondary transition, students and their caregivers should be provided information about the range of options and employment support (GPP 5.19)</li> </ul> </div>

<div>The following were recommendations regarding education:</div> <div> <ul> <li>In recommending educational intervention and school placement, professionals should consider (i) the developmental needs of children, their preferences, and strengths, (ii) family contexts, and (iii) the range of support services available (GPP 5.3)</li> <li>Professionals should ensure that caregivers are supported to make informed decisions to meet educational needs, each child's preferences, and strengths, as well as family contexts (GPP 5.4)</li> <li>School-based support provisions in mainstream schools should be based on the students' observed needs, not on their diagnoses alone (GPP 5.9)</li> </ul> </div>