Autism spectrum disorder, or autism, is the leading specific cause of disease burden in children aged zero to 14 years old in Singapore.1 With increasing worldwide prevalence,2,3 the number of children diagnosed with autism each year at KKH has nearly doubled from about 500 in 2013 to an average of 900 in the 2020s.

The neurodevelopmental condition is characterised by differences in social communication and interaction, together with restricted repetitive behaviours.4 Cognitive abilities may vary from intellectual giftedness to severe intellectual disability.

Caregivers of autistic children experience significant long-term demands, including financial, marital and social strain, parenting and school placement challenges, and concerns for the future of their child. Hence, families of children with autism can benefit from holistic care.

In addition to support in the hospital, educational and early intervention settings, general practitioners (GPs) play a key role in supporting autistic children for their medical and mental health needs, and providing family support and guidance to caregivers from early childhood to adulthood.

KKH has co-led the development of the 2023 Clinical Practice Guidelines on Autism Spectrum Disorder in Children and Adolescents to help general practitioners support autistic children and their families to make appropriate choices based on current scientific evidence, and provide localised resources.

The guidelines were developed by a workgroup co-led by child development specialists from KKH and National University Hospital (NUH) and published by the Academy of Medicine, Singapore.


Three ways GPs can support autistic children and their families

  • Look out for medical conditions which may present differently

GPs can actively screen for medical issues that commonly affect autistic children, which include gastrointestinal disorders, sleep disorders, dental conditions and growth and nutrition problems such as obesity.5 While these conditions mostly present and are treated in the same way as non-autistic children, some different clinical presentations in autistic children include:

  • Constipation, disrupted sleep, or dental issues may present with unexplained, persistent or sudden-onset atypical behavioural symptoms such as agitation, head-banging, or increased stimulatory behaviours.
  • A higher likelihood of being a very picky eater, contributing to constipation or growth and nutrition concerns.
  • Tendency to experience more sleep disruption, necessitating good sleep hygiene measures or psychosocial interventions before any consideration of sleep supplements.6

  • Screen for co-occurring mental health conditions

Children on the autism spectrum are more likely to have co-occurring mental health conditions such as attention deficit/hyperactivity disorder (ADHD), anxiety, depression, obsessive compulsive disorder, bipolar disorders, and gender dysphoria.7

GPs are encouraged to screen for these concerns and make a timely referral to specialist mental health services as necessary. A comprehensive list of recommendations for mental health and other co-occurring conditions is available in Chapter 7 of the 2023 Clinical Practice Guidelines on Autism Spectrum Disorder in Children and Adolescents.

  • Advise on the use of complementary and alternative treatment or medicine

The use of complementary and alternative treatment or medicine (CAM) is common in autistic children or adolescents, despite limited evidence of benefits for the majority of CAM. Injudicious CAM use can be harmful.

GPs can greatly aid in the management of CAM use, particularly in counselling caregivers on potential harm that may result. Should caregivers have a strong preference to use a specific CAM, shared decision-making between doctors and caregivers is highly encouraged, such that any treatment trials are time-based with clear objectives and outcome measures.

GPs should also advise caregivers that CAM treatments should not replace mainstream interventions. A comprehensive list of CAM and their current recommendations are available in Chapter 6 of the 2023 Clinical Practice Guidelines on Autism Spectrum Disorder in Children and Adolescents.


Holistic help for a life-long journey

Children on the autism spectrum have intervention, education, medical and mental health needs that change with time and may span across their lifetime. GPs can play a vital role in supporting autistic children and their families in the community through their life stages, and helping them to make evidence-based, appropriate choices for their holistic well-being.


​Resources for families


​Acknowledgements

The 2023 Clinical Practice Guidelines on Autism Spectrum Disorder in Children and Adolescents was developed by a 22-member workgroup that comprised experienced professionals across the healthcare, education and community services sector within Singapore. The workgroup was led by Dr Mae Wong, Department of Child Development, KKH and Dr Aishworiya Ramkumar, Child Development Unit, NUH. The guidelines have also been reviewed by established experts in the field and underwent a public consultation feedback exercise. Of note, caregivers of children on the autism spectrum were also involved.


​
 ​Dr Mae Wong, Senior Consultant, Department of Child Development, KKH

Dr Mae Wong is accredited as a Specialist in Paediatric Medicine and Neonatology by the General Medical Council, United Kingdom, and is a Fellow of the Academy of Medicine, Singapore, and the Royal College of Paediatrics and Child Health, UK. She also holds a PhD in Medicine.

Dr Wong’s key interests include Autism Spectrum Disorder and the effect of screen time and sleep on children with developmental disorders. She leads the autism track services at KKH and has completed various research projects on autism. She is a member of the International Society for Autism Research (INSAR), Australasian Society for Autism Research (ASFAR), and the Singapore Paediatric Society. She also serves on the SingHealth research ethics Centralised Institutional Review Board.


​References
  1. Epidemiology & Disease Control Division, Ministry of Health, Singapore, Singapore Burden of Disease Study 2010, Singapore, 2014
  2. World Health Organisation. (2022). Autism [Fact Sheet]. https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders
  3. Maenner MJ, Warren Z, Williams AR, et al. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020. MMWR Surveill Summ 2023;72(No. SS-2):1–14. DOI: http://dx.doi.org/10.15585/mmwr.ss7202a1
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. (DSM-5-TR). 5th ed. American Psychiatric Association Publishing; 2022. Retrieved from https://doi.org/10.1176/appi.books.9780890425787
  5. Buie T, Campbell DB, Fuchs GJ 3rd, Furuta GT, Levy J, Vandewater J, et al. Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics. 2010;125 Suppl:S1--18. https://doi.org/10.1542/peds.2009-1878C
  6. Rossignol DA, Frye RE. Melatonin in autism spectrum disorders: a systematic review and meta-analysis. Dev Med Child Neurol. 2011;53(9):783-792. https://doi.org/10.1111/j.1469-8749.2011.03980.x
  7. Lai MC, Kassee C, Besney R, Bonato S, Hull L, Mandy W, et al. Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. Lancet Psychiatry. 2019;6(10):819-829. https://doi.org/10.1016/S2215-0366(19)30289-5