Singapore, 23 April 2024 – Siti Nabilah, a 32-year-old mother to three children, was disheartened when her first child was diagnosed with Autism Spectrum Disorder. She grappled with denial and struggled to accept his diagnosis. On hearing that her second son also had Autism Spectrum Disorder, she started experiencing suicidal thoughts.

However, after enrolling in DayOne – a pilot programme at KK Women’s and Children’s Hospital (KKH) – Siti received mental health support from a medical social worker and care coordinator, in the form of consistent check-ins, home visits, access to printed resources, as well as psychiatric support and medication. Siti’s mental well-being has since improved tremendously, and she now carries a more positive outlook on life.

Siti is one of the parents of young children with development needs who benefited from DayOne, a mental health programme piloted at KKH’s Department of Child Development (DCD) from May 2022 to April 2024.

In the $3.6m pilot jointly funded by KKH and Lien Foundation, mental health screening and support was provided as a standard care protocol to parents who brought their children to KKH to be assessed and supported for developmental needs. Outside of the pilot, mental health screening and support is not always provided for parents as the focus at DCD clinic appointments is the child. Mental health conditions in parents may only be identified if they become obvious to the doctor who may then refer these parents to the DCD social worker for further support. However, this process may not comprehensively identify the parents who require assistance, as mental health conditions are often hidden, especially at a time when parents are coming to terms with news of the diagnosis.

“When a child is diagnosed, parents’ focus is on helping the child,” said Associate Professor Lourdes Mary Daniel, Head and Senior Consultant, Department of Child Development, KKH, and Programme Director, DayOne. “But sometimes, what happens is that it takes place to the extent of neglecting their own well-being. To care for their child, parents must also care for themselves.”

About 7,000 children are diagnosed with developmental needs in Singapore every year. Most of them – about 70% – are attended to at KKH’s DCD.

“As paediatricians, our focus is the child. But in our clinics, we often see parents struggling. At the back of our minds, we always wondered if there was a way for paediatricians to do more for parents,” said Associate Professor Mary Daniel.

In Oct 2023, the National Mental Health and Well-Being Strategy was launched by the Inter-agency Taskforce on Mental Health and Well-Being.

“In it, parents are mentioned prominently, but as part of the support system to strengthen the mental health of children. We believe that for a subset of parents, namely parents of children with developmental needs, they are actually the ones who need help,” said Mr Ng Tze Yong, Programme Director, Lien Foundation.

During the 9-month recruitment period, 1,157 parents, including 801 who were primary caregivers and 356 who were secondary caregivers, were engaged by the programme’s Care Coordinators.

The Care Coordinators’ role was aimed at supporting parents in navigating and overcoming commonly perceived structural and psychological barriers to seeking help and receiving timely treatment. Of the 1,157 parents approached, a total of 626 parents — 439 who were primary caregivers and 187 who were secondary caregivers — consented and completed screening.

The 439 parents were categorised into three tiers based on their mental health and/or psychosocial needs, and corresponding support services from each tier were provided to the respective parents who consented.

Key findings obtained from the screening of parents

At the end of the pilot, results showed 34.6% had nil to minimal needs, 40.6% had mild needs, and 24.8% had moderate to severe needs. In other words, 65% of parents suffer from mental health and/or psychosocial needs of a level requiring formal support services

*The number of sessions indicated is the average. It varies based on need. Sessions are conducted in-person at the clinic, at home, or remotely. Each tier also benefited from the support services offered by the tiers below it. For instance, tier 3 also received the support services provided to tiers 1 and 2.

The percentage of parents who agreed to accept support for their mental health and psychosocial well-being by enrolling in the programme was encouragingly high. 60-70% of parents accepted referrals to support services, be it by a medical social worker, psychologist or psychiatrist. Notably, 66.7% of parents accepted referrals to psychiatrists, a service that arguably grapples most with mental health stigma.

As a broad comparison, the second Singapore Mental Health Study in 2016, which surveyed over 6,000 participants from the general population, found that only 21.4% of persons with a mental disorder sought any professional help, resulting in a treatment gap of 78.6%.

Table 2: Acceptance rate of primary caregivers who were referred to services

“Initially, many parents were hesitant, but emphasising the benefits for both family and child was crucial in persuading them to seek help for their mental well-being," said Ms Majella Irudayam, Master Medical Social Worker, Department of Child Development, KKH and Co-lead, DayOne.

Importantly, 84.3% of parents remained engaged in the programme after the first session with the mental health professionals and did not drop out.

The support succeeded in reducing the mental health symptoms of parents. While data collection and analysis are still ongoing, preliminary pre-post results indicate that primary caregivers with moderate to severe mental health needs reported lower levels of anxiety and depression symptoms after the program. Within the ten-month programme period following the initial screening, the percentage of parents reporting moderate to severe levels of anxiety and/or depression symptoms dropped from 21.3% to 10.6%.

Pre-post scores for Primary Caregivers with Moderate to Severe Needs for Anxiety and Depression Symptoms

In DayOne, all support services were provided at no cost. This was done so that the study could deepen understanding of the commonly-cited taboo that mental health is associated with. Although affordability is known to be a common decision factor, it is not always cited explicitly as a reason when declining mental health services. This leads to insufficient clarity over the extent of a patient’s actual acceptance of a mental health condition as well as the perceived effectiveness of services. In DayOne, the removal of cost from the equation allowed the team to understand more clearly that parents were generally receptive to accepting their mental health conditions and receiving help. This can be gleamed from the high acceptance and engagement rates mentioned in the preceding sections.

“When paediatricians speak, parents listen. Their words carry a long-lasting influence because they are positioned so well at the start of parenthood. The paediatrician’s clinic is an important space we can leverage more to strengthen the national healthcare and social support ecosystem,” said Mr Ng.

Besides screening and support services, other innovative components of the DayOne programme included:

• Parent-Child model: In DayOne, the systems and processes are designed to shift the focus of care from the individual child to the parent-child as a pair. This included expanding paediatric developmental clinic visits to embed screening and support for parents. Direct work with parents at DayOne focuses on their emotional needs to enhance their capacity to connect with and support their children. This approach acknowledges the mutual influence of the child and parent's well-being and emphasises the potential for the parent-child relationship to promote well-being in both parties.
  
  "Engaging parents and supporting their well-being builds parental capacity to provide nurturing care, thereby optimising health and well-being outcomes for the child and family." said Dr Shilpee Raturi, Department of Child Development, KKH, and Co-lead, DayOne.
  
  
• Direct referral to Psychiatrist
  
  DayOne referred parents directly to psychiatrists for those who were assessed to need the service and consented to it. This process reduced the wait time and touchpoints for parents who may require the services.
  
  
• Pre-appointment engagement: As KKH sees the majority of all children diagnosed with developmental needs in Singapore, the wait times may vary. For some families, this waiting period can be a highly stressful time. To address this, DayOne reached out to parents via teleconsults even before their child’s first visit to the DCD clinic. Their stress levels would be assessed via a questionnaire and families assessed to be highly stressed would have their appointments fast-tracked, and support for parents who required urgent help expedited.

Providing support for secondary caregivers

Recognising the crucial role of both parents during the caregiving journey, the DayOne team reached out to secondary caregivers, in addition to primary caregivers. 187 secondary caregivers consented to be screened, most of whom comprised fathers (169 of 187 secondary caregivers, equating 90.4%).

32 (19%) had mild to severe mental health needs. Among them, 11 (6.5%) were found to have more severe mental health needs and referred for professional mental health support.

This indicates the significance of engaging both fathers and mothers, which aligns with DayOne’s commitment to support both parents irrespective of gender. This approach was informed by research findings highlighting the importance of a gender-differentiated approach to supporting parents in caring for children with developmental needs. Recent societal shifts towards more active father involvement and co-parenting indicate an urgent need to further understand the father’s role in child development and how to enhance healthy father-child interactions while supporting the well-being of both parents. “There is limited awareness of the experiences, challenges as well as mental and emotional health concerns of fathers of children with developmental needs. With adequate recognition and provision of necessary support, resources and connections, fathers can build their resilience and be enabled for self-care and care of their child” said Dr Pratibha Agarwal, Senior Consultant and Head of Clinical Services, Department of Child Development, KKH.

Assoc. Prof Mary Daniel said: “DayOne is aligned with the life-course approach to address healthcare at critical life phases of both the parent and child. This is in keeping with the SingHealth Duke-NUS Maternal and Child Health Research Institute’s mission to support the growth and development of every woman and child to their fullest potential to optimise Singapore’s human capital.”

Future plans

The findings from DayOne will be further analysed and shared with the local and global healthcare community to explore the feasibility of a sustainable model within the community.
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¹ Secondary caregivers were only assessed for mental health needs and not socio-emotional needs.

Resources

Should you need to speak with someone, you may contact the following resources available:

• ComCare Helpline: 1800-222-0000 (24 hours)
• CareText: Whatsapp 9151 1767 (24 hours)
  
• Samaritans of Singapore (SOS): 1767 (24 hours)

To learn more about the DayOne programme, view this video on the experiences of 2 parents who faced mental health challenges - Siti (whose story is mentioned above), and Jason (founder of “Beng Who Cooks” and a recipient of the President’s Volunteerism and Philanthropy Awards 2020):

• Main episode
• TikTok adaptation