Friday 19 October 2012

Silent plea for help

Mentally ill children with autism may not get treated if their symptoms are overlooked as autistic traits
By Joan Chew, The Straits Times, 18 Oct 2012

Two years ago, student Anica Mae Fernandez, then 11, used to go into a frenzy whenever someone went into the toilet and closed the door.

She would scream, knock feverishly on the door and stomp her feet until they bled - infuriating the neighbours so much that they called the police one night, recalled her mother, Mrs Minirose Yusi Fernandez.

At three, Anica was diagnosed with autism spectrum disorder, a range of conditions resulting from the abnormal development of the brain, which affect a person's communication and social interaction skills.

Her autism is severe and she has not developed normal speaking skills.

Some autistic people may develop a routine that serves no practical purpose.

But in Anica's case, she was so obsessed with keeping the doors in her home open that she developed an anxiety disorder.

Her family had not realised she was suffering from it as she was unable to tell anyone about how she felt.

Mrs Fernandez said: "I thought her behaviour was just because she was autistic."

In hindsight, the 42-year-old accountant said Anica's anxiety may have been due to the onset of menstruation.

Anica's parents finally took her to the Institute of Mental Health (IMH) only when she was unable to sleep longer than three hours each night for more than two months, making her irritable in school.

She was diagnosed with anxiety disorder and prescribed medication to calm her nerves.

Her anxiety is now under control with the medication.

A study here has shown that more than seven in 10 autistic people have other mental conditions, just as Anica does.

Unlike autism, these can potentially be cured.

But these may be missed as autistic children do not routinely require follow-up care with doctors once they have been diagnosed with autism and are placed in a suitable school, said Dr Sung Min, a senior consultant at the department of child and adolescent psychiatry at IMH.

The specialists who make the diagnosis, usually paediatricians and psychiatrists, may refer them to other professionals for therapy, including speech, occupational and physical therapy.

These professionals may be able to detect mental conditions that their charges may develop, but not all autistic children see such professionals.

Caregivers may wrongly attribute symptoms of other mental conditions to autism, not realising that the psychiatric disorders are separate conditions.


Studies have shown that the autistic population has a higher prevalence of psychiatric disorders than the general population.

In a study done by Dr Sung and published in the Australian And New Zealand Journal Of Psychiatry in 2010, 72 per cent of children here with high-functioning autism, also known as Asperger's syndrome, had at least one behaviour or emotional problem reported by parents, which was of clinical concern.

The study, which Dr Sung spoke about at the Singapore Health and Biomedical Congress last month, relied on medical records of 71 autistic children aged between six and 18 who were referred to IMH.

The study found that the most common problem was attention deficit hyperactivity disorder (ADHD), which affected 35.2 per cent of the children, followed by anxiety disorder (33.8 per cent) and mood problems such as depression (31 per cent).

In contrast, in a 2007 study published in the Singapore Medical Journal, parents reported that 12.2 per cent of Singaporean children aged six to 12 had conditions that troubled them but did not prod them to act defiantly, such as anxiety and depression. Another 4.9 per cent had problems that made them express their feelings in aggressive or delinquent behaviour.

As IMH typically handles more challenging cases, the figures in her study are probably higher than those in the community, Dr Sung said.

But an overseas study published in the Journal Of The American Academy Of Child And Adolescent Psychiatry in 2008 showed similar prevalence of psychiatric disorders among autistic children in the community.

Of the 112 autistic children aged 10 to 14, 70.8 per cent had at least one psychiatric disorder and 41 per cent had two or more.

The most common disorders were social anxiety disorder (29 per cent), ADHD (28 per cent) and oppositional defiant disorder (28 per cent).

The authors noted that autism severity was not a significant predictor of any of the disorders.

The prevalence of autism in Singapore is not known.

The Ministry of Health's Child Development Programme, which sees most children here with developmental problems at its clinics at KK Women's and Children's Hospital (KKH) and National University Hospital (NUH), diagnosed 683 preschoolers with autism last year. This makes up about one in five new cases of developmental problems.

The number of new autism cases diagnosed has increased at an annual rate of 11 per cent since 2005, said a ministry spokesman.

This is mainly due to increased awareness and an expanded medical definition of autism. Previously, only children with the most severe form of the condition were diagnosed as autistic.


Autism is believed to be linked to genetic problems but its cause is not known.

Studies have not proven if autism directly leads to psychiatric conditions, but they often coexist.

Autism may predispose a person to developing ADHD, which, like autism, may have a biological basis.

Abnormal development in any part of the brain can result in autism.

If the abnormal development occurs in the frontal lobe that governs a person's impulse control, which includes the ability to pay attention, the person can have both autism and ADHD, said Dr Christopher Cheok, head and senior consultant at the psychological medicine department at Khoo Teck Puat Hospital.

Autistic people could possibly be "more vulnerable to developing mental illnesses in view of their core deficits", said Dr Sung.

They have difficulty reading social cues in order to understand what is happening in their environment, so they may have a constant feeling of uncertainty that gives rise to anxiety.

Changes in the environment, such as meeting new people, or an inability to complete routines also breed anxiety.

Their social difficulties and aversion to change also make them more likely to develop oppositional defiance, which is a disorder that causes disobedience toward authority figures.

If they also have difficulty communicating their needs and emotions, they may feel frustrated, which can contribute to the development of mood disorders, Dr Sung said.

She added that people with high-functioning autism are more aware of their social and communication deficiencies and, hence, are more likely to feel depressed.

Dr Cheok said their condition may make autistic children targets for bullying, raising their risk of mental disorders.

For instance, when a high-functioning autistic boy was in Primary 4, his classmates teased him about being in the wrong line during assembly, when in fact he was not.

But for months after that, he lost confidence in getting around school and would stand in the courtyard alone after assembly. His mother told his teachers about his anxiety disorder and they assigned pupils to lead him around.

The boy, now 14, was treated with medication at IMH and has learnt coping strategies to allay his anxiety, such as stroking his own arm and going to a quiet room to calm down.


In the last five years, doctors at IMH's Child Guidance Clinic have been routinely screening their charges for any psychiatric disorders using a checklist of questions on symptoms.

This is so that they can detect any such disorders early and treat them.

Previously, such problems would be addressed only when they were brought up by caregivers, said Dr Sung.

At other hospitals, such as KKH, a diagnosis of psychiatric conditions is based on the patients' history given by the patients if they are high-functioning, and their caregivers, as well as based on doctors' observations.

Dr Janice Wong, a paediatrician at Thomson Paediatric Centre at Thomson Medical Centre, said she refers two in every 10 autistic children she sees to a clinical psychologist to manage their psychiatric conditions.

Ms Alina Chua, a psychologist at the Autism Resource Centre that runs special education school Pathlight School, said staff members of the school look out for changes in students' behaviours which may signal issues with mental health.

They then talk to the students to find out what caused the behavioural changes and teach them steps to manage their emotions. For example, a student with an anger management problem will be taught how to identify the triggers for his aggression and the ways to calm himself down.

Ms Chua said: "We also put staff on alert and work with families to monitor students for a period of time to see how they are coping."

Students who need medical attention will be referred to IMH or other hospitals, she added.

She estimated that one in 10 students at Pathlight School will require intervention beyond the school for conditions such as ADHD.

In recent years, more referrals have been made to the neuro-behavioural clinic at IMH, which sees children between five and 19 years old who have autism or ADHD. The majority of these referrals come from special education schools.

Last year, there were 262 new referrals to the clinic, close to 21/2 times that of the 113 new cases in 2006 when the service first began.

Ultimately, the picking up of mental disorders largely depends on active surveillance by professionals who work with autistic children, said Dr Chong Shang Chee, the head of the child development unit at the department of paediatrics at NUH.

So two IMH teams under the community programme for youth mental health called REACH, or Response, Early Intervention and Assessment in Community Mental Health, have been giving talks to school counsellors and teachers at special education schools to build awareness about psychiatric disorders in autistic children.

This was after the programme was extended from mainstream schools to special education schools in October last year.

The teams also assess the students and refer them to doctors at IMH if necessary, said Ms July Lies, a clinical psychologist with the programme.

The teams have visited seven special education schools and hope to visit the remaining 13 by 2014.

For now, the teams cannot say how many mentally ill autistic children have been picked up from their outreach effort.


Diagnosing and treating mental disorders early improve the chances of recovery for autistic people, just like it would for non-autistic people.

The treatment - typically psychological therapy and medication - is also similar for both groups.

Ms Denise Phua, president of ARC and supervisor on the boards of Pathlight School and Eden School for autistic children and youth, said the factors that contribute to the recovery from mental illnesses do not vary greatly between autistic people and other people.

"These include early detection, access to appropriate interventions and a stable and caring environment," she said.

Psychiatric conditions in autistic people may be harder to treat than those in non-autistic people, as those with autism are less able to verbalise their problems and report on improvements, Dr Cheok said.

But success rates are similar to that for non-autistic people, he added.

Dr Lim Hong Huay, a consultant at the department of child development at KKH, said detecting and treating psychiatric conditions early can improve the functional, educational and vocational outcomes of an autistic individual, averting instances of suicide and crime.

Warning signs

The American Psychiatric Association's Diagnostic and Statistical Manual, which is revised regularly, provides standardised criteria for diagnosis of autism spectrum disorders.

A diagnosis of autism requires impairments in all three symptom areas, but not all symptoms in each area.

High-functioning autism, also called Asperger's disorder, does not involve serious language delay.


1. Marked impairment in the use of multiple non-verbal behaviour, such as eye-to-eye gaze, facial expression, body postures and gestures, that are normally present in social interaction.

2. Failure to develop peer relationships appropriate to developmental level.

3. A lack of spontaneous desire to share enjoyment, interests or achievements with other people.

4. Lack of social and emotional reciprocity.


1. Delay in, or total lack of, the development of spoken language, without an attempt to communicate through other means such as gesture or mime.

2. In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.

3. Stereotyped, idiosyncratic or repetitive uses of language that are not directly relevant to the social context.

4. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.


1. Preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.

2. Apparently inflexible adherence to specific, non-functional routines or rituals.

3. Stereotyped and repetitive motor mannerisms, such as hand or finger flapping or twisting, or complex whole-body movements.

4. Persistent preoccupation with parts of objects.

The number of new autism cases diagnosed has increased at an annual rate of 11% since 2005

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