Family Health Assessment

898

Child Development Programme in Singapore—Lai Yun Ho

Child Development Programme in Singapore 1988 to 2007
Lai-Yun Ho,1-3MMed (Paed), FAMS, FRCPCH

Abstract
Early childhood intervention programmes can shift the odds toward more favourable outcomes in development, especially for children at risk. However, there is no quick fix in the world for early childhood interventions. Programmes that work are rarely simple, inexpensive, or easy to implement. Each country must decide its own model and strategies and develop its resources based on existing infrastructures. Since its independence to become a sovereign nation in 1965,
Singapore has undergone significant socio-economic changes. The infant and under-5 childhood mortality rates are among the lowest in the world. A number of “new morbidities” have been identified to pose major challenges to child health in the next decades. They are chronic medical illnesses, developmental disabilities, learning problems, injuries and neglect, behavioural disturbances and disorders, sequelae associated with unhealthy life-styles, and social and emotional disorders. The need for a comprehensive child development programme is therefore obvious. The main objectives are identification and treatment of children with developmental and behavioural problems so as to correct developmental dysfunctions, minimise the impact of a child’s disability or of prevailing risk factors, strengthen families, and establish the foundations for subsequent development. A child development programme has evolved in Singapore over the last 20 years. The programme is multi-disciplinary, community-based, family-focused, and childcentric, with partnership and integration between government and voluntary community organisations. Ann Acad Med Singapore 2007;36:898-910
Key words: Children with special needs, Developmental problems, Early childhood intervention

The Basis of a Comprehensive Child Development
Programme
Singapore is a small country without natural resources.
Children are our nation’s most important resource and they are the future of our society. Since its independence in
1965, Singapore has enjoyed economic success and this is due primarily to the fundamental principle that Singapore’s continued prosperity depends largely on its people to maintain its competitiveness. The Singapore family size is small and its population is ageing. As such, great importance must be placed on health and well-being of the next generation. In UNICEF’s report on “The State of the World’s Children
2007”,1 Singapore was ranked first, together with Japan,
Sweden and Switzerland, for the lowest infant mortality rates and under-5 mortality rates in the world in 2005.
Childhood mortality rates in Singapore have fallen to very low levels and are now mainly associated with conditions

that modern medical care cannot affect. These include stillbirths of unknown cause, serious congenital malformations and genetic disorders, extreme low birth weight, serious accidents and cancers. This means that death rates are no longer adequate indices of medical care, particularly the traditional perinatal and infant mortality rates in relation to obstetrics, neonatal and general maternity care. Other population-based indices must be developed to enable proper evaluation of “how we are doing” as a community in the provision of holistic care to mothers and children. Furthermore, relative good health by usual statistical criteria may mist the awareness of subtle and soft issues that interfere with quality of life, especially for children. We must therefore guard against complacency and unawareness, which may deflect services and support away from the special needs of children and families, diffusing services and running into the risk of diluting or diminishing standards.

1

Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
Child Development Unit, KK Women’s and Children’s Hospital, Singapore
3
Child Development Programme, Ministry of Health, Singapore
Address for Correspondence: Dr Ho Lai Yun, Department of Neonatal and Developmental Medicine, Singapore General Hospital, Outram Road,
Singapore 169608.
Email: ho.lai.yun@sgh.com.sg
2

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Child Development Programme in Singapore—Lai Yun Ho

A number of “new morbidities” have been identified to pose major challenges to child health in the next decades.
They are chronic medical illnesses, developmental disabilities, learning problems, injuries and neglect, behavioural disturbances and disorders, sequelae associated with unhealthy life-styles, and social and emotional disorders. These problems are not new and they are interrelated. They are just becoming proportionately more significant and more prevalent in our maturing society.
They emerge and become matters of concern when the more urgent demands of acute medical or economic conditions are met.
The need for child development and intervention/ rehabilitation service in Singapore is therefore obvious.
Furthermore, how a society cares for the disabled reflects the kind of society it is. The objectives of a comprehensive child development programme are early identification and treatment of children with developmental and behavioural problems so as to correct developmental dysfunctions, if possible, minimise the impact of a child’s disability or of prevailing risk factors, strengthen families, and establish the foundations for subsequent development. A disabled child will handicap the entire family. There is only a small window of opportunity and this is in the preschool years of the child. When our resource is limited and finite, the most cost-effective approach is to focus on early intervention rather than on late rehabilitation
Historical Perspective
Child development and rehabilitation services in
Singapore have come a long way, and special education has been in Singapore for more than 50 years.2
In 1987, a Task Force under the then Singapore Council of Social Service conducted a review of the status of programmes and services for children with special needs in
Singapore.3 It was not surprising to find that virtually all the services for the disabled, including special education and rehabilitation, were initiated by voluntary welfare organisations (VWOs). They were also entirely responsible for fund-raising. Therefore, historically, they have their own missions and a strong sense of ownership for their programmes and services. However, there were marked variations in the approach and the structure of their programmes with no common standards and poor coordination in service delivery. As a result, there were uneven distribution of caseloads and demands of services among the VWOs. The age group they served and the length of their programmes were variable and not comprehensive. Services were also limited and mainly rehabilitative rather than interventional, focusing on children with severe disabilities such as mental retardation, cerebral palsy and autism. Furthermore, no proper follow-up services were available after completion of the early rehabilitation

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and long-term outcomes were completely unknown.
In many developed countries, developmental-behavioural paediatrics is already an established medical discipline. In
Singapore, teaching and training of child development and developmental disabilities in our paediatric undergraduate and postgraduate training programmes remained fragmentary and received minimal emphasis. There was also hardly any serious research work in this field.
The Childhood Developmental Screening Programme was started in the Maternal and Child Health Clinics in
Singapore in the mid-1980s. The Denver Developmental
Screening Test (DDST), Singapore was then developed for the Singapore children. However, there is little point in having a community-wide system for early detection of infants and children suspected of having developmental and behavioural problems unless there are concomitant resources available for the comprehensive assessment of these young children, followed by appropriate management and care.
The turning point for a better-coordinated partnership to enhance the quality of programmes and services for the special needs population in Singapore was the report by the
Advisory Council on the Disabled in 1988.4 Several recommendations with significant impact on the improvement of child development and rehabilitation services in Singapore were made. The government became an equal partner with the National Council of Social
Service for the funding and management of special education. School buildings were leased out and land was set aside for the construction of purpose-built special schools. Financial support of up to a maximum of twice the cost of educating a primary school child was granted to a special child, matched by a similar contribution from the
Community Chest of Singapore. The Advisory Council also recommended the setting up of a programme for the early identification and management of children with developmental problems.
The Development Assessment Clinic (DAC) was set up at Singapore General Hospital in 1991 as a pilot project with a block vote grant of 1.9 millions. In 1995, the
Ministry of Health (MOH) approved the DAC as an established programme in public health service. The DAC was relocated to the old Kandang Kerbau Hospital in 1996.
With the opening of KK Women’s and Children’s Hospital
(KKH) in 1997, the DAC was renamed Child Development
Unit (CDU).
However, continued funding of the child development programme remained an unresolved issue. In 2002, the
MOH decided to fund the programme under the Health
Service Development Programmes (HSDP) for 5 years.
Two CDUs were then established at KKH and National
University Hospital (NUH). While the diagnostic services

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are hospital-based on initial referral, the intervention services would be community-based – one sited at the SingHealth
Polyclinic at Health Promotion Board, under KKH; and the other at Jurong Polyclinic under NUH.
Principles of Child Development Programme
From the outset, the Child Development Programme has been committed to evolve and develop along certain basic principles. It should build on existing structures and strive to be sustainable. It should adopt a multi-disciplinary and team-based approach and encourage partnerships with professional bodies, consumer groups, schools, charities and VWOs, parent groups and associations. The MOH
CDP would establish links and integrate its services with the social and community support programmes under the
Ministry of Community Development, Youth and Sports
(MCYS) and the National Council of Social Service
(NCSS), as well as with the education programmes under the Ministry of Education (MOE). The services of CDP should be family-oriented or family-focused, and deliver in community-based settings. Its programmes must be evidence-based or follow the best practice guidelines, have a quality framework and can be evaluated. Hopefully, the programmes are flexible and replicable.
Components of a Comprehensive Child Development
Programme
There are 5 main components in the referral process and management of a comprehensive child development programme, i.e.: locating children at risk, developmental screening, comprehensive developmental assessment, individual intervention programmes and continuing and follow-up evaluation.
Locating Children at risk
a. “At-risk” registers are established at the time of birth or soon after birth. Examples of high-risk infants are the preterm infants, children born with asphyxia and congenital abnormalities. Some children are at risk because of the family’s social background. e.g., teenage mother, single mother, substance abuse, poverty, etc.
These are catered for by the Healthy Start Programme, linking at-risk families to community support services such as the Family Service Centres.
The concept of “at risk” registers is to ensure the close monitoring and assessment of those most likely to be developmentally delayed. The limitations of such registers must be acknowledged. Many developmentally delayed children do not have any identifiable aetiological or risk factors, and many children who have suffered clear identifiable insults, and are very much at risk, develop quite normally. Furthermore, the inclusion of all possible risk factors necessitates large numbers of

children being placed on the “at risk” registers, making the concept logistically difficult and practically impossible most of the time. The clear advantages of early diagnosis must be counterbalanced by the dangers of inappropriate labelling. Nevertheless, the “at risk” registers maintained by the neonatal departments in the public sector serve to ensure that the high-risk populations, such as the very-low-birth-weight infants or those who have experienced perinatal stress, can be closely monitored.
b. Getting children to attend playgroups, nurseries and other preschools by 2 years of age will provide early opportunities of exposure to learning, together with relevant challenges to developmental skills and social interactions. VWOs, religious and ethnic community groups, together with Community Development Councils, have programmes to pro-actively seek out families with children in the preschool age not attending any preschool setup between 2 and 3 years old. They will provide social and financial support to get these children to preschools. Developmental Screening
Developmental screening is aimed at providing presymptomatic detection of disability by examining apparently healthy children serially to determine whether they are developing normally. Community health workers, particularly maternal and child health nurses and family physicians, are uniquely placed to detect developmental problems at an early stage.
In Singapore, the DDST Singapore has been adopted as a validated formal screening procedure.5 Potential problems of screening programmes include variable knowledge and skills, as well as attitude, among those healthcare workers doing the screening.6 Another challenge is that children and families with the highest level of possibility of developmental problems are sometimes the least likely to avail themselves to the services.
To improve our system of child search and locating children at risk, the CDU has been involved in the review and design of developmental surveillance checklists and questionnaires based on the validated items in the DDST
(Singapore). These have been included in the revised standardised Health Record Books for children, available to all children born in Singapore. Parents will play the central role in monitoring a child’s health and development.
This method of developmental surveillance has been extended to involve preschool teachers who will be the caretakers of children once they are in the playgroups, nurseries or kindergartens.
Screening can only indicate that a child may have a

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Child Development Programme in Singapore—Lai Yun Ho

problem that should be further investigated. It cannot describe definitively the nature and extent of a dysfunction or disability. Screening should not be used to label children as being delayed, nor can it be used to develop intervention strategies. Screening must be followed by comprehensive assessment to confirm or dismiss the suspicions raised by the screening procedure.
Comprehensive Developmental Assessment
The purpose of a comprehensive developmental assessment is to accurately determine a child’s developmental status in a number of domains. It will include a search for the cause(s) of the delay, although most of the developmental problems remain uncertain or idiopathic in aetiology even after the best possible search.
A complete assessment is a complex procedure. It is often time consuming and is expensive. Therefore, it should be carefully planned. A multi-disciplinary team coordinated by a trained paediatrician as case manager is required to obtain a thorough understanding of the child’s abilities – his weaknesses and strengths. The number and type of professionals that are involved may vary, but a “core” team is usually involved in every assessment, the features of the delay in a child will suggest which specialty groups need to be involved.
Individualised Care Plan and Follow-up
The diagnosis and confirmation of a child’s developmental and behavioural problems should be followed by the process of planning for intervention and rehabilitation strategies, which should be individualised and specifically tailored to the child. Any eventual intervention plan must involve the parents as a focal point, so their participation in the entire process is of paramount importance. Subsequently, a followup evaluation system should be in place to monitor the progress of the child and the family and to provide continuing care and support.
Current Role of the Child Development Unit
The CDU functions as the national referral centre for the assessment and management of infants and children with developmental and behavioural problems. It is uniquely positioned to serve children in their preschool years, and it complements the existing nationwide childhood developmental screening programme. Before the establishment of DAC/CDU, the care for this group of children with special needs, aged 0 to 6 years, had been inconsistent and poorly coordinated. By the time these children reached primary schools, their developmental problems and disabilities would have gone undetected or been ignored for too long, and any late rehabilitative attempts would be very difficult or futile. They would also develop secondary disabilities related to relationship

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problems with peers, school failure, loss of self-esteem, and family dysfunction, with devastating consequences.
Figure 1 depicts the detection and screening processes and the sources of referral to the CDUs.
Currently, the CDUs at KKH and NUH receive between
1200 and 1400 new referrals per year. The figure is very close to the projected estimation that about 3% of the annual births (about 40,000 annual births in Singapore in the last few years) will require the care of the early child development service. It is important to note that this represents the pattern of developmental problems amongst the preschoolers. It does not represent disability at this stage. Disability will only follow if these early childhood developmental problems are not being looked into or are totally ignored, allowing the dysfunctions to perpetuate and deteriorate with development of secondary consequences. The estimate may, however, represent only the tip of the iceberg.
The number of follow-up medical consultations is between 4000 and 5000 per year. About 90% to 95% of these children are in their preschool ages and their first referral to the CDU is usually between 2 and 3 years of age.
About 85% to 90% of the referrals are from the primary healthcare services, i.e., polyclinics and family physicians.
Other referrals are from the paediatric services in the public and private sectors. In addition, the CDU also provides consultation and assessment service for children from the region.
We would like the teachers in the childcare centres and the preschools to be equipped with skills in the early identification of children with developmental problems under their supervision and be knowledgeable in the process of referral. In this respect, the availability of the revised
Health Books will be of great help in providing them with the user-friendly method in the early detection process.
However, we strongly encourage parental participation and encourage them to seek help as early as possible.

Fig. 1. Developmental screening and assessment.

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Child Development Programme in Singapore—Lai Yun Ho

The multi-disciplinary assessment at CDU will arbitrarily channel the children into 4 categories of management strategies, based on our available resources. The 4 categories are used for local funding purposes and are not internationally accepted classification.
A. Children with Low-prevalence High-severity
Developmental Problems
These are children with mental retardation, global developmental delay, severe cerebral palsy, classical autism, and multiple handicaps. They require early placement in special schools where they receive appropriate special training and education. The role of CDU is mainly assessment, diagnosis, followed by family counselling and management planning. There will be minimal commitments in intervention and therapy for these children at the level of
CDU, except for some parental guidance sessions before they are enrolled into the appropriate schools. The medical staff will continue to provide medical treatment to these children if they subsequently present with developmentallyrelated medical problems, such as self-injurious behaviour and hyperactivity.
The initial projected number of children in this category was about 20%, and it was also reflected in our earlier experience with the DAC. As we gain experience and confidence, together with concurrent improvement in social, community and educational supports through our collaborative and advocacy efforts with MCYS, NCSS and
MOE and with the families, the number of children in this category has declined to between 10% and 12% among the annual new referrals. This has been most encouraging as it has wide implications on the needs to build more special schools for these children if the proportion remains high or increasing. This is clearly the most significant benefit of the early childhood intervention programme under the CDU.
B. Children with High-prevalence Moderate-severity
Developmental Conditions, Fair Prognosis with Early
Intervention and Therapy
These are children with severe attention deficit hyperactivity disorder, high-functioning autistic spectrum disorder, severe learning disability, and other moderately severe motor, sensory and behavioural problems
C. Children with High-prevalence Low-severity
Developmental Conditions, Good Prognosis with Early
Intervention and Therapy
These are children with inattention, mild learning disability, speech and language delay, problems in special senses (hearing and visual problems), mild cerebral palsy with intact intelligence, and other mild behavioural problems. Children in B) and C) have intellectual capabilities

within the normal range but are limited by their individual developmental and behavioural disabilities. They should never be sent to special schools in the first place. The challenge is early identification of these developmental differences so that they can be successfully integrated into regular preschool education with their peers, through appropriate intensive intervention and therapy. They should be well prepared to proceed to mainstream education. The combined efforts of the child development and rehabilitation service, the schools, and the families are crucial in ensuring the success of the treatment programmes for these children.
Children in categories B (approximately 40%) and C
(approximately 30% to 35%) constitute between 70% and
75% of the annual referrals.
D. Children with Developmental Delay and Behavioural
Problems with no Apparent Biological Basis, Excellent
Prognosis with Early Intervention (10% to 15%)
These are children with definite developmental and behavioural problems and they are entirely environmental in nature (nurture). Their problems are reversible when detected at early age, but the children will remain at-risk if the adverse environmental factors are not corrected. The parents should have the primary responsibility for the wellbeing of their children. However, they need guidance and assistance in dealing with a child with developmental problems. Figure 2 illustrates the flow of intervention and management for children with low-prevalence high-severity developmental problems (Category A). The majority will continue to require placement in special schools.
Table 1 shows the different types of low to moderate severity but high prevalence developmental problems diagnosed under categories B, C and D. They made up 85% of the annual cases going through the CDUs. They should not be placed in special schools in the first place. The most appropriate placement is in the integrated, least restrictive and inclusive preschool environment and be provided with therapeutic interventions, educational support as well as

Fig. 2. Low-prevalence high-severity problems.

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Child Development Programme in Singapore—Lai Yun Ho

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Table 1. High-Prevalence Low- and Moderate-Severity Developmental
Problems
High-functioning autism spectrum disorder
Asperger syndrome
Attention deficit hyperactivity disorder
Learning disabilities
Mild cerebral palsy with intact intelligence
Speech and language disorders
Other motor, sensory and behavioural problems
Developmental delay from environmental factors
Fig. 3. Individualised management plan and placement.

social and community support. The care provision is therefore community-based, child-centric and familyfocused, with the services one step closer to the doorstep of the families. This is the most important group of children where early intervention will produce the most optimal outcomes, negating future needs of setting up even more special schools to cater to their needs as they grow up. This is in fact the main objective of the establishment of CDU and the child development programme (Fig. 3).
Networking of Child Development and Rehabilitation
Service
To provide an optimal child development and rehabilitation service, and to benchmark its standards against some of the well-established programmes in the developed countries, the works of CDU will be quite limited without the contributions and participation of related community and education services.
CDU has already established good working relationships with the following services, but we need to further develop and strengthen the bonds between each component:
1. Primary and community health services in both public and private sectors.
2. Schools and organisations providing special training and educational service for children with special needs.
3. Preschools (child care centres, nursery schools, kindergartens) and mainstream primary schools.
4. Community clubs and professional societies to provide outreach education and training for the public and parent groups.
5. Liaison with regional and international child development centres.
6. Collaboration with consumer groups with interest in child development, e.g. Launching of Touch Therapy
(infant massage) to the Singapore public, as well as sponsorship of public education events.
7. A good working relationship with the media is also important in dissemination of news on the CDU activities and child health information to the public.

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Fig. 4. Networking of child development units with related services in the community. Figure 4 summaries the relationships of the essential components of the child development service network.
Pattern of Developmental Problems in Preschoolers
Table 2 shows the pattern of developmental problems in preschoolers seen at the CDUs at KKH and NUH from
2004 to 2006.
Autism spectrum disorder is the leading diagnosis of children seen at CDUs. This is followed by speech and language problems. Therefore, about 50% to 60% of children have problems and difficulties in communications.
The increased identification of children with autism spectrum disorder is attributed to increased awareness of this condition, the widening of its definition under DSM IV
(revised), as well as improved methodology of diagnosis.
The high prevalence of these disorders is also due to the fact that the CDUs cater to children in their preschool age between 0 and 6 years old. This is also the main objective of CDUs – to identify children with developmental problems in their preschool years so that early interventions can be offered in the most cost-beneficial ways.
The prevalence of learning disabilities and attention deficit hyperactivity disorders is below 10% among our preschoolers. The reason for this is that these problems will

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Table 2. Patterns of Developmental Problems in Preschoolers in Singapore (CDU 2004-2006)
Developmental problems

2004

2005

Autistic spectrum disorders

508

(29%)

361

Speech and language delay/disorders

417

(24%)

376

(28%)

485 (29%)

Global developmental delay

289

(17%)

198

(16%)

230 (14%)

Learning problems/disabilities

126

(7%)

131

(10%)

152

(9%)

Behavioural problems

106

(6%)

108

(8%)

136

(8%)

Attention-deficit-hyperactivity disorder

103

(6%)

56

(4%)

72

(5%)

Environment-related delay

74

(4%)

32 (2.5%)

26 (1.6%)

Motor developmental delay

45

(3%)

36 (2.8%)

56

Cerebral palsy

34

(2%)

17 (1.3%)

10 (0.8%)

Syndromic disorders

29 (1.5%)

17 (1.3%)

8 (0.5%)

9 (0.5%)

1 (0.1%)

1 (0.1%)

1740 (100%)

1333 (100%)

1637 (100%)

Impairment of special senses
Total

only surface in the later part of the preschool years or even in the primary school years, when children are systematically challenged with academic tasks and expose the differences in their individual learning styles. As these children progress into their school years, both these conditions will be identified with increased frequency. This is well illustrated in the published statistics by the US Department of Education under the Individuals with Disabilities Education Act
(IDEA), where specific learning disabilities were featured eminently as the leading disability among students aged between 6 and 21 years who required special education services (Table 3).7
The relatively low prevalence in the diagnosis of cerebral palsy, visual and hearing impairments is indicative of the improvement and excellence of perinatal care in Singapore.
Even when children have these conditions, the majority of them can be successfully included and integrated into mainstream schools.
It is also the experience of the CDUs that the number of children under category A has stabilised from the initial projection of 20% to between 10% and 12%. This can only be achieved with the continued establishment and improvement of early intervention infrastructures in the community and would require the close collaboration between the services from the MOH, MCYS and MOE.
In the follow-evaluation of children under the CDU, it has been consistently shown that between 85% and 90% of children demonstrate improvement in their performance and functional skills. This is the assessment from both professionals and parents, and the improvement has been uniform across all the 4 categories.
It is important to emphasise that these encouraging results are not achieved by the CDUs operating in isolation

(27%)

2006
461 (28%)

(4%)

but with the development of many initiatives in education, social and community supports.
Providing Quality Education for All
Education is an important component in the jigsaw puzzle of a comprehensive child development programme.
It is the key enabler in imparting to our children the values, skills and knowledge needed to thrive in a rapidly changing world. With the implementation of the Compulsory

Table 3. Number of Students Ages 6-21 Who Received Special Education
Services Under the Federal Government’s Disability Categories
(2003-2004 School Year)
Developmental problems

No.

%

Specific learning disabilities

2,816,361

47.2

Speech or language impairments

1,118,543

18.8

Mental retardation

570,643

9.6

Emotional disturbance

482,597

8.1

Other health impairments

449,093

7.5

Autism

140,473

2.3

Multiple disabilities

151,225

2.2

Hearing impairments

71,188

1.2

Orthopaedic impairments

67,772

1.1

Developmental delay

65,878

1.1

Visual impairments

25,284

0.4

Traumatic brain injury

22,459

0.4

Deaf-blindness

1,603