Autism: What have we learnt so far?

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Autism is a neurodevelopmental disorder in which individuals have difficulties with social interactions and communication and a reliance for routines and/or repetitive behaviours (Read this NIH fact sheet for more information). Individuals with autism also tend to display sensory seeking behaviour and according to more recent scientific endeavours, experience high rates of gastrointestinal issues.

It’s a disorder which receives much attention in both the press and in research. But research findings, despite advancing at the pace of greyhounds chasing a bunny on the race track, don’t always accompany news stories. The public’s understanding and awareness of this disorder is still work-in-progress, even though local resources for autism has vastly improved.

Research links the use of joint attention — the ability to use gaze and gestures to share attention — to autism, but a recent study points to a more accurate red flag for autism — a social smile during joint attention. This 2014 study observes that infants at 8 months tend to look at an object of interest and then smile at the person they are interacting with, before looking back at the object of interest, during joint attention. In contrast, infants at risk for autism tend not to direct the social smile at the other person in between looking at object and at the other person.

Other research has established that individuals with autism find faces aversive, and as a result have difficulties recognising the emotions of others (more about their difficulties with empathy here). In fact, a hot-off-the-press study finds that individuals with autism focus on areas of contrast and colour of real photographs and the centre of the image, whereas those who don’t have autism look almost exclusively at faces in the same photographs. And this tendency emerges at a young age: a 2014 study observes infants at 6 months to fixate on faces when someone is speaking. In contrast, infants diagnosed with autism later look away from the eyes and mouth when someone is speaking.

Recent research has also identified two other markers useful for screening autism among children aged 9 to 12 months. A 2014 study finds that babies with a head circumference that is at or higher than the 75th percentile at 9 months and infants who fail the tonic neck reflex (also known as the head tilt reflex) are at a higher risk for autism.

With slightly older children, nonverbal screening tools may be useful. A 2015 study proposes a novel way of screening for autism: It turns out that individuals with autism don’t reduce their sniffing of unpleasant smells (and conversely increase their sniffing of pleasant ones). In contrast, their peers who don’t have autism “stop” a wiffy smell in about 305 ms. Another 2015 study finds a higher proportion of children who are subsequently diagnosed with autism among families where parents voiced concerns about their child’s sensory and motor abilities from the age of 6 months, and their child’s language and social communication abilities from the age of 12 to 15 months. So although autism cannot be diagnosed till 2 years of age, there are clear indications and red flags which are proving to be effective for screening autism at a much younger age.

Screening for autism aside, there are still no clear answers to what contributes to autism. Recent research does however indicate differences in brain structure between individuals with autism and peers who don’t have autism. Apart from differences which have been observed in the brain structures which connect the two brain hemispheres to each other, a 2014 study observes a lack of neural pruning — the process by which neural connections which we don’t use are eliminated — among children with autism (for a more in-depth discussion, read this article). Genetic factors are acknowledged to contribute to autism, but environmental factors are also considered to play an important role. Increasing evidence that the composition of gut bacteria differs in individuals with autism from that of their peers who don’t have autism, has led some to suggest that gut bacteria to be a possible contributing factor to autism. While a 2015 study definitively excludes MMR vaccines as a contributing factor to autism (read more about the study here), another 2015 study speculates that other chemicals, such as solvents and pesticides, to which expectant mothers may have exposure, can adversely affect foetal development.

Despite the mixed findings about the cause of autism, more recent research does offer some promising news about effective interventions and strategies found to be useful for helping children and adolescents with autism. Just as children who don’t have autism can be trained to enhance their ability to identify emotional expressions and young preschoolers with autism can be taught social skills, recent research demonstrates that early intervention programmes play an important role in helping children with autism improve their social skills, as well as cognitive and language abilities.

One 2012 study has reported that an intensive programme comprising 20-hours-a-week one-to-one training with interpersonal exchanges over a period of 2 years, yields improved brain responses to faces among infants with autism aged 12 to 30 months. Use of this therapeutic intervention by parents has been shown to be effective on even young infants with autism. In this 2014 study, at-risk 6-month-olds, who showed signs of autism at the start of intervention (e.g., a lack of interest in social interactions and communication), had better cognitive and language skills 12 to 30 months later. In a follow-up study of these infants, further improvements were observed after 2 years of intervention. Infants’ cognitive, communication, and adaptive skills (skills for everyday living) were observed to undergo greater improvement compared to peers with autism who attended a preschool programme and who were given speech therapy.

Other groups of researchers have also shown that parent training is also an effective way to improve the quality of social interactions between parents and infants with autism. A 2014 study has shown that teaching parents to support their children’s learning during everyday activities results in better language and social communication among toddlers with autism. In another recent study, one-year-olds with autism whose parents received coaching on how to attract their infant’s attention and interest their infant in social interaction games produced better outcomes than peers receiving community-based early intervention and monitoring. A separate 2015 study has also shown that the benefits of parent training over a period of 24 weeks to include a reduction in disruptive and aggressive behaviours among children with autism aged 3 to 7 years (Supernanny also some useful tips…). It’s evident that there are various effective therapeutic options available to families of children with autism.

Interventions which reduce the severity of children’s autistic behaviours are important. But support for families are as, if not more, important. This is particularly true for caregivers and parents of children with autism, who experience a high level of caregiving stress on a daily basis and can be at risk for caregiver burn out. Journal writing has been found to help mothers manage their stress levels, while mothers are less likely to experience depression if their partners share the burden of caregiving. But it’s often easier said than done. Respite care — which provides parents and caregivers with time off to take of themselves — can play an important role for helping parents and caregivers manage their stress. And more public awareness won’t do anybody any harm either.

World Autism Awareness Day is a few months away but there’s no time like the present to support a greater public awareness of autism.

What’s the difference between mental health and mental illness?

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There are many local news stories which implicate mental health issues. But rarely an explanation about the mental health issue involved.

We use the term “mental illness” to refer to medical conditions including schizophrenia, depression, and bipolar disorder. Other times, we use the term “mental health” to refer to the same things.

But there are conceptual differences. WHO defines mental health as “a state of complete physical, mental and social well-being, and not merely the absence of disease“. That means that mental health is also about our immune system, physical health indices, life satisfaction, and psychological wellbeing, as well as our capacity to regulate mood and manage emotions, ability to manage daily stress, resilience, and coping mechanisms for dealing with stressful events.

The collaboration between mental health professionals and the police service (e.g., a UK pilot scheme) is a step in the right direction. Education is of course a reliable way to address mental health awareness issues at the workplace.

But what information is available about mental health in Singapore? A speedy search on google for local information about individual mental health issues and concerns yields at least one relevant website. Here’s a cheat sheet:

1. Stress
HPB lists the impact of stress on our physical and mental health: SAMH has useful tips for managing stress levels.

2. Depression
HPB lists symptoms to look out for: Insights into myths and misconceptions here.

3. Eating disorders
AWARE offers an FAQ on eating disorders here.

4. Anxiety
HPB offers an overview of anxiety, including symptoms and treatment options.

5. Obsessive Compulsive Disorder
HPB lists the symptoms of OCD.

6. Alcohol Dependence
NAMS lists the warning signs.

7. Gambling Problems
NAMS lists the signs to watch out for and offers a tool for self-assessment.

8. An Addiction to Gaming
Among the signs is the use of gaming as a means of escaping problems and the act of concealing game playing from family and friends. Read this NAMS overview.

9. Substance Dependence
Watch out for these behaviours in your co-workers (NAMS).

10. Schizophrenia
Schizophrenia is defined by IMH as “a disorder of fragmented mental processes”. Click here for more information.

11. Dementia
Working adults are increasingly faced with the challenges of juggling work and caregiving roles: Alzheimer’s Disease Association and HPB have fact sheets.

12. Learning Difficulties
Employees are also often parents who may have children with learning difficulties at school. Attention deficit (hyperactivity) disorder or ADHD information is available on Spark, while dyslexia assessments are available through the Dyslexia Association of Singapore. Autism resources are abundant at the Autism Resource Centre.

The International OCD Foundation has a useful fact sheet on hoarding. Finally, Singapore Focus on the Family offers advice for families faced with bullying at school, while the Media Literacy Council has information for individuals experiencing cyberbullying and AWARE has advice for personal protection orders and family violence.

Information is power. Don’t be afraid to use it.

Autism: Facts and Tips

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Autism is a developmental disorder which leads to difficulties with verbal and nonverbal communication, with social interactions, and with understanding and predicting other people’s intentions and behaviours. On this Autism Awareness Day, it’s important that we know the facts:

1. The cause for autism is as yet unknown.

2. Not everyone who has autism has a special talent like that of Raymond in Rain Man (1988).

3. Autism can be diagnosed in early childhood. 

4. More boys than girls are diagnosed with autism.

5. There are support groups for families of individuals with autism.

6. It’s important for parents to receive emotional support as well.

“Let’s find out more about mental illness”

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Yes, let’s. The article “Let’s find out more about mental illness” published in Straits Times, 16 Nov 2013, talks about childhood mental health disorders, and specifically, depression, anxiety, and schizophrenia.

It’s timely, given that understanding about mood and anxiety disorders involving adults tends to be poor, let alone mental health disorders involving children and adolescents. And it’s a good time as any to talk about mental health disorders, especially in the light of recent news reports involving individuals with depression.

But what is it that we understand about mental health disorders? From the resources made available to various organizations dealing with mental health issues, quite a lot actually.

But first, maybe we should know at least a few things worth knowing:

1. Stigma is everywhere, not just in Singapore.

That there is local stigma about seeking help for mental health disorders is not surprising.

But these are ubiquitous issues, relevant to other communities such as those in UK (“Understanding anxiety and mental health stigma”, The Guardian, 27 Sep 2013), Australia (“Mental health stigma still affecting Australian workers, with research showing 4 in 10 hide depression from their employers”, ABC, 12 Nov 2013), Canada (“Montrealers demonstrate to end mental health stigma”, CBC, 20 Oct 2013), Hong Kong (“First mental health web radio in Hong Kong raises the community’s awareness on mental illness and mental health”, UHK, 15 Nov 2013), and Taiwan (“Society must confront mental health stigma, redefine success”, The China Post, 3 June 2013).

We may not have progressed very far (“S’poreans fear mental patients, study finds”, Straits Times, 29 Oct 2007), but at least we’re increasingly cognizant of the issues and are adding to facts not fiction.

This Huffington Post article provides 3 helpful suggestions for how you and I can make a difference. The UK campaign which started in 2009 to end mental health discrimination at their www.time-to-change.org.uk offers useful tips on how to talk about mental health issues.

2. There are resources out there for the public.

3. There’s information about mental health disorders in children and adolescents.

4. Other resources include information about developmental disorders.

5. We can always do more.

A 2012 report in the Singapore Annals Academy of Medicine did not investigate whether their stratified sample of 6616 respondents, among whom 12% met the criteria for mood, anxiety, or alcohol use disorders but less than a third had sought professional help, used the internet to find out more about mental health disorders. Given that the same report acknowledges 80% or more of the local population aged 49 years and below (and 40% of those aged 50 to 59 years) has internet access, there’s much scope for accurate information about mental health to be provided on an online platform. This BBC Wales health report presents possibilities, while the UK Child and Maternal Health Intelligence Network offers ideas via a Tackling Stigma Toolkit. There are always more things that can be done. Something we can work towards perhaps?