Starting 2007, Singapore’s government has proposed three Enabling Masterplans with the commitment to constructing “a caring and inclusive society where persons with disabilities are empowered to achieve their fullest potential and participate fully as integral and contributing members of society”1. To achieve this goal, as stated in the Third Enabling Masterplan, four key thrusts have been recommended. The first key thrust is to improve the quality of life of persons with disabilities. According to the Steering Committee, in addition to providing responsive and adaptable services and support as well as opportunities for development, education, and learning opportunities, one of the essential strategic directions is to “ensure timely and effective detection of developmental needs in children by enhancing the existing network of touchpoints2.”
This network of touchpoints in the community is established according to the Second Enabling Masterplan (2012-2016). It includes primary healthcare agencies such as hospitals, polyclinics, family medicine practitioners, and community partners such as childcare centres and the family service centres (see Table 1 below). The plan assumes that professionals at these touchpoints, equipped with appropriate skills, would be able to detect children showing developmental delays. Specifically, the child’s Health Booklet is used as the primary platform for caregivers, nurses, and doctors to screen children’s development in personal social, fine motor, gross motor, and language domains at age 1-2 months, 3-5 months, 6-12 months, 15-18 months, 2-3 years, and 4-6 years. Additionally, teachers of childcare centres empowered with professional skills could help detect children with special needs. For those children from disadvantaged social backgrounds or dysfunctional families who may not attend childcare centres, the network of Family Service Centres (FSC) are expected to assess the children’s developmental needs, though mainly for families seeking help.
These plans represent a good first step. Yet, there are still gaps to implement these plans fairly and effectively. The most recent roadmap, the Third Enabling Masterplan (2017-2021), reflects the challenges that come with early detection. To enhance this network, the third Masterplan suggests improving the accessibility of information on key developmental milestones and increasing the training of primary care doctors in areas such as developmental screenings.
On the surface, the plan appears to be comprehensive, strategic, and family-oriented. However, a careful analysis reveals some flaws which must be addressed. The first relates to how developmental delays are detected at primary healthcare agencies. The child Health Booklet, the primary developmental screening tool, provides information on multiple milestones across multiple dimensions at multiple ages. These are intended to assist doctors or nursing staff to evaluate children’s development in a relatively efficient manner. Nevertheless, this screening tool depends too much on the quality and thoroughness of parental reports3. The Health Promotion Board encourages parents to complete checklists and discuss the results with doctors if their child is unable to achieve a certain milestone at a certain age. If a parent does not read the questions, does not understand them, or has not been looking out for these milestones all along, the checklist will fail, and primary healthcare agencies have little chance to detect any developmental delay in children.
The second flaw is related to how childcare teachers can detect developmental delays. Although in recent years, with the effort of the Early Childhood Development Agency, the quality and training of and standards for early childhood teachers have improved greatly, it remains unreasonable to expect childcare teachers to detect developmental delays without any concrete guidance. After all, a systematic and accurate assessment and diagnosis requires medical doctors, developmental psychologists, and educational psychologists.
A third flaw is related to how the FSC network can be involved in detecting developmental delays. FSCs focus on serving vulnerable and low-income families and individuals by providing information and referral, casework, group work, and community work. It can provide assessment and referral services if parents seek them for support. However, if parents do not report any concerns about their children’s development, the FSC will not have an opportunity to assess and detect children’s developmental needs. Many overburdened families may not even realise that their children need help, and thus fall through the cracks.
Hence, this Early Detection Network, though complex and involving various agencies, still mainly relies on parental reports. Of course, family and caregivers play an essential role in detecting early developmental delays. However, some strategic measures can be adopted to promote the efficiency and effectiveness of primary healthcare providers, childcare providers, and the FSCs in their roles of detecting special developmental needs.
First, for primary healthcare agencies, instead of asking parents to complete checklists, trained nursing staff or even a well-designed screening app can help guide parents to reflect on and answer these questions appropriately (it is important, for instance, that these questions are read aloud to parents and that the questions are clarified). Results showing signs of developmental delay can be brought to doctors for further assessment. Second, for childcare centres, straightforward checklists similar to those used in the child Health Booklet can help teachers record and evaluate children’s development routinely. Such checklists can serve as a general guideline, can simplify the screening process, and can further increase the chance to detect developmental delays without increasing teachers’ working load dramatically. Third, as the FSCs often provide free health screenings in communities, it can also adopt these checklists to provide free developmental screening for children. Instead of waiting for parents to go to the FSCs for support, in this case, the FSCs can help increase parental awareness, promote healthy development, detect developmental needs efficiently, and enhance public awareness and integration.
While the Masterplans make a good effort to establish a more inclusive society, there are several steps as a community we can take to ensure that the promises contained in the Masterplan are fulfilled. Additional training for parents, childcare providers, workers at FSCs, and medical professionals, as well as new and better tools for early detection, are necessary to ensure that these goals are met.
FACTS ABOUT SPECIAL NEEDS
What is developmental delay?
Developmental delay is a condition that an individual does not meet expected milestones in one or multiple domains of development such as motor, cognitive, language, and social development.
Why is it important to detect developmental delay?
With an accurate assessment, conditions of developmental delay (temporary or ongoing, one or multiple domains) as well as causes of development delay (e.g. harmful environment, malnutrition, heredity, or medical conditions) can be identified, and then appropriate intervention (e.g. safe environment, healthy diets, specialised training programmes, and compensatory strategies) can be provided to prevent further developmental delay and a vicious cycle of maldevelopment as well as promote continuous vigorous development.
Why is it important to detect developmental delay and provide intervention during early childhood?
During early childhood, children’s body, brain, motor functions, cognitive functions such as language and thinking, and socio-emotional functions develop rapidly. For example, six-month developmental differences may not be obvious for an adult but may have a considerable impact on a preschooler. Hence, it is important to detect developmental delays as early as possible. Additionally, during this period, children are very sensitive and responsive to environmental inputs. Intervention during early childhood, which is cost-efficient, can optimise outcomes for children, families, and society.
What are the areas of caution when diagnosing developmental delay?
Accurate diagnosis is very important. Misdiagnosis is very dangerous.
Case 1
a. A girl was regarded as special. She received various diagnoses including learning disability, mildly autistic, borderline schizophrenic, and depression. In fact, her problem was due to her maldeveloped depth perception. A special pair of glasses which corrected her depth version solved her problems easily.
b. Labelling a child with a developmental disorder may cause him/her to become stigmatised and devalued, even depersonalised.
Case 2
a. Once we visited a childcare centre, we were told that a 4-year-old boy who participated in our study was autistic. The child behaved normally during our interaction with him. Upon our departure, the boy approached us to hug us and thank us.
b. Developmental delay can be temporal. Follow-up assessment is needed. The label of developmental delay should be removed when appropriate.
Case 3
a. A 13-year-old boy once was diagnosed as having global developmental delay due to his parents’ neglect. Once he stopped living with his parents, he developed relatively smoothly. He received the highest PSLE score of his class and did not show any further developmental delay. Unfortunately, he was still labelled as the child with global developmental delay.
b. Developmental delay should not be an identity stuck to a person for his whole life. ⬛
1 Third Enabling Masterplan 2017 – 2012, Caring and Inclusive Society, (Singapore: Third Enabling Masterplan Steering Committee, 2016), 10.
2 Ibid, 25.
3 Refer to Health Promotion Board’s Health Booklet (2014) for Children, Pages 15 to 17 (Screening at 15 months to 18 months), Retrievable from: https://www.healthhub.sg/sites/assets/assets/programs/screening/pdf/health-booklet-2014.Pdf
Dr Qu Li is a developmental psychologist, the founder of Quality Development Research & Consulting Pte Ltd, and a lecturer with Nanyang Technological University. She received her PhD from University of Toronto, Canada. A recipient of various grants, including those from Ministry of Social and Family Development (MSF), Early Childhood Development Agency (ECDA) and Ministry of Education (MOE), Dr Qu’s articles have been published in top journals. Her comments have appeared on Channel NewsAsia, The Straits Times, Lianhe Zaobao, and TODAY.
