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WHAT IS AUTISM SPECTRUM DISORDER? 'Autism', derived from the Greek word 'autos', or 'self', refers to someone who 'lives in a world of his own'. Hence, autism spectrum disorder (ASD) is a neurodevelopmental condition that affects a person's ability to make sense of the world and relate to other people. It is characterised by persistent deficits in social communication and interaction, as well as restricted, repetitive patterns of behaviour and interests. These manifest during the early developmental period and cause clinically significant impairment of social and occupational function (Box 1). (1) The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, refers to ASD as a single condition with different levels of severity, collectively representing four subtypes that were previously defined in DSM-IV (autistic disorder, Asperger's syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified). (1) ASD is also associated with psychiatric comorbidities such as anxiety, aggression, attention deficit hyperactivity disorder and obsessivecompulsive disorder. (2) The exact aetiology of ASD is unknown; it is thought to have strong and complex genetic underpinnings with modulation of phenotypic expression by environmental factors. (3) Normal childhood vaccines have been falsely implicated in the causation of ASD, and extensive research has now proven no link between vaccination and ASD. (4) Factors associated with increased risk of ASD include: (5) male gender; family history of sibling or parent with ASD; advanced paternal and maternal age; prematurity (gestational age < 35 weeks) or antenatal infections; antenatal exposure to medications (e.g. valproate and antidepressants); and genetic syndromes such as fragile X syndrome, tuberous sclerosis, Rett syndrome, Down syndrome, muscular dystrophy and neurofibromatosis. ASD is not uncommon. Based on local data from KK Women's and Children's Hospital and National University Hospital, the prevalence of ASD in Singapore is estimated to be one in 100 individuals, and most children are formally diagnosed at approximately three years of age. (6)

Early childhood is a phase of rapid development during which children develop motor skills, language and social skills. They learn to regulate emotions and, to some extent, control their behaviour. These skills help the children function in different settings. It is not uncommon for behavioural problems to emerge during this period, as children are trying to make sense of the world, assert their independence and adjust to various transitions such as making new friends or starting school. Behavioural problems in children can be divided into externalising problems such as aggression, oppositional behaviour and hyperactivity, and internalising problems such as anxiety and depression. (1) Internalising problems are more likely to be picked up by parents, whereas externalising problems may be identified by parents or teachers. (2) In contrast to their Australian and American counterparts, who demonstrate an equal or greater number of externalising problems compared to internalising problems, (1,3) children in Singapore tend to demonstrate more internalising problems. (2)

Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at a median age of 44 months. As early detection and intervention depends on an effective developmental screening programme, we aimed to improve the detection of developmental delays before the age of 3 years in a primary care setting. We did this by implementing a novel two-tiered screening programme which uses three standardised screening tools (Parents’ Evaluation of Developmental Status, PEDS-Developmental Milestones and Ages and Stages Questionnaire-3). We used quality improvement methods to integrate and optimise this two-tiered programme into the existing 9-month and 18-month screening schedule, with an additional screening at 30 months to replace the pre-existing 36-month screening of the National Child Health Surveillance Programme. A total of three Plan–Do–Study–Act cycles were performed to ensure programme feasibility and sustainability. They focused on adequately training the primary care nurses, targeting an 80% screening rate and aiming for 20 min screening tool administration time per child. We assessed the proportion of children referred to the child development units after positive screening for developmental concerns under the new programme, with a pre–post and with–without intervention comparison, and reviewed the screening rates and screening tool administration time. The proportion of 18-month old children referred for developmental concerns improved from 3.5%–7.1% over a 6-month period. For those who received further assessment by developmental specialists after the two-tiered screening, 100% received a definitive diagnosis of developmental delays, similar to the situation before programme introduction. Our quality improvement efforts facilitated successful integration of the two-tiered programme into the pre-existing screening schedule with minimal impact to the clinic workflow. While we highlight challenges in implementation that need to be addressed, our findings support a potential nationwide adoption of the two-tiered programme.