SINGAPORE – When housewife Safirah Oshin, 33, first hired a behavioural therapist in 2018 for weekly home sessions to help her then five-year-old son Ali, she did not imagine the prolonged distress it would cause her family.

The therapist from a private centre was supposed to teach her son, who has autism and attention deficit hyperactivity disorder, how to cope better with his tantrums.

After four months, she saw some positive changes in her son, who is non-verbal. He could remain in his seat to do tasks and express his needs.

But one day, she noticed Ali running out from a therapy session in tears and locking himself in another room, she said. From closed-circuit television footage, she saw the therapist had grabbed Ali by the neck and handled him roughly.

The therapist was later fired by the company, said Madam Safirah, who also made a police report. But because there were no physical injuries and Ali was not able to verbally recount his experience, not much else could be done, she added.

As parents of children with special needs, like Ali, turn to the private sector due to long wait times for subsidised support, industry practitioners say more protection and standards are needed to help them navigate the space.

The lack of national standards results in varying practices and quality across service providers, they added.

These services could be offered by the likes of behavioural therapists and educational therapists, as well as psychologists, who are currently not regulated under the Allied Health Professions Council (AHPC). Such services may cost a parent $150 to $200 an hour or higher.

From 2019 to 2023, the Response, Early Intervention and Assessment in Community Mental Health service and the Institute of Mental Health’s (IMH) Child Guidance Clinic saw a yearly average of about 200 new cases of children with autism spectrum disorder, said Dr Goh Tze Jui, principal clinical psychologist at IMH.

More therapy providers

A behavioural therapist may help individuals with autism manage certain behaviours, such as self-harm, aggression and attaining daily living goals or social skills. An educational therapist can help individuals with learning challenges and differences.

Given that “therapists” is a very broad group, it is difficult to discern if the therapist is qualified or credible, said Dr Goh.

“Albeit a minority, there has been an increasing pool of supposedly skilled therapists and shadow educators in the private industry due to demand arising from higher awareness and diagnosis levels,” said Ms Denise Phua, president of Autism Resource Centre (Singapore) and chairman of Autism Association (Singapore).

This minority may have undergone only fairly generic training, do not belong to any professional association, nor are they supervised by more senior competent professionals, said Ms Phua, who is also an MP for Jalan Besar GRC. “If uncontrolled, the standard and image of the professionals would be negatively impacted.”

She added: “Not all cases of malpractice or client abuse have been reported, and concerns often arise only for abuses that are highlighted in public. The commotion then subsides after a period; without any longer-term solution to ensure the quality of intervention and protection of the clients. (This is) not a healthy state of affairs.”

The Register of Educational Therapists (Asia), or Reta, saw a gradual increase in membership in recent years, with 231 members in Singapore currently, said Dr Geetha Shantha Ram, the registrar of Reta.

An increasingly popular form of therapy for children and adolescents with autism is behavioural therapy and applied behaviour analysis, with a goal of increasing positive behaviours and reducing negative behaviours, said Mr Johnny Fok, a board-certified behaviour analyst with 20 years of experience.

A check by The Straits Times on April 9 showed around 60 individuals in Singapore actively accredited with the Behaviour Analyst Certification Board (BACB), an international body based in the United States. Those on the registry have passed some form of training, which could range from a master’s-level course that requires thousands of hours to a 40-hour training course for a certificate.

Mr Fok estimates that there are more than 200 practising behavioural therapists in Singapore.

He said the situation of inadequately trained therapists has worsened over the years. They used to function independently, as freelancers or in smaller circles previously. But over the years, these people are working on a larger scale and starting businesses, he said.

Questionable practices

Not receiving the right support early on in a child’s life can be detrimental in the long run, said Mr Fok, who is clinical director of private clinic Intervention Services for Autism and Developmental Delay. He believes the private behavioural therapy space needs regulation.

“We can never get those years back. If you are lucky, we are catching up. If you are not lucky, we are not only catching up, we are also dealing with severe problem behaviours that could last a lifetime.”

In December 2023, an educational and behavioural therapist was sentenced to three weeks’ jail for assaulting a non-verbal severely autistic nine-year-old.

The offender graduated with a degree in psychology and completed a registered behavioural technician course, which, according to BACB, is a 40-hour training course.

Senior occupational therapist Jewel Yi, who is a director of private clinic Little Marvels, said some therapists claim to be able to do what allied health practitioners specialise in, and charge significantly cheaper fees. They may also not allow parents to sit in on sessions.

Some therapists also claim to be experts with children when they hold irrelevant degrees, such as in business, she said.

Professions that are currently regulated under the Allied Health Professions Act 2011 include occupational therapists, physiotherapists and speech-language therapists.

It is an offence to practise as an allied health professional (AHP) or wilfully and falsely pretend to be a duly qualified AHP in Singapore without registration and a valid practising certificate, said AHPC, which is under the Ministry of Health, in response to queries.

Speech therapist Beatrice Teo, who is director of private practice Amazing Speech Therapy, said some therapists may resort to physically restraining a child, particularly if they are not properly trained to handle challenging behaviours like meltdowns or sensory overstimulation.

“That’s not going to help the child. It just makes it worse,” she said.

Madam Safirah said she has no issues with behavioural therapy itself, as she has seen how it can be effective. She still hires a behavioural therapist for her younger six-year-old son, who also has autism.

But she hopes a governing body can ensure quality and accountability in the profession.

Madam Safirah said Ali, now 10, still remembers what happened to him. He has become more fearful of others and shows more disruptive behaviours, such as spitting at others, she said.

She also sits in on all therapy sessions for her younger son.

Ms Lim Yung Wei, 47, a senior manager, has engaged private behavioural therapists for her 17-year-old son, who has autism, for over a decade.

She is satisfied with the sessions, as she has seen improvements in her son’s behaviour, such as being able to make more eye contact and communicate with others. But she said regulation is necessary as it will help to raise standards.

“Imagine a parent who just received the child’s diagnosis and is feeling helpless, desperate and vulnerable. I think many parents would just try something, even if they knew the industry was unregulated because, what if it’s that ‘one shot’,” said Ms Lim.

“It’s the clutching at straws, thinking maybe something like this is going to cure my child? But they should be protected against people who advertise and say that they can do this when they can’t.”