Sustainability of a Care Pathway for Children and Adolescents with Autism Spectrum Disorder on an Inpatient Psychiatric Service

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

Individualized Care Delivery for Children With Autism and Related Disabilities Undergoing Overnight Video Electroencephalography (EEG): One Hospital's Experience With a Coordinated Team Approach

Background and Purpose: Children with developmental disabilities have increased risk of epilepsy and need for overnight video electroencephalographic (EEG) monitoring. However, video EEGs have historically been considered difficult to complete for this population. An autism support service at a pediatric tertiary care hospital implemented a coordinated team approach to help children with developmental disability tolerate overnight video EEGs. The project included completion of a caregiver-report preprocedure questionnaire that then was shared with the multidisciplinary team and used to create individualized care plans. The current study aims to describe rates of video EEG completion and need for lead placement under general anesthesia among children with autism and related disabilities who received these supports. Methods: Rates of video EEG completion and general anesthesia use were analyzed for children referred to the support service between April 2019 and November 2021. Results: A total of 182 children with developmental disability (mean age  = 10.3 years, 54.9% diagnosed with autism) met inclusion criteria. 92.9% (n = 169) of children successfully completed EEG (leads on ≥12 hours). Only 19.2% (n = 35) required general anesthesia for video EEG lead placement. The majority (80.2%) of parents (n = 146) completed the preprocedure questionnaire. Video EEG outcomes did not differ based on completion of the questionnaire. Parent-reported challenges with communication and cooperation were associated with shorter video EEG duration and greater use of general anesthesia. Conclusions: These findings suggest that most children with developmental disability can complete video EEG with sufficient support. Preprocedure planning can identify children who would benefit from additional accommodations. Further research is necessary to clarify which supports are most helpful.

Mental Health Crises in Autistic Children: A Framework for Prevention and Intervention in Primary Care

Children with autism are at high risk for experiencing a mental health crisis, which occurs when psychiatric and behavioral symptoms become a danger and caregivers do not have the resources to safely manage the event. Our current mental health systems of care are not fully prepared to manage crisis in autistic individuals, due to the shortage of available mental health providers and programs that are tailored for autistic children. However, new strategies to address crisis are gradually emerging. This article provides a framework to define crisis and implement prevention and intervention approaches that could potentially mitigate risk for crisis.

Optimizing Care for Autistic Patients in Health Care Settings: A Scoping Review and Call to Action

OBJECTIVE

We conducted a scoping review of interventions designed to improve the health care experiences of autistic individuals and assessed the methodology and outcomes used to evaluate them.

METHODS

Literature from January 2005 to October 2020 was searched using PubMed, Excerpta Medica dataBASE (EMBASE), Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycINFO as well as hand searching. Studies included described an intervention for autistic individuals in inpatient or outpatient settings and evaluated the intervention using standardized methodology. Results were exported to Covidence software. Ten reviewers completed abstract screening, full text review, and then systematic data extraction of the remaining articles. Two reviewers evaluated each article at each stage, with a third reviewer arbitrating differences.

RESULTS

A total of 38 studies, including three randomized controlled trials (RCTs) were included. Twenty-six (68%) took place in dental, psychiatric, or procedural settings. Interventions primarily focused on visit preparation and comprehensive care plans or pathways (N = 29, 76%). The most frequent outcome was procedural compliance (N = 15), followed by intervention acceptability (N = 7) and parent satisfaction (N = 6). Two studies involved autistic individuals and caregivers in study design, and no studies assessed racial/ethnic diversity on intervention impact.

CONCLUSIONS

Well-designed evaluations of interventions to support autistic individuals in pediatric health care settings are limited. There is a need to conduct large multi-site intervention implementation studies.

Physical and Pharmacologic Restraint in Hospitalized Children With Autism Spectrum Disorder

OBJECTIVES

Children with autism spectrum disorder (ASD) have high rates of cooccurring conditions and are hospitalized longer and more frequently than children without ASD. Little is known about use of involuntary physical or pharmacologic restraint in hospitalized children with ASD. This study compares use of restraint because of violent or self-injurious behavior during inpatient pediatric hospitalization in children with ASD compared with typical peers.

METHODS

This retrospective cohort study examines electronic health records of all children aged 5 to 21 years admitted to a pediatric medical unit at a large urban hospital between October 2016 and October 2021. Billing diagnoses from inpatient encounters identified ASD and cooccurring diagnoses. Clinical orders identified physical and pharmacologic restraint. Propensity score matching ensured equivalency between ASD and matched non-ASD groups on demographic factors. Logistic regression determined the odds of restraint in children with ASD compared with children without ASD, controlling for hospitalization factors and cooccurring diagnoses.

RESULTS

Of 21 275 hospitalized children, 367 (1.7%) experienced restraint and 1187 (5.6%) had ASD. After adjusting for reason for admission, length of stay, and cooccurring mental health, developmental, and behavioral disorders, children with ASD were significantly more likely to be restrained than children without ASD (odds ratio 2.3, 95% confidence interval 1.6-3.4; P < .001).

CONCLUSIONS

Hospitalized children with ASD have significantly higher odds of restraint for violent or self-injurious behavior compared with children without ASD after accounting for reason for admission, length of hospitalization and cooccurring diagnoses. Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation and restraint.

Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.

Crisis stabilisation services for people with intellectual disabilities: A systematic review

People with intellectual and developmental disabilities sometimes engage in challenging behaviours. When behaviours escalate to the point where they pose imminent risk to the safety of people and environments, a crisis occurs that jeopardises community living and participation. In these situations, timely access to crisis stabilisation services is required. We conducted a systematic review of the literature to synthesise evidence on effective crisis stabilisation service models for challenging behaviours. A total of 46 publications met the inclusion criteria. The literature describes a spectrum of crisis stabilisation services of varying intensities including: outreach, outpatient, inpatient, respite, and capacity building through education and training. However, there is limited guidance on how to best structure service models. This review highlights the need for comprehensive and person-centred programme evaluations.

How People with Autism Access Mental Health Services Specifically Suicide Hotlines and Crisis Support Services, and Current Approaches to Mental Health Care: A Scoping Review

For people with autism spectrum disorder (ASD), the risk of mental illness, including suicidality, has a higher prevalence than the general population. This scoping review explored how people with ASD access suicide hotlines/crisis support services; and current approaches to delivering mental health services (MHS) to people with ASD. A search identified 28 studies meeting the selection criteria with analysis revealing four key findings. The support received by the person with ASD influenced how they accessed MHS; people often encounter barriers to accessing MHS; a separation exists between autism and MHS; and no studies on accessing or delivering MHS through crisis hotlines. The presence of such autism-specific crisis hotlines and the dearth of studies suggest a void in the existing research.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit

BACKGROUND

In inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions.

METHOD

Multi-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions.

RESULTS

There was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July-September 2015, to 4.7 episodes in January-March 2016, reaching 0.0 episodes by April-June 2016. This reduction was maintained until April-June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant.

LIMITATIONS

Due to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change.

CONCLUSIONS

Multidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.

Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care

Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.

Staff Perceptions and Implementation Fidelity of an Autism Spectrum Disorder Care Pathway on a Child/Adolescent General Psychiatric Inpatient Service

While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173-3180, https://doi.org/10.1007/s10803-019-04029-6 , 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082-4089, https://doi.org/10.1007/s10803-018-3666-y , 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient's stay.