Management of Children with Autism Spectrum Disorder in the Anesthesia and Radiographic Context

Use of an adaptive sensory environment in patients with autism spectrum disorder (ASD) in the perioperative environment: a parallel, randomized controlled trial

Background

Patients with autism spectrum disorders (ASD) experience higher rates of perioperative anxiety and are likely to receive premedication. Little is known about nonpharmaceutical interventions which may decrease anxiety. This study aims to evaluate the use of an adaptive sensory environment (ASE) to reduce ASD patient anxiety during the perioperative process.

Methods

Our feasibility study (ClinicalTrials.govNCT04994613) enrolled 60 patients in two parallel groups randomized to a control (no ASE) or intervention group (ASE). We included all surgical patients aged three to twelve years, with a formal diagnosis of ASD, Asperger's Syndrome, or pervasive developmental disorder not otherwise specified. Preoperative behaviors were recorded by an unblinded nurse utilizing the validated Modified Yale Preoperative Anxiety Scale (mYPAS). The difference in score on the mYPAS was the primary outcome, and an intention-to-treat analysis was employed. A generalized estimating equations model was used to compare mYPAS scores controlling for significant independent variables.

Findings

58 patients were analyzed after 1:1 randomization of 30 patients to each group. Groups were balanced except the median number of intraoperative pain medications was significantly lower in the ASE group (1 vs. 3, p = 0.012). Mean (SD) age for all patients was 7.2 (2.9) years, range 2.6-12.7. 72.4% (42/58) were White and all were Non-Hispanic or Latino. 74% were Male (21/30 ASE and 22/28 Control) and 26% were Female (9/30 ASE and 6/28 Control). No differences were found in mYPAS scores between groups at three time periods (43.5 vs. 42, p = 0.88, 47.8 vs. 48.4, p = 0.76, and 36.4 vs. 43.8, p = 0.15, ASE vs. control group, respectively). The ASE group had a significant within-group decrease in mYPAS scores from nursing intake to transition (p = 0.030).

Interpretation

An ASE did not significantly reduce perioperative anxiety. However, the promising results deserve further investigation.

Funding

Dayton Children's Hospital Foundation Robert C. Cohn Memorial Research Grant.

Digital citizenship of children and youth with autism: Developing guidelines and strategies for caregivers and clinicians to support healthy use of screens

LAY ABSTRACT

Children and youth with autism use screens in their daily lives and in their rehabilitation programs. Although parents and clinicians experience specific challenges when supporting positive screen time use of children and youth with autism, no detailed information for this group exists. Therefore, this study aimed to develop clear guidelines that are agreed by expert clinicians and parents of children and youth with autism. Using a method called Delphi, 30 experts-20 clinicians and 10 caregivers, who have experience working with or caring for children and youth with autism were invited to complete a series of three surveys. In each round, the experts had to rate their agreement with statements regarding screen time management. The agreement level was set to 75%. The final themes to be included in the guidelines were accepted by more than 75% of the panel. The final guidelines included six main sections: (1) general principles, (2) considerations for timing and content of leisure screen time use, (3) strategies for caregivers and clinicians to monitor and regulate screen time use, (4) behaviors to monitor for screen time overuse, (5) additional guidelines for clinicians, and (6) resources. The new guidelines developed in this study can provide potential guidance on how to further the development of digital citizenship for children and youth with autism and provide strategies to families to help manage screen time use.

Strategies, challenges and enabling factors when imaging autistic individuals in Swiss medical imaging departments

INTRODUCTION

Autistic individuals may require medical imaging but they can face barriers that are related to lack of adjustments in their care. This study aims to explore and understand strategies currently used by Swiss radiographers to image autistic patients and to propose recommendations for clinical practice.

METHODS

The Swiss Ethics of the canton of Vaud committee approved the study. Data collection was gathered using a mixed method approach by an online survey and followed by selected interviews. Descriptive statistics and thematic analysis were used to analyse the data.

RESULTS

A hundred completed responses to the survey were obtained and five individual interviews were conducted. Sixty participants reported having managed autistic patients. The main enablers identified were: the support from carers, adapting the behaviour of staff and customising communication. The main challenges were a lack of communication and the lack of knowledge about autism to appropriately manage the patient. Only five radiographers had received prior training in autism.

CONCLUSION

Medical imaging departments must develop protocols to overcome the lack of communication between services, radiographers, and autistic service users. The lack of radiographer knowledge about autism can impact autistic patient management, resulting in carers playing an important role during the examination. Customised education for radiographers about autism is needed.

IMPLICATION FOR PRACTICE

The development of a scheduling protocol for each imaging modality could improve communication with the patient. The organisation of the physical environment and the patient's preparation for the examination are critical to provide adequate imaging care. It is suggested that medical imaging professionals, autistic service users, and autism organisations collaborate to develop autism related guidelines for medical imaging examinations.

[Health simulation, access to somatic care for people with ASD]

The clinical characteristics of people with autism spectrum disorders can make it difficult for them to access care, including treatment and medical imaging examinations. Simulation-based learning can facilitate the performance of a CT scan, as in the case of Irène, who was able to adopt the expected body positions thanks to this intervention.

A systematic review of person-centred adjustments to facilitate magnetic resonance imaging for autistic patients without the use of sedation or anaesthesia

LAY ABSTRACT

Autistic patients often undergo magnetic resonance imaging examinations. Within this environment, it is usual to feel anxious and overwhelmed by noises, lights or other people. The narrow scanners, the loud noises and the long examination time can easily cause panic attacks. This review aims to identify any adaptations for autistic individuals to have a magnetic resonance imaging scan without sedation or anaesthesia. Out of 4442 articles screened, 53 more relevant were evaluated and 21 were finally included in this study. Customising communication, different techniques to improve the environment, using technology for familiarisation and distraction have been used in previous studies. The results of this study can be used to make suggestions on how to improve magnetic resonance imaging practice and the autistic patient experience. They can also be used to create training for the healthcare professionals using the magnetic resonance imaging scanners.

Role of information and preparation for improvement of pediatric perioperative care

The perioperative period is a significant and stressful experience that may cause negative consequences in children, both in a short-term and long-term perspective. Despite a wide base of evidence stating the importance of adequate preparation to reduce anxiety, improve coping, cooperation and enhance recovery, many children continue to report that they feel unprepared for their perioperative experience. To secure children's right to request and need for preparation, the content, format, and availability of existing programs need to be scrutinized. Preparation programs in perioperative care must change from simply providing information to embracing the importance of children's need to process the information provided in order to learn and understand. Interactive web-based technology can function as a significant resource for preparation of children for perioperative procedures. By changing perspective from children's need for information to their need for learning and by developing preparation programs including adequate educational principles, web-based technology can be used to its fullest advantage as a healthcare learning and preparation resource.

A meta-synthesis of how parents of children with autism describe their experience of accessing and using routine healthcare services for their children

In order to present a greater understanding to parental experiences of supporting their child with autism to access healthcare services, a systematic review of qualitative research was undertaken, addressing the review question: 'How do parents of children with autism describe their experiences of utilising routine healthcare services?'. After a systematic search and selection process, 12 studies were identified and appraised independently by paired reviewers using an adapted version of the Critical Appraisal Skills Programme (CASP) tool. Data were synthesised by two reviewers in line with the Joanna Briggs Approach for meta-aggregation. The 12 studies included in this review (spanning 2012-2020), represented the voices of 240 parents. The synthesis resulted in the following synthesised finding (based on four categories that emerged from the original studies' themes): parents report challenges in accessing and use of mainstream health services, for their child with autism, due to not having a voice, inadequate communication and lack of understanding from health service providers. This review raises our awareness of parents' experiences of healthcare services and will assist healthcare practitioners to reconsider their own communication style, understanding and approach with children with autism and their families. From these findings, we recommend that healthcare practitioners more readily incorporate parents' contributory expertise into healthcare visits. These recommendations will help facilitate effective, supportive and positive healthcare experiences for all involved.

A balancing act: An interpretive description of healthcare providers' and families' perspective on the surgical experiences of children with autism spectrum disorder

Children with an autism spectrum disorder (autism) are vulnerable to negative experiences within the surgical setting. This qualitative study used Interpretive Description. Individual interviews were conducted with 8 parents of children with autism who had recently undergone surgery, and 15 healthcare providers (HCPs) with experience caring for children with autism. Participants were asked open-ended questions on the approaches used to support children with autism around the time of surgery and their effectiveness, how the surgical experience could be improved, and the barriers and facilitators to potential improvements. Results yielded three main themes within an overarching metaphor of a balancing act. The first theme, finding your footing through an uncertain journey, described individual factors (e.g. anticipatory anxiety) that set the foundation for surgery-related experiences. The second theme, relationships can help to keep everyone steady, highlighted how interpersonal dynamics (e.g. collaboration and empathy) influence the experience. Finally, the systems shape the experience theme captured the impact of systemic factors (e.g. the hospital environment) on the balancing act. These findings enriched our understanding of how individual, interpersonal, and systemic factors influence the surgical experiences of children with autism, families, and HCPs. Insights gained from this study can be used to inform future interventions.

Behavioral training and mirroring techniques to prepare elective anesthesia in severe autistic spectrum disorder patients: An illustrative case and review

Children with autistic spectrum disorder are more likely to become distressed during induction of anesthesia. Inhalational induction is almost always the preferred route with acceptance of the face mask often presenting a considerable challenge. Tempering measures to facilitate gas induction such as forced premedication and physical restraint are no longer viable options except in extenuating circumstances. Recent research interest has focused on the need for advanced planning in collaboration with the caregiver to tailor an individualized perioperative plan. This plan may include both pharmacological and non-pharmacological interventions. Applied behavior analysis strategies have a well-documented efficacy in this unique population to systematically change an individual's usual behavior. These can be used, as a non-pharmacological strategy, to ensure a smooth perioperative course. We present a successful case of preoperative desensitization of a child with severe autistic spectrum disorder using a mirror demonstration technique associated with positive reinforcement to prepare him for general anesthesia. We discuss the potential application of applied behavior analysis strategies for anesthesia in this unique population. From a practical point of view, early communication with carers is required to establish who may benefit from this behavioral training. Planned individual preparation for general anesthesia must be provided by trained multidisciplinary staff.

Determinants of Parent Satisfaction with Emergency or Urgent Care When the Patient Has Autism

OBJECTIVE

The purpose of this study was to identify factors that predict parent satisfaction (PS) with their child with autism spectrum disorder (ASD)'s visit to a hospital emergency department (ED) or urgent care (UC) center.

METHODS

Parents recruited through a national database whose child (3-21 years; N = 378) with ASD had been treated in an ED/UC center within the previous 3 years completed an anonymous on-line questionnaire. They answered questions about whether they were satisfied overall with the visit and the care provided, their demographics, patient characteristics, their expectations and preparation for the visit, and the ED/UC center experience itself, including their observations of staff interpersonal and communication skills (ICSs) and behaviors, and whether the patient was disruptive (D). Multiple correspondence analysis (MCA) was used to demonstrate the relative effects of individual variables on PS.

RESULTS

Among the 10 most important determinants of PS with the visit were the 9 assessed staff ICS behaviors. These were followed by shorter than expected waiting time and the patient not being disruptive (ND) during the visit. PS was not associated with any of the 3 measures of patient disability severity (ASD subtype, communicative competence, or restrictiveness of educational placement), whether the patient is hyperreactive to sensory stimuli, reason for the visit, or parent's education.

CONCLUSION

PS with an ED/UC center visit when the patient has autism depends mostly on the quality of staff interactions with the patient and family. It is important for ED/UC center administrators to ensure that staff understand how to interact and communicate effectively with patients with ASD and their families.