Caring for the child with an autism spectrum disorder in the acute care setting

Autism-Friendly Healthcare: A Narrative Review of the Literature

Disparities in healthcare access, delivery, and outcomes exist between autistic and non-autistic individuals. Autism-friendly healthcare initiatives aim to facilitate and improve the healthcare experience of autistic individuals by addressing commonly encountered challenges. While there is no consensus regarding the definition of autism-friendly healthcare, in this narrative review, we examine previously published research to determine the most important components of autism-friendly healthcare. Patient-related factors, provider-related factors, and system-related factors should be addressed. Proactivity, flexibility, and collaboration should guide the process of transforming the healthcare system. Finally, multiple strategies can be utilized as appropriate to the setting and individuals.

Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs

The objective of this review was to explore parents' experiences and information needs regarding management of their child with an intellectual and/or developmental disability (IDD) in the emergency department (ED). We searched six electronic databases and grey literature to identify primary studies in English published since 2000. We synthesized quantitative and qualitative outcome data simultaneously using a convergent integrated approach and used a Mixed Methods Appraisal Tool (MMAT) to assess methodological quality of the included studies. Nine articles derived from seven studies were included (3 qualitative, 3 quantitative, 1 mixed method). Four main themes related to parents' self-reported experiences were identified: 1) appropriateness of the ED to manage and support their child; 2) acknowledgement/recognition of their child's IDD and incorporation of those considerations into overall care and management; 3) managing and navigating the ED environment; and 4) decision to disclose their child's condition when visiting the ED. Two articles provided data relevant to information needs, highlighting parents' desire to have resources supporting ED orientation and access to services within and outside of the ED setting. From the limited number of studies, it was evident that parents wanted better communication with healthcare providers and a greater understanding by ED staff around physical space settings needed to support their child. Resources supporting ED staff and parents to communicate effectively and work together can ensure that children with IDDs care needs are met. Further research into understanding parents' experiences and information needs related to managing a child with an IDD in the ED is needed to guide the development of effective resources.

Factors Associated With Prolonged Mental Health Admissions at US Children's Hospitals

BACKGROUND AND OBJECTIVES

Mental health (MH) hospitalizations at medical hospitals are associated with longer length of stay (LOS) compared with non-MH hospitalizations, but patient factors and costs associated with prolonged MH hospitalizations are unknown. The objective of this paper is to assess patient clinical and demographic factors associated with prolonged MH hospitalizations and describe variation in MH LOS across US children's hospitals.

METHODS

We studied children aged 5 to 20 years hospitalized with a primary MH diagnosis during 2021 and 2022 across 46 children's hospitals using the Pediatric Health Information System database. Generalized estimating equations, clustered on hospital, tested associations between patient characteristics with prolonged MH hospitalization, defined as those in the 95th percentile or above (>14 days).

RESULTS

Among 42 654 primary MH hospitalizations, most were aged 14 to 18 (62.4%), female (68.5%), and non-Hispanic white (53.8%). The most common primary MH diagnoses were suicide/self-injury (37.4%), depressive disorders (16.6%), and eating disorders (10.9%). The median (interquartile range) LOS was 2 days (1-5), but 2169 (5.1%) experienced a hospitalization >14 days. In adjusted analyses, race and ethnicity, category of MH diagnosis, and increasing medical and MH complexity were associated with prolonged hospitalization.

CONCLUSIONS

Our results emphasize several diagnoses and clinical descriptors for targeted interventions, such as behavioral and inpatient MH resources and discharge planning. Expanded investment in both community and inpatient MH supports have the potential to improve health equity and reduce prolonged MH hospitalizations.

Acute intestinal obstruction secondary to ingested foreign body in an adult with autism spectrum disorder: A rare case report and review of literature

Key Clinical Message

Foreign body ingestion is common in pediatric age group however can be found in any age group with intellectual disability and neurodevelopmental delay. There is usually a delay in presentation and interventions following foreign body ingestion in patients with neurodevelopmental delay, leading to increased morbidity, mortality, and complications owing to inability of such patients giving relevant history. Most ingested foreign bodies naturally pass through the digestive tract without untoward effects. Only a few patients may require surgical interventions. Principle of management should be to reduce anxiety among patients and their visitors. Speedy recovery is enhanced so that they can return to their familiar environment soon.

Abstract

Foreign body ingestion is common in pediatric populations and may be found in any age group with intellectual disability and neurodevelopmental delay. As the patient cannot give a clear and relevant history, there is usually a delay in presentation and interventions following foreign body ingestion in patients with neurodevelopmental delay, leading to increased morbidity, mortality, and complications. Most foreign bodies pass through the digestive system without any complications, and very few require surgical intervention. The goal should be to reduce anxiety among patients and their visitors and to enhance speedy recovery so that they can return to their familiar environment soon. Here we report a case of Acute intestinal obstruction secondary to ingestion of the head portion of a doll which was managed with emergency laparotomy with enterotomy and removal of foreign body in a 16 years female with Autism Spectrum Disorder.

Effectiveness of Cognitive Behavioral Therapy (CBT) on Psychological Distress among Mothers of Children with Autism Spectrum Disorder: The Role of Problem-Solving Appraisal

Mothers of children with autism spectrum disorder (ASD) face considerable psychological distress. Cognitive behavioral therapy (CBT) has shown promise in reducing caregiver burden, but evidence in the Arab world is lacking. Problem-solving appraisal training may optimize CBT's benefits. This study evaluated a tailored CBT program emphasizing the role of problem-solving appraisal in managing distress through the process of CBT. Sixty mothers were randomly allocated in a 1:1 ratio to either the CBT intervention group or the control group. The CBT group received 3-month sessions incorporating problem-solving appraisal training within a CBT curriculum from October 2022 to April 2023. Problem-solving techniques are focused on equipping individuals with the skills to identify, approach, and effectively resolve problems, leading to a reduction in stress levels and an improved capacity to cope with difficult situations. All mothers completed assessments of socio-demographics such as age, level of education, marital status, occupation, and adequacy of family income, the Depression Anxiety Stress Scale (DASS-21) and the Problem-Solving Inventory (PSI) before and after the program. The CBT group showed significant pre-to-post reductions in depression, anxiety, stress, and general psychological distress compared to controls (all p < 0.05). They also exhibited significant improvements in problem-solving confidence, approach-avoidance style and personal control (all p < 0.05). The customized CBT program markedly improved psychological well-being for mothers of children with ASD in Egypt. Incorporating problem-solving techniques may optimize CBT's benefits cross-culturally. These findings have implications for the implementation of evidence-based support programs for families impacted by ASD worldwide.

Exploring the experiences of parents of Autistic children when attending the diagnostic imaging department for an X-ray examination

INTRODUCTION

Autism is a neuro-developmental condition which affects the social-emotional skills, behaviour, language, communication skills and flexibility of thoughts of an individual and their sensory processing. This can result in Autistic service users finding it difficult to navigate current healthcare provision and cope with the unpredictable environment. This paper explores the experiences of parents of Autistic children when attending the diagnostic imaging department for an X-ray examination.

METHODS

A cross sectional, mixed methods approach was adopted and the initial phase consisting of an online survey for parents to complete is the subject of this paper. The quantitative data was analysed using descriptive statistics and cross comparison between questions was also completed. Thematic analysis was taken to analyse the data from the two open questions at the end of the survey.

RESULTS

The online survey results are presented in this paper under four key themes; waiting times and environment, forms of communication, lack of understanding of staff regarding Autism and preparation for the X-ray examination.

CONCLUSION

The overall rating of the parents' experience whilst in the X-ray/diagnostic imaging department was positive, however there are several areas which received low scores which need further attention. These were waiting areas, waiting times, staff development and patient preparation.

IMPLICATIONS FOR PRACTICE

The development of more inclusive waiting areas is needed, more effective lines of communication between staff to expedite the patient journey where possible, staff development of both radiographers and also support staff and the review of design of more accessible and inclusive patient information.

Pain communication in children with autism spectrum disorder: A scoping review

Children with autism spectrum disorder (ASD) experience social interaction and communication challenges and often display repetitive, restricted patterns of behavior, activities, and interests. The concept of pain is regarded as one of the most complex human stressors due to its subjective and personal nature and the influences of multiple internal and external factors. Due to the complexity of this disorder, it remains concerning how children with ASD communicate their pain and how observers (i.e., parents, carers, and health care practitioners) respond to these children's pain communication. This scoping review aimed to identify how children with ASD communicate or express their pain. Ten studies met the inclusion criteria for further data extraction. Through reflexive thematic analysis, two main themes were identified: verbal and nonverbal responses used by children with ASD to communicate their pain that could influence pain assessment and management strategies. This review highlighted that children with ASD utilized various verbal and nonverbal methods to communicate their pain experiences and that these methods differed compared to children without disabilities. Furthermore, this review emphasizes the importance of holistic pain assessment strategies as well as additional pictorial support for children with ASD. This review recommends that future research should focus on understanding how the inclusion of different stakeholders in pain assessment for children with ASD, can contribute to holistic pain assessment.

Assessing Child Life Specialists' Management of Challenging Behaviors in Autistic Pediatric Patients

Given that autistic children are hospitalized at higher rates than neurotypical peers, it is important to understand the autism-specific preparedness of healthcare providers. Certified Child Life Specialists (CCLSs) play a crucial role in pediatric hospitalizations by providing socioemotional support and coping strategies. The present study assessed perceived competency and comfort levels among 131 CCLSs regarding the management of challenging behaviors exhibited by autistic pediatric patients, including aggression and self-injury. All participants reported experiences providing care to autistic children who exhibited challenging behaviors, but very few reported both high perceived competency and high comfort in managing these behaviors. Autism-specific training positively correlated with perceived competency and comfort. These results have implications for providing autistic children high quality hospital care.

Nursing care for persons with developmental disabilities: Review of literature on barriers and facilitators faced by nurses to provide care

AIMS

To identify barriers and facilitators to nursing care of individuals with developmental disabilities (DDs).

BACKGROUND

Individuals with DDs experience health disparities. Nurses, although well positioned to provide optimal care to this population, face challenges.

DESIGN

Narrative review of extant published peer-reviewed literature.

DATA SOURCES

Electronic databases, ProQuest and EBSCO, were searched for studies published in English between 2000 and 2019.

REVIEW METHODS

Three reviewers reviewed abstracts and completed data extraction. Knowledge synthesis was completed by evaluating the 17 selected studies.

RESULTS

Emerging themes were: (1) barriers and challenges to nursing interventions; (2) facilitators to nursing care; and (3) recommendations for nursing education, policy and practice.

CONCLUSION

Nursing has the potential to be a key partner in supporting the health of people with DDs.

IMPACT

There is a need for specific education and training, so nurses are better equipped to provide care for people with DDs.

Identifying Components of Autism Friendly Health Care: An Exploratory Study Using a Modified Delphi Method

OBJECTIVES

Autistic individuals report lower health care satisfaction. However, there is currently no set of "best practice" standards about caring for autistic individuals. In this exploratory study, we aim to identify features of Autism Friendly practice according to a sample consisting of mainly professionals whose interests include autism using a modified 3-round Delphi-a method that identifies a consensus view across subject participants.

METHODS

Statements about components of an Autism Friendly health care practice were compiled in consultation with the steering committee of an Autism Friendly Initiative at a single, urban academic safety-net hospital. Participants were recruited through our national network of professionals and patients/families mailing list. Examples of invited professionals included researchers, health care workers, and educators. In the first 2 rounds, we distributed electronic surveys to participants, who scored statements from 1 to 9 regarding importance. In round 2, statements that were scored low by all stakeholder groups were eliminated. Seventy-eight participants responded to the first-round survey, and 51 participants responded to the second-round survey. In the third round, 38 participants ranked 16 statements from most to least important. Statements are summarized and presented in the Results section.

RESULTS

Topics that emerged from highly ranked statements include environmental/operational modifications (e.g., longer appointment times) and staff training to support autistic patients.

CONCLUSION

Highly ranked statements represented previously reported barriers, including the need for staff training and inclusive engagement with the autistic community. The findings can help inform health care organizations to determine priorities when building an Autism Friendly health care practice.

Adaptive Care for Perioperative Patients With Developmental Disabilities: An Exploration of Interventions and Family Experience

INTRODUCTION

Patients with developmental disabilities commonly experience psychological distress during health care visits. There is limited research describing which individualized interventions are being implemented to promote optimal care in the perioperative area.

METHOD

In this prospective observational study of 60 patients with developmental diagnoses, aged 3-21 years, we recorded adaptive care plan (ACP) interventions and assessed family experience.

RESULTS

Patients receiving ACPs had diverse diagnoses, including autism spectrum and 10 other unique syndromes. Most patients received previsit planning (90%), adaptations to standard protocols (60%), child life specialist preparation (67%), procedural support (90%), and were given fast-acting anxiolytics before anesthesia induction (68%). Families reported that ACPs were important for managing a child's stress (94%) and promoting safety (92%).

DISCUSSION

ACPs promote safe, productive health care encounters for patients with various diagnoses, ages, and coping abilities. Families find ACPs important for stress management and promoting safety.

The sensory experiences of autistic people: A metasynthesis

LAY ABSTRACT

Sensory atypicalities are very common among autistic people and are integrated in several theories and explanatory models of autism. Qualitative studies have explored these singular sensory experiences from the perspectives of autistic people themselves. This article gathers all these qualitative studies and provides original findings regarding the everyday sensory experience of autistic people, that is, around four dimensions - physical, emotional, relational and social - experienced holistically, as inseparable, and not hierarchically or in terms of cause and effect. Adopting this holistic view could improve the adaptation of the sensory environment in health care facilities and the training of professionals around this specific issue.

Matching Level of Clinical Support to Patient Risk When Caring for Children With Behavioral Challenges

Adaptive care plans (ACPs) are an innovative method to providing care for children and adolescents with developmental disabilities who have challenging behaviors during healthcare encounters. ACPs take a family-centered approach to ensure that children with developmental disabilities are able to receive safe and appropriate healthcare by increasing communication and collaboration between caregivers and healthcare team members. Differing healthcare professionals are strategically involved in order to appropriately match the level of support to the patient's behavioral risk through a review of two case examples from the pediatric physical medicine and rehabilitation department. Specifically, case examples describe varying levels of accommodations and support provided to children with challenging behaviors, whose behaviors may have otherwise prevented them from receiving appropriate health interventions.

A Scoping Review of Targeted Interventions and Training to Facilitate Medical Encounters for School-Aged Patients with an Autism Spectrum Disorder

Individuals with an autism spectrum disorder (ASD) have a greater number of healthcare provider interactions than individuals without ASD. The obstacles to patient-centered care for this population, which include inflexibility of hospital environments, limited resources, and inadequate training, has been documented. However, there is little knowledge on efforts to address such concerns. A scoping review was conducted and the systematic search of the literature resulted in 23 relevant studies. The predominant themes include the use of data collection instruments, application of evidence-based practices and resources, and training of providers. The results of this review have implications for practitioners and future research to adapt and improve upon the provision of medical care for individuals with ASD across the lifespan.

Keys to Success: A Professional Development Program to Support Care of Patients With Autism Spectrum Disorder

Patients with autism spectrum disorder present with an extensive range of communication and social skills that require healthcare workers to have a comprehensive understanding of best practices for providing holistic care. This article presents the planning, curriculum development, implementation, and evaluation of a professional development program aimed at providing interprofessional staff with strategies and resources to use when caring for patients with autism spectrum disorder.

Emergency Department Utilization of Adolescents and Young Adults with Autism Spectrum Disorder

This study examined emergency department (ED) utilization by adolescents and young adults, 12-30 years of age (AYA) with autism spectrum disorder (ASD) using the 2016 Healthcare Cost and Utilization Project/National Emergency Department Sample (HCUP/NEDS). We investigated the principal reason for an ED visit, presence of an ambulatory care sensitive condition (ACSC), and likelihood of hospital admission following ED encounter in ASD and Non-ASD cohorts. The ASD cohort had a higher proportion of ED visits for ACSC diagnoses as compared to the Non-ASD cohort. In addition, the likelihood of admission following an ED visit in the ASD cohort was 3.7 times greater than in the Non-ASD cohort.

Planning surgery for young people with learning disabilities

Surgery for spinal deformity is complex and preparation involves a wide multidisciplinary team. For young people with learning disabilities, especially those who have behaviour that challenges, there are further considerations to ensure that their hospital stay is a positive experience and all their additional needs are met. Staff and carers need to be well informed and there must be effective communication. Evaluation of one patient's journey through pre-assessment, surgery and rehabilitation has identified the need for more input from learning disability liaison nurses in acute children's services.

Autism spectrum disorder and kidney disease

Neurodevelopmental impairments have been recognised as a major association of paediatric kidney disease and bladder dysfunction, presenting challenges to clinicians and families to provide reasonable adjustments in order to allow access to investigations and treatments. Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterised by impairments in social interaction/communication and repetitive sensory-motor behaviours. Mental health, learning and physical co-morbidities are common. There is emerging evidence that ASD and kidney disease have some overlaps with genetic copy number variants and environmental factors contributing to shared pathogenesis. Prevalence rates of ASD in kidney disease are currently not known. A high index of suspicion of underlying ASD is required when a young person presents with communication difficulties, anxiety or behaviour that challenges, which should then trigger referral for a neurodevelopmental and behavioural assessment. We discuss practical approaches for providing care, which include understanding methods of communication and sensory, behavioural and environmental adaptations.

Development and evaluation of a novel caregiver-report tool to assess barriers to physical healthcare for people on the autism spectrum

INTRODUCTION

People on the autism spectrum often experience poorer health than the general population despite higher engagement with the health services. This suggests a disparity in the accessibility of appropriate healthcare for autistic individuals. To improve access, barriers the autism community experience in healthcare first need to be identified. This paper aimed to: 1) develop and evaluate a caregiver-report tool; 2) identify barriers to physical healthcare for autistic individuals; and 3) identify potential contributing factors.

METHODS

A previously established taxonomy of barriers to healthcare for autistic individuals informed the development of the tool; this was then distributed to caregivers of autistic adults and children. Exploratory factor analysis (EFA) assessed validity and reliability of the tool. Multiple Regressions were performed to identify predictors of barriers.

RESULTS

In total, caregivers of 194 autistic children or adults participated in the study. The EFA produced four factors: 1) patient-level barriers; 2) healthcare provider-level (HCP) barriers; 3) healthcare system-level barriers; and 4) barriers related to managing healthcare. The greatest barriers included difficulties with identifying/reporting symptoms (endorsed by 62.4% of participants); difficulties handling the waiting area (60.3% of participants); and a lack of HCP knowledge regarding autism (52.1% of participants). Autism severity, general adjustment problems, anxiety, age and having unmet needs predicted the frequency and/or severity of barriers.

CONCLUSIONS

A tool that allows assessment of patient-, HCP-, and system-level barriers to healthcare was developed and evaluated. Patient-level barriers appear to occur frequently and pose substantial challenges. This tool will help identify areas most in need of intervention and support intervention evaluation.

Effectiveness of Adaptive Care Plans for Children with Developmental Disabilities During Outpatient Clinic Appointments

Children with developmental disabilities require more medical experiences than typically-developing children and struggle to cooperate with healthcare encounters. Adaptive care plans, delivered by child life specialists, are individualized patient-centered plans created to address the challenges that children with developmental disabilities experience. The current study evaluated if adaptive care plans affect the psychosocial outcomes of children with ASD compared to those with other developmental disabilities. One-hundred and sixty children between 3 and 18 years of age (child's M_age = 8.10, SD = 3.75) participated. Although children with developmental disabilities who had adaptive care plans did not generally experience less psychosocial distress; children with ASD who had adaptive care plans experienced fewer challenges with anxiety and coping compared to children with ASD who did not have adaptive care plans.

Barriers to Healthcare for Persons with Autism: A Systematic Review of the Literature and Development of A Taxonomy

Purpose: This review aimed to 1) synthesize extant research on barriers to healthcare access experienced by persons with autism, their caregivers, and health-care providers; and 2) present a taxonomy of barriers to physical healthcare for individuals with autism.Method: Systematic searches were conducted in five electronic databases. Methodological rigor was assessed using the Quality Assessment Tool for Studies with Diverse Designs. Thematic analysis was used to classify barriers and to develop a taxonomy.Results: In total, 31 articles were included in the review. The resulting taxonomy consisted of four themes: 1) Challenges Associated with Autism-related Characteristics; 2) Health-care Provider-based Issues; 3) Healthcare System Issues; and 4) Patient-related factors.Conclusions: Barriers to healthcare access for persons with autism are prevalent and occur at the patient, provider, and system levels. The taxonomy developed may facilitate measurement of barriers within health-care facilities and prompt identification of areas where interventions are warranted to improve care.

Providing Inpatient Medical Care to Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder, affecting an estimated 1 in 40 children. Children with ASD have high rates of medical comorbidity and often experience high levels of distress during medical admissions, increasing the risk of agitation. Pediatric hospitalists receive minimal formal training on the inpatient care of children with ASD. In this article, we review strategies that pediatric hospitalists can use to optimize the care of children with ASD during inpatient admissions. These include gathering an ASD-related history early in the admission to understand the child's baseline core ASD symptoms, including social and communication ability, sensory needs, and restricted or repetitive behaviors. This information can be used to tailor the hospitalist's approach in each of these 3 domains. We conclude by reviewing procedure-related considerations, an approach to managing agitation, and quality improvement interventions.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Addressing Challenging Behavior During Hospitalizations for Children with Autism: A Pilot Applied Behavior Analysis Randomized Controlled Trial

This study evaluated the feasibility, acceptance, and potential clinical benefit of brief applied behavior analysis (ABA)-based interventions for children and adolescents with autism spectrum disorder (ASD) displaying challenging behaviors during hospitalizations. Participants included 36 children diagnosed with ASD, 6-17 years of age, who were medically or psychiatrically hospitalized. Children in the intervention group received a brief ABA intervention and were compared to children in the evaluation and monitoring-only group. Families and staff recommended the intervention, children receiving the intervention demonstrated significantly more improvement in unblinded ratings of clinical severity, data from physicians indicated a positive effect of the intervention on levels of staffing and restraints and attending medical providers universally reported satisfaction and benefit of the intervention. Improvements in challenging behaviors were not significantly different as reported by parents, and the length of hospitalization did not differ between the groups. Ultimately, the outcomes of this pilot study suggest incorporating specialized ABA-based assessment and intervention during hospitalization may be feasible and well accepted by clinicians and families. However, future research must address potent methodological challenges related to capturing meaningful data during hospitalizations in order to answer questions of ultimate pragmatic, clinical, and system-level benefits. Trial Registration ClinicalTrials.gov Identifier NCT02339935, Registered 16 January 2015, First participant consented 23 February 2015. Autism Res 2020, 13: 1072-1078. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Inpatient hospitalizations for children with autism spectrum disorder (ASD) and severe behavior are common, challenging, and costly in terms of human experience. This study evaluated the benefit of brief applied behavior analysis-based interventions to children and adolescents with ASD displaying challenging behaviors during hospitalizations. Families and staff evaluating the procedures noted perceived potential benefits of the intervention, but this initial pilot study did not document changes in hospitalization length or blinded rating of improvement.

Increasing Comfort with Sensory Processing Difficulties in the Prehospital Setting: Pre-Post Study of Education and Sensory Tools in EMS Providers

OBJECTIVES

Interfacing with patients with sensory processing difficulties is challenging to healthcare providers and even more problematic for emergency medical services (EMS) personnel in the acute care setting. Sensory training may be an effective nonpharmacologic method to deal with these patient populations. The purpose of this study was to evaluate whether an educational session and placement sensory tools would improve the comfort of EMS providers in the prehospital setting.

METHODS

EMS providers from two agencies in the Alabama Gulf EMS System were selected for this study. Preeducation questionnaires were administered to EMS providers to assess their frequency and comfort level in taking care of patients with sensory processing difficulties. The educational session included a video presentation of various topics related to sensory processing difficulties and education on sensory tools. Posteducation questionnaires were administered to EMS providers 3 months posteducational session to assess the use of sensory tools and their comfort in patient care. Comfort level was assessed on a Likert scale of 1 to 10, with 1 being not comfortable at all and 10 being extremely comfortable. We performed descriptive statistics and the nonparametric Wilcoxon signed rank test to compare medians.

RESULTS

A total of 177 of 225 (78.6%) EMS providers completed the preeducation questionnaire. In the preeducation period, 159 (89.8%) EMS providers transported patients with sensory processing difficulties. The preeducation median comfort level was 7.5 (range 1-10). At postsurvey, 135 of 177 (76.3%) EMS providers received educational training; 37 (27.4%) used the sensory tools within the previous 3 months. The posteducation median comfort level was 8 (range 3-10). Pre- and post median comfort levels were significantly different using the Wilcoxon signed rank test (P = 0.006).

CONCLUSIONS

Sensory training can be an effective method for EMS providers to increase comfort levels in taking care of patients with sensory difficulties. Further research with larger sample sizes is needed to confirm/refute these findings.

Evaluation of the validity of psychological preparation for children undergoing polysomnography

STUDY OBJECTIVES

Nocturnal polysomnography (PSG) is an essential diagnostic technique to assess sleep abnormalities, including sleep-disordered breathing (SDB). Although low in invasiveness, it is extremely difficult to conduct PSG with children who are not cooperative with wearing electrodes and sensors. Particularly, it is difficult to conduct PSG on children with autism spectrum disorder (ASD) because they have poor predictive ability, exhibit extreme anxiety about novel and unfamiliar things, and have difficulty understanding verbal instructions. Recently, the usefulness of psychological preparation was reported. The primary aim of this study was to assess the usefulness of psychological preparation for PSG.

METHODS

The goal of our study was to assess the usefulness of psychological preparation for PSG. A total of 253 children were enrolled in the study: 131 in the control group (19 with ASD) and 122 selected for psychological preparation (51 with ASD).

RESULTS

In the preparation group, 110 of 122 (90.2%) could undergo regular PSG, a significantly higher percentage than the control group at 104 of 131 (79.4%), P = .018. Regarding hypnotic drugs, in the preparation group 111 of 122 (91.0%) underwent PSG without hypnotic drugs, which was a significantly higher percentage than in the control group at 107 of 131 (81.7%), P = .032. Additionally, 45 of 51 children with ASD in the preparation group (88.2%) could undergo PSG without hypnotic drugs.

CONCLUSIONS

This study indicated that psychological preparation was effective in facilitating PSG without hypnotic drugs in children who have difficulty cooperating with PSG, including those with ASD.

Caring for Children with Autism in the Emergency Department

Children with autism spectrum disorder (ASD) and similar conditions experience and cope with their surroundings in a unique way. Although a visit to the emergency department (ED) is stressful for any child, the stress for those with ASD and similar conditions can overwhelm their ability to cope. Many elements of visiting the ED contribute to the stress children with ASD experience; they are not feeling well or have an injury, the environment is foreign and filled with harsh stimuli, and the medical professionals they encounter may not understand their unique needs. Fortunately, through staff education, modifications to the environment, and individualizing care plans, a visit to the ED can be a more positive experience for children with ASD. [Pediatr Ann. 2019;48(8):e333-e336.].

Medical Encounters for Youth With Autism Spectrum Disorder: A Comprehensive Review of Environmental Considerations and Interventions

Approximately 1 in 59 youth are currently diagnosed with autism spectrum disorder (ASD), a neurodevelopmental disorder. In comparison to typically developing peers, youth with ASD encounter hospitalization at higher rates due to their heightened health care needs. While visiting the hospital is a stressor for youth with neurotypical needs, the experience contains unique challenges for those with ASD. This systematic literature review highlights research that considers the psychosocial impact of the hospital environment on the coping and adjustment of youth with ASD. Specifically, the review focuses on recommendations and interventions that may be used by health care professionals while supporting this population as they encounter the health care system. Ninety-six articles were identified as meeting inclusion and exclusion criteria. The findings suggest that practicing clinicians should implement a wide variety of interventions for youth with ASD including diversion techniques, comfort positions, and picture schedules. Although there are published evidence-based interventions for supporting youth with ASD in the hospital, most clinicians lack ASD-specific training. This article concludes with recommendations for future research.

Disparities in Care: Do Children with Autism Spectrum Disorder Experience Differential Medication Receipt In The Emergency Department?

OBJECTIVE

The primary objective of this study was to describe analgesia administration between neurotypical (NT) individuals and those with autism spectrum disorder (ASD) diagnosed with appendicitis or long bone fractures in the emergency department (ED). A secondary objective was to compare the rates of complicated appendicitis as a proxy for delayed diagnosis between the groups.

METHODS

This is a retrospective cohort study using the Pediatric Health Information System database. Study participants were children aged 6 to 18 years with ASD and with an ED visit for appendicitis or fracture between 2004 and 2015 who were matched to demographically similar NT children. Children with a developmental disorder and/or complex chronic condition were excluded. Coarsened exact matching and logistic regression were used to investigate the association between ASD status and opioid and non-opioid medication receipt. Comparison of the rates of complicated appendicitis in children with ASD and NT children was conducted before matching.

RESULTS

From 2004 to 2015, 126,412 children with appendicitis and 392,151 children with long bone fractures were identified. Of these, 889 children had a diagnosis of ASD and were matched to 35,672 NT controls with appendicitis. In addition, 2117 children with ASD were matched to 200,635 NT controls with long bone fractures. Receipt of opioids or nonsteroidal anti-inflammatory drugs was not found to be significantly different between the 2 groups. However, a larger proportion of children with ASD presented with complicated appendicitis compared with NT controls (37.1% vs 29.9%, respectively; p < 0.001).

CONCLUSION

Receipt of analgesia did not differ significantly between populations of ASD and NT peers. Children with ASD have increased rates of complex appendicitis, possibly suggesting limited access to care or provider difficulty in evaluating this patient population.

See-Hear-Feel-Speak: A Protocol for Improving Outcomes in Emergency Department Interactions With Patients With Autism Spectrum Disorder

The presentation of children and adolescents with autism in the emergency department (ED) poses a unique set of challenges to clinicians and their teams, which have not yet been met. Children and adolescents with autism spectrum disorder (ASD) are more likely than their age and ethnically matched counterparts to visit both pediatric and general EDs and are more likely to use it for primary care complaints and dental care and to present for psychiatric concerns including suicidality. Despite the higher relative frequency, individuals with ASD demonstrate lower patient satisfaction, lower healthcare self-efficacy, and higher odds of unmet healthcare needs related to physical health, mental health, health maintenance, and vaccination. This can be ameliorated by simple strategies regarding communication, sensory and environmental modification, and distraction. After performing a literature review of existing evidence-based recommendations via PubMed as well as resources from autism advocacy and self-advocacy groups, we compiled a 4-step system: "See-Hear-Feel-Speak" an approach conducive to learning with the goal of enabling clinicians and their teams to facilitate patient-centered encounters with pediatric patients with ASD. The protocol meets the practicality requirements defined by published research.

Creating a Sensory-Friendly Pediatric Emergency Department

INTRODUCTION

For children with autism spectrum disorder (ASD) and sensory-processing disorder (SPD), an unexpected visit to the emergency department can be an overwhelming experience that creates intensifying behaviors and an unsafe clinical interaction for the child, nurses, and providers. Although resources exist to help nurses work with this specialized group, there are limited examples of the challenges and opportunities of modifying an emergency department to be a place where nurses can provide sensory-informed care.

METHODS

Guided by Watson's Theory of Caring, nurses and child life specialists in our pediatric emergency department initiated a practice improvement (PI) project to create a sensory-friendly emergency department. The nurses (1) engaged with community members and families, (2) examined current practices, (3) modified the patient care environment, (4) collaborated in an interprofessional educational session, and (5) created a shared vision for the modified patient-care environment.

RESULTS

This article describes the nurse-initiated PI process and the journey to create an evidence-based sensory-friendly pediatric emergency department. A model is presented so that other facilities can embark on their own initiative, and case studies are used to evaluate project outcomes.

DISCUSSION

Integrating current evidence, staff suggestions, community input, and expert advice allowed us to find creative solutions to the unique sensory needs of children who visit our emergency department. Modifying both the patient-care environment and the patient-flow process to accommodate for the needs of children with ASD/SPD created a more peaceful and healing environment for children and their families and gave nurses the support they needed to provide sensory-informed care.

Utilization of a Novel Pathway in a Tertiary Pediatric Hospital to Meet the Sensory Needs of Acutely Ill Pediatric Patients

Objective: To identify pediatric patients with sensory sensitivities during a hospital visit, and to implement a clinical pathway that can meet their sensory needs. The goal is to remove barriers to care delivery that is related to the sensory need for pediatric patients who present with an acute medical illness. Methods: The clinical pathway (identified as 'Sensory Pathway') was developed as a joint effort between key stakeholders within the community and medical providers. The pathway was conducted in a tertiary pediatric hospital from September 2016-April 2019. The main components of this pathway included- 1. Staff training; 2. Provision of sensory toolkits and story board; 3. Early collaboration with allied professionals; and 4. Early and continuous parental involvement. The Sensory Pathway was implemented first in the emergency department, followed by inpatient units. Patients triggered the pathway through caregiver or staff identification. Demographic of patients who triggered the pathway was extracted. A detailed qualitative analysis of any parents' feedback received was performed. Results: A cohort of patients with sensory needs was identified amongst pediatric patients who presented to the hospital with an acute illness. The most common comorbidity associated with sensory sensitivity/need was Autism Spectrum Disorder (48%), followed by cerebral palsy (22.8%) and Attention-Deficit/Hyperactivity Disorder (16%). 1337 patients (51.8%) had a single comorbidity while 45.9% patients had more than one comorbidity. Only 1.3% patients had a known diagnosis of sensory processing disorder. The pathway was triggered in 2,580 patient visits with 1643 patients and 937 repeat visits. The vast majority of patients who triggered the pathway had a medical presenting complaint (vs. behavioral). The following themes emerged from the parents' feedback: 1. Additional help received specific to the child's sensory needs; 2. Feeling of comfort; and 3. Improved overall experience. Conclusion: The Sensory Pathway identified a unique profile of pediatric patients who have sensory needs during their hospital stay. The pathway was successfully implemented for children with sensory need in our hospital across a wide range of demographic and with varied medical illness.

Contemporary Trainee Knowledge of Autism: How Prepared Are Our Future Providers?

Background: Over the last several decades, the prevalence of Autism Spectrum Disorder (ASD) has continued to increase, creating a unique challenge for general physicians who are likely to encounter these patients in their practice. The primary aim of this cross-sectional study design was to identify potential knowledge gaps that were present among medical students and pediatric trainees (interns, residents, and fellows) particularly during the management of a sick child with ASD. Methods: A 23-question online survey was developed and distributed to medical students and pediatric trainees at a tertiary children's hospital affiliated with a medical school. Results: Medical students and pediatric trainees reported a low general knowledge of ASD and were unfamiliar with sensory issues that are often present in these children. Increased discomfort and insufficient didactic and clinical training for providing care to children with ASD during an acute illness were also identified. Both medical students and trainees reported the need for increased education and training, preferentially via patient interaction and small group-based learning. We found that as education/training levels increased, participants perceived increased comfort, and knowledge in managing an ill child with ASD. Conclusions: A perceived knowledge gap and discomfort is present amongst medical students and pediatric trainees on the management of children with ASD. Across all education levels, awareness for sensory dysregulation in ASD children is low. Education programs using direct patient interaction and small group learning were the preferred training modalities to learn how to provide optimal care for children with ASD.

Medical care experiences of children with autism and their parents: A scoping review

Children with autism spectrum disorder (ASD) and their families may benefit from the provision of additional supports in health care settings, particularly when preparing for and attending medical appointments. This review examined literature that describes experiences in medical care settings from the perspective of patients under age 18 with ASD and their caregivers. A scoping review was conducted to examine the experiences of children with ASD and their families in medical care settings. Twenty-nine studies meeting inclusion criteria were identified and reviewed. The review indicated a number of challenges (e.g., parent-reported problems in parent-provider communication and overwhelming environments) as well as factors that facilitate positive experiences (e.g., providing positive reinforcement and explaining exam steps) during medical appointments. Children with ASD and their families are faced with many challenges while receiving care in medical settings. The present review identified many challenges families face, as well as facilitators of positive experiences. Understanding the unique experiences of patients with ASD and their parents will help to improve experiences in medical care settings for children, caregivers, and health care providers.

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.

How do Parents Manage Irritability, Challenging Behaviour, Non-Compliance and Anxiety in Children with Autism Spectrum Disorders? A Meta-Synthesis

Although there is increasing research interest in the parenting of children with ASD, at present, little is known about everyday strategies used to manage problem behaviour. We conducted a meta-synthesis to explore what strategies parents use to manage irritability, non-compliance, challenging behaviour and anxiety in their children with ASD. Approaches included: (1) accommodating the child; (2) modifying the environment; (3) providing structure, routine and occupation; (4) supervision and monitoring; (5) managing non-compliance with everyday tasks; (6) responding to problem behaviour; (7) managing distress; (8) maintaining safety and (9) analysing and planning. Results suggest complex parenting demands in children with ASD and problem behaviour. Findings will inform the development of a new measure to quantify parenting strategies relevant to ASD.

Relationship between Psychological Capital and Psychological Well-Being of Direct Support Staff of Specialist Autism Services. The Mediator Role of Burnout

This study investigates the specific role of burnout as a mediator in the relationship between psychological capital and psychological well-being (PWB) in direct support staff of specialist autism services. A time lagged design with three data-collection points was conducted to survey 56 professionals (direct support staff) who work at a Spanish center specialized in autism. Participants completed measures of psychological capital, burnout and PWB. The hypothesized model was tested using structural equation modeling. Our findings show that psychological capital has a significant main effect on PWB. The results also show that psychological capital in the work environment should result in lower burnout which in turn, should lead to higher degrees of PWB in the direct support staff of autism services. Our results support that psychological capital is a key variable in the working life of the direct support staff of autism services. The findings suggest the need of implementing programmes which strengthen each individual's psychological capital in order to prevent burnout and achieve a greater PWB.

Safety Profile of Children in an Enclosure Bed

PURPOSE

Pediatric nurses care for many children in the hospital setting whose behavioral challenges can impact safety. One intervention utilized to prevent injury and improve safety when caring for this population of children has been the enclosure bed. Scant information was found in the literature that discusses the use of the enclosure bed in the pediatric setting. The purpose of this article is to examine the use of the enclosure bed in the pediatric setting. A secondary aim is to identify the population of children where an enclosure bed was implemented and the safety factors associated with use of the enclosure bed.

METHODS

An exploratory retrospective chart review was conducted of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period. Variables included demographics, length of stay and bed use, behavioral medications, restraint and sitter usage, skin breakdown, fall risk, and falls.

RESULTS

Three categories of children based on cognitive function, no cognitive impairment, new cognitive impairment, and congenital cognitive impairment, were extracted from the chart review. Significant differences were found between groups of children and between safety variables observed with enclosure bed use. Children with new-onset cognitive impairment were more likely to incur falls, skin breakdown, and injury during use of the enclosure bed.

CONCLUSION

Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety in the hospital setting. This information will enhance nursing knowledge related to providing safe and optimal care of this challenging population of children.

Interventions for paediatric surgery patients with comorbid autism spectrum disorder: a systematic literature review

AIMS

To survey perioperative management practices for paediatric patients diagnosed with autism spectrum disorder (ASD).

METHODS

A systematic review was carried out of empirical studies and case reports published in peer-reviewed journals of current best practices and behavioural interventions for paediatric patients with ASD who had undergone surgery.

RESULTS

The final sample included 11 articles published between 1997 and 2016 that met broad inclusion criteria of surveying perioperative interventions for the ASD population. There is broad endorsement across the scant publications on this topic of the following practices: increased attention to individual patient needs, rehearsal and other desensitisation efforts, departure from a sole focus on sedation or restraint of the combative or uncooperative patient and engaging caregivers in tuning perioperative management to individual needs.

CONCLUSIONS

This review supports the need for an individualised structure and approach to the perioperative care of these unique patients.

Perioperative and Anesthesia Guidelines for Children with Autism: A Nationwide Survey from Sweden

OBJECTIVE

The overall aim of this study was to describe the current set of guidelines for the preparation and care for children with autism spectrum disorder (ASD) in the perioperative setting across Sweden and explore the content of these guidelines in detail.

METHOD

An online questionnaire was distributed to the chairpersons of all anesthesia departments (n = 68) and pediatric departments (n = 38) throughout Sweden. Follow-up phone calls were made to those departments that did not return the questionnaire. The presence of guidelines was analyzed through descriptive statistics. These guidelines and comments on routines used in these departments were analyzed inspired by conventional content analysis.

RESULTS

Seven of the 68 anesthesia departments and none of the 38 pediatric departments across Sweden have guidelines for preparing and/or administering care to children with ASD within the perioperative setting. From the guidelines and routines used, 3 categories emerge: "lacking the necessary conditions," "no extra considerations needed," and "care with specific consideration for children with ASD." These 3 categories span a continuum in the care. In the first category, the anesthesia induction could result in the child with ASD being physically restrained. In the last category, the entire encounter with the health care service would be adapted to the specific needs of the child.

CONCLUSION

There is a lack of evidence-based guidelines specifically designed to meet the needs of children with ASD in the preoperative period in Sweden. Further research is needed to understand if children with ASD would benefit from evidence-based guidelines.