Toward Practice Advancement in Emergency Care for Children With Autism Spectrum Disorder

The use and prevention of procedural restraint in children - A scoping review

PROBLEM

In healthcare facilities, restraint may be used on children to perform treatments or procedures. Restraint can be harmful, and little is known about how to prevent the use of restraint during medical procedures. A scoping review was conducted to find and map knowledge about (1) the use and prevention of restraint and (2) approaches, such as interventions and guidelines, available to prevent the use of restraint.

ELIGIBILITY CRITERIA

This review was conducted following Arksey and O'Malley's framework, the JBI framework for scoping reviews, and the PRISMA-ScR (Protocol registration number GN5R3). Medline, EMBASE, PsycINFO, Epistemonikos, CINAHL, Cochrane Library were searched sept 2023. The search encompassed texts about children 1-18 years of age undergoing procedures conducted in non-psychiatric health care facilities.

SAMPLE

The sample size was 2943 texts, and 288 texts met the inclusion criteria, of which 188 were considered research.

RESULTS

Non-research texts consisted of reviews, demonstrations, opinions, and guidelines. The research lacked definitions of restraint though they described observations and attitudes toward restraint. Eight studies reported children's experiences. No evidence of how to prevent restraint was found, only reduction. Eleven guidelines were identified.

CONCLUSIONS

Few approaches have addressed how to reduce and prevent the use of restraints. Lack of a clear and united understanding and definition of restraint hinders the development of effective trials and guidelines.

IMPLICATIONS

Going forward, it is important to develop and explore approaches that build upon existing knowledge concerning restraint and positive procedural practice, including healthcare personnels competence, attitudes, and resources.

Improving patient-centred care in the emergency department: Implementation of a Sensory Toolkit for children with autism

Emergency department (ED) visits for children with autism can present challenges due to the unique sensory needs of this population. This Quality Improvement (QI) project executed two Plan-Do-Study-Act (PDSA) cycles to create and implement a Sensory Toolkit in the ED for children with autism. Most caregivers (94%; n = 31/33) and healthcare providers (HCPs; 86%; n = 37/44) identified the need for sensory items in the ED. In PDSA Cycle 1, 100% of caregivers (n = 21) and HCPs (n = 3) agreed/strongly agreed that the ED Sensory Toolkit was helpful. In PDSA Cycle 2, 92% of caregivers (n = 12/13) and 100% of HCPs (n = 3) agreed/strongly agreed that they were helpful. The Sensory Toolkit was positively evaluated by caregivers of children with autism and HCPs during the child's visit to the ED. There is an opportunity to adapt the Sensory Toolkit for other EDs and areas of the hospital.

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.

Designing a Sensory Kit to Improve the Environment for Children with Autism Spectrum Disorder in the Pediatric Emergency Department

Children with autism spectrum disorder (ASD) have more frequent use of healthcare services, including visits to the emergency department (ED). Medical care for children with ASD can be adversely affected by the highly stimulating environment of the ED. In this study, we gained insights from stakeholders with lived experience (parents of children with ASD, children with ASD, and ED healthcare providers) to create and implement a sensory equipment kit. The kit was evaluated and iteratively improved based on observations of children using the sensory equipment, satisfaction surveys from their parents, and interviews with healthcare providers in the ED. Findings from this study can be used to guide other EDs in creating their own ASD sensory kit.

Caregiver Satisfaction with Emergency Department Care for Pediatric Patients with Neurodevelopmental Disorders

OBJECTIVE

Children with neurodevelopmental disorders (NDDs) often encounter increased adversity when navigating the health care system. In this study, we explored the pediatric emergency department (PED) experience for patients with NDDs and their caregivers compared with that of patients without NDDs.

METHODS

Data for this study were obtained from National Research Corporation patient experience survey questionnaires and electronic medical record (EMR) data for patients presenting to a PED between May 2018 and September 2019. ED satisfaction was determined by the top-box approach; ED ratings of 9/10 or 10/10 were considered to reflect high ED satisfaction. Demographics, Emergency Severity Index, ED length of stay, time from arrival to triage, time to provider assessment, and diagnoses were extracted from the EMR. Patients with NDDs were identified based on International Classification of Diseases, Tenth Revision codes; patients with intellectual disabilities, pervasive and specific developmental disorders, or attention-deficit/hyperactivity disorders were included in the NDD cohort. One-to-one propensity score matching between patients with and without NDDs was performed, and a multivariable logistic regression model was built on the matched cohort.

RESULTS

Patients with NDDs represented over 7% of survey respondents. Matching was successful for 1162 patients with NDDs (99.5%), resulting in a matched cohort sample size of 2324. Caregivers of patients with NDDs had 25% lower odds of reporting high ED satisfaction (95% confidence interval [CI], 0.62-0.91, p = 0.004).

CONCLUSION

Caregivers of patients with NDDs make up a significant proportion of survey respondents and are more likely to rate the ED poorly than caregivers of patients without NDDs. This suggests an opportunity for targeted interventions in this population to improve patient care and experience.

Effects of the physical environment on children and families in hospital-based emergency departments: A systematic literature review

Every year, millions of children seek care in emergency departments (EDs) for various conditions. Though the physical environment of the ED provides the context and setting for care delivery, influences workflows, and shapes interactions between users, the noisy, sterile, stimulating nature of the ED can be counter-therapeutic to pediatric patients and families. This systematic literature review investigates this complex dynamic and asks how the physical environment of emergency departments affects children and their families or guardians. Using PRISMA methods, this review searched four databases to identify and analyze twenty-one peer-reviewed articles that explored the impacts of the physical environment of hospital-based EDs on children or family members. Several themes emerged from the literature - concerning control, positive distractions, family and social supports, and designing for a safe and comfortable experience - that illustrate opportunities for future ED design and highlight knowledge gaps and avenues for future research.

Sensory-Friendly Emergency Department Visit for Patients with Autism Spectrum Disorder—A Scoping Review

Our goal was to develop non-pharmacologic strategies for addressing sensory challenges that patients with autism spectrum disorder (ASD) face in emergency departments (EDs). Search of five databases for articles written in English and published since 1980 returned 816 citations, of which 28 papers were selected for review. All studies were published in the last nine years, with 92.85% (n = 26) conducted in North America. We developed 26 consolidated strategies, encompassing five major domains, including guiding principles, care processes, people (behavior of staff members), objects, and places (facility design). Sensory-friendly care in ED requires an integrative approach and its success depends on guiding principles that tie various aspects of care and distinguishes ASD care from non-ASD care.

Assessing Ease of Delivering Emergency Care for Patients with Autism Spectrum Disorders

OBJECTIVE

The aim of this study was to develop a method for objectively assessing the delivery of care to children with autism spectrum disorder (ASD) in the emergency department (ED).

METHODS

A case-control study of patients ages 2 to 18 years admitted to the hospital from January 2016 to January 2018. Cases were defined as patients with an International Classification of Diseases, Tenth Revision diagnosis of ASD or other pervasive developmental disorder (F84) in their medical record and were matched 1:1 with neurotypical controls. The primary outcome was ability to complete several core tasks clinically necessary within an ED visit and summarized into a Task Completion Index (TCI).

RESULTS

Overall, children with ASD had higher median TCIs of 0.25 (interquartile range [IQR] 0-0.45) versus 0 (IQR 0-0.25) when compared with children without ASD (p < 0.01). Children with ASD were 5 times more likely to have difficulty with triage vitals, 3 times more likely to require additional staff for peripheral intravenous placement, and 4 times more likely to experience delays or disruptions to their plan of care. The TCI was also associated with 8-fold increased odds of receiving pharmacologic or physical restraint.

CONCLUSIONS

The TCI reflects difficulty accomplishing core tasks necessary to complete an ED visit. Children with ASD have higher TCIs than neurotypical controls, which puts them at higher risk for care disruptions. Evaluation of initiatives to improve quality of care for children with ASD should focus not only on metrics of overall experience and satisfaction but also how these initiatives affect the ability to effectively administer care.

Brief Report: The Experiences of Families of Children with an Autism Spectrum Disorder When Seeking Patient-and Family-Centered Care

Patient-and family-centered care (PFCC) is a partnership among healthcare professionals, patients, and families that is grounded in mutual respect and is an approach that impacts delivery of care, decision-making, and information sharing. PFCC should be implemented for all, including individuals with Autism Spectrum Disorders (ASD), who experience adverse medical encounters despite increased prevalence and healthcare utilization. Insights into the experiences of families during medical experiences can inform clinical practice by increasing healthcare professionals' understanding of the population. Using a mixed-methods approach, the perspectives of 40 families were analyzed. The themes include barriers and opportunities to improve upon the delivery of PFCC, which help to advance healthcare interactions and inform solution-based initiatives to facilitate medical visits that may benefit all patients.

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.

An Australian Cross-Sectional Survey of Parents' Experiences of Emergency Department Visits Among Children with Autism Spectrum Disorder

Parents of children with ASD who had attended an Australian emergency department (ED; n = 421) completed a questionnaire relating to their experiences in the ED, including (1) child's reason for presentation and existing comorbidities, (2) quality of care during the visit (3) child's behaviour during visit, e.g. sensory responses to the ED environment, and disruptive behaviours. Children with comorbid ASD and intellectual disability were more likely to present with gastrointestinal issues and seizures, while those with comorbid ASD and oppositional defiant disorder were more likely to present with self-injury. ED staff awareness of ASD-related issues, including communication and expression of pain, were common difficulties for parents. The ED environment (e.g. lights, sounds, waiting areas), exacerbated child anxiety and led to disruptive behaviour.

Improving Emergency Care for Children With Medical Complexity: Parent and Physicians' Perspectives

OBJECTIVE

Children with medical complexity (CMC) have high rates of emergency department (ED) utilization, but little evidence exists on the perceptions of parents and pediatric emergency medicine (PEM) physicians about emergency care. We sought to explore parent and PEM physicians' perspectives about 1) ED care for CMC, and 2) how emergency care can be improved.

METHODS

We performed semistructured interviews with parents and PEM physicians at a single academic, children's hospital. English-speaking parents were selected utilizing a standard definition of CMC during an ED visit in which their child was admitted to the hospital. All PEM physicians were eligible. We developed separate interview guides utilizing open-ended questions. The trained study team developed and modified a coding tree through an iterative process, double-coded transcripts, monitored inter-rater reliability to ensure adherence, and performed thematic analysis.

RESULTS

Twenty interviews of parents of CMC and 16 of PEM physicians were necessary for saturation. Parents identified specific challenges related to ED care of their children involving time, information gathering, logistics/convenience, and multifaceted communication between health teams and parents. PEM physicians identified time, data accessibility and availability, and communication as inter-related challenges in caring for CMC in the ED. Suggestions reflected potential solutions to the challenges identified.

CONCLUSIONS

Time, data, and communication challenges were the main focus for both parents and PEM physicians, and suggestions mirrored these challenges. Further research and quality improvement efforts to better characterize and mitigate the identified challenges could be of value for this vulnerable population.

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.

Patient- and Family-Centered Care in the Emergency Department for Children With Autism

BACKGROUND

Emergency department (ED) care processes and environments impose unique challenges for children with autism spectrum disorder (ASD). The implementation of patient- and family-centered care (PFCC) emerges as a priority for optimizing ED care. In this article, as part of a larger study, we explore PFCC in the context of ASD. Our aims were to examine how elements of PFCC were experienced and applied relative to ED care for children with ASD.

METHODS

Qualitative interviews were conducted with parents and ED service providers, drawing on a grounded theory approach. Interviews were audio recorded, transcribed verbatim, and analyzed by using established constant comparison methods. Data were reviewed to appraise the reported presence or absence of PFCC components.

RESULTS

Fifty-three stakeholders (31 parents of children with ASD and 22 ED service providers) participated in interviews. Results revealed the value of PFCC in autism-based ED care. Helpful attributes of care were a person-centered approach, staff knowledge about ASD, consultation with parents, and a child-focused environment. Conversely, a lack of staff knowledge and/or experience in ASD, inattention to parent expertise, insufficient communication, insufficient family orientation to the ED, an inaccessible environment, insufficient support, a lack of resources, and system rigidities were identified to impede the experience of care.

CONCLUSIONS

Findings amplify PFCC as integral to effectively serving children with ASD and their families in the ED. Resources that specifically nurture PFCC emerge as practice and program priorities.

Working with Children with Autism Spectrum Disorder in a Medical Setting: Insights from Certified Child Life Specialists

This study aimed to gain an understanding of Certified Child Life Specialists' (CCLS) experiences with and suggestions for working with children with autism spectrum disorder (ASD) in a medical setting. Using a mixed-method design, 118 CCLS completed an online survey and 16 participated in follow-up interviews. Participants believed many medical professionals, including CCLS, are not adequately prepared to work with children with ASD, negatively impacting quality of care. Participants emphasized that outcomes are best for children with ASD when parents and medical staff collaborate to meet the unique needs of each child. CCLS reported working with children with ASD can provide insights for enhancing the quality of care for all children. Participants' suggestions for training and resource development are discussed.

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.

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.

Health social work in Canada: Five trends worth noting

Highlighting a strong human rights and social justice orientation underlying health social work in Canada, this paper describes recent contributions of Canadian health social work practitioners and scholars to five areas identified by Auslander (2001) in a delphi study of health social work in its first century. Five current 'trends' are discussed which correspond with Auslander's themes of professional legitimacy and scope, social causation, dissemination of knowledge, interventions, and cultural appropriateness. These trends are: 1) defining the scope of health social work practice; 2) addressing the social determinants of health; 3) promoting evidence-based practice in health social work; 4) delivering client and family-centered care; and 5) implementing cultural safety and trauma-informed practice. Suggestions are made to further strengthen the position of health social work in Canada.

Parental Perception of the Perioperative Experience for Children With Autism

Children with autism spectrum disorders (ASDs) face unique challenges when preparing for and undergoing surgery in the perioperative setting. Our goal was to describe this experience via the qualitative evaluation of interviews with parents whose children with ASD had recently undergone surgery in a tertiary medical center. Twelve parents or guardians participated in these interviews. Two independent researchers recorded interviews and analyzed transcripts. The researchers analyzed the interview transcripts using qualitative software to determine the categories of frequent answers to interview questions. Important categories that emerged included behavioral triggers (ie, response to sounds, expression of anxiety and pain), objects used for comfort, communication issues, important people, and advice. We found that children with ASD have specific and unique needs for reassurance and comfort during a perioperative visit. We created a tool, included in this article, to provide a patient-centered framework for interactions with children with ASD in the perioperative environment.

Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members

BACKGROUND

Children with autism spectrum disorder are challenging to sedate because of communication, sensory, and behavioral challenges.

AIMS

The aim of this survey was to determine how procedural sedation is provided to children with autism spectrum disorders and whether sedation programs have specialized protocols for procedural sedation of these children.

METHODS

We surveyed physician Medical Directors of sedation programs who are members of the Society for Pediatric Sedation, asking about practice characteristics and resource utilization during procedural sedation of children with autism spectrum disorders.

RESULTS

Of 58 directors, 47 (81%) responded. Of the programs surveyed, 53% were either a large university medical center and 40% were a freestanding children's hospital. Only (12/47, 25.5%) of the programs used an individualized autism coping plan. To accomplish procedural sedation in this study cohort, 36% of the programs used additional nurses, whereas a child life specialist was used in 55% of the programs surveyed. Only 28% of the centers allotted additional time to accommodate children with autism spectrum disorders. Distraction methods were used in 80% whereas restrains were used in 45% programs for were used most commonly for i.v. catheter placement. Propofol was the preferred agent for 70% of programs for imaging, while propofol + fentanyl was used by 66% of programs for painful procedures. Although 57% of directors reported that their program staff was extremely comfortable providing procedural sedation for children with autism spectrum disorder, 79% of the directors wanted more education about behavioral management strategies for procedural sedation of these children.

CONCLUSION

Among the Society for Pediatric Sedation programs, significant institutional variation exists on the delivery of procedural sedation to children with autism spectrum disorders. A better understanding of resources required, standardization of behavioral management strategies and pharmacologic approaches, and protocol development may help optimize care to this vulnerable population.

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.

Outpatient Procedural Sedation of Patients With Autism Spectrum Disorders for Magnetic Resonance Imaging of the Brain Using Propofol

OBJECTIVE

To quantify the number of personnel, time to induce and complete sedation using propofol for outpatient magnetic resonance imaging (MRI) of the brain, and the frequency of serious adverse events (SAEs) in children with autism spectrum disorder (ASD) compared with children without ASD.

RESULTS

Baseline characteristics were the same between both groups. Overall sedation success was 99%. Although most children were sedated with ≤3 providers, 10% with ASD needed ≥4 providers (P = .005). The duration of sedation was less for the ASD group compared with the non-ASD group (49 minutes vs 56 minutes, P = .005). There was no difference in SAE frequency between groups (ASD 14% vs non-ASD 16%, P = .57).

CONCLUSION

Children with ASD can be sedated for brain MRI using propofol with no increased frequency of SAEs compared with children without ASD. Sedation teams should anticipate that 10% of children with ASD may need additional personnel before propofol induction.

Predictors of emergency department use by adolescents and adults with autism spectrum disorder: a prospective cohort study

OBJECTIVES

To determine predictors of emergency department (ED) visits in a cohort of adolescents and adults with autism spectrum disorder (ASD).

DESIGN

Prospective cohort study.

SETTING

Community-based study from Ontario, Canada.

PARTICIPANTS

Parents reported on their adult sons and daughters with ASD living in the community (n=284).

MAIN OUTCOME MEASURES

ED visits for any reason, ED visits for medical reasons and ED visits for psychiatric reasons over 1 year.

RESULTS

Among individuals with ASD, those with ED visits for any reason were reported to have greater family distress at baseline (p<0.01), a history of visiting the ED during the year prior (p<0.01) and experienced two or more negative life events at baseline (p<0.05) as compared with those who did not visit the ED. Unique predictors of medical versus psychiatric ED visits emerged. Low neighbourhood income (p<0.01) and living in a rural neighbourhood (p<0.05) were associated with medical but not psychiatric ED visits, whereas a history of aggression (p<0.05) as well as being from an immigrant family (p<0.05) predicted psychiatric but not medical emergencies.

CONCLUSIONS

A combination of individual and contextual variables may be important for targeting preventative community-based supports for individuals with ASD and their families. In particular, attention should be paid to how caregiver supports, integrative crisis planning and community-based services may assist in preventing or minimising ED use for this vulnerable population.

Evidence-Based Considerations and Recommendations for Athletic Trainers Caring for Patients With Attention-Deficit/Hyperactivity Disorder

CONTEXT

Patients with attention-deficit/hyperactivity disorder (ADHD) can be noncompliant, impulsive, and disruptive in an athletic training or physical rehabilitation facility. Athletic trainers (ATs) are valuable and essential health care providers for active patients with ADHD. However, for a patient with ADHD to have a successful outcome in a busy athletic training environment, the AT or health care provider must tailor the treatment setting to the patient's needs.

OBJECTIVE

To educate and raise awareness among ATs about patients with ADHD and to provide ATs with strategies and tools that will allow them to treat patients with ADHD more effectively.

DATA SOURCES

We retrieved and reviewed articles from PubMed, PsychINFO, and Ovid without date restrictions. Search words were attention deficit hyperactivity disorder plus 1 of the following topics or search words: athletic training, athletics, coaching, sport, or sport psychology.

STUDY SELECTION

Any ADHD articles that were not applicable or translatable in good faith to athletic training, physical rehabilitation, or sport and exercise were excluded.

DATA EXTRACTION

Nonpharmacologic interventions were reviewed and amassed into categories from which the recommendations were created. No statistical analyses were conducted for this review.

DATA SYNTHESIS

We identified 1241 articles, and 86 met the inclusion criteria. Five groups of evidence were observed: (1) goal setting and coaching, (2) reinforcements and outcomes, (3) routines and treatment timing, (4) simplified feedback and instructions, and (5) environmental control. Reliable evidence suggests that these techniques can be translated and applied within an athletic training and physical rehabilitation setting.

CONCLUSIONS

Athletic trainers are a vital component in providing health care for patients with ADHD. Using goal contagion creates a structured environment and positive reinforcements that accommodate patients with ADHD. Furthermore, ATs may use the evidence-based recommendations in this review to create a treatment and physical rehabilitation program and space that are tailored to the needs of the ADHD patient to increase the chance of a successful outcome.

Experiences of emergency department care from the perspective of families in which a child has autism spectrum disorder

Care for children with autism spectrum disorder (ASD) in the emergency department (ED) is increasingly recognized as difficult. Communication, sensory and behavioral challenges in a high intensity environment pose risks for negative experiences and outcomes. Through semi-structured interviews, parents (n = 31) and their children (n = 4) with ASD shared their perspectives on ED care. Participants identified issues that negatively affected care experiences, including care processes, communication issues, insufficient staff knowledge about ASD, and inadequate partnership with parents. Elements contributing to an improved ED experience were also cited, including staff knowledge about ASD, child- and family-centered care, and clarity of communication. Findings inform an emerging model of ED care. Recommendations for capacity building and practice development are offered.

An Instrument to Prepare for Acute Care of the Individual with Autism Spectrum Disorder in the Emergency Department

We present an instrument to allow individuals with autism spectrum disorder, their families and/or their caregivers to prepare emergency department staff for the care needs of this patient population ahead of acute presentation.