Managing Autism Spectrum Disorder Behavior in the Pediatric Hospital Setting

Nicole Englebert, MS Psychology Intern Pediatric Behavioral Health Primary Childrens Medical Center Salt Lake City, Utah

Prevalence
How common are Autism Spectrum Disorders?
8.4% of all the 8-year-old children in the US in 2008 were diagnosed with an ASD 1 in 88 children in the United States has been identified as having an Autism Spectrum Disorder (ASD) 1 in 47 children diagnosed with an ASD in Utah
Boys: 1 in 32 Girls: 1 in 85

Children with an ASD may present with unique health care needs related to underlying conditions
Fragile X Syndrome Tuberous sclerosis Epilepsy (prevalence ranges from 11-39%) Gastrointestinal Problems

Diagnostic Classifications
Autism Spectrum Disorders include:
Autism Aspergers Syndrome Pervasive Developmental Disorder Not Otherwise Specified

Diagnostic Classifications
Clinical features

Coexisting difficulties

Impairments in social interaction Impairments in communication Restrictive/repetitive behavioral repertoire Over or under sensitivity to sensory stimuli Difficulty with changes
Sleep dysfunction Challenging behaviors/psychiatric conditions Developmental and cognitive delays Learning disorders Sensory integration issues

Diagnostic Considerations
1. Rule out or treat medical causes for behavior/behavior deterioration 2. Consider environmental factors that may precipitate challenging behaviors 3. Consider trial of psychopharmacological medication

Behavioral Health Assessment

Identify coexisting problems/disorders Provide behavioral management strategies Provide information to assist in treatment planning Provide staff with techniques and information regarding at-risk behaviors
Offer recommendations for self injurious or physical harm/aggressive behaviors

Provide information about patients pain experience Assess the need for medication management Provide outpatient referrals

Case Example
13 year old female with Autism s/p peritonsillar abscess incision and debridement and tonsillectomy who presents with agitation and aggression towards staff
Behaviors include: extubated herself on one occasion, hitting, kicking, & screaming

Reason for referral: provide recommendations to manage patients behavior while the team weans sedation and patient undergoes daily wound care for about a 3 week time period

4 Areas of Assessment
1. Behavior

2. Communication/social skills
Forms of communication used Ability to follow commands

Baseline, current, and problematic behaviors Meaning of behavior ABCs of behavior Ability to imitate/role model

3. Somatosensory disturbances

4. Effective strategies for compliance

Over-reactivity vs. under-reactivity Fixations/perseverations Abhorrence to sensory stimuli

Effective coping/distraction/behavioral techniques Previous medical experiences (pos & neg)

Assessment of Case Example

Behavior
Baseline behavior
aggressive, combative, history of attacking professionals, eating hair/objects, digging out bowel movements, inattention

Communication
Rote/repetitive verbal language Writes using idiosyncratic language Hand signals

Illness impacts behavior

Pain triggers irritability Fever and advanced illness patient becomes more calm

Somatosensory
Sensitive to light, personal boundaries, sensitive to change

Effective strategies
Holding, sensory stimulation and weighted vests Ineffective strategies- fights restraints Rewards- food, coloring, stickers, play Calming strategies- tactile, visual, and auditory stimulation Constant redirection

Current behavior/target behaviors

hitting, kicking, physical agitation

Triggers
boredom, weather, sensory issues, changes in environment

Protocols
rewards at school, one on one attention Consequences include holding, safe timeout room

Interventions
Behavioral Issues
Structure environment to avoid triggers Difficulties adjusting Consistent routines/staff Establish clear expectations 1 on 1 supervision for at risk behaviors Behavioral reinforcement program/ Offer choices Distraction techniques Exercise
Psychoeducation Instruct family to bring in familiar materials from home

Modeling, shaping, rewards, token economy, differential reinforcement Toys, games, music, etc.

Interventions
Communication issues
Use communication methods Provide materials Speech therapy consult Use of visuals Occupational therapy consult Dietary consult for food aversions/malnutrition concerns Minimize stimulation/increase stimulation Utilize sensory strengths as calming strategies
Body-hold techniques

Somatosensory concerns

Effective strategies

Implement previously effective strategies Child life consult Utilize volunteers & therapeutic pets Parental support- utilize social work Education consult/music therapy consult Psychoeducate team/staff and provide support

Case Example Intervention Recommendations

Psychoeducation Behavioral programming
1 on 1 supervision Consistent caretakers/limit amount of professionals in the room Rewards as implemented at school Redirection with activities Consistent schedule/post schedule on board Use calming strategies, especially during wound care Dim lights Parents to bring in familiar toys, games, etc. Allowed patient to decorate her room Prepare for procedures
Bubble machine, calm music

Additional teams consulted:

Child life, occupational therapy

Key Points
ASD is common and children with ASD require the same medical care as children without ASD and may even require more medical care than the average child for underlying medical conditions. They present with behavioral, communication, and sensory deficits that can range and potentially impact compliance in the hospital. Assess behavior, communication/social skills, somatosensory issues, and effective strategies for compliance to help guide environmental modifications. Identify and avoid triggers of problematic behaviors Behavioral health interventions
Provide psychoeducation Modify the environment to reduce triggers of problematic behavior Implement behavioral programming and calming strategies Provide consistency in the patients environment

Multidisciplinary team approach is necessary to not only implement interventions but to support patient, parents, and staff.

Additional Autism Resources

CARD
http://www.centerforautism.com/

Autism Speaks- Utah Resource Guide

http://www.autismspeaks.org/resource-guide-bystate?long_state_name=Utah&field_resource_sta te_value=UT

Working With Autism- Guide

http://www.workingwithautism.info/visualschedu les.htm

References
Centers for Disease Control and Prevention (2012, March). Prevalence of Autism Spectrum DisordersAutism and Developmental Disabilities Monitoring Network. Retrieved May 3, 2012, from Morbidity and Mortal Weekly Report (MMWR), 61(3): http://www.cdc.gov/ncbddd/autism/documents/ADDM-2012-Community-Report.pdf Myers, S. M., Johnson, C. P., & the Council on Children With Disabilities (2007). Management of Children With Autism Spectrum Disorders. The American Academy of Pediatrics, 120(5), 1162- 1182. doi: 10.1542/peds.2007-2362 Scarpinato, N., Bradley, J., Kurbjun, K., Bateman, X., Holtzer, B, & Ely, B. (2010). Caring for the Child With an Autism Spectrum Disorder in the Acute Care Setting. Journal for Specialists in Pediatric Nursing, 15(3), 244-254. doi: 10.1111/j.17446155.2010.00244.x Souders, M. C., Freeman, K. G., DePaul, D., & Levy, S. E. (2003). Caring for Children and Adolescents with Autism Who Require Challenging Procedures. Pediatric Nursing, 28(6), 555-562. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/12593340