Assessment and Care for Patients on the Autism Spectrum

Transcription

1 Assessment and Care for Patients on the Autism Spectrum

2 Autism Spectrum Disorder (ASD) refers to a group of complex neurodevelopment disorders characterized by repetitive and characteristic patterns of behavior and difficulties with social communication and interaction. The symptoms are present from early childhood and affect daily functioning.

3 ASD is a brain-based developmental disability, which differs from mental retardation. A characteristic feature of ASD is a dramatic deviation from normal development and not a delay in development that one would observe with mental retardation. Deviations become apparent by 3 years of age.

4 Patient Encounters Public Locations Schools, stores, MVC s, anywhere they can wander (found by others) Know where your group homes, adult daycare centers, or other facilities that service an ASD population are located. At Home Family or household member - call for medical care, fire, domestic disturbance, etc. Individual with ASD (whether child or adult establish guardianship) May be there for an issue with the ASD or may be a separate medical/traumatic event.

5 If unconscious - treat just as any other patient. If conscious - Carefully consider all actions and focus on initial observational assessment. Once they become frightened it might not be reversible. Inquire from parent if the are acting differently. General Impression Look past the disability. If the parents are calling, it is bad! They do not want to stress their child further. The fear of judgment or misunderstanding also prevents them from calling unless absolutely necessary. Many have heard about or had negative encounters with first responders.

6 Communication Tips Speak Slowly Use five or less words Use simple, concrete language Give commands or requests one at a time Consider other means of communications such as picture boards, sign language, writing information down, offering pen and paper or computer, demonstrating what is required, singing or whispering the request or instruction (even with adults)

7 Communication Tips Speak simply; give plenty of time for an individual with autism to respond to questions. A 3 4 second delay is not uncommon. Repeat your question and wait again. Use a calm voice. Be aware that some autistic persons use of yes and no to answer questions may be random and misleading. Try inverting your questions to validate the patient s response. Some on the spectrum will utilize aggression as their means of communication when they cannot be understood. Don t presume a nonverbal child or adult who seems not to be listening, can t understand. Many with autism won t look directly at you.

8 Exam Tips Expect the unexpected. Children with autism may ingest something or get into something without their parents realizing it. Look for less obvious causality and inspect carefully for other injuries. If possible ask a caregiver what the functional level of the individual with autism is, then treat accordingly. Stickers, stuffed animals and such which are used to calm young children may be helpful even in older patients. If a caretaker is present, allowing the caretaker to ask the questions involved in an exam may increase the likelihood of getting information from the person.

9 30 40% of individuals with autism will develop epilepsy or some other seizure disorder during adolescence. Exam Tips Individuals with autism have a difficult time reading facial expressions. The Wong-Baker Faces Pain Rating Scale will NOT be an accurate measurement for pain. Some individuals with autism do not have a normal range of sensations and may not feel the cold, heat or pain in a typical manner. In fact they may fail to acknowledge pain in spite of significant pathology being present. They may show an unusual pain response that could include laughter, humming, singing and removing of clothing. Individuals with autism often have tactile sensory issues. Band-Aids or other adhesive products could increase anxiety and aggression. Some can have extreme response to smells

10 Exam Tips Individuals with autism may engage in self stimulatory behavior such as hand flapping, finger flicking, eye blinking, string twirling, rocking, pacing, making repetitive noises or saying repetitive phrases that have no bearing on the topic of conversation. This behavior is calming to the individual, even if it doesn t appear calming. They may repeat something you said or something they heard over and over and over again. This is called echolalia and can be calming to the individual. If these behaviors are NOT presenting as a danger to themselves or others it is in the your best interest not to interfere with it. Allow it to continue as long as they are safe and safe to be around. Trying to stop it will increase their anxiety and may cause the individual to act out aggressively.

11 Exam Tips When restraint is necessary, be aware Explain what you plan to do in advance that many individuals with autism and as you do it. Explain where you have a poorly developed upper trunk are going and what they may see and area. Positional asphyxiation could who might be there. This may avert occur if steps are not taken to prevent unnecessary anxiety and/or outbursts it: frequent change of position, not or aggressions from the patient. keeping them face down. Individuals with autism may continue to resist restraint; and can be very strong. Allow a caretaker to ride with the patient if possible. This will reduce anxiety improving patient condition and make your job less difficult.

12 Common Medical Conditions Psychiatric anxiety, depression, OCD, schizophrenia (Substance Abuse among PDD-NOS, Suicide among Aspergers) GI Diseases Most common is chronic diarrhea and constipation. (Abd pain may be evidenced in unusual behavior including frequent clearing of throat, screaming, moaning, wincing or facial grimacing, sleep disturbances or self-injurious actions.) Nutritional and Metabolic Conditions Often due to extended patterns of only eating certain foods or particular times results in nutritional deficiencies. Neurological Conditions epilepsy/seizure disorders, motor impairments Catalepsy Decreased speech or mobility, freezing during actions, posturing, staring, negativism, and echophenomena. Sleep Disorders Self-Injurious Behavior Cardiovascular May be due to autonomic dysfunction. Must rule out acute causes of these conditions; do not assume normal for the patient.

13 Common Medications in Autism

14 Common Medications continued

15 Common Medicines in Autism

16 Management Strategies Imitation/Role Modeling Paired with Rewards After patient complies with a Reinforcement Modeling is a procedure request, such as move your toes during a that presents a sample of a given behavior to physical examination, offer a reward (high an individual to induce that individual to five or good job ). engage in a behavior. To obtain an axillary temperature, initially use a non-threatening object, such as a pen. Model the procedure on yourself, and then have the parent and child do it. Next, have the child use the thermometer probe on themselves. Follow each step with praise or reward. The process is as follows: medic s turn ( my turn) and then patient s turn ( your turn ).

17 Management Strategies Shaping Shaping is the development of a High-Probability Request/Low-Probability new behavior by successive reinforcement of Request To obtain a blood pressure (BP) closer approximations and the extinguishing reading: In a fashion similar to Simon Says, of preceding approximations. Shaping can be quickly give requests, Touch your ear, touch used in the task of moving to the stretcher. your nose, and hold your arm out straight. Ask to move and if a small attempt is Praise. Repeat, and then put on the cuff. made, praise the patient. Ask again for the Repeat, pump up cuff, and then deflate. desired behavior (imitation can be Praise. Repeat and auscultate BP. Praise. incorporated here). Initially, reward any attempt. Slowly delay praise or reward until a close imitation of the behavior is achieved.

18 Differential Reinforcement Praise the Token Systems At the start of the physical patient when they are compliant to a request exam, give the child a token upon or behaving appropriately. Give no reaction, compliance with a simple request. Intervals praise or reinforce when a request is refused for tokens should be short initially, and as or when an inappropriate behavior is exam proceeds, the frequency of token demonstrated. Catch the patient being reward can be reduced. The predetermined good, responding to a request or making a reward can be a sticker, high five or activity. good effort, and immediately praise and/or The key is that the anticipation of the reward reward the patient. will motivate the child to comply

19 Choices It is important for patients with autism to express preferences and make choices to increase personal autonomy and quality of life. Research has found that choice making can help decrease avoidance behavior and improve task performance. Make choice a detail within the task and not the task itself. Example, Which arm would you like to use to check your blood pressure? or What color band aid do you want? Visuals Most with autism are visual learners. When information is presented with a visual as opposed to verbal cues, they are more successful at accomplishing the task or accepting treatment. Show equipment prior to using it and show a picture of the hospital before going there.

20 Distraction Techniques Use conversation, singing, counting, reciting the alphabet, or toys to decrease the amount of anxiety related to assessment, treatment, and transport. For example, sing a song with the patient to make them comfortable with you or let them bring a favorite toy to make them feel safe. Body-Hold Minimizing the use of restraint is optimal. Gentle holding by parents or caregivers and health care providers is preferred over devices. It is important to work as quickly as possible to decrease the frustration level of all involved. Preparing the parents or caregivers for their role in the procedures, particularly IV insertion, is an important step and can be done through demonstration. Never underestimate their strength, especially if become agitated or frightened.

21 SOURCES: National Institute of Health. National Library of Medicine ( Autism Asperger s Digest May-June 2008 ASDF Autism 101 for Paramedics/EMS (Emergency Medical Service) Arvind Venkat, Edward Jauch, William Scott Russell, et al., Postgrad Med J : Pediatric Nursing Journal 2002 (28)(6 Tami and Lee Kayea; Pam and Matthew Owens Autismspeaks.org