When a child with autism arrives at the emergency department, the approach to care should be as individualized as the treatment itself.
The ED itself is almost a caricature of everything that can tip the delicate behavioral balance for children on the autism spectrum: bright lights, loud noises, and scurrying strangers who want to get close with dangerous-looking implements. Combine that sensory onslaught with the pain of an injury or illness, and the result can be a bomb that threatens the child’s optimal care at least, and the safety of staff at worst.
Dr. Thomas Chun
"When you are caring for a child with autism, you are a stranger in a strange land," said Dr. Thomas Chun, an emergency physician at the Hasbro Children’s Hospital, Providence, R.I. "You don’t know who you are to them, or who they are, or where they are," on the autism spectrum.
A core trait of autism is hypo- or hyperreactivity to stimuli, according to Dr. Joseph Horrigan, a child psychiatrist who is head of medical research for the advocacy group, Autism Speaks. "The hyperreactivity can be really challenging for many children with autism and their medical caregivers. In conjunction with this, it’s not at all unusual for these children to have anxiety, so there is a very low threshold for catastrophic stress responses, particularly if there is some sort of intellectual disability, or no decent method of communication."
Absence of social reciprocity is another unifying characteristic of autism, Dr. Chun said at a meeting sponsored by the American College of Emergency Physicians. But that characteristic can be expressed in a multitude of ways, from completely withdrawn and silent, to parroting adult speech, to full-blown violence. "It’s an incredibly wide spectrum, and in order to help that child, you need to know" where he or she falls on that spectrum. In this maze, the parents should be your most-trusted guides, he said.
"They have been dealing with this the child’s entire life. They know what calms and bothers him. They know the cognitive level, the best ways to communicate, what scares and how to soothe. It’s always worthwhile to take the time to ask them how they think their child will react to the situation."
In a perfect world, parents will have incorporated desensitization into their teaching about how a doctor’s or dentist’s visit will go. But as emergency physicians know all too well, the world is far from perfect. And when an emergency arises, there’s usually little time for parents to rehearse a trip to the ED – which means the physician is responsible for at least some destressing.
"Systematic desensitization can be very helpful here. Walk in, say hi, talk to the parents, and then walk out for a while. Let the parents play with the stethoscope and have them introduce it to the child," Dr. Chun advised. Although this approach takes some time, that delay could be nothing compared with the time consumed by a full-blown encounter with a stressed-out, uncooperative child. "I’m betting that a lot of the things we spend time on actually decrease time spent with that patient in the long run."
Interventions like these work best if everyone in the ED is on the same page, Dr. Chun said. His hospital instituted a 16-hour training program designed to decrease the need for patient restraint, and the injuries incurred during restraint. The program helped prevent or minimize incidents by teaching de-escalation techniques and avoidance of power struggles; it also included a debriefing component. In the year after implementing the program, the hospital saw an 83% decrease in patient injury due to restraint.
Practically Speaking
It’s one thing to intellectualize what interventions should look like, and entirely another to put them into action. Fortunately, said Dr. Horrigan, many of the more useful modifications are both easy and inexpensive.
Because overstimulation is a key component in troublesome interactions, one easy and very effective intervention is simply to reduce it, Dr. Horrigan said.
"Simply find a quiet place" to examine and treat the child in the parents’ company, he said in an interview. "A bay with a curtain in the ED is really not a good fit for a child with autism."
"When you are caring for a child with autism, you are a stranger in a strange land."
A private exam room is optimal; facilities that don’t have that luxury can make good use of a quiet family waiting room. Dim the ambient lighting, he said, and use a procedure lamp instead of glaring overhead fixtures.