There has been increasing attention on the impact of the rising prevalence of autism spectrum disorder (ASD) on the healthcare system. People with ASD can present with behaviors and agitation that can be dangerous and create stress and difficulty for families and caregivers as well as healthcare providers. “The prevalence of ASD is rising, and many of these patients will present to EDs for care,” says Arvind Venkat, MD. “Unfortunately, ED personnel receive minimal formal training and have limited experience with treating children, adolescents, and adults with ASD. This has led to limited treatment success and often results in unwanted outcomes.”
Addressing Unique Needs
In a study published in the journal Child and Adolescent Psychiatric Clinics of North America, Dr. Venkat and colleagues described important aspects of managing agitation in patients with ASD who present to the ED. The article notes that ASD is characterized by impairment in social interactions and communication skills. ASD is also characterized by other non-specific atypical behaviors, such as anxiety, depression, attention issues, temper tantrums, and aggression or self-injury. “Those with ASD often have impairments in cognitive and adaptive functioning, learning styles, attention skills, and sensory processing abilities,” Dr. Venkat says. “ED personnel and crisis responders need to understand the unique needs of individuals with ASD so that they can rapidly assess and optimally treat patients in a manner that is least restrictive.”
According to Dr. Venkat, the challenge for ED personnel is to gather the key information that is needed to address issues that may be underlying or contributing causes of the ED visit. “Signs of acute agitation may be the tip of the iceberg to the underlying causes beneath the surface,” he says. ED personnel need to conduct an initial assessment that focuses on what’s driving the crisis behaviors and differentiate them from those that may be typical of ASD symptoms.
During patient assessment, ED personnel should explore possible contributing medical, psychiatric, and sensory factors as well as issues with communication, social, and motor skills. It is also important to gather information on cognitive and academic issues as well as family or community environment issues. “EDs are challenging settings to care for patients with ASD because they’re fast-paced environments that are filled with many people trafficking the halls and exam rooms,” says Dr. Venkat. “There are also many noises that can affect sensory processing. These factors can increase the likelihood of patients becoming agitated.”
It is important to individualize treatments and interventions to patients and their families during emergency treatment and in crisis situations. For individuals with ASD, agitation symptoms are often expressed in atypical and unusual ways. It is important to rule out or address any medical factors that may be contributing to the presenting symptoms. “We need to determine if there are underlying medical causes that change behaviors and if we can intervene with treatment to improve these behaviors,” Dr. Venkat says.
A primary goal of healthcare providers in ED settings should be to provide safe and effective care using a least-restrictive treatment model (Figure). “Ideally, we want to avoid using restraints in patients with ASD because they can be unsafe and reduce satisfaction with care from patients, families, and caregivers,” says Dr. Venkat. “In some cases, sedation may be a better option. By taking a stepwise approach, we can systematically meet the needs of patients based on their unique circumstances.”
Pharmacologic management of acute agitation in patients with autism in the ED can be a helpful adjunct, but Dr. Venkat says this should be reserved for use only after therapeutic communication using verbal de-escalation techniques are tried. “Efforts should be made to ensure that patients and staff are safe, but medication should be considered if necessary,” he says. “We should also ask parents or caregivers about previous needs for medications to reduce anxiety or agitation and how patients responded to these treatments.”
It is critically important to educate parents and caregivers about all processes and decisions that are made throughout the treatment of patients with ASD in the ED, according to Dr. Venkat. “Parents and caregivers can help ED personnel find effective strategies to communicate with patients,” he says. “They can also help us make adaptation to environmental stimulants, such as lighting in the exam room or the number of staff members that are working on the patient.” Parents and caregivers can also help weigh the risks and benefits of using specific treatments to reduce agitation.
Ultimately, Dr. Venkat says the key to managing ASD in the ED is to consider how best to care for patients with this condition before they present. “Adapting protocols in the ED to meet the needs of patients with ASD and their families will ultimately lead to more successful outcomes,” he says.
Readings & Resources (click to view)
McGonigle JJ, Venkat A, Beresford C, Campbell TP, Gabriels RL. Management of agitation in individuals with autism spectrum disorders in the emergency department. Child Adolesc Psychiatric Clin N Am. 2014;23:83-95. Available at: http://www.sciencedirect.com/science/article/pii/S1056499313000850.
McGonigle JJ, Migyanka JM, Glor-Scheib SJ, et al. Development and evaluation of educational materials for pre-hospital and emergency department personnel on the care of patients with autism spectrum disorder. J Autism Dev Disord. 2014;44:1252-1259.
Venkat A, Jauch E, Russell WS, Crist CR, Farrell R. Care of the patient with an autism spectrum disorder by the general physician. Postgrad Med J. 2012;88:472-481.
Kalb LG, Sturat EA, Freeman B, et al. Psychiatric-related emergency departments visits among children with autism spectrum disorders. Pediatr Emerg Care. 2012;28:1269-1276.
Owley TB. Treatment with individuals with autism spectrum disorders in emergency department: special considerations. Clin Pediatr Emerg Med. 2004;5:187-192.