Caring for autistic children in emergencies

Key Points

Caring for patients with autism spectrum disorder (ASD) in medical settings can be very challenging, both in terms of determining how to best care for the child and the resources and physical limitations of the settings. What is the significance of the patient's observed behavior? Is he or she in pain, upset, or self-soothing? What are the child's cognitive, verbal, and social interaction abilities? What is the best way to communicate with and interact with this child? What calms and soothes the child, and what has the opposite effect? What can be done to facilitate the medical care of the child? The lack of successful strategies and resources for caring for children with ASD is often a common problem for pediatric clinicians.

Case 1

A 12-year-old boy is brought to the emergency department (ED) with an angulated midshaft radius and ulna fracture. He has a history of anxiety and severe ASD, for which he takes 1 mg of risperidone twice a day. As long as medical personnel are not examining him, he does not appear to be in pain, although he does constantly rock back and forth in his chair. Since being placed in the examination room, he prefers to keep a blanket over his head. When approached by medical staff, he becomes tactilely defensive, withdrawing from attempts to touch him, and does not engage in eye, verbal, or physical contact. His mother tells you that he has limited expressive language abilities. He has not had anything to eat or drink in 7 hours, and fracture reduction and cast placement could begin if an intravenous catheter (IV) can be placed and sedation medications given.

An 8-year-old girl, a patient of one of your partners, is brought to your primary care office with a 2-day history of fever. She appears to be uncomfortable. Her mother reports that it hurts when her daughter swallows; the patient is rubbing both ears and has noticeably swollen cervical lymph nodes. The mother denies any other airway or respiratory illness symptoms. The girl has a history of mild ASD, for which her only treatment is supplemental school-based services.

In the examination room, the patient appears mildly anxious, wandering around the room, touching everything. You also notice that she twirls her finger around her ear. When you approach her, she runs to and clings to her mother. While she is in her mother's lap, you are able to complete most of the physical examination but are unable to get her to open her mouth or to look into her ears.

Resources for ASD-sensitive care

The most critical experts to consult regarding the care of a child with ASD are the child's parents or caregivers. They likely have dealt with this and similar situations before. They tend to know what works well with their child and what doesn't. Parents usually know which words, actions, or stimuli calm and help their child and which have the opposite effect. They can also function as an interpreter, informing you of the significance of the child's actions and behaviors, translating what the child is trying to communicate, and helping you to convey your messages to the child. It is well worth taking a few minutes to ask the parents about their experience caring for their child-what works, what doesn't, and how comfortable they are caring for their child.

Autism-sensitive medical care need not fall on the physician's shoulders alone. Given the increasing incidence of ASD, it is very likely that a medical staff member in your setting has personal experience in caring for a child with ASD. As such, any number of other health professionals with an interest in ASD can champion, organize, and coordinate such care in your setting. Depending on your resources, this may include nurses, nursing assistants, nurse practitioners or physician's assistants, social workers, or child-life specialists. A coordinated, multidisciplinary, team approach is commonly and successfully used in educational and mental health settings. Other professional resources who may be able to assist you in tailoring and implementing a program for ASD-sensitive care in your setting include developmental-behavioral pediatricians, child psychologists and psychiatrists, special education teachers, speech/language therapists, and occupational therapists.