Dr. Chun said some children enjoy the feeling of pressure all around their bodies. A weighted blanket is one way to achieve this, but a radiologist’s apron or a beanbag chair can be just as effective. If the child brings in a beloved toy or blanket from home, keep it close at hand to take full advantage of its soothing properties.
"Some children like light pressure," Dr. Chun noted. "For these, an electric foot massager or even a paint roller can be a good idea. Some like rocking, so we have a rocking chair with a small weighted blanket."
Say What?
Communication deficit is a universal manifestation of autism spectrum disorders. Children with autism tend to think in pictures or symbols rather than words. Many make use of adaptive communication tools at home, and it’s a good idea to have a few types of these in the ED.
A picture book with images of hospital personnel and procedures can be very helpful. An effective and virtually free method is to take photographs of the treatment bays, medical tools, and people with whom the child might interact; showing the child these is a good way to help her understand what to expect, Dr. Chun said.
"Go through the ED and take a bunch of pictures, laminate them, and you have an instant communication system. You can prepare a child for almost any procedure this way."
Even if there isn’t much reciprocal communication, most children with autism are taking in spoken language, so be sure to talk them through their experience, giving them descriptions of medical tools and devices, how they’re going to be used, and what procedures might feel like.
Pragmatic Procedures
Trust is the basis for any successful medical treatment, but trust is something children with autism don’t readily give, said Dr. Alan Rosenblatt, a neurodevelopmental pediatrician practicing in Skokie, Ill.
"Some of this will have to be done at a distance because some of these children don’t want to be touched by strangers," he said in an interview. "Only after a certain level of trust is established can that be done. You must be very careful about intruding too quickly and too intensely into the child’s personal space."
Fingers and toes are a good place to start the exam, he said. "That’s one of the tricks I use. I start at the periphery – away from the trunk and face – and slowly move more centrally so that they’re not overwhelmed all at once. Even with this approach, certain kids are so overwhelmed by anxiety that there is going to be resistance when you touch any part of them."
Drawing blood can be particularly troublesome. The Autism Treatment Network, part of Autism Speaks, offers a free guide to effective phlebotomy technique in children with autism. The pamphlet briefly explains how distraction, relaxation, and picture communication can improve results for everyone involved.
(The publication is available online.)
The Center for Autism and Related Disabilities, an autism support center affiliated with the University of Miami, also provides a "tip pamphlet" for EDs. "Autism and the Hospital Emergency Room" includes background information on autism, as well as lots of practical tips on making an ED more "autism friendly," Dr. Horrigan said.
Managing Medications
Children with autism don’t always react predictably to medications, especially anesthetics and psychotropic drugs, Dr. Horrigan said.
"A bay with a curtain in the ED is really not a good fit for a child with autism."
The small-dose benzodiazepine that might help a normally developing child relax could send an autistic child over the edge. "These individuals can have unique, idiosyncratic responses to medicines. Some of the medications a ‘normal’ child would get could provoke serious adverse reactions in a child with autism – especially a younger child."
Topical anesthetics, if appropriate, are usually a better choice for these children. Systemic medications must be handled very carefully – even antihistamines can provoke serious agitation and even violence.
On the other hand, some children with autism are so withdrawn that they may not express anxiety or pain, he said. But this doesn’t mean forgoing medication on the assumption that withholding it might actually be less stressful than giving it.
"Medications can and should be used in the same way as they are used on anyone else, to improve comfort and alleviate distress," Dr. Horrigan said. "But we must be thoughtful about the drug selection and dose. It requires a more sophisticated approach."
Generally, the rule should be to start with a lower test dose than usual, observe its effect and any reactions, and then increase the dose. Again, the parent is the provider’s best guide. "It’s critical to get as much medical history as possible about any past adverse reaction," he said.