AUTISM

AUTISM

AS UNIQUE AS A SINGLE SNOWFLAKE

Kimberly Martin, RN, BSN

Autism As Autism Spectrum Disorder rises in

prevalence, it is imperative nurses in any setting to understand the unique challenges of this population. There has been very little information and many misconceptions about best practices for improving care to children with ASD

Autism Autism affects 1 in every 110 children

(Center for Disease Control and Prevention [CDC], 2010). As the incidence of Autism increases, nurses will experience increased interactions with patients with Autism. Little awareness or education has been devoted to this complex neurological disorder and health professionals are left with unsuitable knowledge or tools available to properly care for this population of patients.

Autism A course is designed to educate

nurses about Autism, levels of impaired social interaction, communication needs, stereotypical behaviors, learning barriers, therapies, and nursing adaptations and tools that will increase the ability to provide integrated care for a child and family with Autism in the acute care setting.

Objectives

Purpose: The health care provider will demonstrate holistic care to a person with Autism in the hospitalized setting.

Goal: To provide information, knowledge, and awareness about Autism so the health care provider can effectively provide care for patient with Autism.

Objectives

After completion of the course participants will be able to:

classify the triad of impairments exhibited in the autistic spectrum.

identify and discuss the presenting behaviors a person with Autism might display.

discuss three therapies utilized in treatment of Autism.

Objectives develop three nursing interactions

required in caring for a person on the Autistic Spectrum.

identify personal barriers when interacting with a person with Autism.

examine a caring and effective approach with patient interaction in the clinical setting based on latest insights and tools

Autism Misconceptions

Assumptions about the child’s ability cannot be solely based on their diagnosis. There are many misconceptions regarding autism such as:

Autism does not present as a learning disability

Autism is just an emotional/behavior disorder

Autism Misconceptions

Children with autism grow up to be schizophrenic adults;

Parents need to set firmer limitations and discipline when dealing with these children;

Children with autism are usually mentally retarded

Autism

Autism is a developmental brain disorder that impairs basic behaviors needed for social interactions, such as eye contact and speech, and includes other symptoms, such as repetitive, obsessive behaviors.

The symptoms sometimes cause profound

disability, and they persist throughout life. Treatments may relieve some symptoms, but no treatment is fully effective in treating the core social deficits.

Autism

Autism Spectrum Disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior.

Autistic disorder, sometimes called autism or classical ASD, is the most severe form of ASD, while other conditions along the spectrum include a milder form known as Asperger Syndrome.

Autism

ASD varies significantly in character and severity; it occurs in all ethnic and socioeconomic groups and affects every age group. Experts estimate that 1 out of every 96 children are being diagnosed with autism.

Increase in Autism

http://www.nutritionreview.org/library/saving.eli.html

Question

What is Autism?a.Autism is an overused label for a person

with behavioral disordersb. Autism is synonymous with mental

retardationc.Autism is a range of complex neuro-

developmental disorders

Signs to Look For

Lack or delay in spoken languageRepetitive use of language and/or

motor mannerisms (hand flapping, twirling objects, placing objects in line)

Little or no eye contact Lack of interest in peer relationships Lack of spontaneous or make believe

playPersistent fixation on parts of objects

Autism Society of America

Signs to Look For

Autism Checklist

http://www.myomancy.com

Questions

Which of the following is a behavior commonly associated with an ASD?

a. Cooing and smilingb. Telling a story to another personc. Sharing toys with othersd. Spinning objects

A Day with Autism

http://www.youtube.com/watch?v=FDMMwG7RrFQ

Triad of Impairments

Communication: difficulty with verbal and non –verbal communication

Child may have suddenly stopped talking or unable to comprehend or speak knew words.

Delayed language May only communicate through pictures or sign

language Trouble with pronouns; refer to themselves by

name instead of “I” or “me” Does not point to objects

Triad of ImpairmentsCommunication (continued) Use language in a unusual way i.e. combine

words, repeat phrases, parrot what they hear instead of initiate or respond to questions (echolalia speech)

Lack of reciprocal language Do not understand tone, body language or

phrases of speech Have difficulty letting other know what they

want and as a result often emit an un-emotive scream


Social Interaction: difficulty with verbal and non- verbal communication lead to social impairment

Unable to decipher pitch and tone differentiation

Unable to decipher facial expressions Restrictions with receptive and expressive

language skills Inability to form a theory about what people

think; take social cues in and form interpretation


Social Interaction (continued) Difficulty with give and take of human

interaction Difficulty generalizing Poor eye contact Poor bonding; do not seek comfort from

parents; prefer to be left alone

Triad of ImpairmentsSocial Interaction (cont) Difficulty interpreting what others are thinking

or feeling Tendency to “loose control” when in a

unfamiliar situation Self destructive behavior “Impaired hearing” or tuning people out

Triad of ImpairmentsBehavioral Flexibility: difficulty with

interpersonal play and imagination (i.e. thinks in concrete images,) copied and pervasive rigidity with repetitive movements, routines and tasks.

Dislike unexpected change Depend on ritualistic mannerisms,

obsessional behaviors (stimming) “Stimming” is a useful barometer that can be

viewed by clinicians of current anxiety levels


Behavioral Flexibility (continued) Motor tics Have difficulty with new environment and

change in normal routine Low frustration levels, mood swings, and over

stimulation results in agitation, anxiety or inattention

Question

Which of the following deficit is least often associated with autism spectrum disorder?

a. Communicationb. Cognitionc. Sociald. Behavior

Cognitive Processing

Visual learners, not linguistic Information stored in visual “pictures” and in

chunks received, not unified in past experience based on like or dislike

Impaired abstraction: In ability to compose their information about

the world in an orderly fashion based on like or similar concepts.

Cognitive Processing

Impaired abstraction (cont) Poor abstraction abilities Poor base of knowledge Cannot make sense of incoming stimuli and

relate it to previous information or apply their interpretations of the world to experience

Sensory IntegrationIn addition to this triad, repetitive

behavior, and resistance to change in routine are often characteristic. They may also appear hyper- or hypo-sensitive to sound, touch, pain, lights, environmental stimuli.

Sensory Integration

Sensory Integration (continued) Difficulties with crowds and commotion Abnormal sensory inspection by mouthing and

smelling toys or objects Hyper-sensitivity to touch and textures Visual perception distortion Hypotonia, fine motor deficits, and motor

planning

People on the Spectrum May

Appear to not understand what you sayResist change or insist on samenessBe unable to speak without difficultyEngage in repetitive behaviorsRepeat words or phasesAppear anxious or nervousDart away from you unexpectedlyEngage in self-stimulating behavior (hand

flapping or rocking)Have little or no eye contact

When Approaching a person with Autism

Speak slowly and use concrete termsRepeat simple questionsAllow more time for responsesAsk if they mind if you touch themSpeak in a normal toneRemember that each individual is

unique and may act differently than others

Question

When caring for a person with ASD one should

a. Create a quiet, non- cluttered and calming environment

b. Put them close to the nurse’s station and in the open as to monitor them closely

c. Have multiple caregivers gather history and physical in order to obtain an accurate assessment

d. Provide quick, rapid, care as any socialization causes anxiety

Therapies

Music Assists in fostering interpersonal contact, joint

attention and understanding. Facilitates social ability

Provides context and a vehicle for reciprocal interaction, repetitive, unchanging patterns, and need for sameness

Provides framework for the development of learning and adaptability

TherapiesPet Therapy Animals are trained to be a calming

influence, provide consistency between home, school, new places and assist in transitions.

Trained to prevent the children from running away or escaping (search and rescue dogs)

Promotes improvement human physical, social, emotional and cognitive functioning

Therapies

Pet Therapy (continued) Research shows that pet therapy increases

cognitive ability, self care scales, physical functioning and life satisfaction

Research shows that pet therapy decreases heart rate, blood pressure, anxiety, and depression

Therapies

Communication Sign language Computer board Picture boards

Therapies

Sensory IntegrationIf you have all these sights and sounds

coming at you but you can't put them together in a meaningful way, the world can be an overwhelming place.” Sophie Molholm, Ph.D., associate professor in the Dominick P. Purpura Department of Neuroscience and of pediatrics.

Therapies

Sensory Integration (continued)Deep pressureWrapping in blankets Brushing

Therapies

Speech therapyAssists with pronunciationAssists with reciprocal language skills

Physical Therapy/Occupational Therapy

Assists with fine motor skill, space concepts, and gross motor skills

Therapies

Diet Theory The enzymes designed to digest wheat and

milk are not functioning properly, resulting in the proteins from gluten (wheat) and casein (dairy) peptides to break down into casomorphin and gliadimorphin that have an opioid effect on the brain.

These peptides escape the gut, enter the bloodstream, cross the blood brain barrier causing serious neurological damage.

Therapies

Diet (continued)

A diet free from gluten and casein has resulted in increase communication skills, increase socialization and decrease in behavioral outbursts

Supplemental vitamins may also be added to the diet therapy

TherapiesSocial Stories

A written story to assist with everyday social events; what will happen and the “rules” of social behavior.For example: A birthday party.

Kara is invited to Sheena's birthday party. Kara needs to bring a gift for Sheena. There will be other people there. Sometimes games are played, sometimes music is loud. There will be lots of noise. This is Sheena’s special day. The presents are for Sheena. The cake is for Sheena. Everyone is laughing because they are happy.

Therapies

MedicationDoctors may prescribe medications for treatment

of specific ASD-related symptoms, such as anxiety, depression, or obsessive-compulsive disorder. Antipsychotic medications are used to treat severe behavioral problems. Seizures can be treated with one or more anticonvulsant drugs. Medication used to treat people with attention deficit disorder can be used effectively to help decrease impulsivity and hyperactivity

QuestionTherapies that are implemented for a

person with ASD could include:a. Acupuncture

b. Pet therapyc. Low cholesterol, high fiber dietd. Sensory integration therapye. Communication adaptationsf. Speech therapyg. Aroma therapy

Nursing Assessment

Children’s type of communication: Augmentative, sign language, picture

exchange Effective social strategies and

commands used by parents

Behavioral mannerisms and protocol for compliance

Signs of over stimulation or melt downs Problem behaviors Procedures that might trigger behaviors

c

Nursing Assessment

Regular routinesSpecial interest/toysTherapies, special diet, medicationsSocial interactions

Nursing Assessment Sensory Tactile defensiveness Hyper-sensitivity to smells, tastes,sounds Visual fixations Perseverations (obsessions) Successful strategies for compliance Distraction techniques Counting Favorite foods Rewards, tokens Play Songs

Nursing AssessmentParents take comfort in health care

provider’s empathy and understanding of the disability and challenges that parents of children with ASD face

Health care providers need to be creative and have a sense of humor when caring for children with developmental disabilities.

Interacting with Patients and Families with ASD

Medical proceduresWaiting in a hospital corridor will

increase the stress level of an already anxious child or adult. If possible, find a small side room the family can wait in.

Always explain what you are going to do before starting any procedure or examination.

If possible, show a picture of what is going to happen or demonstrate on a parent to explain what you are doing.


Medical procedures (continued)

Physical examinations can be stressful to the patient and it is essential that you warn them before touching them.

Explain what you are doing and why

Question

When caring for a school age child with an ASD, it is priority to determine:

a. What type of ASD the child hasb. How many words the child can speakc. What words are used for toiletingd. The child’s specific routines

Enlist caregivers/parents

help whenever possible, especially if

the patient is non-verbal or uses an

alternative communication method or aid.


Your Language Use clear, simple language with short

sentences People with ASD take everything literally.

Thus if you say “You have a belly bug” they will take it to mean there is a bug in their belly.

Make your language concrete; avoid using irony, metaphors, and words that have double meaning, i.e. “It’s raining cats and dogs”.

Give single, short direct requests.


Your Language (continued) Check that they understand what you have

told them. Some people with ASD may speak clearly but lack full understanding.

Avoid using body language, gestures, or facial expressions without verbal instruction. These may not be understood.

Ask for the information that you need. A person with ASD will not volunteer vital information without being asked directly.


PainPeople with ASD can often have a very

high pain threshold. Even if the child does not appear to be in pain, they may, for example, have a broken bone.

They may show an unusual response to pain that could include laughter, humming, singing, and repetitive movement (flapping of the hands or arms), repetitive phrases, or pacing


Pain (continued)

Agitation and behavior may be the only clues that the child or adult is in pain

People with ASD can be either under or over sensitive to pain so that some may feel the pain acutely and be very distressed whereas others may not appear to react at all.

Pain (continued)

The pain scale will have to be modified as facial expressions are difficult for a person with ASD to interpret as well as sequence of numbers being more means greater pain. Suggest measurements such as “small”, “medium” or “large” amount of pain.


Sensory Overload If autistic patients suddenly become agitated

or “zone out” consider sensory overload as the cause.

Lighting causes two sensory issues: they can see and hear the cycle frequency

Often individuals with an ASD easily become over stimulated by sensory overload, emergency room lights and machines that emit high pitched “whistle” sounds can be agonizing to the person with ASD.


Sensory Overload (continued)

Some might withdraw from the stimuli, others may “stim” (make motions such as flapping hands, rocking, flicking fingers, pace) in order to stimulate sensation or to deal with the stress. This behavior is usually calming to the person, so do not try to stop it unless it is absolutely essential



Parents take comfort in health care provider’s empathy and understanding of the disability and challenges that parents of children with ASD face

Health care providers need to be creative and have a sense of humor when caring for children with developmental disabilities.

Nursing concept map

autismbehaviors

cognitive

therapies

medications

environment

Discussion List five behaviors that are characteristic List five behaviors that are characteristic

of Autism and name several interventions of Autism and name several interventions that can assist the child with Autism in that can assist the child with Autism in adapting.adapting.

List three different therapies utilized with List three different therapies utilized with a child with Autism. Discuss the theory a child with Autism. Discuss the theory behind the therapy, the purpose of the behind the therapy, the purpose of the therapy and briefly describe what the therapy and briefly describe what the therapy entails.therapy entails.

Case Study

A nine year old boy is admitted to the A nine year old boy is admitted to the pediatric floor with vomiting and pediatric floor with vomiting and dehydration. Mother states that the child dehydration. Mother states that the child has a history of Autism. He has limited has a history of Autism. He has limited communication skills, anxiety, is a picky communication skills, anxiety, is a picky eater and loves Legos. He participates in eater and loves Legos. He participates in Speech therapy, music therapy, sensory Speech therapy, music therapy, sensory integration and medication management. integration and medication management. Develop a nursing care plan that will meet Develop a nursing care plan that will meet this child’s medical and behavioral needs.this child’s medical and behavioral needs.

http://www.youtube.com/watch.com/watch?v=FDMMwG7RrFQ&feature=Playlist=31C7F1C65DAD636F&playnext=1&playnext_from=PL&index=5

A Day with AutismMedia videos

http://www.autismkey.com/autism_videos/wp-content/themes/Cleaker/favicon.ico

Autism

If the music cannot be heard, the dance will seem insane.

If one does not understand the behaviors and neuro- deficits of a person with Autism, their behavior and social communication will seem insane.

ReferencesAutism Society. (2010). What is Autism? Retrieved

March, 31, 2010, from http://autismharrisburg.org/What_Is_Autism.php.

Cade, M., & Tidwell, S. (2001). Autism and the school nurse. Journal of School Nurse, 71(3), 96-100.

Cashin, A.,& Barker, P. (2009). The triad of impairment in autism revisited. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 189-193.

Center for Disease Control and Prevention [CDC]. (2010), National Center for Birth Defects and Developmental Disabilities, counting autism. Retrieved from http://www.cdc.gov/ncbddd/features/counting-autism.html.

Helps, S., Newsom-Davis, I.C., & Callias, M. (1999). Autism: A teacher’s view. Autism, 3(3), 287-298. Lewis, L. (1998). Special diets for special kids. Arlington, TX: Future Horizons, Inc.

Morrison, M. (2007). Benefits of animal assisted interventions. Complementary Health Practice Review 12(1), 51-62.

National Institute of Health, National Institute of Neurological Disorders and Stroke. (2010) Autism Fact Sheet. Retrieved from National Institute of Health http://www.ninds.nih.gov/disorders/autism/detail_autism.htm?csss=print

National Institute of Mental Health. (2009) Autism Spectrum Disorders (Pervasive Developmental Disorders). http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorder

Scarpinato, N., Bradley, J., Kurbjan, K., Bateman, X., Holtzer, B., & Ely,B. (2010). Caring for the child with an autism spectrum disorder in the acute care setting. Journal for Specialist in Pediatric Nursing, 15(3), 244-254.

Souders, M.C., Freeman, K.G., DePaul, D., & Levy. (2003). Caring for children and adolescents with autism who require challenging procedures. Pediatric Nursing, 28(6), 555-562.

Tanner, L. (2009, August 31). Service animal or comfort dog? (2009). The Bulletin. Retrieved from http://www.bendbulletin.com/apps/pbcs.dll/article?AID=/20090831/NEWS0107/908310310/1092/10927n.

The National Autistic Society. (2010). Patients with autism spectrum disorders: information for health professionals. Retrieved April 5, 2010, from http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=128&a=8521.

Wigram, T. & Gold, T. (2006). Music therapy in the assessment and treatment of autistic spectrum disorder: clinical application and research evidence. Child: Care, Health and Development 32(5), 535-542.

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