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.
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
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
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
Triad of Impairments
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
Triad of Impairments
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
Triad of Impairments
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
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
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.
Interacting with Patients and Families with ASD
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.
Interacting with Patients and Families with ASD
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.
Interacting with Patients and Families with ASD
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.
Interacting with Patients and Families with ASD
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
Interacting with Patients and Families with ASD
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.
Interacting with Patients and Families with ASD
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.
Interacting with Patients and Families 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
Interacting with Patients and Families with ASD
Interacting with Patients and Families with ASD
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.
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.
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