Management of Pediatric Patients With Autistic Spectrum Disorders in the Emergency Department

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Children and adolescents with autistic spectrum disorders present a special challenge in the emergency department setting due to highly individualized emotional-behavioral and communicative characteristics. When an autistic patient presents with agitated behavior, the emergency care provider must consider both emotional and somatic etiologies as well as which treatment modalities best serve the patient. Effective communication with parents, caretakers, and outpatient providers provides useful insights into likely etiologies of agitation as well as effective management strategies.

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Medical Sources of Agitation

Unlike children and adolescents with typical communication and social abilities, this patient population may, even with high functioning patients, yield potential confusion as to the source of bodily discomfort. Complicating the consideration of pain and discomfort is the well-known feature of patients with ASDs to potentially exhibit atypical responses to pain (such as little reaction to substantial injuries yet having seemingly excessive responses to mild sensations such as particular

Emotional Sources of Agitation

If a reasonable medical investigation does not suggest an etiology potentially leading to the agitation, the ED physician should then consider potential emotional-behavioral causes. As described above, patients with ASDs characteristically possess intense and restricted patterns of interests and routines. Not uncommonly, patients with ASDs will experience some degree of agitation if changes in environment interfere with adherence to such preferred themes. Some examples include changes in daily

Treatment Approach

If available, requesting consultation from a psychiatrist or psychologist experienced in treating children and adolescents with ASDs may yield helpful insight into both the management of the acute crisis as well as disposition planning. As above, the treatment of a child or adolescent with an ASD in crisis will be largely based on determination of the etiology of the distress. Efforts should be made to treat identified medical causes while remaining cognizant that the child may still require

Use of Psychotropic Medications

At times, agitated patients with ASDs may exhibit a level of behavioral dyscontrol that requires careful consideration of psychotropic medications to protect the safety of the patient and others (including family members and ED staff). Ideally, emergent use of psychotropic medication is avoided due to potential side effects and the creation of further confusion regarding the etiology of the discomfort. In addition, this patient population is well known to have highly individualized responses to

Disposition

The typical options for follow-up psychiatric care are outpatient services, partial hospital program (PHP), or inpatient psychiatry unit (IPU) admission. Disposition planning for a child with an ASD from the ED setting may prove complicated, and it is important to match a child's potential and specific needs with treatment strategies that are most likely to be effective. Ultimately, the options vary by region, and unfortunately, access is often limited for this particular patient population.

Summary

The evaluation and treatment of an agitated child or adolescent with an ASD present a unique treatment challenge to the emergency care provider. Because these patients typically maintain uniquely individualized communication styles, interests, and patterns of behavior, the treating physician must rely on a categorical approach and collateral information to determine the etiology of distress as well as best treatment. Timely consultation with a psychiatrist or psychologist experienced in

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