Behavioral Management of Children With Autism in the Emergency Department

Abstract

Autism spectrum disorder (ASD) is characterized by impaired social communication in conjunction with patterned behaviors. Often associated with emotional dysregulation, irritability, aggression, depression, and suicidality, ASD youth frequently present to the emergency department for behavioral and mental health evaluation. Psychiatric comorbidities, agitation, and depression are commonly encountered. During these visits, practitioners must thoughtfully consider organic etiologies for presenting symptoms, formulate plans to address risk of agitation, and understand how to effectively formulate disposition options in this patient population.

De-escalation Techniques for the Agitated Pediatric Patient

“…Medical professionals should deliver clear and concrete instructions and may need to repeat instructions. Acute behavior changes in children with autism may indicate an underlying medical cause, such as dental infections, acute otitis media, or urinary tract infections, and should warrant an appropriate medical workup if indicated 34,35 . Nonpharmacologic de-escalation strategies are particularly important for children with autism or other developmental disabilities, as this population is at increased risk for adverse drug events from the medications commonly used to treat acute agitation 7 .…”

“…Acute behavior changes in children with autism may indicate an underlying medical cause, such as dental infections, acute otitis media, or urinary tract infections, and should warrant an appropriate medical workup if indicated. 34,35 Nonpharmacologic de-escalation strategies are particularly important for children with autism or other developmental disabilities, as this population is at increased risk for adverse drug events from the medications commonly used to treat acute agitation. 7 If medications are to be administered, providers should elicit a history of prior medication responses-both positive and negative-from parents or caregivers.…”

“…Children with autism are 4 times more likely to present to EDs than their neurotypical peers, with behavioral issues including acute agitation leading to ED referrals 31 . It is important to communicate with the child's parent or caregiver to understand any accommodations the child may need, his/her preferred communication style, any potential stressors leading up to their presentation, and any effective de-escalation strategies that have worked well in the past 32 . While decreasing sources of stress and stimulation is a key step in reducing agitation for all patients, the loud and unpredictable environment of the ED can be especially triggering for neurodivergent patients.…”

“…31 It is important to communicate with the child's parent or caregiver to understand any accommodations the child may need, his/her preferred communication style, any potential stressors leading up to their presentation, and any effective de-escalation strategies that have worked well in the past. 32 While decreasing sources of stress and stimulation is a key step in reducing agitation for all patients, the loud and unpredictable environment of the ED can be especially triggering for neurodivergent patients. Somatosensory interventions such as headphones, books, or videos can help reduce anxiety, decrease stress, and prevent agitation.…”

Drug-refractory irritability and related factors in autistic children

“…Pharmacological interventions may involve antipsychotics, mood stabilizers, antidepressants, or other medications that can modulate the child's mood and behavior. Non-pharmacological interventions may involve behavioral therapy, cognitivebehavioral therapy, social skills training, parent training, or other psychosocial approaches that can enhance the child's emotional regulation, coping skills, social communication, and adaptive functioning [5,9]. However, psychopharmacological treatments are frequently used when nonpharmacological treatments fail [10].…”