Clinical Question – How Do I Approach Agitation and Aggression in Children with Autism Spectrum Disorder in the Emergency Department?

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A 7-year-old boy with autism spectrum disorder presents to the emergency department (ED) with upper respiratory infection symptoms. He starts becoming agitated as you try to auscultate his lungs and aggressively comes towards you. You are unsure of the best method to approach this situation.

Research has demonstrated that almost one third of children with autism spectrum disorder (ASD) who present to the emergency department had negative experiences or unwanted outcomes.​1,2​ Children with ASD may become agitated or act aggressively in the ED as a result of an unforeseen, novel environment with multiple enhanced visual and auditory stimuli. Furthermore, health care workers often report a lack the training to provide the appropriate care to these patients.​3​

Least Restrictive Treatment Model

  1. Initial evaluation. This is typically the first encounter with the patient and includes the initial interview and the medical evaluation. In addition to collecting a standard history and physical for diagnosis, you should take their time to ally with caregivers and understand their child. Every child with autism is unique and requires individualized care. In the initial interview, you should understand the child’s typical behaviours, coping strategies, past medical and psychiatric history, communication skills, motor skills and social skills.
  2. Environmental adaptations. Patients should be directed to a quiet room with low lighting and sound. The number of people in this room should also be minimized. Investigations may need to be arranged to occur serially, and in one room (e.g., portable ultrasound).
  3. Communication adaptations. You should always explain exactly what you are doing to help decrease anxiety. This includes both verbal and nonverbal methods of communication. Some examples are social stories, pictures, schedules, technology (e.g., iPads). It is important to remain patient and be willing to repeat questions and give patients appropriate time to answer.
  4. Behavioural approaches. Recruit caregivers and work together to determine the best strategies to manage certain behaviours. Incentives such as stickers, candy, snacks, toys, treats, etc. can be useful.
  5. Somatosensory interventions. Relaxation techniques using auditory, tactile, visual, olfactory, and physical exercise can help to reduce agitation. Examples include music, books, light-up wands, and rocking chairs.
  6. Restraint and seclusion. This should only be used as a last resort when other methods have failed and the patient poses a risk to themselves and/or others. Restraint refers to any method or equipment that is used to immobilize the patient. Secluding a patient involves placing them in a room where they are prevented from leaving.​3,4​

Pharmacological Management

Sedative medications (e.g., Ketamine, benzodiazepines, antipsychotics) can be used as an adjunct to the least restrictive treatment model.​3​ Consider whether similar medications have worked in the past and to also consider the risks versus benefits. Adequate local analgesia for procedures including topical anesthetics is imperative.

Case Resolution

You decide to use the least restrictive treatment model to approach your patient with agitation. They respond well to your use of verbal and non-verbal communication adaptations, such as explaining you plan step-by-step, and you are able to proceed with the visit.

This post was copyedited by Casey Jones and edited by Daniel Ting.

References

  1. 1.
    Pennsylvania Department of Public Welfare. Unwanted Outcomes— Police Contact & Urgent Hospital Care. Pennsylvania Department of Public Welfare; 2011:1-5. https://www.med.upenn.edu/autism/asert/Needs%20Assess_UnwantedOutcomes_Sept%202011.pdf
  2. 2.
    Nicholas D, Zwaigenbaum L, Muskat B, et al. Toward Practice Advancement in Emergency Care for Children With Autism Spectrum Disorder. Pediatrics. 2016;137 Suppl 2:S205-11. doi:10.1542/peds.2015-2851S
  3. 3.
    McGonigle J, Venkat A, Beresford C, Campbell T, Gabriels R. Management of agitation in individuals with autism spectrum disorders in the emergency department. Child Adolesc Psychiatr Clin N Am. 2014;23(1):83-95. doi:10.1016/j.chc.2013.08.003
  4. 4.
    Fitzpatrick S, Srivorakiat L, Wink L, Pedapati E, Erickson C. Aggression in autism spectrum disorder: presentation and treatment options. Neuropsychiatr Dis Treat. 2016;12:1525-1538. doi:10.2147/NDT.S84585

Reviewing with the Staff

Children with autism spectrum disorder (ASD) who present to the emergency department (ED) often have unwanted or difficult experiences. This can be partially attributed to the lack of training in health care providers for patients with ASD who arrive in the ED, which includes how to approach agitation and aggression. This article provides a brief framework for health care professionals and students on how to approach an agitated and aggressive patient with ASD, including an initial evaluation, the least restrictive treatment model, and pharmacological management.

James Leung and Mohammed Zubairi
Dr. James Leung is a Pediatric Emergency Medicine Attending Physician at McMaster Children\'s Hospital, and an Assistant Professor in the Department of Pediatrics at McMaster University. Dr. Zubairi is a Developmental Pediatrician at Ron Joyce Children’s Health Centre, and Associate Professor in the Department of Pediatrics at McMaster University.
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Devika Singh

Devika Singh

Devika Singh is a second-year medical student at McMaster University. She is interested in emergency medicine, pediatrics, and medical education.