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ASD

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Autism Spectrum Disorder Point-of-Care Tool

Section IconAutism Spectrum Disorder
Developmental disability
Can be on a spectrum from barely noticeable to profoundly disabling.
Can have significant social, communication and behavioral challenges.
Can have intelligence that ranges from intellectually disabled to gifted.
Frequently have comorbid conditions (genetic, behavioral, and medical/mental health).
Autism Spectrum Disorder
In DSM-V, Autistic Disorder, Pervasive Developmental Disorder (PDD-NOS), and Asperger syndrome were combined into a broader category called Autism Spectrum Disorder and identified severity by the levels of support needed.
The core features of ASD are persistent deficits in social communication and social interaction and restricted, repetitive patterns of behavior, interests or activities.
Core symptoms can present as: repetitive routines or rituals, peculiarities in speech and language, socially and emotionally inappropriate behavior, inability to interact successfully with peers, problems with non-verbal communication, and clumsy, uncoordinated motor movements.
Signs and symptoms that may be evident
Social/Communication may exhibit the following
Delayed speech and language skills.
Talk in a flat, robot-like, or sing-song voice.
Reverse pronouns (“you” instead of “I”).
Repeat or echo words or phrases said to them or repeat words or phrases in place of normal language.
Trouble expressing their needs using typical words or motions
May not use or have difficulty understanding gestures and body language.
May be unusually talkative (verbose) with little conversational turn taking.
Appear to be unaware when people talk to them but respond to other sounds.
Avoid eye contact and prefer to be alone.
Have difficulty relating to others or have little or no interest in other people
Have trouble understanding other people’s feelings or talking about their own feelings.
May not understand jokes, sarcasm, or teasing.
May be very interested in people but not know how to talk, play, or relate to them.
Have deficits in attention (don’t point at objects to show interest or look at objects when another person points at them).
Sensory
Some may avoid or resist physical contact. and others may seek (rather than resist) particular sensory input – e.g. weighted blanket, etc.
Can have unusual reactions to the way things smell, taste, look, feel, or sound.
May not understand personal space boundaries.
Adaptive Behavior
May engage in stimming (self-stimulatory) behavior -Repeating actions over and over again (ie, rocking, swaying, jumping, finger flicking).
Can have trouble adapting when a routine changes.
Exhibit meltdowns - Increased when stressed, fatigued, or feeling unwell (see common medical conditions).
References
  1. Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (2018). What is Autism Spectrum Disorder?
  2. Johnson CP. Early Clinical Characteristics of Children with Autism. In: Gupta, V.B. ed: Autistic Spectrum Disorders in Children. New York: Marcel Dekker, Inc., 2004:85-123.
Section IconInteracting with ASD Patients for History & Physical
Approaching the patient
Approach the individual slowly and calmly keeping some distance between you.
Use the person's first name and assure that you are there to help.
Talk in a quiet and calm voice.
Try to establish a rapport no matter how urgent the situation.
Gathering history
Determine the best way to approach or communicate with the individual. (i.e., pictures, communication device, sign language). Patient may be verbal or non-verbal.
Gain as much information as possible from both the patient and the caregiver.
Ask simple "yes" or "no" or closed-ended questions.
Avoid questions or sentences that require complex responses.
Avoid the use of idioms or figures of speech, as they may be taken literally. Use plain, direct language.
Allow the person time to calm themselves and add time for them to process and respond.
Examining the patient
Do not attempt to touch, grab or restrain without preparing the individual first.
Tell the individual what you are going to do or want him/her to do before examining. Use of visual supports maybe beneficial.
Demonstrate on yourself or a parent/caregiver first (for example, show use of the reflex hammer on the parent’s knee) if you think it will help.
Point on a picture or a doll which part of the body you are going to examine if you think it will help.
Be flexible – You may need to modify your typical physical exam to accommodate the patient’s need.
Increased/decreased behavior or behavior that is atypical for that person may be indicative of pain or illness. Patients may not be able to accurately sense or convey pain.
Section IconMedical and/or Psychiatric Conditions
Psychiatric
Anxiety/depression
Higher rates of anxiety (particularly among higher functioning ASD).
Higher rates of depression.
Increased rates of suicide among females with ASD and number one cause of premature mortality.
Substance abuse
Higher rates of alcohol abuse.
High rates of overdose (both accidental and intentional).
ADHD/OCD
Considerable overlap in definitions of ASD and ADHD/OCD leading to coexistence in some. (High level of co-occurring)
Agitation
May be a symptom of physical illness or pain in non-verbal patients. A trial of analgesia may be effective while assessing for the underlying cause.
May be a symptom of sensory overload and respond to environmental therapeutic interventions.
Psychotic disorders
May coexist with ASD. Haloperidol has shown efficacy, but pharmacologic restraint should be a last resort.
Medical
Seizures
Epilepsy incidence as high as 35% and is treated the same in patients with ASD.
Gastrointestinal/nutritional
May utilize restricted diets due to sensory aversions and non-conventional treatments.
Thiamine, B12, Vitamin A and C deficiency have been described with ASD.
Pica is common and may result in bezoars and obstruction.
Chronic constipation and diarrhea are common.
Infectious
Under-vaccination is common, which may result in higher incidence of childhood infectious diseases.
Trauma
Self-injury is the most common cause of trauma.
Increased rates of abuse, bullying, exploitation, and trafficking.
Dental
Dental pain should be considered in those with agitation or decreased oral intake.
Bruxism, anticonvulsant medications, restricted diets, and sensory aversion to oral care may lead to gingivitis.
A good oral exam should be routine in patients with ASD.
References
  1. Iannuzzi DA, Cheng ER, Broder-Fingert S, et al. Brief report: Emergency department utilization by individuals with autism. J Autism Dev Disord. 2015;45(4):1096-102.
  2. Kalb LG, Stuart EA, Freedman B, et al. Psychiatric-related emergency department visits among children with an autism spectrum disorder. Pediatr Emer Care. 2012;28(12):1269-76.
  3. Liu G, Pearl AM, Kong L, et al. A profile on emergency department utilization in adolescents and young adults with autism spectrum disorders. J Autism Dev Disord. 2017;47(2):347-58. doi: 10.1007/s10803-016-2953-8.
  4. McDermott S, Zhou L, Mann J. Injury treatment among children with autism or pervasive developmental disorder. J Autism Dev Disord. 2008;38(4):626–33. doi: 10.1007/s10803-007-0426-9.
  5. National Institute of Health, National Institute of Neurological Disorders and Stroke (NINDS). (updated 2019). Learn More
  6. Venkat A, Jauch E, Russell WS, et al Care of the patient with an autism spectrum disorder by the general physician. Postgrad Med J. 2012;88(1042):472-81.
  7. Vohra R, Madhavan S, Sambamoorthi U. Emergency department use among adults with autism spectrum disorders (ASD). J Autism Dev Disord. 2016;46(4):1441–54. doi:10.1007/s10803-015-2692-2
  8. Kalb LG, Vasa RA, Ballard ED, et al. Epidemiology of injury-related emergency department visits in the US among youth with autism spectrum disorder. J Autism Dev Disord. 2016;46(8):2756-63.
  9. Fosdick C, Wink L, McClellan L, et al. (2017). Pharmacological treatment options for children and adolescents with autism spectrum disorder. Clinical Pharmacist. 2017 Oct online, doi: 10.1211/CP.2017.202033
  10. Weiss JA, Fardella MA. Victimization and perpetration experiences of adults with autism. Front Psychiatry. 2018;9:203. doi: 10.3389/fpsyt.2018.00203
Section IconManaging Agitation
Identify the underlying cause
Behavior is communication!
The most effective and enduring treatment for agitation requires identifying and treating the underlying cause. Treatments targeting only the agitation, though necessary emergently when safety is at risk, are often only temporary measures
One study found the most common etiologies for acute behavioral crises to be: non-ASD psychiatric condition (47%) organic causes (28%), environmental changes (25%).
Behavioral approaches
Patients presenting to the ER often exhibit agitation that is insufficiently treated behaviorally either due to limited access or symptom severity. However, the following guidelines may help in preventing the escalation of behaviors, and thereby minimize the use of pharmacologic treatment:
  • Ask caregivers about sensory sensitivities unique to the patient.
  • Ask caregivers for known factors triggering and alleviating behaviors.
  • Be sure to interview and assess the patient despite any communication challenges (not just caregiver).
  • Modulate voice to complement the patient’s emotional state (if they are high go low; if they are low, lethargic, then increase emotion).
  • Control noise: provide headphones (noise cancelling or music), vibroacoustic music (if available), rocking chairs when able.
  • Dim bright lights.
  • Provide space to retreat/isolate and maximize private space.
  • Provide weighted blankets or vests if you have them.
  • Use protective gloves or helmets to minimize both self-injury and use of physical or chemical restraint when able.
  • Consult behavioral technicians or services such as Child Life for assistance while a patient boards in the ED when able (note: these services may be available from inpatient units to assist in the ED).
Pharmacologic Intervention
Consider only after medical/comorbid psychiatric disorders have been addressed and behavioral interventions have been insufficiently successful.
May be required first if there is an imminent risk of physical harm.
Most evidence supports the use of atypical antipsychotics as first-line pharmacologic agents for agitation in ASD. However, the majority of these studies are conducted in children and adolescents.
There are only two FDA approved medications for irritability (targeted behaviors include aggression, deliberate self-injury, tantrums) associated with ASD:
  • Risperidone (5-16yo)
  • Aripiprazole (6-17yo)
Olanzapine also has shown to have efficacy in treating irritability in ASD in double-blind, placebo-controlled trials.
Chlorpromazine is FDA approved for the treatment of severe behavioral problems in ages 1-12 years (though not specific to ASD).
Most commonly reported adverse effects to antipsychotics include: somnolence, extrapyramidal symptoms, weight gain, increased appetite, dizziness, sedation, sialorrhea, tachycardia, QTc prolongation.
There is evidence that alpha 2 adrenergic agonists (clonidine, guanfacine) may help in irritability associated with ASD, especially when associated with hyperactivity and impulsivity. Though less likely to be effective acutely, these medications may be considered when antipsychotics are not an option.
Evidence for mood stabilizers and anticonvulsants in treating irritability in ASD has involved smaller controlled studies and produced inconsistent results. However, these medications, such as divalproex sodium, may also be considered when other medications are not options.
Algorithm
References
  1. Fung LK, Mahajan R, Nozzolillo A, et al. Pharmacologic treatment of severe irritability and problem behaviors in autism: a systematic review and meta-analysis. Pediatrics. 2016;137 Suppl 2:S124-35.
  2. Guinchat V, Cravero C, Diaz L, et al. Acute behavioral crises in psychiatric inpatients with autism spectrum disorder (ASD): recognition of concomitant medical or non-ASD psychiatric conditions predicts enhanced improvement. Res Dev Disabil. 2015;38: 242-55.
  3. Lundqvist, LO, Andersson G, Viding J. Effects of vibroacoustic music on challenging behaviors in individuals with autism and developmental disabilities. Res Aut Spec Disabil. 2009;3(2):390-400.
  4. Matson JL, Jang J. Treating aggression in persons with autism spectrum disorders: a review. Res Dev Disabil. 2014;35(12):3386-91.
  5. McGonigle JJ, Venkat A, Beresford C, et al. Management of agitation in individuals with autism spectrum disorders in the emergency department. Child Adolesc Psychiatr Clin N Am. 2014;23(1):83-95.
  6. Stigler KA. Psychopharmacologic management of serious behavioral disturbance in ASD. Child Adolesc Psychiatr Clin N Am. 2014;23(1):73-82.
Section IconLearn More about ASD
Recommended websites
HHS.gov: Autism Information
paautism.org
autismspeaks.org: Healthcare Professional
NIH.gov: Autism Spectrum Disorder Fact Sheet
autismspeaks.org: Tool Kits
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Acknowledgments

ASD:

Developed by members of the Emergency Medicine Practice Committee, September 2019 Reviewed by the ACEP Board of Directors, October 2019

Contributors:
Lorna Breen, MD, FACEP Michael Gertz, MD, FACEP Connie Kasari PhD Sheryl Kataoka, MD MSHS Jena Lee, MD Joann M. Migyanka, DED Arvind Venkat, MD, FACEP


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