Kimberly Martin, RN, BSN
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 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
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.
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.
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
 discuss three therapies utilized in treatment
of Autism.
 develop three nursing interactions required
in caring for a person on the Autistic
 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
 Autism does not present as a learning
 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
 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 Spectrum Disorder (ASD) is a range of
complex neurodevelopment disorders,
characterized by social impairments,
communication difficulties, and restricted,
repetitive, and stereotyped patterns of
 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
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.
Increase in Autism
What is Autism?
a. Autism is an overused label for a person with
behavioral disorders
b. Autism is synonymous with mental
c. Autism is a range of complex neurodevelopmental disorders
Signs to Look For
 Lack or delay in spoken language
 Repetitive 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 play
 Persistent fixation on parts of objects
Autism Society of America
Signs to Look For
Autism Checklist
Which of the following is a behavior commonly
associated with an ASD?
a. Cooing and smiling
b. Telling a story to another person
c. Sharing toys with others
d. Spinning objects
A Day with Autism
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
 Trouble with pronouns; refer to themselves by name
instead of “I” or “me”
 Does not point to objects
Triad of Impairments
Communication (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
 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 nonverbal communication lead to social
 Unable to decipher pitch and tone differentiation
 Unable to decipher facial expressions
 Restrictions with receptive and expressive language
 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 Impairments
Social Interaction (cont)
 Difficulty interpreting what others are thinking or
 Tendency to “loose control” when in a unfamiliar
 Self destructive behavior
 “Impaired hearing” or tuning people out
Triad of Impairments
Behavioral 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
Which of the following deficit is least often
associated with autism spectrum disorder?
a. Communication
b. Cognition
c. Social
d. 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
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 Integration
In addition to this triad, repetitive behavior, and
resistance to change in routine are often
characteristic. They may also appear hyperor 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 say
 Resist change or insist on sameness
 Be unable to speak without difficulty
 Engage in repetitive behaviors
 Repeat words or phases
 Appear anxious or nervous
 Dart away from you unexpectedly
 Engage in self-stimulating behavior (hand
flapping or rocking)
 Have little or no eye contact
When Approaching a person with
 Speak slowly and use concrete terms
 Repeat simple questions
 Allow more time for responses
 Ask if they mind if you touch them
 Speak in a normal tone
 Remember that each individual is unique and
may act differently than others
When caring for a person with ASD one should
a. Create a quiet, non- cluttered and calming
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
d. Provide quick, rapid, care as any socialization
causes anxiety
 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
Pet 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
Pet Therapy (continued)
 Research shows that pet therapy increases cognitive
ability, self care scales, physical functioning and life
 Research shows that pet therapy decreases heart
rate, blood pressure, anxiety, and depression
 Sign language
 Computer board
 Picture boards
Sensory Integration
If 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
Sensory Integration (continued)
 Deep pressure
 Wrapping in blankets
 Brushing
Speech therapy
 Assists with pronunciation
 Assists with reciprocal language skills
Physical Therapy/Occupational Therapy
 Assists with fine motor skill, space concepts,
and gross motor skills
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.
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
Social 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.
Doctors 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
Therapies that are implemented for a person
with ASD could include:
a. Acupuncture
b. Pet therapy
c. Low cholesterol, high fiber diet
d. Sensory integration therapy
e. Communication adaptations
f. Speech therapy
g. Aroma therapy
Nursing Assessment
Children’s type of communication:
 Augmentative, sign language, picture
 Effective social strategies and commands
used by parents
Behavioral mannerisms and protocol for
 Signs of over stimulation or melt downs
 Problem behaviors
 Procedures that might trigger behaviors
Nursing Assessment
 Regular routines
 Special interest/toys
 Therapies, special diet, medications
 Social 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 Assessment
 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.
Interacting with Patients and
Families with ASD
Medical procedures
 Waiting 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
When caring for a school age child with an ASD,
it is priority to determine:
a. What type of ASD the child has
b. How many words the child can speak
c. What words are used for toileting
d. 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
 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
 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
 People 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.
Interacting with Patients and Families
with ASD
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
 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.
Nursing concept map
 List five behaviors that are characteristic of
Autism and name several interventions that can
assist the child with Autism in adapting.
 List three different therapies utilized with a child
with Autism. Discuss the theory behind the
therapy, the purpose of the therapy and briefly
describe what the therapy entails.
Case Study
A nine year old boy is admitted to the pediatric
floor with vomiting and dehydration. Mother
states that the child has a history of Autism. He
has limited communication skills, anxiety, is a
picky eater and loves Legos. He participates in
Speech therapy, music therapy, sensory
integration and medication management.
Develop a nursing care plan that will meet this
child’s medical and behavioral needs.
A Day with Autism
Media videos
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
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