Thoughts on caring for individuals with Autism Spectrum ...c.ymcdn.com/sites/ · Thoughts on caring for individuals with Autism Spectrum Disorder ... to a total lack of facial expressions

Ideas for care for ASD

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Thoughts on caring for individuals with Autism Spectrum Disorder

Objectives for presentation

Categorize behaviors in children with autism spectrum disorder (ASD)

which differ from typical neurological development.

Develop interventions to providing safe and effective medical care for a

child with ASD in the health care setting.

Consider non medication treatment options for ASD to ease an office visit.

Definitions

Diagnostic Criteria DSM 5

A. Persistent difficulties in the social use of verbal and nonverbal communication

as manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and

sharing information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or

the needs of the listener, such as speaking differently in a classroom than on

the playground, talking differently to a child than to an adult, and avoiding

use of overly formal language.

3. Difficulties following rules for conversation and storytelling, such as

taking turns in conversation, rephrasing when misunderstood, and knowing

how to use verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g., making

inferences) and nonliteral or ambiguous meanings of language (e.g., idioms,

humor, metaphors, multiple meanings that depend on the context for

interpretation).


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B. The deficits result in functional limitations in effective communication,

social participation, social relationships, academic achievement, or occupational

performance, individually or in combination.

C. The onset of the symptoms is in the early developmental period (but deficits

may not become fully manifest until social communication demands exceed

limited capacities).

D. The symptoms are not attributable to another medical or neurological

condition or to low abilities in the domains or word structure and grammar, and are

not better explained by autism spectrum disorder, intellectual disability

(intellectual developmental disorder), global developmental delay, or another

mental disorder.

Autism Spectrum Disorder 299.00 (F84.0)

Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across

multiple contexts, as manifested by the following, currently or by history

(examples are illustrative, not exhaustive, see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from

abnormal social approach and failure of normal back-and-forth conversation;

to reduced sharing of interests, emotions, or affect; to failure to initiate or

respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction,

ranging, for example, from poorly integrated verbal and nonverbal

communication; to abnormalities in eye contact and body language or

deficits in understanding and use of gestures; to a total lack of facial

expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships,

ranging, for example, from difficulties adjusting behavior to suit various

social contexts; to difficulties in sharing imaginative play or in making

friends; to absence of interest in peers.

Specify current severity:


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Severity is based on social communication impairments and restricted

repetitive patterns of behavior

B. Restricted, repetitive patterns of behavior, interests, or activities, as

manifested by at least two of the following, currently or by history (examples are

illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech

(e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia,

idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized

patterns or verbal nonverbal behavior (e.g., extreme distress at small

changes, difficulties with transitions, rigid thinking patterns, greeting rituals,

need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus

(e.g, strong attachment to or preoccupation with unusual objects, excessively

circumscribed or perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory

aspects of the environment (e.g., apparent indifference to pain/temperature,

adverse response to specific sounds or textures, excessive smelling or

touching of objects, visual fascination with lights or movement).

Specify current severity

Severity is based on social communication impairments and restricted,

repetitive patterns of behavior

A. Symptoms must be present in the early developmental period (but may not

become fully manifest until social demands exceed limited capacities, or may

be masked by learned strategies in later life).

B. Symptoms cause clinically significant impairment in social, occupational, or

other important areas of current functioning.

C. These disturbances are not better explained by intellectual disability

(intellectual developmental disorder) or global developmental delay.


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Intellectual disability and autism spectrum disorder frequently co-occur; to

make comorbid diagnoses of autism spectrum disorder and intellectual

disability, social communication should be below that expected for general

developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder,

Asperger’s disorder, or pervasive developmental disorder not otherwise specified

should be given the diagnosis of autism spectrum disorder. Individuals who have

marked deficits in social communication, but whose symptoms do not otherwise

meet criteria for autism spectrum disorder, should be evaluated for social

(pragmatic) communication disorder.

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental

factor

(Coding note: Use additional code to identify the associated medical or genetic

condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated

neurodevelopmental, mental, or behavioral disorder[s].)

With catatonia (refer to the criteria for catatonia associated with another mental

disorder, pp. 119-120, for definition) (Coding note: Use additional code 293.89

[F06.1] catatonia associated with autism spectrum disorder to indicate the

presence of the comorbid catatonia.)

Table 2 Severity levels for autism spectrum disorder

Severity level Social communication Restricted, repetitive

behaviors


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Level 3

"Requiring very

substantial support”

Severe deficits in verbal and

nonverbal social

communication skills cause

severe impairments in

functioning, very limited

initiation of social interactions,

and minimal response to social

overtures from others. For

example, a person with few

words of intelligible speech

who rarely initiates interaction

and, when he or she does,

makes unusual approaches to

meet needs only and responds

to only very direct social

approaches

Inflexibility of behavior,

extreme difficulty coping with

change, or other

restricted/repetitive behaviors

markedly interfere with

functioning in all spheres. Great

distress/difficulty changing

focus or action.

Level 2

"Requiring substantial

support”

Marked deficits in verbal and

nonverbal social

communication skills; social

impairments apparent even with

supports in place; limited

initiation of social interactions;

and reduced or abnormal

responses to social overtures

from others. For example, a

person who speaks simple

sentences, whose interaction is

limited to narrow special

interests, and how has markedly

odd nonverbal communication.

Inflexibility of behavior,

difficulty coping with change,

or other restricted/repetitive

behaviors appear frequently

enough to be obvious to the

casual observer and interfere

with functioning in a variety of

contexts. Distress and/or

difficulty changing focus or

action.

Level 1

"Requiring support”

Without supports in place,

deficits in social

communication cause

noticeable impairments.

Difficulty initiating social

Inflexibility of behavior causes

significant interference with

functioning in one or more

contexts. Difficulty switching

between activities. Problems of


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interactions, and clear examples

of atypical or unsuccessful

response to social overtures of

others. May appear to have

decreased interest in social

interactions. For example, a

person who is able to speak in

full sentences and engages in

communication but whose to-

and-fro conversation with

others fails, and whose attempts

to make friends are odd and

typically unsuccessful.

organization and planning

hamper

Common Characteristics

Very little or no eye contact.

Resistance to being held or touched.

Tends to get too close when speaking to someone (lack of personal space).

Responds to social interactions, but does not initiate them.

Does not generally share observations or experiences with others.

Difficulty understanding jokes, figures of speech or sarcasm.

Difficulty reading facial expressions and body language.

Difficulty understanding the rules of conversation.

Difficulty understanding group interactions.

Aversion to answering questions about themselves.

Gives spontaneous comments which seem to have no connection to the current

conversation.

Makes honest, but inappropriate observations.

Seems unable to understand another’s feelings.


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Prefers to be alone, aloof or overly-friendly.

Difficulty maintaining friendships.

Finds it easier to socialize with people that are older or younger, rather than

peers of their own age.

Unaware of/disinterested in what is going on around them.

Talks excessively about one or two topics (dinosaurs, movies, etc.).

Overly trusting or unable to read the motives behinds peoples’ actions.

Minimal acknowledgement of others.

Linguistic/Language

Abnormal use of pitch, intonation, rhythm or stress while speaking.

Speech is abnormally loud or quiet.

Difficulty whispering.

Repeats last words or phrases several times. Makes verbal sounds while

listening (echolalia).

Often uses short, incomplete sentences.

Pronouns are often inappropriately used.

May have a very high vocabulary.

Uses a person’s name excessively when speaking to them (“Mary, we are

having lunch. Right, Mary?”).

Speech started very early and then stopped for a period of time.

Difficulty understanding directional terms (front, back, before, after).

Behaviors

Obsessions with objects, ideas or desires.


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Ritualistic or compulsive behavior patterns (sniffing, licking, watching objects

fall, flapping arms, spinning, rocking, humming, tapping, sucking, rubbing

clothes).

Fascination with rotation.

Play is often repetitive.

Many and varied collections.

Unusual attachment to objects.

Quotes movies or video games.

Difficulty transferring skills from one area to another.

Perfectionism in certain areas.

Frustration is expressed in unusual ways.

Feels the need to fix or rearrange things.

Transitioning from one activity to another is difficult.

Difficulty attending to some tasks.

Gross motor skills are developmentally behind peers (riding a bike, skating,

running).

Fine motor skills are developmentally behind peers (hand writing, tying shoes,

scissors).

Inability to perceive potentially dangerous situations.

Extreme fear (phobia) for no apparent reason.

Verbal outbursts.

Unexpected movements (running out into the street).

Difficulty sensing time (Knowing how long ten minutes is or three days or a

week).

Difficulty waiting for their turn (such as in a line).

Causes injury to self (biting, banging head).

Emotions or sensitivities


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Sensitivity or lack of sensitivity to sounds, textures (touch), tastes, smells or

light.

Difficulty with loud or sudden sounds.

Unusually high or low pain tolerance.

Intolerance to certain food textures, colours or the way they are presented on

the plate (one food can’t touch another).

Inappropriate touching of self in public situations.

Desires comfort items (blankets, teddy, rock, string).

Laughs, cries or throws a tantrum for no apparent reason.

Resists change in the environment (people, places, objects).

An emotional incident can determine the mood for the day - emotions can pass

very suddenly or are drawn out for a long period of time.

Becomes overwhelmed with too much verbal direction.

Tends to either tune out or break down when being reprimanded.

Calmed by external stimulation - soothing sound, brushing, rotating object,

constant pressure (hammock, rolled in a blanket).

May need to be left alone to release tension and frustration.

School-related skills

Exceptionally high skills in some areas and very low in others.

Excellent rote memory in some areas.

Difficulty with reading comprehension (can quote an answer, but unable to

predict, summarize or find symbolism).

Difficulty with fine motor activities (coloring, printing, scissors, gluing).

Short attention span for most lessons.

Resistance or inability to follow directions.

Health/movement

Walks on toes.


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Unusual gait.

Difficulty changing from one floor surface to another (carpet to wood, sidewalk

to grass).

Odd or unnatural posture (rigid or floppy).

Difficulty moving through a space (bumps into objects or people).

Walks without swinging arms freely.

Incontinence of bowel and/or bladder.

Constipation.

Frequent gas (flatulence, burping) or throwing up.

Appearance of hearing problems, but hearing has been checked and is fine.

Seizure activity.

Allergies and food sensitivities.

Irregular sleep patterns.

Apparent lack of concern for personal hygiene (hair, teeth, body odors).

Difficulty transitioning from one activity to another in school.

Retrieved from http://calgaryautism.com/characteristics.htm

Copyright 2009 Rocky Point Academy. All rights reserved.

www.calgaryautism.com

Suite 230, 295 Midpark Way S.E.

Calgary, Alberta T3H 2X6

Practical tips

1) Schedule the first visit of the day

2) Look at the environment

3) Quick tips profile card

4) Picture schedule

5) Supports during exams: Sing, blow bubbles, distraction toys,

http://calgaryautism.com/characteristics.htm

http://www.calgaryautism.com/


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6) Allow hand flapping, spinning, rocking

7) Allow time for adaptation

8) Communication avoid idioms

The office experience

How is the image of an office not as autism friendly?

How is this image of an office more autism friendly?

How could you modify this environment to be more autistic friendly?

Communication tips

Avoid idioms

Idioms: a group of words established by usage as having a meaning not deducible from

those of the individual words

o Give it a shot = Try it

o Be in hot water = Be in trouble

o Cost an arm and a leg = expensive

o Play it by ear = improvise

o See eye to eye = agree

Use first and then (sequences)


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First we will do this

Then we will do that

Be creative

Jump up and down

Stretch

Touch toes

Spin

Rock

Videos used in the presentation

Autism Video Model- Going to the Dentist (Look at Me Now!®)

https://www.youtube.com/watch?v=UE_rElU3BS0 Autism behaviors at a visit

https://www.youtube.com/watch?v=EAGe9cgI5e0 Severe autism meltdown

From an ear infection and sore throat

Ways to protect your self form problem behaviors

https://www.youtube.com/watch?v=RdHxMQJ1zCY

Autism help- Pinching, Biting and Hitting - The Son-Rise Program

https://www.youtube.com/watch?v=6GD8reBVc4A

Autism Help- Tantrums - The Son-Rise Program

https://www.youtube.com/watch?v=WVFEo0ttSLM

Autism Help with Flexibility - The Son-Rise Program


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References

Bultas M., McMillins S., & Zand D. (2016). Reducing Barriers to Care in the

Office-Based Health Care Setting for Children With Autism.Available online 31

October 2015 Journal of Pediatric Health Care. 30 (1) 5-14. retrieved 5/31/16

from http://www.sciencedirect.com.ezproxy-

eres.up.edu:2048/science/article/pii/S089152451500

Bultas M. (2012). The Health Care Experiences of the Preschool Child with

Autism. Journal of Pediatric Nursing. 27 (5) 460-470. Retrieved 5/31/16 from

http://www.sciencedirect.com.ezproxy-


Chebuhar A. , McCarthy A., Bosch J., Baker S. (2013). Using Picture Schedules in

Medical Settings for Patients with an Autism Spectrum Disorder. Journal of

Pediatric Nursing. 28, (2) 125 – 134. retrieved 5/31/16 from



Johnson N., Burkette K., Reinhold J., & Bultas M. (2016). Translating Research to

Practice for Children with Autism Spectrum Disorder: Part I: Definition,

Associated Behaviors, Prevalence, Diagnostic Process, and Interventions.

Journal of Pediatric Health Care. 30 (1) 15–26. retrieved 5/31/16 from



Johnson N., Burkette K., Reinhold J., & Bultas M. (2016). Translating Research

to Practice for Children with Autism Spectrum Disorder: Part 2: Behavior

Management in Home and Health Care Settings. Available online 31 October 2015

Journal of Pediatric Health Care. 30 (1) 27–37. retrieved 5/31/16 from



Rocky point academy (2009) Common autism characteristics. Retrieved from


http://www.sciencedirect.com.ezproxy-eres.up.edu:2048/science/article/pii/S089152451500












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Thoughts on caring for individuals with Autism Spectrum ...c.ymcdn.com/sites/ · Thoughts on caring for individuals with Autism Spectrum Disorder ... to a total lack of facial expressions