News and Knowledge

A member of OAR’s Scientific Council and the recipient of the 2004 Autism Society of America’s Outstanding Professional Award and the 2006 Princeton Fellowship Award, Brenda Smith Myles, Ph.D., has written numerous articles and books, including Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns (with Southwick) and Asperger Syndrome and Adolescence: Practical Solutions for School Success (with Adreon). She has made over 500 presentations all over the world, written more than 150 articles and books on autism and Asperger Syndrome, and served as the co-chair of the National ASD Teacher Standards Committee.

Jill Hudson, MS, CCLS, is a certified child life specialist. Trained at Johns Hopkins, she formerly worked at the Children’s Hospital of Philadelphia. She is the author of several books on autism spectrum disorders, including Prescriptions for Success: Supporting Children with Autism Spectrum Disorders in the Medical Environment. She currently works at the Ohio Center for Autism and Low Incidence and presents and consults internationally.

Going to the doctor’s or dentist’s office or the hospital is anxiety-producing for most people, but especially so for children. Not only is the child sick or injured and needs care, but she is in a new setting and everything around her is unfamiliar. The sights, sounds, and smells are new. The routine is different. New people come and go, and the child quickly becomes the victim of fast-paced decisions that are often made without considering the child’s level of understanding. As a result, even an otherwise well-adjusted child can get anxious.

Now imagine that an individual with an autism spectrum disorder (ASD) enters the hospital environment. New people, sounds, smells, and expectations affect the child or adolescent, in ways similar to their neurotypical peers. In addition, the child with ASD usually has higher levels of anxiety and generally reacts negatively to novel situations. The result is a highly stressed, anxious child who may soon become unable to cope in this confusing environment by become hyperactive; acting nervous or silly; withdrawing; or having a tantrum, rage, or meltdown.

This situation is exacerbated by interactions with medical personnel who are not trained specifically to work with individuals with ASD. Medical personnel, without understanding the unique characteristics of those with ASD and how they perceive the environment, often unintentionally increase the child’s anxiety and promote behavior problems. The purpose of this brief article is to provide an overview of some easy-to-use strategies that medical personnel can use to minimize the trauma associated with medical care for children and youth with ASD.

Four Easy Steps

Individuals with ASD present with myriad challenges across domains ranging from social to sensory to visual learning. As shown in Table 1, these characteristics revolve around not understanding the environment, experiencing the environment in an unfriendly manner, and not understanding how and when to react. Thus, interventions that can address these challenges are essential. Interventions that can make medical visits easier for individuals with ASD include priming, predicting, wrap-up, and countdown (Sakai, 2005).

Priming

Priming is a method of preparing the individual for an activity that she will be expected to complete. Priming accommodates a preference for predictability and promotes more consistent responding. With the emphasis placed on previewing activities before they will occur, the child is often less likely to experience anxiety and stress about what lies ahead. With anxiety and stress at a minimum, the child can focus her efforts on successfully completing activities. Because the individual with ASD is a visual learner, a picture schedule of activities (see Figure 1) or a narrative that describes the activities can be very helpful. Often narratives describing an event can be presented as a brief story with digital photos or simple drawings showing equipment or procedures. Another priming activity would include allowing the child or adolescent to take along a favored item. In this way, the individual with ASD is more prepared for the new environment because the favored item makes the setting more familiar.

Predicting

When a child or adolescent is primed for an event, she expects it to happen in just that way. Often schedules or procedures change, so it is important that predicting be a part of the routine. Predicting answers the “What if …” question. This is something parents of children with ASD need to anticipate for medical visits. Medical personnel may ask parents to be sure to bring the indicator for change that they use at home or that their child uses at school (see Figure 2) to an appointment. This can be inserted into a picture schedule of activities or even into a story describing a procedure. Parents of verbal individuals with ASD can ask or write out “What if …” questions to prepare the child. Examples of “What if …” questions are:

• What if the doctor is late for the appointment?
• What if the doctor takes your temperature before she listens to your heart?

Predicting helps the child increase flexibility and provides some semblance of routine in the face in the change.

Countdown

A simple countdown of 5, 4, 3, 2, 1 using a countdown strip can help the child understand that an event will last only a short while. For a quick, one-time use, the numbers could be written on a piece of paper and crossed off as the events happen or as time passes (i.e., such as time passage to take temperature). For children with special interests, the special interests could be incorporated into a countdown strip. One mom we know whose son likes teddy bears carried a small cup and plastic teddy bears with her. As time passed, she would count down by putting the teddy bears in the cup.

Wrap-Up

Wrap-up is a celebration of the completed activities. Most often, the wrap-up should include reinforcers–items that the child prefers. They could be presented in a form of a “First/Then” card (see Figure 3) or a series of cards that have pictures of potential preferred items. This step is essential because the child or adolescent with ASD has completed a very challenging activity overcoming many ASD-related obstacles. The wrap-up ends the experience on a positive note.

Summary

Priming, predicting, countdown, and wrap-up are strategies that can be easily incorporated into medical visits. Compatible with the needs of individuals with ASD, these four easy-to-use strategies have the flexibility to be easily implemented in doctors’ or dentists’ offices or hospital settings.

Note. Help your child’s nurses and doctors understand your child with ASD by giving them a poster designed to provide medical professionals with some tips for working with an individual with ASD. It’s available free from the Autism Asperger Publishing Company (www.asperger.net or 913-897-1004).

References

Hudson, J. (2005). Prescription for Success: Supporting Children with Autism Spectrum Disorders in the Medical Environment. Shawnee Mission, KS: Autism Asperger Publishing Company.

Sakai, K. (2005). Finding Our Way: Practical Solutions for Creating a Supportive Home and Community for the Asperger Family. Shawnee Mission, KS: Autism Asperger Publishing Company.