News and Knowledge

Individuals with autism spectrum disorder (ASD) are psychiatrically hospitalized at significantly higher rates than peers with other developmental or psychiatric conditions, according to several studies from the past few years. Not only that, but they are more likely to go to an emergency department due to a psychiatric or behavioral crisis, more likely to be psychiatrically hospitalized following an ER visit, and have longer hospital stays, those studies note.

“Treatment as usual” for individuals with ASD admitted to general psychiatry units is not effective, in part because the health care staff who provide care in those units are not equipped to provide the specialized care patients with ASD need.

Jill Fodstad, PhD, an associate professor of clinical psychology in clinical psychiatry at the Indiana University School of Medicine, will develop and evaluate a diagnosis-specific protocol for treating youth with autism spectrum disorder admitted to acute general psychiatry units in her OAR-funded study. The study’s aims are to:

• Evaluate stakeholder perceptions of the barriers to providing acute care to persons with ASD
• Perform usability testing of an ASD-specific training and intervention program developed by Dr. Fodstad
• Develop measures to assess improvements after program implementation

The two-year project will take place at the Riley Hospital for Children in Indianapolis, Ind. The hospital’s child and adolescent behavioral health unit provides care to youth ages 8 to 17 with a variety of diagnoses, including ASD.

Dr. Fodstad and her research team will recruit a total of 50 to 65 participants from four groups:

• Parents/legal guardians
• Physicians/other mental health care providers
• Nurses/direct care staff employed on general psychiatry units providing care to patients with ASD
• School personnel who teach students with ASD who are at high risk for hospitalization

Phase 1: Evaluate Stakeholder Perceptions

In semi-structured interviews conducted by the research assistant, 30 to 45 participants, 10 to 15 from each of the four groups, will answer questions tailored for their group. The questions will gather information about the participant’s perspectives on the difficulties and needs in providing care to individuals with ASD admitted to general psychiatry units. Physicians, other mental health care providers, nurses, and direct care staff will describe the knowledge, training, and intervention materials they think are needed to enable them to provide care for patients with ASD. Parents/legal guardians and school personnel will describe what type of supports or training they feel would be helpful to improve care during admission and improve outcomes after discharge.

Phase 2: Usability Testing of an ASD-Specific Training and Intervention

Twenty participants, five from each group, will test the program’s usability. In a two-hour session with each group, the research assistant will introduce the program. Participants will review a handout describing program procedures and interact with materials – visuals, videos, internet-based modules, other written materials – that may be used during an admission with the patient or to enhance training. The research assistant will also facilitate behavioral skills training sessions for each group to allow participants to understand how staff will be trained to use the tools in the treatment package.

Phase 3: Piloting the Training and Intervention Prototype

Dr. Fodstad will pilot the training and intervention prototype at the Riley Hospital in the pediatric inpatient psychiatric unit. Thirty-five full-time staff will participate in groups of 10 to 14 people each.

The pilot will comprise two phases: staff training and intervention use. Before training, participants will complete a survey to assess their knowledge of ASD and evidence-based practices. Dr. Fodstad anticipates that there will be a minimum of four training sessions:

• Introduction to ASD (e.g., prevalence, core features)
• Care foundations (e.g., functional behavior assessment, medical assessment, limiting attention, offering choices, praise, using appropriate language)
• Building the environment (e.g., physical and visual structure, schedules and predictability, activity engagement, and identifying reinforcers)
• Treatment strategies (e.g., functional communication, skill building, safety-related goals, generalization)

Each training session will last 45 minutes and include in-person and video instruction, behavioral skills training, handouts, and “mock patient” simulations. Participants will receive toolkits with reminders of basic milieu strategies, relevant visuals or treatment materials, specific assessments to use for treatment planning, and tips for adapting materials for diverse patient needs. Post-training surveys will assess their satisfaction with the training process.

Participants will then implement the strategies they learned with 10 patients with ASD. During admission, the research assistant will conduct random checks to ensure the strategies taught during training are being correctly implemented. If the research assistant notes an error, they will review the skill that was not used or used incorrectly. After each patient is discharged, parents will complete the unit’s regular care satisfaction survey and staff will complete a survey to assess the intervention prototype.

At the end of the study, staff will retake the ASD knowledge survey. The research team will collect data, including each patient’s length of stay; number of holds, restraints, or seclusions; and number of “as needed” intramuscular or oral medications for immediate de-escalation.

Outcomes

Dr. Fodstad’s long-term goal is to develop an evidence-based ASD-specific process of care for existing general psychiatry hospitalization programs. Beyond that, outcomes could apply across settings—providing care to adults with ASD admitted to general psychiatry units, for example, as well as testing the application of the developed training and intervention program in non-psychiatric hospital settings.

Persons with ASD have inherent unique learning styles, needs, and abilities that generally do not lead to successful outcomes in general psychiatric hospital environments. If the outcomes of this study are positive, it could increase access and capacity for providing appropriate and effective care to those with ASD and psychiatric needs.