Tips for Emergency Room Staff

September 17, 2015

When a child with autism is in a behavioral crisis, the family may have to call 911 to ensure the safety of their loved one and those around them. The child will most likely be transported to the emergency room first.

A behavioral crisis, whether it is the first or one of many, can be a highly stressful and frightening time for the child and their family. The decision to seek emergency services is usually due to extremes in behavior such as self-injury, aggression toward others and property destruction. Because emergency medical services and emergency room staff are the first point of contact in assisting the individual in crisis, it is helpful for them to be familiar with the characteristics of autism and to know what can be helpful when interacting with a person with autism. Even if the child has “calmed down” somewhat by the time they reach the emergency room, they may present with unusual communication and behavioral patterns that require patience and understanding.

Autism 101

Autism Spectrum Disorder (ASD) or autism is a neurological disorder characterized by impairments in social interaction and communication as well as restricted, repetitive patterns of behavior. Many individuals on the spectrum will also have an intellectual disability (IQ lower than average) that needs to be considered. These characteristics fall across a “spectrum” ranging from mild to severe. No two people with ASD are the same.

Social Interaction

Individuals with ASD have difficulty interacting with others: building relationships, using language, regulating their own emotions, and understanding others’ points of view. Some prefer to be alone, do not seek social interaction, or may not seem to notice other people at all. Others want to be social but may not understand how to do so effectively.

An additional resource that can be accessed through the Children’s System of Care is Children’s Mobile Response Stabilization Services (MRSS). Mobile response services are available to any child experiencing a behavioral crisis, and can be called even if the child is not currently eligible for developmental disability services. MRSS may be the family’s first point of contact to enter the service system, and can be helpful if the family thinks that the situation can be managed with support coming to the home, or if they need help determining what they should do next. MRSS may assess the situation and advise the family on whether to call 911 for additional help. To access MRSS services call 1-877- 652-7624

Communication

Some individuals with ASD develop fluent conversational speech, others speak only to get their basic needs met, and still others remain nonverbal but may communicate with pictures, sign language, or other technical devices like smartphones or tablets.

Behavior

Individuals with ASD may have repetitive physical mannerisms (rocking, pacing, waving) or vocalizations (using the same sounds or phrases over and over). They may also have intense interests in certain topics, insistence on strict routines, and have unusual responses to sensory input. Because of these difficulties, there is an increased possibility of frustration which may lead to challenging behaviors including aggression and self-injury. A change in behavior may be a way to express that something is wrong. Health and safety concerns include seizures, significant eating and sleeping problems, and eloping or wandering.

Important Reminder

Never make presumptions about what a child can and cannot comprehend. Even if they cannot speak, avoid eye contact or have unusual mannerisms, they may be listening and understanding what you are saying. Conversely, they may have difficulty understanding questions or following instructions. Asking the family the following questions can help create a clear picture of how the individual is affected by autism so everyone can best meet their needs:

What is the best way to communicate with their child? Does he/she use an alternative method of communication? If they use a device, did they bring it with them?
How do they respond to strangers? Will it help if a specific family member remains present with them during any testing or evaluations?
What is typical behavior for the individual?
Do they have any sensory issues? (e.g., sensitivity to bright lights, sounds, textures)
What helps calm the child?
What helps motivate them to comply with directions?
Does the child ever elope or wander?

How Does this Affect the Family?

Autism caregivers are prone to chronic stress and burn out. Recent studies have shown that mothers of individuals with autism have physiological profiles similar to combat soldiers and those with posttraumatic stress disorder. It is essential to understand that a crisis affects the entire family and adds to the stress already experienced by families on a daily basis. They may face judgment from others who don’t understand their child’s needs. Families facing a behavioral crisis need compassion, support and resources to assist them.

Ways to Help the Family

Try to relieve the anxiety of the patient and family by allowing them to bring familiar and comforting objects from home (e.g., pillow, blanket, favorite foods or toys).
Assure the family that they are not alone. Periodically ask them if there is anything they need that can help them or their child.
If the individual must undergo a psychiatric screening, explain what is involved and ask the family what will help make it less stressful for the individual. Communicate their concerns to other professionals who are involved in the person’s care.
Document rejections from psychiatric treatment centers. Not all treatment centers accept individuals with ASD, and the individual may have to spend more time than is typical waiting in the ER or a hospital room for an appropriate placement. It is important to document all rejections to show the family is exhausting all resources.
Make sure parents know their medical rights, especially in situations where an involuntary psychiatric hold might be necessary.
Families often face many barriers when trying to access the services their loved one needs. They may have limited resources, or they may not be sure what type of help is available to them. The Autism New Jersey helpline is a comprehensive resource for information, referrals and support. The helpline provides information on effective behavioral interventions for autism, and educates families about accessing services through health insurance, school and the Children’s System of Care.
Inform the family about state-funded developmental disability services provided by the New Jersey Department of Children and Families’ Children’s System of Care (DCF-CSOC). Services include mobile crisis response and intensive in-home supports (IIS) that incorporate behavioral interventions to address behaviors such as aggression, self-injury, property destruction, and elopement. These supports can potentially offset the severity of a behavioral crisis or reduce the need to go the ER. Information and an eligibility application for CSOC services are available through PerformCare at www.performcarenj.org or by calling 877.652.7624. Offer to assist them in connecting to these services.
Parents themselves can become stressed and overwhelmed by their child’s behavioral challenges. Connect them to supportive resources such as the Mom2Mom Helpline Program, coordinated by Rutgers University Behavioral HealthCare. Mom2Mom provides a 24 hour, 7 day a week helpline staffed by moms of special needs children trained in peer counseling and crisis support, telephone assessments by clinical staff, a network of referral services and support groups. Parents can call 877.914.6662 or visit www.mom2mom.us.com.

For additional information about behavioral crisis management and prevention or for assistance with accessing resources, contact Autism New Jersey at 800.4.AUTISM or email information@autismnj.org.

Additional Training Resources

For information regarding behavioral crisis specific to adults:

Family Crisis Handbook