Examination of Pediatric Patients with Autism Spectrum Disorders

In this podcast, Thomas Meersman, DHSc, MMsc, PA-C, speaks about ways clinicians can improve communication and examination of pediatric patients with autism spectrum disorders, including behavioral techniques to assist a clinician while using instruments or performing procedures that are often difficult in the examination of children with ASD. He also presented on this topic at the annual AAPA 2021 meeting. 

Additional Resources:

• Data and Statistics on Autism Spectrum Disorder. Centers for Disease Control and Prevention. Updated September 25, 2020. Accessed May 20, 2021. https://www.cdc.gov/ncbddd/autism/data.html
• Cuvo, AJ, Reagan AL, Ackerlund J, Huckfeldt R, Kelly C. Training children with autism spectrum disorders to be compliant with a physical exam. Res Autism Spectr Dis. 2010;4(2):168-185.https://doi.org/10.1016/j.rasd.2009.09.001
• Drake J, Johnson N, Stoneck AV, Martinez DM, Massey M. Evaluation of a coping kit for children with challenging behaviors in a pediatric hospital. Pediatr Nurs. 2012;38(4):215-221. https://doi.org/10.1016/j.pedn.2012.02.009
• Hudson J. Prescription for success: supporting children with autism spectrum disorders in the medical environment. Autism Asperger Publishing Co; 2006. 
• Orellana LM, Martínez-Sanchis S, Silvestre FJ. Training adults and children with an autism spectrum disorder to be compliant with a clinical dental assessment using a TEACCH-based approach. J Autism Dev Disord. 2014;44(4):776-785. https://doi.org/10.1007/s10803-013-1930-8 
• Meersman, T. Lost at sea in ASD: Techniques for improved communication and examination of pediatric patients with autism spectrum disorders. Presented at: American Academy of Physician Assistants 2021; May 23-26. https://ww3.aievolution.com/aap2101/index.cfm?do=ev.viewEV&ev=1053

​​​
Thomas Meersman, DHSc, MMSc, PA-C,  is the Program Director and Assistant Professor at the developing Master of Science in Physician Assistant Studies program at North Central College in Naperville, Illinois.

TRANSCRIPTION:

Jessica Bard: Hello everyone and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

According to the most recent data available from the CDC, about one in 54 children has been identified with autism spectrum disorder. Dr Thomas Meersman is here to speak with us about ASD today.

Dr Meersman is the program director of the Master's of Science in Physician Assistant Studies, and an Assistant Professor of Physician Assistant Studies at North Central College in Naperville, Illinois.

Thank you for joining us today, Dr Meersman. You're presenting the session Lost at Sea in ASD techniques for improved communication and examination of pediatric patients with autism spectrum disorders at AAPA 2021. Can you please give us an overview of your session?

Dr Thomas Meersman: Sure, I'd be happy to. First, let me say it's my absolute pleasure to be here with you today and have the opportunity to get the word out about ASD and providing medical care to this special population.

That ties in, that's the intention of the session is to point out and address knowledge gaps and skill deficits that currently exist in medical and PA education curricula regarding the care of individuals with autism. When it comes to learning the knowledge skills and abilities within the ASD population, PA education tends to cover things like knowledge quite well.

Medical providers are familiar with the DSM‑5 criteria for autism. They can rattle off repetitive, restrictive, ritualistic behaviors, the impairments in social and emotional functioning, coherence in speech, things of that nature. Then taking it the next step and receiving formal training on how to navigate some of the unique needs of individuals and ASD populations is lacking.

The goal of this lecture is to fill those gaps and skill deficits, cover within the lecture a study where health care providers self‑rate themselves on their ability to care for individuals with ASD. It's quite shocking. I think, 77 percent of health care providers self‑rated their ability to care for individuals with ASD as at best, fair or poor.

Over three‑quarters of medical providers realized that they're lousy in working with this population. Furthermore, rates of specific phobias are higher in the ASD population that receives medical care, 44 percent versus 6 percent in the neurotypical population.

The end result is that health care providers, unfortunately, because they're not comfortable and because challenges are higher, over rely on things such as sedation, physical restraint, or even foregoing procedures that are necessary all together, because they're not comfortable, and they don't have the proper skills and abilities to evaluate these individuals.

The end goal is to try to fill that gap. That's tough to do in an hour, but at least provide some basic coverage so that PAs and other health care providers can feel more comfortable, and do a better job with individuals with ASD.

Jessica: We certainly want to improve that. How does a clinician categorize the unique sensory needs of children with ASD?

Dr Meersman: An excellent question. It's difficult to categorize those needs because it's a spectrum. Those needs are so individual. An individualized approach is fast but having familiarity, painting in broad strokes, is important to have an understanding of the basic sensory needs throughout the spectrum, I should say.

There are hypersensitivities and those tend to be categorized as sensory avoiding behaviors. An example of that would be an auditory hypersensitivity in an autistic child. Having knowledge of that before you enter in the room is vital for having a successful examination of that child.

Making accommodations for that that sensory hypersensitivity. An example would be something simple, noise canceling headphones or even closing the door as that individual's waiting to be seen so that they're comfortable.

At the same time, again, in those broad strokes, there are hypo‑sensitivities. Those tend to be categorized as sensory‑seeking behaviors. Example of that, the result of approprio receptive or auditory hypo‑sensitivity.

That individual, that child with ASD would be more comfortable with an accommodation such as opportunities for movement in the clinic, rocking, swinging, or if you have a coping kit providing increased sensory input, like a weighted blanket.

Those are examples, but being aware that individuals with ASD throughout the spectrum have sensory hyper and hypo sensitivities almost universally. Knowing how to identify those, being aware of those before you walk in to see that patient, and then being familiar with some of these really easy in retrospect intuitive accommodations that you can make. First being forewarned is forearmed.

Jessica: As you mentioned in the beginning, children with ASD can have challenges related to anxiety and phobias during a physical exam. How can a clinician identify those responses?

Dr Meersman: This is something that I build towards in the lecture. The short answer is you have to perform an ASD needs assessment. There are formalized assessment tools. There's a wonderful text by Hudson. It's an older text, a book that came out in 2006, that's called "Prescription for Success, Supporting Children with ASD in the Medical Environment."

I wouldn't be put off at the fact that it came out in 2006. The recommendations are still timely and still apply to individuals with ASD. There's a section of that text that has a detailed outline of what an ASD needs assessment looks like. I review that in the lecture, or something similar to that in the lecture.

However, that can be overwhelming, especially if you're not evaluating children with ASD on a regular basis. A lot of people are familiar with a SWOT analysis, strengths, weaknesses, opportunities and threats. That's essentially what you're doing with this needs assessment.

You're identifying the strengths that these individuals have with ASD. The things that they may excel at during the evaluation, things they're comfortable with, weaknesses that they may have. Hypo or hyper sensitivities that need to be accommodated for, for them to be comfortable and to decrease the anxiety.

Opportunities to help them which you could seek the guidance of the parent or guardian that's present. You don't have to reinvent the wheel. There are excellent resources. Then, threats to the successful completion.

If there's an area of the physical exam that's known to be problematic, to identify that. If you did something as simple as having a pre‑screening of individuals with ASD, to identify the strengths, weaknesses, opportunities for success and threats to a successful examination.

Identifying that, reviewing it before you walk in, you're so far ahead of the game. That's key to having a successful medical evaluation in this population.

Jessica: What behavioral techniques can assist a clinician while using instruments or performing procedures that are often difficult in the examination of children with ASD?

Dr Meersman: There are a number of techniques that have been identified both anecdotally and mentioned in the medical research. Those that have been more heavily researched, there's a section at the end of the lecture that reviews the research in more granular detail.

Some highlights studied by Kubo et al from 2010, highlights ABA, applied behavioral analysis‑based techniques. If you're unfamiliar with ABA, it's a common therapy that's provided to individuals with ASD. ASD‑like needs involves multiple discrete trials and positive reinforcement.

The study by Kubo et al, they performed multiple trials in individuals with ASD to try to train them to be compliant with a 10‑component physical exam. The end result was that over time, they were able to get these individuals with ASD comfortable enough to being examined that all were compliant with a physical exam, when they had severe non‑compliance at the beginning of the study.

Can we do that type of intervention? Most of us as clinicians, admittedly, probably can't. It was proof that if you have an ASD patient that's coming in for multiple evaluations that if you do it correct, you examine them correctly and you take the time to identify their needs, they should get better over time as you would expect of a neurotypical patient as well.

Another useful technique because it has great face value, it's intuitive that anyone can use. There was another research study that highlighted a dental‑based study. The technique is summarized as Tell‑Show‑Feel‑Do or TSFD. I get into more detail about this in the lecture as well.

Essentially, you're telling the individual what it is that you're going to do. An example would be, "I'm going to examine your ears." You show them to display that on either anatomical model, or a stuffed animal. That's been researched as well and shown to be useful. You allow them to feel the instrument that they may be anxious about, for example, an otoscope, then you proceed to do the exam.

Taking a step back, slowing things down, telling them, showing them, allowing them to feel the examining device, and then doing that exam, making that a deliberate process. That alone has been shown to be extremely effective. It slows things down.

It outlines the process in terms that individuals with ASD are more accustomed to, provide some interaction with a fearful instrument, and leads to more successful examination. It's a simple technique, but quite profound. The research supports that, and its ability to help with these difficult components of the evaluation.

Jessica: That sounds like a wise advice. What are the common components of coping kits and visual communication tools? How should a clinician use them during the examination?

Dr Meersman: Coping kits can be as varied as the needs of individuals with ASD. You'll see some common components. For those who are unfamiliar with coping kits, typically, they're comprised of toys or tools that provide increased visual, tactile, or auditory input.

The goal is to decrease anxiety stress and also to address some of those sensory hyper or hypo sensitivities similar to those that I discussed before. How does a coping kit do that? What is it comprised of?

You'll typically see things like fidget spinners that provide tactile input. Headphones, again, to decrease the auditory input for those that are hypersensitive in that domain. Small fans, both with visual and some tactile input from the fan, bubble wands.

There are chewy tubes. Some individuals with ASD have oral hyposensitivity. They're oral seeking, so a chewy tube has medical grade rubber that, it'd be single‑use, of course, individuals can chew on, that they find soothing.

These devices can sometimes provide something familiar from outside the clinic that they're used to interacting with at home. Getting some guidance from the parent or caregiver is useful with the coping kits. My favorite coping kit tool is the tool that everyone has, pretty much, 24/7, or all waking hours in their pocket, smartphone, or some kids will have tablets.

Bringing up something as simple as a familiar clip, or a preferred cartoon or movie. Relying on the parent or caregiver to guide that healthcare asking, "What's Johnny's favorite cartoon?" Bringing that cartoon up on the phone, even playing a short clip over and over.

It's familiar, it's repetitive, it can have an immediate soothing effect for that individual. Bringing something that's familiar into this unfamiliar environment. Those are examples and techniques that anyone can use. You just have to have it available.

Jessica: What research is being done to support these guidelines for examination of children with ASD? You did mention a few previously, but what research is being done?

Dr Meersman: I'll apologize off the bat because I'm a bit of a research nerd, especially [laughs] in this area. I could go on and on about research. I'll save you [laughs] from that. I would say there's not a paucity of research. Studies exist, but my personal feeling is this is an under researched topic within the realm of medical research.

I had highlighted earlier that Coveux et al study from 2010 training compliance with physical exams, so that's one example. Coping kits have been more often researched within this area.

Study by Drake, et al, from 2012, looked into the use of a coping kit in the emergency department and showed significant improvement using a coping kit versus not having that coping kit available when evaluating children with ASD. There are other studies I highlighted that Tell‑Show‑Feel‑Do technique, that's a dental study.

It was a study showing compliance with a dental exam from 2014. That Tell‑Show‑Feel‑Do has so much face value. It's so intuitive that it's easy to see how that would be successful in the medical environment.

My personal feelings are if it works during a dental exam, knowing how much I enjoy a dental exam, or a typically developing individual struggles with a dental exam. If it works in that realm, it's going to work for us as PAs as well.

Jessica: You told me while we were emailing back and forth before this, that it's your mission in creating the last EdC and ASD lecture to get the word out to other clinicians regarding the evaluation of individuals with autism. Why are you particularly so passionate about this subject?

Dr Meersman: Thanks for that question. You can't see, but I'm nodding in recognition, this is a personal topic. I have a young son who's autistic and nonverbal, and raising him opened my eyes to this population as a medical provider as aware of before witnessing his struggles during medical exams. They're all of our struggles.

As a clinician, physician assistant educator, researcher, I saw opportunities to fill a knowledge, skill, and ability gap that currently exists. I saw this as my call to action. It's all of our call to action if you're interacting with this population. Increasingly, these days, all of us are and in our own ways.

The more clinicians I talked to about this topic, the more I hear refrains, like, "I wish I would have learn that in school." They never covered that in my clinical training. That was a call to action for me to having some additional perspective adds to the ability.

I stepped through some case‑based examples of challenges. They highlight challenges that I've had both as a provider and as a parent. I hope that's useful to those that hear the lecture. That's how I got in on this rabbit hole. It's been so enlightening. It's been something I've enjoyed so much more than I ever anticipated when I started. When the germ of the idea spread. [laughs]

Jessica: I can tell you're passionate about it. Thank you so much for joining us today. Is there anything else that you'd like to add or touch on?

Dr Meersman: Oh, I'm sure it's not surprising. There are a few things.

[laughter]

Dr Meersman: Thanks for asking. Overall, small efforts make big differences in the ASD and special needs populations in general. We're all busy as clinicians. Increasingly, we're under more pressure to increase our RVU's to improve our metrics, and improve our patient satisfaction scores. Certainly, I feel that.

When you're evaluating the ASD population, it's important to hit the brakes. Slow down, take the time to utilize simple and effective techniques such as Tell‑Show‑Feel‑Do, using coping kits, etc.

Doing so will improve not only the current interaction, but the future interaction down the road for individuals with ASD. Once clinicians practice these techniques and implement them, you see an immediate improvement in the medical interactions within this population.

A little knowledge goes a long way. That's the idea, is to cover the tip of the iceberg. Get that out there into clinicians hands to utilize those techniques. Getting this right in the ASD population is unbelievably rewarding, so spread the word to your medical colleagues. You'll be glad you did and it'll make you feel good.

Jessica: Thank you again for joining us today.

Dr Meersman: Sure. It's been my absolute pleasure. Thank you so much for reaching out to me.