Autism Spectrum Disorder and Challenging Behaviours Demonstrated in a Paediatric Hospital Environment

Background: Children and young people (referred to as children) with autism spectrum disorder (ASD) often exhibit challenging behaviours which can be magnified in the hospital environment (Johnson, Bekhet, Robinson, & Rodriguez, 2014; Lecavalier, 2006). Challenging behaviours, whether self-directed or directed at parents/ caregivers or staff result in injury and distress for the child (Carroll et al., 2014).

The Code Grey/ Black procedures are two of a series of Emergency Response Codes used in Australian hospitals to provide guidance to staff, patients and their carers with regard to the provision of health care services. A Code Grey will be called “when an individual fails to respond to initial defusing mechanisms undertaken by staff” (Royal Children's Hospital, 2017).

Objectives: The objective of this study is to review data from an Australian tertiary paediatric hospital to understand the proportion of Code Grey/ Black activations that are for children with ASD and the accompanying circumstances.

Methods: The total number of Code Grey/Black activations from 1 July 2016- 30 June 2017 were identified through the Victorian Hospitals Incident Management System (VHIMS). Incidents caused by parents, carers or visitors were removed from the data set. Each remaining incident was reviewed to identify the context, response and outcomes. Patient medical records were reviewed for each incident to describe if the child had a diagnosis of ASD, Intellectual Disability (ID) or both. The Electronic Medical Record (EMR) was also reviewed to decide if the child had an identified behaviour of concern. Descriptive statistics were used to analyse the data.

Results: In one year 675 Code Grey/Black activations occurred with 622 (92%) of these initiated due to the behaviour of a hospitalised child. Aggressive incidents occurred in paediatric mental health units, paediatric wards, emergency department and outpatient clinics and were triggered by 165 patients. Twelve patients triggered more than ten incidents each and contributed to 309 (50%) of all Code Grey activations. Behaviours of concern were known in 85 of the 165 (50%) children who triggered code grey activations.

Children with ASD with or without ID triggered 223 (36%) code greys. Of these, 54 were triggered by children with ASD only and 169 by children with ASD and ID. One patient with ASD and ID accounted for 102 Code Grey activations in the 12 month period. Of all patients with ASD who triggered code greys, 85% had known behaviours of concern.

Conclusions: Children with ASD account for 36% of all clinical aggressive incidents at an Australian tertiary paediatric hospital. Challenging behaviours when exhibited in hospital and the resulting staff response, can cause distress or injury to the child and their family and influence future health care use. Understanding the profile of children who trigger Code Grey/ Black incidents will enable targeted clinical strategies and staff training approaches to be developed to reduce the triggers for stress, distress and aggression from patients with ASD & ID. This in turn may result in short and long term benefits for staff, children and their families.