28198
Reducing Emergency Room Admissions for Individuals with ASD and Severe Behavior
Individuals with Autism Spectrum Disorders are often remanded to the Emergency Departments (EDs) of local hospitals following episodes of severe aggression, self-injury, or property destruction. Unfortunately, community hospital EDs are often ill-equipped to stabilize these patients, resulting in excessive stays in the ED or premature release back to the home setting where repeat referrals to the ED are more likely. It is well-documented that children with ASD are 9 times as likely to visit the ED than children without ASD, that they are at greater risk for psychiatrist hospitalization than children with other disorders, and that aggressive and self-injurious behaviors combined with lack of appropriate community services increases the risk of hospitalization.
Objectives:
The BRISC project investigated the development and implementation of a subacute program providing a comprehensive and coordinated system of care, designed for children with ASD admitted to the ED. Key components included rapid deployment of functional analytic behavioral assessment and positive behavior supports for the child upon admission, discharge planning from the date of admission linking parents to effective community and educational resources, intensive parent training, and training parents to work with their child to generalize positive and adaptive replacement skills while maintaining the reduction of significant problem behavior upon returning home.
Methods:
Eight children (7M, 1F) and their families currently admitted to emergency departments at local hospitals for severe aggression, self-injury, or property destruction between the ages 5-13 years old with ASD participated in this program. Each had a history of high intensity and high frequency severe problem behavior, co-morbid psychiatric diagnosis or significant trauma history, repeated hospitalizations or emergency room visits, multiple school placements, complex family histories and different levels of community provider involvement. Comprehensive assessments were conducted to determine behavior function(s) and guide the development of function-based treatment plans. Treatment protocols emphasized acquisition of functional replacement skills, coping skills, and maintenance of zero or low rates of challenging behavior. Program staff, parents and community providers were trained on these plans to fidelity in the program, on home visits, and upon discharge.
Results: Compared to baseline assessments, results indicate a significant reduction in problem behavior in program and at home, high rates of acquisition of functional replacement skills, high rates of skill acquisition among staff and family caregivers upon discharge, and improvements on parent-reported quality of life and use of positive parenting strategies following discharge (see Table). Most importantly, of all children admitted to the program 2 experienced an ED re-admission within the 6 months after discharge but were quickly stabilized.
Conclusions: While hospitalization and ED visits are sometimes warranted, their overuse may also represent a failure to provide appropriate community-based care. As such, the need for intervention strategies that divert from ED and hospital admissions is evident. Results are discussed in terms of the importance of a coordinated system of care for these high-risk children, the importance of intensive and function-based assessment and treatment planning, and the critical impact of treatment fidelity in parent training.