Pediatricians have an important role in the chronic management of autism spectrum disorders (ASDs). According to guidance from the American Academy of Pediatrics, “optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life” for such patients.
Anxiety, challenges with sensory processing, and expressive and receptive language deficits among the ASD population require physicians to take a different approach. “People with ASD have trouble forward imagining to what [the visit] is going to be like, so they don’t know what to expect,” said Dr. Susan Connors, an internist who works with ASD patients at the Lurie Family Autism Center in Lexington, Mass. “Usually they’re pretty tense when they first get into the room.”
“They can communicate, but they communicate differently,” she added. And their expression of pain is different because their sensory processing is different. “If you see someone banging his head, he might have a migraine, an ear infection, a sinus problem, or even chest pain.”
Virtually all of Connors’ patients come in with a trusted adult — typically a parent or a caregiver — and that’s a good place to start. “You should sit down, be calm, and talk to the trusted adult for a few minutes,” she said. “Show [the patient] that this trusted adult is calm and is sharing information with you freely.”
When the patient is less anxious, move to the physical exam, she advised. “If I think they have good receptive language, I ask permission, or I model parts of the exam on myself or with the trusted adult. Sometimes I say, ‘first this, then this,’ starting with the least invasive procedure.”
It can be useful to have manipulative and visual toys available for the patient to fidget with during the visit, and perhaps some treats the patient can look forward to after the visit, said Connors. The caregiver can help the patient understand what to expect through ‘familiarization’ visits and social stories (illustrated stories about an event with the patient as the main character) to help alleviate the patient’s anxiety on the day of the actual appointment.
Clinically, certain medical problems — such as sleep problems, GI issues, and seizures — are seen more frequently in autistic patients than in the general population, said Connors. It’s also important to note that some can be very sensitive to certain medications, such as antidepressants, cold medicine, beta blockers, and atypical antipsychotics. She recommends starting with very small doses when prescribing those medications to an ASD patient.
In addition, patient charts should be flagged for ‘no waiting’ for imaging and lab work, because autistic patients can get very anxious about those procedures. Sedation may be necessary in some cases, which presents additional challenges.
Connors noted that some medical schools are beginning to train medical students about how to approach patients with ASDs. “They deserve the same medical care and respect as anyone else.”
Robyn Alie writes about public-health issues for Vital Signs, a publication of the Mass. Medical Society, where this article first appeared.