Faculty Bibliography

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.

While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173-3180, https://doi.org/10.1007/s10803-019-04029-6, 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082-4089, https://doi.org/10.1007/s10803-018-3666-y, 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient's stay.

Children with autism spectrum disorder (ASD) are frequently hospitalized within general psychiatric settings, which are not usually designed to meet their needs. An initial evaluation of a care pathway developed for youth with ASD receiving services in a general psychiatric inpatient unit (ASD-CP) showed promise in improving outcomes while using few resources (Kuriakose et al. in J Autism Dev Disord 48:4082-4089, 2018). As sustainability of inpatient psychiatric initiatives is imperative but rarely investigated, this study examined the stability of ASD-CP outcomes during an 18-month follow-up period (n = 15) compared to the 18-month initial evaluation (n = 20) and 18-month pre-implementation (n = 17) periods. Decreased use of crisis interventions, including holds/restraints and intramuscular medication use, was sustained in the 18 months after the initial implementation period. Implications and limitations are discussed.

Youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates. Though specialized psychiatric units are effective, few specialized units exist. The ASD Care Pathway (ASD-CP) was developed as a scalable approach to improving care in general psychiatric units through staff training and a package of autism-specific intervention strategies. An evaluation of the effectiveness of the ASD-CP in a public hospital child psychiatric service compared 18 months (n = 17) versus 18 months (n = 20) post implementation. Average length of hospital stay decreased 40% (22.4-13.4 days) and use of crisis interventions decreased 77% (holds/restraints; 0.65/day to 0.15/day), though each result only approached statistical significance (p = 0.07; 0.057). This study provides preliminary evidence for improved outcomes after implementation of an ASD-CP.

Objectives: This clinical perspectives session presents preliminary data on the outcomes of a clinical pathway (CP) for children and adolescents with autism spectrum disorder (ASD) or intellectual disability (ID) who were hospitalized in a general child psychiatric unit at a public hospital. Methods: Children with ASD are at greater risk of psychiatric hospitalization than their neurotypical peers. Although care in specialized psychiatry units has preliminary evidence for positive outcomes, the vast majority of children in the United States are treated in general units that are not designed for this challenging population. Review of best practices and expert consensus was used to design and implement a CP in three child and adolescent inpatient units at Bellevue Hospital Center. Fidelity to the CP was examined by use of a checklist. Retrospective chart review was used to identify patients eligible for the CP in the 18 months before implementation and compare outcomes (mean length of stay, use of intramuscular medications, and use of restraint) of patients exposed to the CP in the first 18 months of implementation. Results: Treatment fidelity to the CP was acceptable based on checklist review. Record review identified over 70 patients with ASD who were admitted in the 18 months before implementation. Of these patients, approximately 50 percent met CP eligibility criteria. Outcomes for these admissions were compared with outcomes for 30 admissions to the CP. Preliminary analysis indicated improved outcomes post-CP implementation. Conclusions: Expert consensus has indicated that expanded, targeted admission assessment; basic supports for functional communication; predictable routines; developmentally appropriate milieu of activities, including physical activities; and increased density of positive reinforcement are critical elements for effective inpatient care of children with ASD or ID. The design and pilot implementation of a clinical pathway using these elements at Bellevue Hospital Center over 18 months showed that it is feasible to incorporate these principles in a general inpatient child psychiatry unit and may improve outcomes

Objectives: A growing literature indicates that caregiver-mediated social skills interventions increase social competence among children with autism; however, very little is known about the role of parent characteristics in treatment success. As an initial step toward closing this gap, we examined the following: 1) the feasibility of collecting measures of caregivers and children enrolled in these interventions in a clinic setting; and 2) the relationships between baseline measures of caregivers and their children. Methods: We enrolled 19 children with autism (15 males; mean age = 11 +/- 3 years) and 19 caregivers (one per child; 15 females; mean age = 48 +/- 8 years) in either the Program for the Education and Enrichment of Relational Skills (PEERS) or the Children's Friendship Training. The Social Responsiveness Scale, 2nd Edition parent report (SRS-2-P) and the Child Behavior Checklist (CBCL) parent report were used to index children's autism severity and their internalizing and externalizing symptoms of psychopathology. Parent autistic traits were assessed using the SRS-2 adult form (SRS-2-A), which were completed by their spouses. Parent-rated Positive Affect Index (PAI) assessed the quality of the parent-child relationship. We measured the relationship between child and caregiver characteristics using two-tailed bivariate correlations. Results: Relationship quality, as measured by the PAI, varied across families (mean age = 47 +/- 8 years). High relationship quality was correlated negatively with scores of the CBCL Externalizing Problems Scale (r = -0.69, P = 0.004) and several subscales that load onto this scale (e.g., aggressive behavior, r = -0.73, P = 0.002). The SRS-2-P scores indicated that children have clinically significant scores, whereas the SRS-2-A scores indicate their caregivers do not. There was no significant relationship between SRS-2-P and SRS-2-A scores (r = -0.03, P = 0.94) or PAI and SRS-2-P scores (r = -0.30, P = 0.40). Conclusions: Results indicate that it is feasible to collect caregiver and child data in the context of a clinic-based, caregiver-mediated intervention. Preliminary data underscore the relationship between caregiver-child relationship quality and externalizing behavioral challenges in children with autism. This relationship should be investigated as a potential mediator of treatment effects

Social engagement by children with autism spectrum disorder (ASD) in unstructured school settings generally occurs at very low levels, if at all. Although many interventions improve peer socialization, generalization and maintenance of such gains when interventions are faded are typically low. The present study employed a multiple baseline design across participants to target generalization in the absence of interventionists in elementary school children with ASD at recess. Teaching initiations has been suggested as one method to increase generalization. The results of the present study showed that when initiations were targeted during intervention for social play, the participants demonstrated generalized peer social engagement, increases in unprompted peer-directed initiations, and more positive affect during peer interactions. Results are discussed in terms of theoretical and applied implications of incorporating initiations training into social interventions.