Each month the Prehospital Care Research Forum combs the literature to identify recent studies relevant to EMS education practices. In this segment PCRF board member Megan Corry reviews an effort to train responders to better deal with children with autism spectrum disorder.
Cheung V, McCarthy ML, Cicero MX, Leventhal JM, Weitzman C. Emergency Medical Responders and Adolescents With Autism Spectrum Disorder. Pediatr Emerg Care, 2018 Jan 2 [epub ahead of print].
A rise in the prevalence of children and adolescents with autism spectrum disorder (ASD) means EMS personnel are more likely to encounter this pediatric population in the field. The National Autism Association and Autism Society, among others, have developed training curricula for public-safety professionals. One curriculum by public-safety trainer Dennis Debbaudt (2009) specifically targets EMS personnel. But no single curriculum has demonstrated improved recognition and treatment of patients with ASD in the field, and in fact, no research has yet determined what aspects of EMS practice define quality of care for ASD patients.
This month’s study takes a closer look at EMS responder experience and skills for communicating with ASD patients. The study objectives were to describe interactions between EMS responders and adolescent ASD patients; determine if EMS responders can recognize a patient who may have ASD; and identify any EMS responder demographics that affect the quality of interactions with ASD patients.
This study, by a group of physicians from the Yale School of Medicine, was part of a larger research project on EMS and disaster preparedness in pediatric populations. The setting was a simulated bus accident involving 10 pediatric patients, one of whom was an actor portraying an adolescent with autism spectrum disorder. Behaviors displayed by the actor followed the DSM-5 definition of autism spectrum disorder: failure to make eye contact, absence of communicative gestures, and presence of repetitive movements.
EMTs, paramedics, and paramedic students participated in the triage exercise, which took place between 2011 and 2013. Researchers evaluated 156 videos, but only 75 met inclusion criteria. Actors portraying the ASD patient were required to display at least two of the three behavioral criteria of ASD, and after evaluating the videos it was determined that 10 of the actors in 75 video segments met inclusion criteria. Two researchers coded the videotaped interactions using a scoring system with five domains established in the Debbaudt curriculum. Demographics and experience levels of the EMS responders were taken from a precourse survey completed by participants. Most responders were male (n=56; 75%), EMTs (44%), and had five years or less of EMS experience (56%).
The highest scores were achieved in the “quality of interactions” category (making eye contact and using short, direct phrases); however, fewer than 50% of test subjects adjusted their tone of voice, provided information to the patient, or asked permission prior to performing an exam. The majority of the 27% who provided reassurance to the patient did so through nonverbal gestures such as touching the patient on the shoulder. Since ASD patients may also have sensory-processing difficulties, these actions can overwhelm and/or threaten these patients. Overall, out of a possible 21 points, the maximum score achieved was 12 (range 3–12), and only 35% recognized that their patient may have a disability. Only 13% suggested ASD. Subjects with experience (greater than five years) and paramedic-level training were associated with higher scores and were more likely to elicit information directly from the ASD patient or utilize bystanders to determine patient information.
The major limitation of this study was the lack of EMS responders on the research team, which these authors identified as having “not asked (EMS responders) about their previous experiences interacting with the ASD population.” This study would have been greatly benefited by enlisting EMS responders in its design, implementation, analysis, and publication, and might have produced stronger conclusions about EMS responder behavior.
Despite this limitation the authors point out that, at least in this videotaped simulated trauma incident, EMS responders did not always recognize ASD and used limited strategies to communicate with an ASD adolescent patient. Some strategies used by the EMS responders, like physical touch and not asking permission prior to their exam, could escalate anxious behaviors in patient with neurodevelopmental disabilities such as ASD. Future research should examine the development and validation of standardized training on ASD and other special populations of patients evaluated and treated on emergency scenes by EMS responders.
Megan Corry, EdD, EMT-P, is the program director and full-time faculty for the City College of San Francisco paramedic program and on the board of advisors of the UCLA Prehospital Care Research Forum.