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Autism

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BobA

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How comfortable are all of you with Autism?

A place where I moonlight as a general/inpatient/Consult/ER psychiatrist seems to attract a lot of ER visits for outbursts in patients with autism. I don't feel well prepared to treat these people - or to know if I should admit or not.

Do you get training on dealing with this is residency? Know any good sources?
 

whopper

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This is one of those phenomenon that no one is tackling as to what to do, but in real life practice, it happens and when it does, no one wants to touch it.

MR patients, children, people in nursing homes, autistic patients, etc, sometimes, just like all human beings, they act out. When they act out, especially while in the care of someone earning a small income (e.g. child-protective services, nursing homes, etc), that caretaker usually doesn't know what to do and drops them off to the hospital. The hospital then drops them to the psychiatrist.

So okay, now they're in your lap, what do you do? The answer (IMHO) is actually quite easy though because no one's happy with it it doesn't seem like it's the right answer.

I try not to medicate them unless there's reason to do so. E.g. I had an MR patient in the hospital that was crying because she broke up with her boyfriend. Geez, most people break up in things like that. What am I supposed to do? Not suicidal, not homicidal, crying was within a cultural norm. I wrote that on my note and discharged her.

Okay, autistic patient, no homicidal, not suicidal. What's the least restrictive safe environment? You send them there. Usually it's back to where they came from. Yeah, the caretaker will be pissed with you, but guess what? Usually the caretaker just wants to you take the patient off their hands by admitting them or zonking them out with meds in a manner that is not therapeutic for the patient (but it makes the caretaker's life easier). Our job is to treat mental illness, not to make the jobslof people who make less than $10 an hour easier.

Or how about the kid that because of the Columbine-induced scare on teachers, now sends almost any kid to the ER. E.g. "This child wrote a poem about the death of his grandfather. Obviously he is very saddened by this." Me...."This child shows no evidence that meets reasonable medical certainty that he is homicidal or suicidal. Sadness over the death of a loved one is within a cultural norm. After social workers talked to his family, they told me they had no reason to believe he was dangerous to himself or others and quite frankly are upset that he was sent to the hospital."

Discharge.

Okay, now that about takes care of about over 50% of these types of cases. The rest become hard. You will sometimes gets patients that are in a grey area where you cannot decide. In these cases, some doctors will admit the patient so more time can be given to determine the best disposition. Another problem I've encountered is I'll want to discharge a patient, but then the caretaking facility refuses to take them back, in effect dumping them to the hospital. What are you supposed to do then? It's not ethical or legal to admit a patient simply because you can't find housing for them, but what about situations where the patient cannot care for him/herself?

In cases like this, I'd talk to the social workers and hospital administration about what to do in these situations. A lot of this I'm sure will depend on the state and local services.
 
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BobA

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In patients with autism, is there any general rule that if they have one outburst they are going to have another soon? or do they calm down after that? Or is it dependent on the individual?

I feel like I have a general idea of how to play the odds with other forms of mental illness, but I feel unequipped to deal with autism.
 

whopper

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In patients with autism, is there any general rule that if they have one outburst they are going to have another soon? or do they calm down after that? Or is it dependent on the individual?

As far as I know there is no science to this. Someone please educate us on this if you have more information.

I can say this. I trained under a guy that pretty much advanced the science of predicting future violence to what it is today...and even he'll say that predicting it is still a large grey area.

Unless the incident was severe, or unless the problematic behavior met a reasonable pattern, I wouldn't admit them. I'd do other things such as possibly refer to outpatient if needed, ask the caretakers why they believed sending to person to the hospital was needed, but as I said before, from what I've seen, a lot of times it's a caretaker trying to pass the buck, thinking we psychiatrists have solutions we don't have...such as being able to cure Autism, predict future violence, or being able to keep an MR patient "on a leash" by zonking them out with Thorazine daily.

If you're in the problematic grey area, dig as much information as you can from social workers, but unless there's anything significant, don't admit to the hospital. IF there's something, admit, pass the wand off to the next higher rung, but let the next treatment team know you have you're concerns that this may be overkill.
 

eaglepsych

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unpredictable episodic aggression is relatively unlikely to respond to medication treatment. that being said, depending on the severity, and if all else is being done via behavioral therapy (ABA, etc.), meds are still used and are thought to be helpful in certain cases.

i got most of my training on dealing with this population in child and adolescent fellowship (we had an autism clinic). not much difference in treating autistic adults vs children, other than taking sexuality and fact that medical problems (such as GI, constipation, etc) that this population is more prone to can definitely bring out increased aggression, esp in nonverbal and low IQ pt's.

for training, would look at offerings at child and adolescent meetings such as AACAP, etc.
 
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