Words by David Birch
Whilst performing our duties as paramedics there will be times when we will encounter an autistic patient. We may not be aware that the person is autistic in the initial assessment, but it is essential that paramedics can recognise the signs and adapt their approach to ensure the patient is provided with the most suitable and efficient care possible.
What is Autism?
Autism spectrum disorder (ASD) is often described as a hidden disability. The cause of autism is uncertain and effects one in seventy people. Autism Spectrum Australia describes Autism as “… a condition that affects how a person thinks, feels, interacts with others, and experiences their environment. It is a lifelong disability that starts when a person is born and stays with them into old age. Every Autistic person is different to every other. Therefore, autism is described as a ‘spectrum.”1
Autism is often associated with a range of other disorders including attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), oppositional defiance disorder (ODD), and sensory processing disorder. A broad range of classifications apply to the varying presentations of autism. The most common forms of autism are classic autism, Asperger’s Syndrome (an outdated term and no longer used), and Pervasive Developmental Disorder (PDD) or atypical autism. These classifications share many of the same symptoms, but they differ in their severity and impact. Classic Autism or Autistic Disorder is the most severe. PDD-NOS, or atypical autism, is the less severe variant. It is also of paramount importance to understand that no two persons with autism are the same.
Gendered differences can be seen in autistic disorders with approximately 80% of autistic cases being male. It is believed that the relative rarity of autism diagnoses in females could be due to female tendency to mask symptoms. Females tend to be more capable of adapting and fitting in with their peers, hence those with autism may repress their behaviour. This can often be seen through social imitation skills and a desire to interact directly with others. A high proportion of females also possess introvertive characteristics exhibiting shy or passive behaviours, and often develop better linguistic abilities aiding in the repression of their autistic symptoms.
Autism is often a hidden condition and it can be difficult or near impossible for a paramedic to determine if their patient has an autistic disorder. However, there are numerous features and traits that are recognisable and common with the autistic patient that may offer an indication to guide the paramedic’s assessment.
Poor eye contact: Autistic patients may avoid looking directly at who they are engaging with, or do so inconsistently, fleetingly, or by looking out of the corner of their eye. It is believed that the eyes and face are so expressive that they can overwhelm an autistic person. In this case, do not force this patient to make eye contact with you.
Echolalia: This is the repetition of another person’s spoken word and patients with autism may exhibit this symptom by repeating noises and phrases they hear. These patients may not be able to communicate effectively as they struggle to express their own thoughts. In many cases, echolalia is an attempt to communicate but can be misinterpreted easily.
Heightened sensitivity or sensory aversion: Autism can cause a person’s senses to go into overdrive. A person with autism may be very sensitive to bright or flashing light and loud noises. Everyday sounds may be difficult for these patients to manage and they might hold their hands up to their ears or wear headphones. An autistic person may try to smell everything in their surroundings and certain smells can overwhelm. This is also extended to tactile stimulation and should be identified if possible.
Stereotyped behaviours: A person with autism may get “stuck” on certain habits, routines, interests, or behaviours. For example, an autistic person may want to hold the same object and refuse to put it down even when they are trying to engage in a different activity or task. Other presentations may see them spend a great deal of time lining up or arranging objects in a specific order, which can also be recognised as OCD which many people with autism also suffer from.
Meltdowns / Tantrums: A tantrum usually occurs when a person is denied what they want or what they want to do. Conventionally when a person obtains what they want or what to do a tantrum resolves – however, in the case of a meltdown in an autistic person this is often not the case as the breakdown is not an emotional response. Meltdowns are reactions to feeling overwhelmed and are often seen as a result of sensory overstimulation. Tantrums can lead to meltdowns; hence it can be hard to tell the difference between the two outbursts.
Further, autistic people can also suffer from anxiety and depression. This often results in autism being viewed by members of the public and health care professionals as a mental health condition rather than a neurological condition. However, with more discussions to increase autism awareness, paramedics can more accurately determine and ensure the autistic patient is provided with efficient and effective patient-centred care.
In Paramedic Care
Health care professionals including paramedics may unexpectedly encounter a person with autism. Identifying a patient is autistic can reduce the risk or victimisation of the autistic person or their caregiver and can also reduce unnecessary risk to the paramedic. Autistic patients may respond to simple interventions in unexpected ways; it is essential for paramedics to recognise signs that may indicate the patient is on the autistic spectrum and alter their method of treatment or assessment accordingly. A modified approach by the paramedic can include changes to time, patience, being literal with communication, personal space, rapport and technology which I will briefly outline.
Time: These cases can be complex and can require a modified timeframe. Allowing sufficient time for the patient to deescalate themselves to a level of social engagement is imperative. It is far better to let the person deescalate themselves than to force them into a resolution they are not ready for.
Patience: Having patience with a person on the spectrum may be required to allow the patient additional time to process information. Delayed responses to your questions or commands might be necessary and well received. Speaking in direct, short phrases will give the autistic person a better chance to understand and respond to your questions.
Communication: Ensuring you are literal with your communication Is imperative when interacting with an autistic person. Avoid jargon or expressions such as: “What’s up your sleeve?” or “Are you pulling my leg.” Autistic people are very literal and often do not understand the subtle nuances, meanings of a jargon, sarcasms and other expressions or slang.
Personal Space: Some autistic people don’t fully understand the concept of personal space so make sure there is safe distance between the patient and yourself. The autistic person may suddenly invade your personal space or may think you’re invading their personal space and react accordingly. Further, personal space if highly important when initially approaching the patient as this can enact a negative response and potentially make the patient uneasy.
Rapport: When verbally interacting ensure you speak calmly and softly and physically exhibit the calm and open behaviour you would like the patient to display. To build rapport, take the time to discover their interests and try to engage or find common ground. By establishing a connection, this builds trust and can assist in the assessment of the patient.
Team Game: When treating someone on the spectrum remember it is a team game. Don’t take it personally if the person prefers to engage with your partner instead of you. It could be that the person responds better to male or females, younger or older or an amalgamation of other characteristics. Further, you may even require someone outside of the crew to be part of the team and aid in building trust.
Technology: Autism is a spectrum disorder. At one end of the spectrum the patient could be non-verbal which makes communication hard. This is where an iPad, mobile phone or other technology is an asset. Consider the use of pictures, written phrases or commands and computer images. PECS (Picture Exchange Communication System) allows persons with little or no communication abilities to communicate using pictures. People using PECS are taught to communicate with another person by using a series of pictures allowing them to engage in communication. Emojis can also be used.
If the individual is holding or appears to be fascinated with an inanimate object, allow the patient to continue to hold the item for the calming effect. It could be something like a small soft toy or a finger spinner. Autistic patents often need their routine to maintain a calm state and interruptions or differences in routine can be overwhelming.
Finally, when handing the autistic patient over at hospital, it is imperative that the handover includes the patient’s sensitivities, aversions, or triggers that you may have identified, to ensure that the patient can be placed in a suitable area in the hospital. Also consider that the most appropriate destination might not be hospital. Other options may include patient’s regular doctor, psychologist, therapist or even the patient’s own residence. By transporting the patient to some one that knows the patient well and understands what is required for treatment and management of the patient will result in better outcomes.
- Autism Spectrum Australia [Internet]. Autism Spectrum. 2022 [cited 17 February 2022]. Available from: https://www.autismspectrum.org.au/about-autism/what-is-autism
- Barkley R. Taking charge of ADHD. 4th ed. New York City: Guildford Publications.
- autismRusick J. Understanding autism. North Mankato, Minnesota: Abdo Publishing Company.
Edited by Elise Katrakazos and Cam Anderson