Care of the patient with an autism spectrum disorder by the general physician Arvind Venkat, 1 Edward Jauch, 2 William Scott Russell, 3 Candace Roman Crist, 1 Robert Farrell 1 ABSTRACT Autism spectrum disorders (ASD), comprising classic autism, Asperger syndrome, Rett syndrome, childhood disintegrative disorder and pervasive development disorder-not otherwise specified, represent complex neurodevelopmental conditions characterised by impaired social interactions, difficulties with communication and repetitive, stereotyped behaviours. It is estimated that up to 1% of the general population may be affected by an ASD. Whether due to improved diagnostic techniques or a true rise in incidence, the prevalence of patients with ASD is rising, and these individuals are increasingly encountered in a variety of healthcare settings. Care givers of patients with an ASD report frequently that lack of awareness of the complications of these disorders and the method of appropriately assessing these individuals impair the effective delivery of healthcare to this patient population. It is now clear that patients with an ASD, in addition to the defining characteristics of these disorders, can present to the outpatient, emergency department and inpatient settings with a variety of psychiatric, neurological, gastrointestinal, nutritional/metabolic, dental, ophthalmological, cardiovascular, gynaecological, traumatic and musculoskeletal conditions that can require acute intervention. In addition, the common treatments given to patients with an ASD may result in side effects and complications that may require acute intervention. For physicians who encounter patients with an ASD, the combination of impaired social interactions, difficulties with communication and stereotyped behaviours creates an additional barrier to diagnosis and treatment of these individuals. Careful preparation of the examination environment, direct engagement of care givers and the patient and the use of communication techniques and pharmacological adjuncts can aid physicians in treating the patient with an ASD in the outpatient, emergency department and inpatient settings. INTRODUCTION Autism spectrum disorders (ASD), comprising classic autism, Asperger syndrome, Rett syndrome, childhood disintegrative disorder and pervasive development disorder-not otherwise specified (PDD- NOS), represent complex neurodevelopmental conditions characterised by impaired social interac- tions, communication difficulties and repetitive, stereotyped behaviours. 1 Typically, patients with an ASD show signs and symptoms in childhood that include poor or regressed language skills, impaired ability to respond to common social cues and behavioural patterns that focus on one object or situation to the large-scale exclusion of others. 1 Whether due to improved diagnostic techniques or a true rise in incidence, the prevalence of patients with ASD is rising, and these individuals are increasingly encountered in a variety of healthcare settings. The Centers for Disease Control and Prevention estimate that the prevalence of ASD in the USA is one in 110 births with a male to female ratio of 4:1. 2 Up to 1.5 million Americans carry a diagnosis of ASD with an estimated annual healthcare services cost of $90 billion. 3 In the next decade, with the ageing of the ASD patient population, that cost is expected to rise to $200 billion. 4 Globally, the estimated prevalence of ASD is 0.6%e1% of the population. 5 Increased understanding of ASD has also led to studies on the nature of healthcare utilisation by this patient population. Among children with ASD, utilisation of preventive, outpatient and inpatient care is higher than among patients without ASD. Parents of children with autism reported a higher mean number of preventive care (3.89 (95% CI 3.57 to 4.21) vs 2.51 (95% CI 2.49 to 2.53)), emergency department (0.18 (95% CI 0.12 to 0.23) vs 0.10 (95% CI 0.09 to 0.10)) and non-emergency (2.80 (95% CI 2.44 to 3.16) vs 1.56 (95% CI 1.54 to 1.58)) visits per year in comparison with children without autism. 6 Families of patients with an ASD report significant financial burdens that accompany the treatment of this disorder, unmet medical and social support needs and difficulties with referral within the healthcare system. These factors all likely contribute to presentation to physicians who are not specialists in the care of this patient population. 7 Little data exist on the nature of healthcare resource utilisation by adults with ASD, likely due to the relatively recent focus of the medical community on the treatment of these patients. However, it is foresee- able that with the ageing of the ASD population, presentation of this patient population in a variety of healthcare settings will increase. Despite the above factors that will likely cause patients with an ASD to present more commonly to the non-specialist physician, there is a paucity of literature for general physicians on how to approach the clinical assessment of the patient with an ASD or the common presentations of acute illness that may result in the need for care in either the outpatient, emergency department or inpatient setting. 8e11 This article reviews the existing litera- ture on how general physicians may approach the management of the adult and paediatric patients with an ASD and the common disease processes that can result in their need for acute care. 1 Department of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA 2 Division of Emergency Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA 3 Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA Correspondence to Dr Arvind Venkat, MD, Department of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA; avenkat@wpahs.org Received 28 December 2011 Accepted 18 February 2012 Published Online First 16 March 2012 472 Postgrad Med J 2012;88:472e481. doi:10.1136/postgradmedj-2011-130727 Review Downloaded from https://academic.oup.com/pmj/article/88/1042/472/6986769 by guest on 09 August 2023