One Size Doesn't Fit All:
The Case of Patients with Autism in Emergency Room Settings

Heightened sensory abnormalities have been found to be more prevalent in children with  autism, as compared to children without autism. To this end, Leekman, et. al. utilized the  Diagnostic Interview for Social and Communication Disorders (DISCO) as a tool among  children ages 34-140 months to gauge differences in sensory abnormalities between children  with autism and typical children. Over 90% of children with autism presented with sensory  abnormalities, as compared to just 65% in the clinical control group. Moreover, of the children in  both groups presenting with sensory abnormalities, the ones in the autism group were drastically  more likely to present across multiple domains. Among children with autism, sensory symptoms remained constant with age and IQ in the domains of touch and smell, taste, and auditory.  However, sensory symptoms yielded significant differences with age and IQ among the visual  domain (Leekam et. al., 2007).

To lend itself to contribute to the establishment of pediatric, autism-friendly ER’s the  research on autism and sensory abnormalities must be understood in terms of how these  abnormalities are presented. In a retrospective review of clinical data caregivers of children with  and without autism, ages 3-6 (n=281), were asked to fill out Short Sensory Profiles (SSP’s). Most relevant to this literature review is the finding that children with autism were significantly  more under-responsive/sensory seeking than children without autism. This was exhibited in  children with autism by their tendency to tune out language, especially in the presence of  background noise (Tomcheck & Dunn, 2007). This finding may prove to be problematic in ER’s  where background noise is particularly manifest. In order to provide effective care patients must  be highly attentive to medical care providers. However, the findings of this study suggest that the  ER noise environment triggers a response in patients with autism that is counter-productive to  the provision of high quality care.

The differential effects of auditory stimuli on children and adolescents with autism  (n=11) as compared to those without autism (n=11) were also prevalent in a study based on the  results of psychoacoustic testing. These tests confirmed the researchers’ hypothesis that those  with autism have an enhanced perception of, and reduced tolerance for, loudness. In effect, this  means that sounds deemed moderate by individuals without autism are deemed to be loud by  children with autism. The authors related this finding to heightened annoyance levels, resulting  in irritation (Khalfa et. al. 2004).

The findings produced by Khalfa et al have vast implications for ER design for  individuals with autism. The typical, current ER environment tends to be considered loud by  typical individuals. It could thus be reasoned that the enhanced loudness effect and resulting  irritation felt by children with autism could have a drastic, negative impact on their ER  experience and the quality of care they receive. Purposed design and care adjustments for  pediatric ER’s may include alternative methods to decrease the volume of sound from machines  and overhead speakers, as well as the construction of rooms with sound proof walls such that  patients can quickly be placed away from the noise typical of waiting rooms.

According to a questionnaire assessing hyper and hypo sensitivities in children, ages 4- 14, with autism (n=30) as compared to a control group of normally developing peers (n=30),  children with autism differed from the control group across all domains, including auditory,  tactile, visual, gustatory, and vestibular (Talay-Ongan, A. & Wood K., 2000). Most pertinent to  this literature review are the authors’ discussion regarding the auditory and tactile domains.

Children with autism displayed both hyper- and hypo-acuity. Hyper-acuity presented as  children with autism hearing loud sounds prior to their typically developing peers. Hypo-acuity  was evidenced by children with autism through their lack of responsiveness to certain sounds,  namely the human voice (Talay-Ongan, A. & Wood K., 2000). This finding of hypo-acuity, also  termed as selective hearing, may better lend itself to solutions outside the realm of environmental  design. Such suggestions may include the training of health professionals on best practices in  treating children with autism. Without proper training medical care providers may mistake the  lack of responsiveness by children with autism as being mal-intended, thus producing undue  frustration and detracting from the quality of care provided.

In terms of tactile domain sensitivities, children with autism had adverse reactions, such  as crying, to seemingly harmless experiences, including getting wet, wearing certain clothing,  brushing teeth, and touching sticky materials. Children with autism displayed “tactile  defensiveness” and distress upon being touched by individuals unknown to them. This response,  however, tended to be at least partially mitigated when the child with autism initiated and  controlled the touch. Lastly, children with autism, more so than children in the control group,  displayed a dulled reaction to pain sensations (Talay-Ongan, A. & Wood K., 2000).

It is also worthy to note that the authors’ findings regarding the age effects among  children with autism countered their hypothesis. The study results revealed that sensitivities  among children with autism increased with age. The authors are not sure whether this finding  indicates an actual increase in sensitivity with age, or whether children with autism become more  able to express sensitivity as they age.

It is important to elaborate upon research findings that highlight auditory sensitivities  among individuals with autism. This understanding is bolstered by a literature review that  discusses assessment methods, interventions, and cases related to hyperacusis in individuals with  autism. Hyperacusis is defined as an increased sensitivity to certain frequencies and volumes of  sound. Individuals with autism experiencing hyperacusis tend to engage in compensatory  behaviors such as covering their ears, crying, having tantrums, fleeing the area, humming,  trembling, hyperventilating, and self-injury (Steigler & Davis, 2010). These behaviors may be  mistaken by hospital employees and health care providers as acting out or non-compliance by the  patient. As a result hospital employees and health care providers can become frustrated and/or  may not know how to properly react. This can cause individuals with special needs to receive  less than optimal medical care. One potential drawback of this literature review in the scope of this paper is that it includes research on individuals of all ages, such that it is not limited to the  pediatric patient population.