Research methods and applications

¶ … autism has grown considerably in recent years. The medical and healthcare profession has become more aware of this problem and the number of cases of autism has increased, largely as a result of greater awareness of the problem and earlier diagnosis.

However, research on specific areas of the treatment of autism is not as prolific and this includes the focus on nursing care, treatment and management of the autistic child. While this is an area that is still in need of more in research it is also growing in terms of academic breadth and depth. The following literature review was drawn from a number of resources, including journals and other offline sources, as well as sources and data from verified online databases and journals.

The focus in this review will be on the area of nursing competence in terms of communication in dealing the autistic child; as well as on the question of the hospital environment as an adequate area for treatment. A third area of concern in this review will be the role of the parent and parental stress factors in relation to nursing.

1. General studies

There are many general studies and overviews of autism. Valuable data relating to the main themes of this review can be gleaned from these sources. An example is, Autism: recognizing the signs in young children by Jennifer Humphries. The study stresses that early diagnosis of autism is important, and that this has implications in terms of the role of the nurse. Another general but valuable resource is AUTISM: Assessment and Management ( 2007). This overview discusses the various aspects of autism, including different treatment modalities. Among the modalities that are discussed are pharmacotherapy, special education, speech, communication therapy, and behavior modification. The discussion on communication therapy is particularly pertinent to the present study. (Azeem and Imran, 2007) Another general overview of autism and nursing is Autism Spectrum Disorders by Hollander ( 2003).

2. The problems: communication and environment

Among the articles dealing with the problems that nurses encounter in dealing with the autistic child and pediatric or children's nursing care is Caring for Children and Adolescents With Autism Who Require Challenging Procedures (2003). The authors of the article state that, "Providing nursing care for children with autism or autistic spectrum disorders (ASD) can be challenging." (Souders, De Paul D, Freeman and Levy, 2003) This study included 62 children with autism. Their ages varied from between three and eight years of age. A multidimensional approach was employed in the assessment of the nursing requirements for these children and "…strategies were developed for providing care that incorporated theories and knowledge from the disciplines of nursing, child development, psychology, applied behavior analysis, and pain management." (Souders, De Paul D, Freeman and Levy, 2003)

The study emphasizes that with adequate research a plan of care for the autistic child can be developed but that intervention should be individualized in order to deal with the particular array of symptoms and issues encountered with each child. This is view that is echoed in many other studies and emphasizes the complexity of the task that the pediatric nurse has to deal with in assessing and treating young children with this condition. It also raises but does not answer the question as to whether the nurse is adequately trained to deal with the autistic child.

Another important finding of this study that also impacts on the central question of adequate communication training for nurses is that there has been a significant increase in the number of autistic children under nursing care. The authors stress that the "The prevalence of children with autism or autistic spectrum disorders (ASD) has increased over the past two decades." (Souders, De Paul D, Freeman and Levy, 2003) This is also supported by studies which indicate that the rate of autism may approach one percent of school age children. (Souders, De Paul D, Freeman and Levy, 2003) The reasons that are give for this increase is increased awareness of this condition as well as earlier diagnoses and intervention methods.

A revealing finding which is also echoed in a number of other studies is that children with autism present particular problems for the nurse. Normal procedures and treatments are complicated by factors such as poor communication and language skills as well as restrictive and repetitive behavior on the part of the children. Therefore the implication is that the nurse has to be more proficient in communication needs and abilities to deal with this group of children.

Other problems noted in the study include the difficulties that children with ASD have with new environments and with changes is their daily or normal routine. This points to the problem of the hospital environment and posits the question whether this environment or any new and unfamiliar environment is the best place to treat these children. Furthermore, this study makes the important observation that

Components of a health care visit can be very stressful to the child, parent, and health care professional and painful procedures can leave lasting negative memories. These memories can have a significant impact on future visits resulting in behaviors such as tantrums and aggressions toward health care personnel.

(Souders, De Paul D, Freeman and Levy, 2003)

These are all factors that the professional nurse has to be aware of in treating children with autism. The study also notes that there is a need for the development of effective interventions and management strategies that can result in a more positive healthcare experience for these children.

The problem of treating autistic children in the nursing and healthcare environment is expanded on in other studies and assessments, although it should also be noted that there is a relative paucity of in-death research in this area. Much of the available literature on the subject emphasizes that communication is a central nursing issues in dealing with the autistic child.

A study by Lesinskien? et al. entitled Aspects of nursing of the autistic children (2002) states that "Due to the behavioral and communication difficulties autistic children need individualized approaches providing them medical help…" (Lesinskien? et al. 2002, p. 412) The central purpose of this study is to "…analyze peculiarities of behavior, communication and social adaptation of children with autism disorder" in relation to the problems faced in both inpatients and outpatients in medical services. (Lesinskien? et al. 2002, p. 412) The study also includes intervention and treatment recommendations for pediatric and mental health nurses. The research included a comprehensive questionnaire that was given to mothers of children with and without developmental disorders. The age of the children concerned was between three and twelve years of age.

The study found that these children in general experienced "severe behavioral and emotional difficulties" when being examined and nursing staff. (Lesinskien? et al. 2002, p. 412) This again indicates the importance of environment and, similar to the study by Souders et al. ( 2003), questions the adequacy of the normal hospital environment in treating these children. This study stresses that, "Adaptation difficulties in medical services were very prominent, especially at the in-patient departments." (Lesinskien? et al. 2002, p. 412) These difficulties included unpredictable and impulsive behavior, as well as anxiety, decrease of appetite, and sleep disturbances. It is also suggested in this study that the hospital may not be the best environment for nursing interventions, and the suggestion is that home visits may be a more fruitful form of intervention.

This also raises another cardinal issue that is reiterated in a few other studies; namely that data from research indicates that a central area of concern in nursing is the establishment of adequate and interactive contact with these children. The study also suggests that more knowledge with regard to treating these children from a nursing perspective is needed.

Many studies indicate that the issue of nursing communication with the autistic child is a problem that includes many concomitant aspects; including the issue of creating an environment that is conducive to treatment in the first place. In order to establish more effective modes of techniques fro interaction with these children the nurse should also take into account of research in related fields and disciplines that can shed light on this problem. For example, a study entitled Caring for Children With Autism in the School Setting by Karen Galinat, Kelly Barcalow, and Barbara Krivda, provides some insight into the communicative aspects of dealing with autism that can be use fully applied in a nursing setting. All the authors have a nursing background and Galinat is a school nurse with the Mercer County Special Services School District in Mercer County, NJ.

As is the case in many other studies, the author stress that dealing with the autistic child requires an approach that is customized to cater for the particular individual aspects of that child. In other words it is difficult to administer or adhere to general protocols or strategies. "Each child with an autistic spectrum disorder (ASD) exhibits individual characteristics of the disorder." (Galinat et al.) The authors also stress the importance of community resources in dealing with this disorder, as well as the importance of families and parents in meeting the particular challenges of autism.

A brief but insightful article that stresses the importance of communication is Autistic Kids Benefit from Dads' Involvement. This also applies to the issue of parental stress but echoes other studies that emphasize the importance of communication skills in treating autistic children. There article notes that autism is a disability or disorder that appears during the first three years of life and is characterized by problems interacting and communicating with others. Related to this is a discussion of the father's role in communication. Researchers found that, …teaching fathers how to talk to and play with their autistic children in a home setting improved communication, increased the number of intelligible words the youngsters spoke by more than 50% and helped dads get more involved in their care."

( Autistic Kids Benefit from Dads' Involvement)

An article that explores the issue of communication, nursing and the autistic child is Observing communication skills in staff interacting with adults suffering from intellectual disability, autism and schizophrenia by Bakken et al. (2008). This study emphasizes the need for a more integrated and multi-disciplinary approach to dealing with autistic children. This communicative approach includes sources from both intellectual disability nursing and psychiatric nursing. (Bakken et al. 2008) The authors also reiterate the finding that autism displays a wide range of cognitive impairments which "….include restricted ability of abstraction, introspection, understanding of other individuals, and the ability of sharing attention." (Bakken et al. 2008) This is a major factor that impact of the nurse's ability to deal adequately with these patients. The study therefore finds that nursing staff must "…aim at clarity and a high level of contextual attachment in their communication & #8230;." (Bakken et al. 2008) It therefore follows, as is also suggested in the study by Lesinskien? et al. (2002) that, "The patients' idiosyncratic communication and behavioural acts require that the communicating partner know the patient well enough to integrate both contextual and situational knowledge." (Bakken et al. 2008)

Furthermore, this study also reiterates a point that has already been referred to and which is echoed in many similar studies; namely that dealing with these problems from a nursing perspective requires more in-depth research as well as the development of more cogent theoretical structures to understand issues like communication and the hospital environment. This study isolates aspects such as the nurses' adaptation to the communications level of the patient as a necessary skill in treating the autistic child; as well as the importance of non-verbal communicative acts, such as gestures, augmentation devices etc. These are aspects that are stressed as fundamental nursing skills in dealing with this category of patient.

The study by Bakken et al., is useful in that it points out that while other studies have emphasized the importance of these communication skills in nursing the autistic child, yet "few has examined specific skills." This implies an obvious gap in the knowledge base in nursing these children.

An article which deals with the problem of nursing the autistic patient and which sheds some light on the above-mentioned issue of communications skills in nursing the autistic child is Effective communication related to psychotic disorganised behaviour in adults with intellectual disability and autism (2008). The article states that nursing staff that have work experience in terms of communication were found to be more effective in interacting with the autistic individual. This finding therefore emphasizes that communication skills should be an essential part of any nursing training programs that is directed at any from of treatment of the autistic child.

An innovative theory that deals with this issue is facilitated communication in the treatment of autistic children. In an article entitled Facilitated communication: significance of and use to the nursing of persons with autism with severe disabilities of action and communication by Beste ( 2007), discusses this concept. This refers to a method that is "…applied to persons with autism who are apraxic and unable to speak and communicate with gestures or facial expressions." (Beste 2007)

Another important aspect of research into communication techniques is an insightful article entitled Eye Contact and Autism by Worth ( 2008). This study refers to research to "…determine whether the amount of eye contact made by children with autism was different from that of other children and whether that measurement could be used to predict levels of social disability." (Worth, 2008, p. 21) These and other similar research studies are an important component of the nurse's ongoing need to understand the complexity of improving communication with the autistic child.

As has already been referred to in this survey, much of the literature dealing with the subject of communication and environmental factors in autism quality their research with the view that a more inclusive and comprehensive multidisciplinary approach has to be taken in order to deal adequately with these issues. This is the view that is stressed for example in Autism: An Interdisciplinary Approach ( 2004) by Elias et al. This approach has become necessary because of the wide range and variety of variables that have to be taken into account in dealing with the autistic child.

An article which also delves into the multidisciplinary aspects of nursing treatment of autism is Approach with Care. As more children are diagnosed with autism, nurses learn how to respond to their needs ( 2005). This article also refers to somatosensory disturbances that include hypersensitivity to sounds, smells, touch, textures, and visual perception distortion among children with autism. This leads to a discussion of aspect such as speech therapy and the development of social skills, and, for example, the reading of facial expressions. (Ray 2005)

The literature is also concerned with the view that nurse should be aware of the latest theories and technologies as these can not help with aspects of communication but also in the general treatment of the autistic child. An example is sensory therapy for autistic children. A number of studies indicate a link between sensory integration therapy and improving the quality of life for autistic children. This form of therapy is viewed as a "….valuable tool to teach autistic children how to interact with their environment." ( Evans R.) The problem of sensory integration is a crucial factor for many autistic children. It is very often the case that the sensory impulses of the child conflict with and are contradicted by those expected by the society in which they have to interact.

Sensory integration refers to the "…process in the normal brain which pulls together all of the various sensory messages in order to form coherent information on which we can act. Basically everything we do requires sensory integration." (Evans R.) Sensory integration therapy is therefore an attempt to rectify this sensory disparity and dysfunction in autistic children.

2. Parental issues and stressors

As one commentator notes, "Caring for an autistic child can be a relentless and labor-intensive task." (Autistic Kids Benefit from Dads' Involvement) This refers to the pressure and stress that many parents have to endure in dealing with an autistic child. However, the literature is also clears that parents play a vital role in the treatment of the autistic child and it is often the case that nursing staff work in tandem and in conjunction with parents in devising strategies and implementing protocols in dealing with children who have this condition.