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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

Promoting Interaction Structuring interventions for social isolation should fit the child’s cognitive, linguistic, and developmental lev els. Interventions fostering nonverbal social interactions may be more useful than those based on speech. For higher-functioning children, activities such as getting the mail, passing out snacks, or taking turns in the con text of simple games can engage them in social activities without requiring the use of their limited language skills. Structuring social interactions so that the child shares a task with another, such as carrying a load of books, may help boost confidence in relating to others. ASD calls for extraordinary patience and determina tion. With help, these children can learn social and com munication skills, such as taking turns in conversation and warning the listener before changing the subject in the context of milieu. Ensuring Predictability and Safety When children with ASD are hospitalized, milieu management—a consistent, structured environment with predictable routines for activities, mealtimes, and bedtimes—is necessary for successful treatment. Changes in routine may provoke disorganization in the child, lead ing to emotional disequilibrium and explosive behavior. The safety of the inpatient unit offers an opportunity to try behavioral strategies, such as rewards for man aging transitions. Health care professionals can pass on successful strategies to parents or primary caretakers (Carruthers et al., 2023).

A structured physical environment will most likely be important to a child with a development disorder. Keeping furniture, dishes, and toys in the same place helps ease anxiety and fosters secure feelings. The nurse should identify the child’s individual specific needs for structure. Behavioral Interventions Children with ASD often need specific behavioral inter ventions to reduce the frequency of inappropriate or aggressive behavior (Nuske et al., 2024). For example, a child may have angry outbursts in response to routine transitions. If the tantrum is dramatic, the consequence may be that the transition does not take place. By structur ing the environment and using visual cues to signal the end of one activity and the start of another, it may be possible to reduce the number and intensity of responses to transi tions. Safety is always a concern. Self-injury and aggression are sometimes present, so children may need to be pro tected from hurting themselves and others. If aggressive or assaultive behavior is an issue, a brief “time out” followed by prompt reentry into activities is usually effective. Managing the repetitive behaviors of these children depends on the specific behavior and its effects on others or the environment. If the behavior, such as rocking, has no negative effects, ignoring it may be the best approach. If the behavior, such as head banging, however, is unac ceptable, redirecting the child and using positive rein forcement are recommended. In some cases, especially in severely delayed children, these strategies may not work, and environmental alterations and perhaps protective headgear will be needed (see Box 37.4).

BOX 37.4 Building Clinical Judgment With SBAR: Managing Stereotypic Behavior of a Patient With Autism SBAR S: Situation Ben, age 9, has been diagnosed with autism spectrum disorder (ASD). He was admitted to the inpatient child psychiatric unit due to aggressive outbursts and episodes of self-harm. B: Background Ben’s parents report that he has been increasingly “unpredictable” and has had more frequent outbursts since his teacher was reassigned to a different classroom a week ago. They have noticed an increase in pacing, hand flapping, and vocal stimming. Yesterday in school, Ben was found repeatedly banging his head on his desk, prompting a referral to his health care provider. Ben is nonverbal, but able to communicate somewhat using picture cards. A: Assessment The nurse finds Ben pacing in the day room during a group therapy session. His body language is tense and he is avoiding eye contact. He is covering his ears with his hands and shaking his head back and forth. R: Recommendation • Reduce environmental stimuli. Accompany Ben to a quieter location, away from day room and other patients. • Provide a safe environment. Assess for evidence of self-injurious behaviors. Consider providing helmet if head banging behavior returns. • Monitor and manage sensory sensitivities. • Promote a consistent, structured environment. • Contact health care provider for medication evaluation. • Explore referral to speech language specialist.

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