Jackson was a 10-year-old boy who, at a young age, already had an extensive list of diagnoses, including autism spectrum disorder (ASD), intellectual disability, attention-deficit/hyperactivity disorder, and speech delay. Like many others, Jackson was brought to the acute care children’s hospital emergency department (ED) for increasingly aggressive behaviors toward his family and schoolmates, which emerged when he was prevented from overeating or watching his favorite television shows. His grandmother was at her wits’ end; she knew he needed help but did not know how to get him the care he needed. Jackson’s pediatrician tried to manage his behavior with referrals to outpatient psychiatry and applied behavior analysis (ABA). However, these services had years-long waitlists, and Jackson’s family did not have the resources to obtain private intervention. As Jackson sat in his ED bed, rolling a toy truck across his lap, a social worker sent his clinical information to the local psychiatric hospitals. The denials flooded in quickly: “too acute,” “too young,” and “too autistic.” With nowhere to go, Jackson was admitted to the acute care hospital inpatient unit, where he would board while awaiting a definitive disposition.

Jackson is neither the first nor the last child with ASD to be admitted to an acute care hospital as a last resort option for challenging behaviors. US data suggest that one-third of children with ASD will experience a mental health crisis within any 3-month period,1  and these children are twice as likely to be hospitalized for a mental health condition compared with their neurotypical peers.2  The environment and routines of an acute care hospital can be especially challenging for children with ASD. They often experience interactions with unfamiliar staff who may not understand their method of communicating, their daily routines are disrupted by the unpredictable hospital schedule, and the sterile hospital environment can trigger their sensory sensitivities.3  Because health care professionals frequently lack specialized training to care for children with ASD,4  studies have revealed increased use of chemical and mechanical restraints, staff injuries and burnout, and significant financial costs when caring for children with ASD at pediatric acute care hospitals.5,6 

From a systems-level perspective, families of children like Jackson often rely on acute care hospitalizations because of limited access to ASD-specific services across the pediatric mental health care continuum from outpatient to inpatient.7,8  A “reverse triage” model has been used to describe the phenomenon in which inpatient psychiatric hospitals are less likely to accept children with more challenging or complex behavioral needs, such as aggression, resulting in prolonged boarding at acute care hospitals.9,10  In addition, caregivers of children with ASD may not have opportunities to learn key behavior management strategies in the inpatient setting, thus resulting in caregiver hesitation regarding their ability to safely care for their child at home. The concept of disparate access to care and disparate experiences while hospitalized may be especially salient for ethnically and racially diverse families and families with Medicaid funding,8  who may be impacted by multiple social determinants of health.

Although the authors of previous studies have described evidence-based, multidisciplinary care models at acute care hospitals for children with primary mental health needs,11  research specific to care models in the acute care setting for children with ASD is limited. Existing research predominantly focuses on acute behavioral management with a limited focus on disposition planning.12  Given this need, our institution has designed and implemented a multidisciplinary care model that coordinates care among the teams listed in Table 1 to address the medical and mental health needs of children with ASD. Our model is composed of 4 tenets: (1) medical management of common comorbidities, (2) psychotropic medication management, (3) staff behavioral interventions guided by psychology, and (4) caregiver training to help transition successful behavioral interventions to home.

TABLE 1

Roles of Key Team Members in a Multidisciplinary Care Model for Youth With ASD

Team NameTeam MembersWork ScheduleResponsibilitiesGoals of Service
Primary clinician teams 
 Pediatric hospital medicine  Attending and fellow pediatric hospital medicine physicians  24/7 coverage from attending, fellow, and resident physicians  Function as primary care team  Stabilize patients medically 
Behavioral health advanced practice providers (nurse practitioners and physician assistants)  Advanced practice providers  available 8 to 12 h each day  Manage common medical  comorbidities (eg, sleep,  nutrition, bowel regimen)  Coordinate care between  teams 
Pediatric resident physicians   Coordinate care between teams Communicate between patients, families, and staff 
 Psychiatry  Attending and fellow child and adolescent psychiatry physicians  In-person support available 8 h per day on weekdays  Consult service covering inpatient consults throughout the hospital  Optimize psychotropic medication regimens 
Psychiatric advanced practice providers  On-call support available on  nights and weekends  Conduct psychiatric evaluation  and risk assessments  Assess and plan for  appropriate patient disposition 
   Provide psychiatric medication  management  
   Provide disposition  recommendations  
 Psychology  Doctoral-level psychologist/board-certified behavior analyst  In-person support available 8 h per day on weekdays  Consult service covering inpatient consults throughout the hospital  Stabilize behaviors, focusing on both preventative and responsive strategies staff can use 
Master’s-level board-certified behavior analyst (BCBA)  Conduct functional behavior  assessments, including  assessing for current skills  and preferences  Build patient skills  through therapy 
Registered behavior technicians  Create behavior intervention  plans for staff and conduct  training with staff  Increase caregiver competence  and confidence with  behavioral strategies  through training 
   Design and implement skill-  building protocols (as part of  brief ABA intervention services)  
   Conduct caregiver training  before discharge  
   Assist in disposition  recommendations  
Supporting staff teams 
 Social work  Licensed clinical and medical social workers  In-person support available 24/7  Assess for and address family psychosocial barriers to care  Address patient and family psychosocial needs 
   Coordinate with systems of care  as warranted (eg, child  protective services)  Assist with disposition planning 
 Child life  Certified child life specialists  In-person support available 24/7  Assess for coping and normalization needs  Promote developmentally appropriate coping during hospitalization 
   Provide coping/distraction items  and toys as approved by  provider teams  
 Behavioral health support team  Clinical nurse coordinators  In-person support available 8 h per day on weekdays  De-escalation support  Act as hospital-wide, mobile support for behavioral health patients 
Care coordinator nurses  Multidisciplinary care coordination, including with outside psychiatric facilities as applicable  
Behavioral health educator  Lead educational initiatives  
Behavioral health quality improvement specialist  Manage and analyze system-level  behavioral health data  
Psychiatric technicians (function as part of frontline staff)   
 Frontline staff  Registered nurses  In-person support available 24/7  Frontline support and management of both medical and behavioral needs  Ensure the safety and wellbeing of the patient during admission 
Personal care assistants   
Patient observation associates (sitters)   
Team NameTeam MembersWork ScheduleResponsibilitiesGoals of Service
Primary clinician teams 
 Pediatric hospital medicine  Attending and fellow pediatric hospital medicine physicians  24/7 coverage from attending, fellow, and resident physicians  Function as primary care team  Stabilize patients medically 
Behavioral health advanced practice providers (nurse practitioners and physician assistants)  Advanced practice providers  available 8 to 12 h each day  Manage common medical  comorbidities (eg, sleep,  nutrition, bowel regimen)  Coordinate care between  teams 
Pediatric resident physicians   Coordinate care between teams Communicate between patients, families, and staff 
 Psychiatry  Attending and fellow child and adolescent psychiatry physicians  In-person support available 8 h per day on weekdays  Consult service covering inpatient consults throughout the hospital  Optimize psychotropic medication regimens 
Psychiatric advanced practice providers  On-call support available on  nights and weekends  Conduct psychiatric evaluation  and risk assessments  Assess and plan for  appropriate patient disposition 
   Provide psychiatric medication  management  
   Provide disposition  recommendations  
 Psychology  Doctoral-level psychologist/board-certified behavior analyst  In-person support available 8 h per day on weekdays  Consult service covering inpatient consults throughout the hospital  Stabilize behaviors, focusing on both preventative and responsive strategies staff can use 
Master’s-level board-certified behavior analyst (BCBA)  Conduct functional behavior  assessments, including  assessing for current skills  and preferences  Build patient skills  through therapy 
Registered behavior technicians  Create behavior intervention  plans for staff and conduct  training with staff  Increase caregiver competence  and confidence with  behavioral strategies  through training 
   Design and implement skill-  building protocols (as part of  brief ABA intervention services)  
   Conduct caregiver training  before discharge  
   Assist in disposition  recommendations  
Supporting staff teams 
 Social work  Licensed clinical and medical social workers  In-person support available 24/7  Assess for and address family psychosocial barriers to care  Address patient and family psychosocial needs 
   Coordinate with systems of care  as warranted (eg, child  protective services)  Assist with disposition planning 
 Child life  Certified child life specialists  In-person support available 24/7  Assess for coping and normalization needs  Promote developmentally appropriate coping during hospitalization 
   Provide coping/distraction items  and toys as approved by  provider teams  
 Behavioral health support team  Clinical nurse coordinators  In-person support available 8 h per day on weekdays  De-escalation support  Act as hospital-wide, mobile support for behavioral health patients 
Care coordinator nurses  Multidisciplinary care coordination, including with outside psychiatric facilities as applicable  
Behavioral health educator  Lead educational initiatives  
Behavioral health quality improvement specialist  Manage and analyze system-level  behavioral health data  
Psychiatric technicians (function as part of frontline staff)   
 Frontline staff  Registered nurses  In-person support available 24/7  Frontline support and management of both medical and behavioral needs  Ensure the safety and wellbeing of the patient during admission 
Personal care assistants   
Patient observation associates (sitters)   

Jackson’s grandmother was initially concerned that he had not slept for the 3 days before his admission. Sleep, constipation, and nutrition are some medical factors that may exacerbate mental health conditions for children with ASD,12  and our team began by addressing Jackson’s overarching medical needs. Targeted interventions guided by our hospitalists included (1) the creation of an ideal sleep schedule with guidance on waking hours for staff, complemented by an adjusted vital sign schedule, (2) strategies to promote eating healthy preferred foods using preset meal orders, and (3) daily monitoring of bowel movements with optimization of his bowel regimen. Once Jackson demonstrated improvement in these realms, our team instructed his caregivers on the use of strategies to promote healthy sleeping, eating, and bowel habits at home.

Given the limited access to traditional psychiatric care for children with ASD, our team targeted the psychopharmacological management of Jackson’s mental health needs. Through multidisciplinary communication, our psychiatrists obtained data on Jackson’s patterns of behavior, including aggression, sleep, and eating. Research suggests antipsychotics and alpha-agonists may be successful in managing challenging behaviors in children with ASD,12  but Jackson had not routinely received these medications at home because of financial barriers. By adding an alpha-agonist and a stimulant, our team decreased the impulsivity driving Jackson’s aggression, as well as his appetite and food-seeking behavior. As these changes were being made in the acute care hospital setting, Jackson was linked with an outpatient telehealth psychiatric follow-up appointment to ensure continued mental health support that was aligned with his family’s available resources.

Our team used a structured approach to assess Jackson’s behavioral needs at the bedside, which allowed us to offer recommendations to staff for management in the hospital, provide targeted interventions to address his challenging behaviors, and provide caregiver training during Jackson’s hospitalization.

The psychology team began by assessing Jackson for (1) triggers or functions of behavior (eg, lack of attention, escape from tasks, restricted access to items, waiting, sensory sensitivities, trigger words), (2) preferred leisure and food items, (3) expressive communication modalities (eg, picture board, signs, gestures, words used), (4) receptive communication preferences (eg, visual schedule, warnings, step-by-step instructions), (5) daily living skills (comparing what he could not do vs what he was not motivated to do), and (6) calming strategies (eg, sensory toys, counting, singing, having space). Then, the psychology team generated staff recommendations for use during Jackson’s hospitalization. For Jackson, this included creating a list of preferred videos for staff to play, encouraging staff to avoid the words “home” or “school,” working with nursing to preorder meals to minimize waiting, creating a visual communication board for Jackson to use, encouraging staff to give 1-step instructions to Jackson (especially to promote independence with daily living skills), and working with child life to further assess for and provide sensory toys.

The psychology team simultaneously worked with Jackson’s caregivers to identify his highest behavioral need areas at home, which included transitioning off videos and waiting for food to be prepared. The psychology team provided brief ABA intervention services that included the use of a brief countdown to signal transitions (“my turn in 3, 2, 1”), the use of a visual “availability board” to help Jackson make choices of available items after he transitioned (pictures of other toys he could select as distraction while waiting), systematically increasing wait time for preferred items via a visual timer (increase from a few seconds to multiple minutes), and reinforcing play with alternate items while waiting (including through praise and delivery of the item he was waiting for once the timer rang).

In the days before discharge, Jackson’s caregivers participated in daily training at the bedside. We aim for all identified primary caregivers to participate in care delivery during hospitalization for patients with ASD, although there are times caregivers may not be at the bedside because of psychosocial barriers and caregiver fatigue. In Jackson’s case, our social work team assisted his grandmother by helping her identify childcare for the other children in her care and transportation to the hospital for training. Our psychology team provided multiple hours of intensive training on use of the behavioral interventions implemented during Jackson’s hospitalization, home versions of the visuals used during hospitalization, and written recommendations to aid in use across caregivers and settings. Despite initial hesitation around discharge from the hospital, Jackson’s grandmother reported a high level of satisfaction with the behavior intervention services and increased confidence in her ability to care for Jackson at home. Then, Jackson was able to be safely discharged from the hospital without ever receiving care at an inpatient psychiatric hospital.

Jackson is but one of many children with ASD whose family has looked to an acute care hospital for answers to a problem lacking concrete solutions across the health care spectrum. Our approach to Jackson’s care took a village with pediatricians, psychologists, psychiatrists, and supporting staff teams working together to deliver his multidisciplinary care. Although the coordination of such specialized clinical teams may not be feasible in every hospital setting, our model offers an initial framework for hospitals to adapt on the basis of their resource availability.

Hospitalists can continue to innovate and advocate for improvements in the care of children with ASD via clinician-, hospital-, and community-level interventions. First, hospitalists can assess the overarching needs of the child and partner with clinical teams to provide personalized interventions tailored to the child’s interests and communication preferences. Examples of individualized interventions might include playing music that a child likes, simplifying instructions, preordering desired foods, publishing a list of their communication signs or gestures, and leveraging teams that are available (eg, child life) to help create visual reinforcements or schedules. Teams can then share individualized recommendations, including strategies observed to be helpful in the hospital environment, with caregivers to facilitate discharge from the hospital. At the hospital level, hospitalists can advocate for the creation or bolstering of a team infrastructure to include behavior specialists, such as psychologists and board-certified behavior analysts (BCBAs). By providing a combination of interventions, including patient-specific care and system-level education, psychologists and BCBAs can help improve patient and staff outcomes, such as boarding time, restraint use, staff injuries, and retention.11  Finally, at the community-level, hospitalists can advocate for enhanced ASD-specific services across the pediatric mental health care continuum in an effort to prevent crises and acute care hospitalizations.

We hope the authors of future studies will continue to investigate best practices in caring for children with ASD who present to acute care hospitals in crisis. Further research evaluating the efficacy and implementation of multidisciplinary care models within and across hospitals with varying access to resources (eg, specialized behavioral health clinicians) remains of critical importance. For example, the efficacy of this model should be considered for hospitals in which patients board in the ED, with consideration of variables unique to the ED environment. However, research is also warranted on whether our model might conversely allow for patients to transition out of ED settings more quickly (eg, either to acute care units with specialized teams or by having specialized teams offer support in the ED setting). Clinicians leading the care of hospitalized children with ASD are encouraged to consider safe, holistic clinician-, hospital-, and community-level approaches to addressing this ongoing disposition dilemma.

We thank Ms Jennifer Reece, MA, BCBA, for her support of this project and the entire Texas Children’s Behavioral Health Team for their support of hospitalized children with mental and behavioral health needs.

Dr Klinepeter drafted the initial manuscript and critically reviewed and revised the final manuscript; Drs Dalton, Mbroh, and Ayoub-Rodriguez and Ms Bobbitt cowrote and critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

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