Objectives: This study examined the effect of using a picture schedule paired with a reinforcement system during a routine medical exam with a nurse and medical resident.
Methods: Participants were 15 pre-pubescent children (ages 4 – 10 years) diagnosed with an Autistic Disorder or Asperger’s Disorder and below average adaptive communication impairment and all of whom were rated by their caregivers as either having “Poor Cooperation” or being “Completely Uncooperative” with physical exams on a 4-point scale of cooperation. Participants were randomized into either the treatment (n =8) or control group (n = 7) by the Vineland Adaptive Behavior Scale-II standard Communication scores (<75, or >75). Both groups received a medical examination. Caregivers rated participants’ irritability behaviors using the Aberrant Behavior Checklist-Community (ABC-C) before the exam (in the waiting room) and during the exam. The nurse and medical resident tallied the number of procedures they were able to complete, and the caregiver, nurse, and the medical resident rated the participants’ exam cooperation.
Results: A paired t-test was performed for the change in ABC-C irritability scale scores from before the exam to during the exam for each group separately. Marginal significance was noted (p=0.09) for the treatment group while no significance for the control group (p=0.34). A linear regression was then used to examine the difference between the two groups with respect to the change in ABC-C irritability scale scores after adjusting for age and IQ. The treatment group had a reduction of 12.1 points while the control group showed a 1.2 point increase in ABC-C irritability scores; such a difference was significant (p=0.049). The effects of age and IQ were that older children and children with lower IQ were more irritable during the medical examination.
Conclusions: Subjects in the treatment group had a greater reduction in ABC-C irritability scores during the medical exam using the picture schedule paired with a reinforcement system. However, one cannot exclude the possibility that this result was not a regression-toward-mean effect since the randomization was not made with baseline ABC-C irritability scores or IQ scores. Therefore, these results should be interpreted with caution and future similar studies should consider randomizing groups based on IQ and baseline ABC-C irritability scores in addition to adaptive communication abilities. Finally, this line of research has the potential to improve the success of medical procedures for individuals with an ASD by establishing techniques that can be easily employed by the general medical practitioner and autism researchers.
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