The Feasibility of Implementing and Assessing Acute Behavioral Interventions in an Inpatient Setting for Children and Adolescents with ASD: Challenges and Lessons

Background:  Children with Autism Spectrum Disorder (ASD), while hospitalized, frequently present with severe behaviors (i.e. aggression, self-injury) and due to this, often remain hospitalized beyond medical clearance. These behavioral challenges associated with ASD have resulted in perceived suboptimal treatment in inpatient settings by children, families, and providers (Scarpino et al., 2010; Kopecky et al., 2013). The inability of current systems to adequately respond to behaviors often limits the ability of children to be safely discharged. Though steps have been made toward improving treatment of ASD in medical settings, these children still have higher rates of hospitalization and an increased burden of unmet needs (Lajonchere et al., 2012; Croen et al., 2006; Siegal et al., 2014). There have been few studies of interventions designed to improve hospitalization for this population, leaving questions regarding the ideal organization of care unanswered. Although utilizing the principles of Applied Behavior Analysis (ABA) for assessing and treating challenging behavior can significantly impact functioning of individuals with ASD (Weitlauf et al., 2014), behavioral professionals with ABA-specific training are rarely incorporated into inpatient treatment plans. The development and implementation of innovative care programs to reduce problematic behaviors of children with ASD in inpatient settings has the potential to improve outcomes for all involved.

Objectives:  Our aim was to investigate the feasibility of implementing and assessing the efficacy of brief Analogue Functional Analysis (AFA) in an inpatient setting for children with ASD to guide care during, and hopefully improve, hospitalization.   We sought to evaluate if the proposed level of support and specialized care is possible during hospitalizations, or if additional components must be added and analyzed in future studies.

Methods:  This single site, pilot study attempted to enroll and randomize 40 children with ASD , ages 6-18, admitted to either a medical or psychiatric inpatient unit, with severe challenging behavior(s). Participants were randomized on a 1:1 basis into a treatment group (receiving brief AFA and behavioral intervention) or a control group (receiving “treatment as usual”). Feasibility was assessed by enrollment/completion data as well as staff, parent, and clinician ratings of challenges and successes during hospitalization.

Results:  We recruited 36 children over a brief enrollment period (approximately six months) in both medical (41.7%) and psychiatric facilities (58.3%), with 19 completed, 12 lost to follow-up, and 5 pending 3-month follow-up. Major challenges endorsed by clinicians involved in the protocol included: communication challenges with staff, availability of appropriate/safe space for AFA on medical floors, challenges conducting randomization for services, and availability of behavioral services increasing parental desires to stay in hospital.

Conclusions:  Although several challenges to implementing behavioral intervention in an inpatient setting were identified, we were successful in conducting a randomized intervention in these inpatient settings.  The most significant challenges related to integrating behavioral staff/procedures into an already-established treatment flow and obtaining efficacy data from parents. The latter is not surprising given the pervasive disruption of having a hospitalized child, but highlights the need for novel methods, procedures, and tools that will yield higher levels of efficacy data capture over time.