For children on the autism spectrum, even a well-child visit can be stressful
By Deborah Jeanne Sergeant
Visiting the doctor’s office — even for a well-child visit — can feel stressful for some children.
They may worry about receiving a shot or having an unfamiliar grownup perform an examination.
For autistic children, these worries are magnified as the stimuli that’s mundane for typical children seems intolerable: bright lights in the waiting area and exam room, loud cartoons on the TV, pungent cleaning solution odors, scratchy exam gowns and exam tools that touch their bodies in unfamiliar ways, like the otoscope in the ears. Overstimulation can cause behavioral issues as children try to express their discomfort.
Planning can make doctor’s visits easier for children, including the doctor.
“I’ve found the most important thing is to have the same provider,” said pediatrician Sarah Marsh at St. Joseph’s Health. “Here, I have 70 kids on the spectrum and we know them and that they’re coming. The provider may write a note to the nurses. Parents shouldn’t lie, ‘We’re going to the bank’ and surprise! They’re going to the doctor. I never tell a child it won’t hurt if it will.”
She added that any new nurse should be warned about the child’s needs. Marsh said that most children with autism don’t like having their ears touched, for example. But holding a favorite toy or other significant object or playing on a tablet helps.
Marsh also recommends consolidating doctor’s visits if possible. But that depends upon the child’s tolerance level.
No one likes shots. That’s why Marsh uses “immunizations” or “vaccines” instead of “shots” in children’s presence.
“If parents can be completely attentive during the visit, it helps,” she added. “Put away your phone and be as present as you can.”
Planning at home also makes visits go better. Of course, an emergency visit can’t have the same level of planning as a well-child visit. However, for the latter, prepare with a few strategies. YouTube videos can help children prepare for visits, as well as children’s books about doctor’s visits.
“Research says role playing at home helps,” said Cathy Leogrande, PhD, professor in the education department at Purcell School of Professional Studies at Le Moyne College.
She advises parents to buy their children a toy doctor’s kit to play with at home. Perhaps mom and dad could be patients or a doll or stuffed toy. Leogrande said that this type of play can help normalize doctor’s visits as just another activity.
“Some doctors are good at helping kids through the visit,” she added. “They may say, ‘Would you like to put the stethoscope on your chest? Would you like to touch it?’ Some may put a cover on it.”
Planning the day of the visit can make things go more smoothly as well.
“Arrange the day such that you don’t have to stop a fun or reinforcing activity to transition to the doctor’s office,” said Courtney R. Mauzy IV, Ph.D., and research instructor at Upstate Pediatrics at Golisano Center for Special Needs.
But planning something fun to happen directly after the doctor’s visit can give kids something happy to look forward to. Making the trip more enjoyable could include free access to favorite toys or snacks — a better association than the discomfort from needles and throat swabs at the doctor’s office.
“I encourage parents to not provide a lot of unnecessary demands or instructions during these visits,” Mauzy said. “They are already being asked to do something outside of their normal routine and schedule and are surrounded by a lot of unfamiliar people and things, so we can try and not add to that by adding additional demands.”
This could include advocating only for medically necessary procedures. Why go through measuring height when the child presents with an upset stomach?
Don’t forget the stimuli soothing items such as sunglasses, headphones, favorite stuffed toy or fidget toy to help curb the potential for feeling overwhelmed.
Mauzy said that offering the child the choice of a positive reinforcer during the most difficult parts of the visit such as a blood draw may help, such as a sticker immediately.
“A parent can always ask about conducting certain tests if they know it might be difficult for their child,” he said.
He added that consistently praising behaviors they want to see during the visit and avoiding drawing attention to challenging behavior is particularly helpful during stressful times.
“I encourage caregivers to use very clear and objective instructions to communicate exactly what is expected of the individual,” Mauzy said. “We often refer to this as ‘first/then’ statements. ‘First, you stand on the scale, then you can have your tablet back.’ This both makes the expectations as clear as possible and signals what will happen once the individual complies.”
He offered another strategy to gain compliance: a preferred reinforcer with a “high probability demand” before asking the child to do something hard. If it’s tough to measure weight, start with something easy, like “Give me a high five.”
“If they comply with the easy demand, you can provide the reinforcer and the child starts to experience the rule of ‘OK, I comply, I get something I want,’” Mauzy said. “You build some momentum with compliance with easy demands and sometimes that can make jumping to a more challenging demand easier.”