The Q Word Podcast

"Neurodivergent Trauma, Part 1: Treating The Most Special Population"

Lisa  
Hello, Nyssa, how are you doing today?

Nyssa  
Hi, Lisa. I'm good.

Lisa  
We are back this week with another special kind of episode one those dovetails nicely with the special populations series that we just wrapped up, right?

Nyssa  
That's right, so this is another couple of episodes that have been brought to you by Region 5 RTAC, continuing the education from education during COVID times. And we have a special guest here with us today, we're going to let her tell us a little bit about herself. We have Britanny Smith with us here. And she is not a nurse, she’s a teacher, and she's going to tell us what she teaches and who she teaches, and why she is in a nursing podcast. But Britanny before you tell us a little bit about yourself. So, our podcast is called the Q Word podcast. The word Q has a superstition that when we say it, it brings on bad luck and bad things for us. Do you have any superstitions? Do you say the word or not? Is there anything that correlates with education? 

Britanny  
I don't think we're as cool as y'all honest. You know, we could say, you know, don't get too hot at recess, but everything's straight on.

Lisa  
All right, that's great. Well, we're glad that you don't have a dangerous word as we do.

Nyssa  
We don't have a dangerous word.

 

Lisa  
Now, like, every time the keyword slips out of our mouth, in any context, we must throw salt over our shoulders and cross our fingers because we're afraid that we're going to call havoc down on us, that screen occurs. Absolutely. Well, hello, Britanny. It is lovely to see you. Thank you so much for joining us

  

Nyssa  
Thanks for coming. And tell us all about what you do, who you teach, what ages and what, and why we brought you on to a nursing podcast.

Britanny  
Okay, so a little bit of background, I have a bachelor's degree in counseling. So, I was a counselor on a pediatric psychiatric unit for about a year. And working there was it, that's a difficult setting to be totally transparent. On the medical side of things, I just saw a lot of young kids coming in and being served and upsetting. That was tough, with lots of restrictions. It just kind of gave me a vision for what would that look like if we were to catch some of these kids before they get to this type of restrictive setting. So I went back to school, I added on, and I got my teaching certificate. I work, especially with emotional disabilities. But that varies. That's a big umbrella. The kids that really fall under this umbrella are students with autism, students that have emotional disabilities, students that have intense hyper attention. That looks like ADHD or ADD. We even have some occasional pediatric bipolar, schizophrenia, anything in the classroom that you can think of I've had it at some point. I've worked in a transition program before, and then I switched to elementary school. And the reason why I'm on a nursing show is our school district had a school shooting. And I was struck very deeply by it. So, one of my students was in the classroom that was outside at the time. And sadly, one of his classmates passed away. He was able to make it inside, but he's mid-functioning autism. And it, it kind of haunted me the fact that it was from what I understand it was difficult to get him inside. He didn't understand what was happening. And then when emergency services got there, he was traumatized. And he you know, it became a physical, a physical thing that he ended up needing some support. And a lot of the kids that were involved, needed support. It gave me a passion for what would it look like if we were all a team, and we were all educated, and we all sought to be educated and informed on traumatic situations for our special need’s populations? And how do you come together to approach even adults and students with disabilities outside of school, or worse inside of school and what does that look and sound like? Because of that I started working with some local law enforcement, incorporated a lot of that into my classroom, I created an emergency plan. That's kind of where it started. And the biggest thing was I can educate my students, my autism students, I can practice I can do all the right things. But once they go out of my classroom, or they're at Walmart or at a store, I'm not able to help them at that point. So that would be making sure that the other side is educated as well. So that we're all moving, like a very well-oiled wheel, going in the right direction in the same direction. 

Lisa  
Very good. 

Nyssa  
So how long has this journey been for you?

Britanny  
The school shooting was in 2016. So, it's been about four years since I would say, since then. But long before that, I had a very strong passion for our special-needs population and the medical side of things. If I had not been a teacher, I would have become a nurse. So, it's always tied together for me in a powerful way.

Nyssa  
So, we brought you because of your experience, and because of the resources that you have put together, and because of your obvious passion. And so, we want to talk about what it's like to often deal in the emergency room and in the prehospital setting with students and even adults, children, and even adults who have the diagnosis that you mentioned, usually in a one-on-one setting when they're ill or injured. But there would be some unique and unusual situations where it could be, you know, for instance, I can think of one time when we had a school bus full of children and the bus driver became incapacitated and wrecked the bus. And so, we had an entire school bus full of children come into our emergency department. Now imagine that it was your class on a field trip. And that's the school bus full of children that come now into my emergency department that I'm having to care for. And I need to know, not just the trauma aspect of it, but also all their special needs. On top of that, or, you know, imagine that there's a fire in your school, and now prehospital providers must come in and care for your students. And so, this is kind of what we want to talk about and find out some of the best ways to care for your student population.

Lisa  
How do you think a hospital triage service would handle a group of students who all have different special needs and arrive at the same time? I can see that causing a lot of chaos. And how do you know when students don't react when people don't react in, let's say, predictable ways? Or maybe more familiar ways? How do you best help them, not only medically, but psychologically, get through that? That's a very complicated situation to deal with.

Nyssa  
And that's what we're going to talk about. Britanny would be the resource that we would go to, but she couldn't be in every single room.

 

Lisa  
We're going to distribute her personal home number, and there we go. So, people can call her at any time.

Nyssa  
So, to start, could you just give us a reminder of just kind of a couple of sentences about what each of these diagnoses means? So, like, give us a reminder about autism, ADHD, oppositional defiant disorder.

Lisa  
So people can call her on a dime.

Nyssa  
So to start, could you just give us a reminder of just kind of a couple of sentences about what each of these diagnoses mean? So like, give us a reminder about autism, ADHD, oppositional, defiant, defiant, Oppositional

Britanny  
Defiant Disorder.

Nyssa  
And then there's bipolar, pediatric bipolar, or pediatric or you mentioned childhood bipolar childhood, schizophrenia, pediatric bipolar.

Britanny  
So, I'll start with autism, which is becoming the most common disability that I work with, both in a behavioral setting and in a genetic setting, so autism falls under a big umbrella. They now call that a person with autism. So that can cover a lot of things we used to do. There used to be several different names for it. But, as the DSM gets older, it pretty much writes itself every year. They have recently talked about some of the things that you would see with a person with autism or sensory processing. You have what we call stimming, which is one of the things that are most common. You'll see a hand flapping, you'll hear noises, cheering, a lot of times there's a lot of jerky movements and a very monotone voice. Eye contact is usually not common unless you're high functioning. And so, autism has what we call "low functioning autism," which is someone who's almost nonverbal. So, it's not a lack of intelligence as much as what they know now is that their brain is wired in such a way that it's just misfiring. Constantly, and I even listened to a geneticist once who talked about it, all this information is in your brain, and you have absolutely no way to teach it to come out of your mouth. So, imagine the frustration that that would cause anyway. And then you have your high-functioning autism, which is usually intelligent. The soul might find that monotone voice. You'll see a lot of hygiene issues. A lot of times, it's probably people that might not even know they have autism or high functioning autism, and they just have coped with it their entire life and have been the outcast. And really, it could be a case of high-functioning autism that has just never been diagnosed. ADHD and ADHD are attention deficit disorders, which means your energy is a little lower. And then you have your ADHD, which is your hyper attention. And that's the one who's constantly buzzing around, touching, getting up, moving. I like to say, think of it as a movie, and there was a dog that every time he saw a squirrel, he would go squirrel. That's that person. And many of us probably say that's us to pediatric bipolar is bipolar for kids. It's rare, but it does happen. And it's just where you have manic episodes. And you can almost chart it on a cycle of high periods and low periods. It's not common, because doctors don't like to diagnose someone that young, usually not under 13, with bipolar, but I've had one before. You have your own schizophrenia, which, as I said, is still rare in children, but it does happen. And by that, I mean, if you can have a full-blown hallucination with multiple personalities, then the other personal favorite of mine is oppositional defiant disorder, characterized by absolute non-compliance. So, you'll ask them to do something, even in a safe setting. And they're just not going to do it because it either doesn't benefit them, or they just don't want to because you asked them to. A lot of our odd students end up having conduct disorder, which is characterized, sadly, by eventual incarceration, and so it's usually seen as a similar characteristic, from an oppositional defiant to conduct disorder.

Lisa  
These are both new terms to me. I wasn't familiar with either of these diagnoses.

Britanny  
I have found in personal experience that you see odd in children under 13. You'll see conduct disorder outside of 13 and up, but I will. I used to do things like tutoring at the juvenile center. That's where you'll usually find your kids with conduct disorder. It's just that the likelihood of becoming involved in illegal activities is high, sadly.

Nyssa  
So, I have a follow-up question about autism. I read a lot in the material that you sent us ahead of time about the stimming. And the stimming is S-T-I-M-MING.

Britanny  
Yes.

Nyssa  
So, what exactly is it? Is there a purpose behind stimming? Is it similar to a coping mechanism?

Britanny  
Yes, so stimming is that it’s a sensory portion of autism. But what we've, it's, you know, when you track the data, I would say stimming is mostly self-soothing. It's also a way to let out excess energy, including energy that comes from feeling anxious, feeling upset, or agitated, and sometimes it's purely for pleasure. You know, it's a way to calm yourself, but it also feels nice. I had a student before who spun in circles, and I mean, like spinning hard. To the point that we were really concerned that she was going to have a permanent side effect from the spinning. We sought out some different medical advice on how to help her with that, but she would sleep for as long as we let her, and it was just the way that she self-stimulated, and she would find a lot of satisfaction in it. So, I would say it. It looks many ways. But it all comes back to whether they're really coping. It's just a coping skill that's not always safe or healthy.

Nyssa  
So, if you saw, as a nurse, I saw an autistic patient who was, let's say, flapping, rocking, or pacing. That would be an indication to me that they were feeling anxious or stressed and that they had found a way to cope with it. And if it wasn't for something like this spinning, if it was hand-flapping, and that's not something that's dangerous, then I would just want to leave them alone and let them use their coping mechanism. Okay!

Britanny  
Absolutely. And sometimes when you disrupt a stim, you can have an agitated lash. I've been hit before and spit that scratched. It's almost like they're watching their favorite movie, or they're doing their favorite thing, and you literally abruptly Stop it, it causes agitation. Some kids are great about stopping. So, I always set a timer. And if you want to stim, we're going to stim currently. So, what I usually teach is a time to do it. And then, when the timer rings, we stop. So, if you ever needed that person to stop so that you could do a physical or something like that, you could even set a timer in advance. I'm going to let you finish this for a minute. And when you share this ringer, you're going to know that it's time to stop. Even a nonverbal autistic student would very much understand what you were saying.

Lisa  
I live in Boston, and there's a gentleman who lives in the area who suffers from Tourette's. And his coping mechanism, especially when he's on the tee, is to bite his arm. When I see that, he's a rock. So, he set his stims. But he bites his arm. And I've seen that I know him. I've been around him for years. You know enough to be like, "Yo, what's up?" Do you know what I mean? That kind of thing is no problem. But I've seen a lot of other people nearby who don't know that. And they see him biting his arm, and they believe it's self-harming behavior. And I've seen them talk to the police. Do you know what I mean? Some freakout. But I think, in most cases, they're trying to be helpful.

Britanny  
Yes.

Lisa  
So, does Tourette's fall on the same spectrum?

Britanny  
It does. Tourette's is under the autism umbrella. It used to not be, but now it is. And Tourette's is very much tied to some of the compulsive tendencies. So, I always have them with the internal motto that if the stem is not harmful, it can continue. If it is harmful to the person or others, it must stop. 

Lisa  
So, what I see is him pushing his open mouth against his forearm. 

Britanny  
Yeah. 

Lisa  
What others see is him trying to bite his own flesh. I know he's just muffling; I've learned. It's just his best way of muffling his outbursts, but others don't. And so, listening to what you're saying, Now I'm wondering how much more damage there is and if I should have intervened. I've made eye contact with people who I've seen him with, and yeah, they react weirdly now, like it's cool, it's cool. Do you know what I mean? And yes, but what more damage could be done to a gentleman like that, who has clearly figured out his coping mechanism?

Britanny  
Yeah. 

Lisa  
Because he's forced to live in the city, he must ride public transportation, which obviously makes them anxious. And so, this is his way of dealing with it. But then when he goes to the emergency room, let's say there is an emergency, how is it that a nurse can differentiate between this is the type of behavior that is him, is normal for him, and is, in many ways, I'm assuming, a healthy coping mechanism? He's figured out how to manage it.

Britanny  
As long as he doesn't break the skin. And my only concern is COVID. Maybe this spitting on the arm is a little bit more concerning.  

Lisa  
Yeah.

 

Britanny  
I think for me, I would just say, "it's the power of words." I would ask him. I'm not sure what you're doing. Could you explain it to me? And if it's someone who's nonverbal, you can always, you know, have like picture cards of being hurt or not being hurt. You know, are you hurt right now? Or are you not hurt? And usually, they choose not to hurt because, if you can do the different cards, you'll realize that this is just a soothing thing. And if they're not reading the skin, I would not intervene with that.

Nyssa  
What are some other do's and don'ts for autism children and adults?

Britanny  
Have intense eye contact. You know, for us, looking at each other in the eyes is respectful and is a way to show you that I'm listening to what you're saying. But for someone with autism, sometimes that is really overwhelming. And it's almost like a slap, like, what are you doing staring at me? What have I done? And you know, they could be thinking about something totally different. And while you're staring at them, that can be very uncomfortable. So sometimes I always look at maybe the side of their face or at their forehead as I'm asking certain questions. And then when I need them to really listen to me, I do something. It's quick, but I'll say, what's the color of my shirt? And they'll tell me fast. And then I'll ask my question. And that way, I know I have their attention quickly. And then I got the response. ABA therapy is a great tool, but that's applied behavior analysis. And you can ask, "Hey, what's the color of my hair?" How old are you? What's the color of your shirt? Really quick, easy questions will bring their attention to something quickly. And then you ask the important question right after, like, where are you hurt? Or can you tell me what happened? Or are you bleeding? Can you show me where something like that would be?

Lisa  
It sort of opens the door for them.

Britanny  
It does.

Lisa  
And it gives them something to hold onto, something cognitively familiar to hold on to, that will then allow them to slide into something a little less comfortable.

 

Britanny  
Yes.

Nyssa  
That is a great tip. I love that.

Lisa  
That's very good.

Britanny  
And there's a fancy word for that. I don't know what it is.  

Lisa  
Don't do fancy. Was here the keyword?

 

Britanny  
I have no fancy word.  

Lisa  
That works for us. I like it. I love that.

Nyssa  
Yeah, So, if a nurse was assessing a child with autism or an adult with autism, would there be physical findings? Or would there be drug interactions or other medical considerations or physical things that they would need to consider that would be different than a child or an adult that does not have autism?

Britanny  
Yes, there would be two things. Bruising is common because they're pickers for a lot of my autism. The awesome students are their pickers. I have friends that are pickers who are not autistic. But I would say that picking level can be a stem for some kids, especially as they start getting things like acne, and they'll get a scratch on their arm, and then they're obsessed with it. And a lot of times, they'll get infected with staph infections. So, I always have to keep a really close eye on scratches and wounds. Because in a heartbeat, I'll see what looks like a staph infection. Last year, for example, I had a student who burned himself in the oven at home. And he came to school. And he had it hidden in his home advantage. So, I made him show me just because I wanted to see it, and it smelled like death. And I was like, "Okay, this is really bad." And sadly, to him, the smell, the look, and the pus coming out of it were totally normal. And I mean, he's usually covered in piggy scratches and bruises. But this was a different level. Thankfully, we got to the doctor, and he had to get it packed and cleaned. It was awful. That's just one of the things is that picking the bruising, you know, if you're a spinner or hand flapper, you run into stuff all the time. Another thing is the oral fixation. So oral fixation is another common thing that you'll see, especially with younger, intellectually disabled kids, meaning people whose IQ would be lower than 68. You know, most people like to use 90 and above. If you're intellectually disabled, you're on the lower end. Oral fixation is when you take a common item and stick it in your mouth. And it can happen very quickly. And it could be something sitting on a tray that you sat down right next to, and then BAM it is in their mouth. And you're like, "No, you just say the band-aid." That's very, very common.

Lisa  
So that's not like a sucking mechanism that's like a baby sucking his or her thumb. What’s more, I need to put something in my mouth of any variety because I like the feeling of an object in my mouth.

Britanny  
Yes.

 

Lisa  
Satisfied, excellent. 

Britanny  
Yeah. 

Nyssa  
Choking hazard.

Britanny  
It is.

Lisa  
Another already hurt. Yeah.

Britanny  
I have a horror story about one of my friends with autism. He and I made these little robots and used them like sponges, and then he went home, where he apparently wanted to glue something down. But he's hot glue. And then he stuck it on the other side of his chin. Oh, yeah. Oh, yeah. And it was a disaster. So pretty much the whole scan came off, but he wanted to feel it. And it was innocent. But let it be like that. I mean, the guilt, gosh. Because you know, I'm the person that totally put this all together, and then it was great.

Lisa  
Right Oh, wow. So, how do you tell the difference between a non-autistic child in distress and a child who is freaked out because they were in a terrible accident? So, they are therefore not acting normally when maybe wants to have their Binky, or maybe they are suddenly sucking their thumb because they just went through some trauma versus a child for whom this is the characterization of their normal behavior.

Britanny  
I would say voice inflection is always my biggest go-to for figuring out when someone is on the spectrum. It's not always obvious, it can be very subtle, but anytime somebody has an increasingly monotone voice, even in a very scary situation, I would say that's always something I start to be more aware of. Also, my friends with autism have something called "special interests." Special interests can vary a lot of the time if it's something that they're passionate about. And if your patient starts randomly spouting off facts about the Titanic or bringing you into a world of fantasy or unit, that might be a cue that okay, you might be dealing with something a little different, and that's okay.

Lisa  
What would you do in a perfect world? What would you recommend? What would you like to see nurses do once they go, "oh, I think this patient is on the spectrum?" Here's my list of ABC things that I should do to best treat this patient.

Britanny  
I would go immediately to the toolkit. And that's why you can put the toolkit anywhere. The toolkit is a little box, especially, and honestly, even kids who aren't on the spectrum, benefit from the toolkit, especially after a traumatic incident. From the toolkit, pull it out. I usually offer two choices from the toolkit. Hey, you seem upset, or do you seem scared or nervous? Would you like to choose one of these things to hold or do while we talk? Sadly, I have many students who don't know that they have autism. And that makes me sad because I think you empower someone when you say, "Hey, you have autism, but that's not the end of life." It's the beginning of life for you. So, this is what we can do with it. But I understand a lot of parents’ reasons for holding off. It can lead to other things like bullying, but sadly, some kids might not even know that they have autism. So, asking them outright may be beneficial for no one. So, the toolkit, at least for autism or no autism, can get you started on what I can do to help calm you down. And these are some of the tools that third-party influencers use. While you're doing this with your hands, you're going to be more willing to talk to me. And I might get more out of you than I would if you were sitting here staring into space or being terrified out of your mind.

Nyssa  
So, let's do this. Let's go to some of the other diagnoses and talk about them like we have with autism. And then, as we start talking about the toolkit, this is just my brainstorm. And y'all tell me what you think. How about if I describe some of the interventions that we would have to do in an ER, for instance, starting an IV, drawing blood, putting the EKG leads on and hooking them up to wires, and, you know, squeezing their arm with a blood pressure cuff? And then you can tell me how different things in the toolkit or different How would you approach a child with autism? For each of those things? How would you approach a child with ADHD to try to draw labs or get blood pressure? How would you approach a child with ODD with each of those things? What do you think about that?

Britanny  
That sounds great.

 

Lisa  
Yeah, that sounds great.

Nyssa  
Okay, let's talk about these other diagnoses kind of in a general sense, like some of the things that you would see and some of the do's and don'ts, and then let's get really specific about what things we would be doing and then, like, I like the thing that you said, in the toolkit about, let's try to keep noises to a minimum, let's turn off the lights and sirens if possible, like those kinds of things, we can talk specifically and then we will pull out the toolkit and say, "Put this in their hands while you're starting the IV or whatever."

Lisa  
Yeah, can I interject a question before that? So, the suggestion was made that it might make it easier to approach this portion of the conversation. If you were forced to categorize autistic patients into, say, three general categories, would you be able to do that so that you could say, "Okay, well, this type of patient generally falls into this large portion of the umbrella, and they generally present this way," whereas "this type of patient generally falls into this large portion of the umbrella, and they generally present this way?" What does autism, ADHD and ODD? Would those be the three types of categories into which you might be able to seat them, knowing full well? Well, that means that the spectrum is very variegated and that it doesn't neatly capture everyone. Is there a way to try to sort them into buckets so that when an ER nurse has a moment to try to assess a patient, they can say, "Okay, well, I think that they're most likely to fall into this bucket, in which case, these are the approaches I would most likely take?”

Britanny  
Yeah, I would say yes. And I would say those are three great categories. A pairing of autism is ADHD. A lot of times, they'll be very similar in a very similar way. That's why I say the monotone voice is usually my cue. And I would treat them very much alike. Whereas with oppositional defiant disorder and you’re pediatric bipolar, they're in a whole other bucket.

Lisa  
Okay, that's very helpful. Okay, so those are the two general buckets that we can play with.

Nyssa  
Yeah, one of the things that you mentioned about stimming behaviors is that they are kind of a cue to maybe how an autistic person or a child with autism is feeling. Maybe they're feeling anxious or they're doing some self-soothing. Is there a similar cue with a child who has ODD or ADHD, or something that their behavior would show or something they would do that would alert you that they are stressed? or that they're upset?

Britanny  
Agitated movement? I would say most students have ever had severe cases of agitated movement or verbal aggression. It's just like asking 1000 questions a lot of times. It'll be very stressful. It's almost like you can't even get a word in. It usually brings them down a little bit, to the point where you can even ask those questions.

Nyssa  
Okay, so what's a good intervention for that?

Britanny  
I usually have a nonverbal card. And it's always read, you hope. And I think I read somewhere about people who are colorblind having certain colors that they can still see, or at least a shade or shadow of them. So, I usually just hold up a red card. I don't even say anything. And then another one is a hold-up five. And then I don't say anything. And then, once I get to the status, "Okay, it's my turn." And that's a countdown of Okay, I hear you. And now we're done. Let me introduce our listeners.

Lisa  
You are just holding up five fingers. This is an audio medium, not a visual one. She's holding a five, down, like a mother holding your hand. 

Britanny  
Yeah. 

It's kind of a little kid saying, "You've got to the count of five to stop throwing your temper tantrum," which is basically what you do with a toddler. 

Lisa  
Take the same sort of patient approach and allow a child who has the time to find their center or as much of their center as their can.

Britanny  
I would say intense. ADHD is a toddler in the toy section of Walmart. 

Nyssa  
I think, I think that when they're being super hyper-verbal, and you're doing no talking and just the hand motions, that that is powerful, you know.

Britanny  
And, it is, and it is under control. You still have five seconds to finish whatever it is that you want to say to me.

Lisa  
Right, right, right. You're not doing your job. You're not just interrupting them, but you're giving them the opportunity to try to wrap it up for themselves.

Britanny  
Yes, 

Lisa  
If it doesn't work in five seconds to start over again. 

Britanny  
I'll probably do it one more time. And then you can always try the proximity of just coming closer and saying, you know, asking that icebreaker question of, hey, do you know what color my shirt is? That's usually anything to divert attention from something that you want to talk about. And that's your gate, your gate question.

Lisa  
How much more complicated must it be if that child is in pain, like physical pain, and has gone through a terrible shock? Wow. Okay, so let's look at the epidemiology of these patients and what we will do to best help them if they present themselves in the ER.

Nyssa  
So, for the ADD or ADHD child, if we're assessing them and we're looking at them physically or their medications or whatever, are there other things that we would be looking at for them in other ways that they would be physically present?

Britanny  
Yes, very fit. A lot of medications for ADHD cause suppressed appetite. A lot of my students are very, very slim. It's always like that, especially if they're unmedicated. You'd see the opposite. You'd see a bigger person because they have less impulse control. But if you're on medication, you are very trim. You would almost wonder, "Are you eating?" and then he's really worried about that.

Lisa  
Do those medications work? This might be too technical, but in terms of like, counter-indications, counter-indications for any standard medications that would be issued in the ER for trauma, if that might be something to look into whether or not Yeah, like, we talked about Rocuronium. And what are some of the other fun ones? Nice. I only remember Rocky Aronian because it really sounded like that was.

Britanny  
And it’s cool. 

Nyssa  
I don't think any of the commonly added medicines have a lot of contraindications for the stuff that we would be giving. Yeah, is there anything else for ADD or ADHD students or children that we need to be aware of, as far as things to look for or interventions to use?

Britanny  
The biggest intervention is proximity and setting clearly defined expectations for the room, like "I'm here to do this and this." So, let's start with this, then this, using first his, his teacher's language, but it gives them an idea of what's coming next. So that their desire to be impulsive comes down a little bit. I would always also lay out, "Please don't touch anything."

Nyssa  
Okay. I like them. 

Britanny  
Yeah.

Lisa  
When, if possible, is it helpful to try it again. This may not be possible in the ER, Nyssa, as you can tell me, to try to assign a particular nurse to provide them with merely that information so that the rest of the team can do the actual healthcare work we talked about. I'm thinking about having a family presence at the bedside for Nyssa and having a nurse stay with a family member if a family member is there while their loved one is coding in the ER. If you have the personnel for something like that, would you have the personnel even if it's not a nurse that's specifically trained to work with a special population like autism, but one who knows that their job while this patient is in the ER is to be there to watch for stemming or to hold up the red card? Or to tell them this rather than that? Is that something that's possible?

Nyssa  
So, this is a great question. And there is an intervention kind of theory, where when you have a lot of chaotic things going on, like, for instance, if we were running a trauma code, and there were six, or eight, or 10 people in the room with this one child, and there was a lot of chaos going on. And this is true for any pediatric patient. You would assign either a child life specialist, for instance, or the primary nurse to be the one person who talks to the child. So, there's not a lot of voices, a lot of people talking over each other, a lot of faces in their faces, you'd have the one person while other people do things quietly to be the one that says, "Then this is what's happening." Call them by their name, if you know that they have an autism spectrum disorder, you may want to avoid eye contact. It's a really, really great way for intervention to be used on any child. You can use it on adults, you can use it on adults with psychiatric issues, you can use it on folks who are in a lot of pain, that you're having a lot of trouble directing, instead of everyone yelling all at the same time and trying to get their attention, or everybody talking over each other and asking the same question. You have one person that they can focus on who is asking the questions or giving the information. This, I believe, would be critical in this population.

Lisa  
Absolutely.

Nyssa  
I think that's a great intervention, a great strategy. 

Lisa  
Absolutely, okay.

Nyssa  
So now let's talk about your oppositional defiant disorder and your bipolar schizophrenia. And one thing I can tell you is that this population of patients is not from trauma, certainly not from trauma, but we see them in the ER already when they have acute psychiatric exacerbations. And for me, this is one of the most frustrating populations. Because there are such limited resources for pediatric psychiatry, there are very few inpatient beds available to them. And so, they end up in the emergency room for long periods of time, which is not a great place for them. It's not what an emergency room is set up for. It's very frustrating for them; it's frustrating for their families; it's frustrating for the staff. A lot of times, they come in just simply because of caregiver strain. Their family is exacerbated, you know, by their behavior or by some recent event that has happened, and so they don't have any other idea what to do. So, they brought them to the emergency room. And so that's, that's some of the experience that emergency nurses have with pediatric bipolar, pediatric schizophrenia, even oppositional defiant disorder, but let's talk about them on a more day-to-day basis, so kind of describe to us what we could be looking for, what kind of behavior we would see in them if they were feeling stressed, or some of the interventions that might be good to use with them if we were working with them, what would be some good tips?

Britanny  
A cool thing is that you talk about how they come into the emergency room and how they must sit there for a long time. Sometimes, it's usually the school, or like you said, or the family that ends up sitting them because they're having an episode at school that lasts beyond a certain point, we must call the parent. The parent doesn't know what to do, so they go to the hospital. Some of the things that we try here are weighted items, weighted blankets, lap blankets, weighted plush toys, that's a big one, very soothing, very calming, well.

Lisa  
Hell, I love a weighted blanket. 

Britanny  
My husband sleeps with a weighted blanket every night. One thing that is cool is noise-canceling headphones. I would say that blocking out some of the other noises that you're hearing inside of the emergency rooms while you're there for a while can be very, very helpful. And also, anything digit-wise, small fidgets in the toolkit, I have a link that goes to my top 10 favorites on set. I'd recommend them because they're a cool way to keep their hands busy so that the anxiety that they're feeling is not high, which is sad, especially in pediatric bipolar. If you're having an intense manic episode, sometimes sedation is the only thing that is helpful, which makes me sad. You know, sometimes beings, it's not necessarily a bad thing, but once they're sedated, bringing something to them like a fidget, or a lap blanket is beneficial. Obviously, oppositional defiant disorders are usually your aggressive lives; they'll come in fighting, biting, kicking, and screaming. So, sadly, they also tend to have to be sedated quickly to get them down to a point where you can even be helpful. Or you have the ones that when they left school doing that behavior, by the time they're in the emergency room, they're being perfect because they've gotten what they wanted. They got to leave school and go talk to these cool nurses and doctors, and they're loving it. So, in my toolkit, I highly recommend anything waited for. And the biggest thing is making sure that the things that you're giving to them, I always say that the expectations of how they should be used are so high that they can't keep them. That does have to come back to me, but I want you to borrow it right now.

Nyssa  
That's a very good point to start. 

Britanny  
Yes.

Nyssa  
This is for you to play with for now.

Britanny  
Sadly, I would say your frustration is my frustration when it comes to this population. I think people underestimate manic episodes. And I think it's hard to imagine a child going through a manic episode, but it happens. Imagine that happening, starting in a classroom where you strip butt naked and do some crazy things. And I mean, it's scary what that can look like.

Nyssa  
And then doesn't that do it? So, my frame of reference is what happens in triage when we have a long, long way to go. And we have one person that gets very upset and disgruntled and starts getting very fussy and loud and complaining. It becomes like a ripple effect. And other people start getting very loud and they start complaining as well. And then it becomes just everyone. So, in your classroom, when one of your students starts having some sort of meltdown or episode, does it impact the other students the same way? Do they all start to feel this anxiety? Or do they start?

Britanny  
Yes, absolutely, as I would call it, the ripple effect, I mean, absolutely. It's like it just ripples out to the rest of the classroom. Something that I have is not seclusion, necessarily, as much as finding that quiet space that I have found, especially for my odd kids, and my honesty, any of my kids who are odd but pediatric bipolar, especially a quiet, dark place to sit is very, very helpful. I even cleaned out a cabinet once and I put like a little light in there and pillows and a blanket. And you just go in there and move on until it's time for it to work calm. So minimal stimulation and minimal stimulation as you can, because half the anxiety and agitation and complaining whining are simply, "I'm not just tired of waiting here; I'm agitated and stressed, and I'm anxious about what's going to happen." 

Lisa  
Got it. 

Britanny  
So, you know, turning those lights down in that little cubicle, offering the noise-canceling headphones and a weighted blanket. Good to go.

Lisa  
Okay, so this, I think, is a great place for us to stop the first half of this segment of interviews that we're doing about this special population. Let's take a break here and come back next time. So, we can talk about the toolkit that we've been hinting at all this time. And what you can do if you don't have the toolkit in front of you is how you can use everyday items to fulfill the needs of the toolkit when you're treating this special population. What do you think about that? Yeah, so

Nyssa  
We're going to come back with Britanny and talk specifics on what we're going to do in the ER, using some interventions, some tools, and how to best treat these pediatric patients in our ER.

Lisa  
It sounds great. We'll see you next time. All right. Thanks, Britanny. 

Britanny  
Thanks.

Lisa  
Awesome.

Keywords

autism, students, toolkit, ADHD, ODD, pediatric, nurse, bipolar, oppositional defiant disorder, monotone voice, patient, classroom,

autistic, ER