Opportunities to Improve Inpatient Care for Children With Behavioral Comorbidities

Abstract

A 14-year-old girl with autism spectrum disorder (ASD), intellectual disability, aggressive behavior, and constipation presented to the emergency department (ED) with her aunt and uncle (legal guardians), with 3 days of worsening aggression and abdominal pain. Caregivers reported escalating aggression over the last few months despite regular psychiatric follow-up and titration of her psychotropic medications. She had 2 ED visits during this time for similar complaints, was diagnosed with constipation, and was discharged from the hospital after receiving an enema. Three days before this presentation, she began hitting and scratching herself and caregivers and so was brought to the ED because they felt unsafe caring for her at home.In the ED, vital signs were within normal limits. She was alert but was withdrawn, delayed, and nonverbal, and she was intermittently crying, scratching, and hitting herself and bystanders. Her abdomen was tender in the lower quadrants. The remainder of her examination was unremarkable. An abdominal radiograph demonstrated a significant stool burden. She was admitted for a bowel cleanout and adjustment of her psychotropic medications.On admission, she was placed in an enclosed bed with one-to-one supervision by a dedicated staff member because of aggressive behavior. She was transitioned to an oral bowel regimen after an initial bowel cleanout and stooling well with resolution of abdominal pain by hospital day 3.The inpatient psychiatry team was consulted for escalating aggressive behaviors. In discussion with her primary outpatient psychiatrist, a new pharmacologic regimen was started to manage her aggression and agitation. Despite these changes, she continued having behavioral outbursts (hitting, kicking, and scratching multiple care providers and herself) leading to frequent use of physical and chemical restraints to protect all involved parties. She remained withdrawn and agitated, with no improvement in behavior after 5 days on the new medication regimen. On day 6, further adjustments were made to the medication regimen; social work was consulted to assist with placement in a long-term psychiatric care facility.Her medications were adjusted over the next 4 days while placement was sought. Ultimately, no care facilities were identified that would accept this patient. Although her behavior slightly improved on the new medication regimen, she continued having intermittent aggressive outbursts, making it difficult to provide appropriate care (ie, bathing, administering medications, checking vital signs).