09 June 2011
Fear of Routine Medical Exams in Children with Autism Spectrum Disorders
(Gillis, Natof, Lockshin & Romanczyk, 2009)
As many parents may have experienced, children with Autism can have a very difficult time with medical examinations. It can be a significant source of frustration for both parents and children. This article describes two studies. The first is an assessment of the prevalence of medical examination fears among children with Autism Spectrum Disorders. The second is an evaluation of a behavioral intervention (graduated in vivo exposure and reinforced practice) designed to reduce a child’s fear of medical visits.
Research demonstrates that anxiety disorders occur often in children with Autism. Researchers have examined fears related to the environment and procedures associated with medical exams in typically developing children. However, studies investigating fears in children with Autism have not looked specifically at medical exams. Authors Knapp, Barrett, Groden, and Groden (1992) reported that there are many similarities between the types of fears seen in typical children and those with Autism. A fear of medical exams is one of these standard fears.
The first study in this article examines the specific types of fears that children with Autism have in relation to medical exams. The study found that most parents reported that medical visits were significantly challenging, and that most children were upset by having their ears and throats examined and blood drawn. Fewer children were upset by having their hearts and breathing examined with a stethoscope or by the use of a knee reflex hammer.
The authors argue that finding ways to decrease specific fears of medical exams in children with Autism is extremely important. A large portion of children in this study attend medical visits 2 to 3 times per year. One third of the children have a chronic medical condition that warrants frequent medical visits. If a child refuses to let the doctor perform necessary procedures, it can make health conditions worse and harm the child.
The second study in this article examined behavioral treatments that can help reduce a child’s fear of medical exams. This study included 18 children who attended a special school for children with Autism Spectrum Disorders. The goal of the study was to implement specific behavioral strategies with these 18 children and determine if the strategies decreased the children’s fear of medical exams.
Evaluation took place in the school nurse’s office. All of the children were initially given a brief physical exam to determine how they typically reacted to medical examination. During the initial physical exam, the children’s behaviors (e.g., refusal to enter the nurse’s office, pushing medical instruments away, crying, and running away) were used to measure each child’s level of fear. Throughout the exams, the authors noted which parts of the exam each child feared the most. A hierarchy of fears was created for every child.
During the treatment phase, the children were exposed to the parts of the medical exam that they feared according to their hierarchy. The steps were introduced in the order that they would naturally occur during the medical exam. For example, if a child walked to the nurse’s office without anxiety, but feared the stethoscope, tolerating the stethoscope would be the first step addressed for that child. This child would not participate in the remainder of the exam until he could tolerate the stethoscope without anxiety.
During each treatment session, each child’s behavior was rated. A score of 0 was neutral, scores of +1, +2, and +3 were positive, and scores of -1, -2, and -3 were negative (indicating anxiety). When a child received a neutral or positive score for a particular step, he was given a preferred toy as reinforcement for having participated in that step without anxiety. When a child received a neutral or positive score on two consecutive sessions, that step was considered mastered, and the child moved on to the next step in the fear hierarchy. Treatment was continued until most children could sit through an entire exam without anxiety. A follow up exam was conducted several months later to see if the children had maintained their tolerance of medical exams.
Results indicated that after 25 treatment sessions, 15 of the 18 children were able to tolerate the medical exam across two consecutive weeks with no anxiety. Intervention continued for the remaining 3 children for 62 sessions. These 3 children made progress, but ended up not completing all of the steps. Results indicated that there was a correlation between how many steps were feared at the beginning of treatment and how many sessions it took to complete all of the steps successfully. In other words, children who feared fewer steps took fewer sessions to complete the steps successfully, and vice versa. The 3 children who did not complete all of the steps in the fear hierarchy had significantly more fears than the children who did complete all of the steps. The authors note that these 3 children would likely have been able to complete all of the steps at some point. During follow-up, 14 of the original 18 children were assessed. Ten out of the 14 demonstrated no fear of the medical exam. The remaining 4 children showed fear for only one specific instrument or procedure. The authors comment that the results suggest that graduated in vivo exposure and reinforced practice are useful tools for reducing fear of medical exams. They also note that more studies should be conducted to confirm their findings, and dental exam fears should be studied, as well.