be a means of seeking attention, avoiding nonpreferred activities, mediating pain, expressing frustration, or displaying anxiety Addressing what motivates these behaviors allows for appropriate targeted interventions The AACAP Autism Spectrum Disorders Resource Center can be accessed at https://www.aacap.org/aacap/families_and_youth/resource_centers/Autism_ Resource_Center/Home.aspx Management Early intervention with behavioral therapies can improve communication, learning, and social skills Although there are no effective medical treatments for the core deficits of ASD, medications may ameliorate some of the symptoms of comorbid conditions and complement standard behavioral and educational interventions Pharmacotherapy most successfully temporizes concerns related to inattention, hyperactivity, aggression, repetitive activity, anxiety, depression, disordered sleep, and seizures The most widely studied medications with greatest effect are methylphenidate for inattention and hyperactivity and risperidone and aripiprazole for aggression and challenging behaviors Challenges in Healthcare Environment People with ASD have different ways of learning, paying attention, or reacting to new or unexpected sensations or settings These variances may interfere with the ability of an individual with ASD to understand what is happening during a hospital visit and effectively communicate with medical staff As well, a disrupted routine and overwhelming noxious hospital-based experiences may stress the ability to self-regulate and cooperate with physical examinations and procedures Many patients with ASD require no additional supports during medical encounters other than provider awareness of how and why they interact and communicate differently Importantly though, a small population of individuals with ASD will benefit from simple proactive environmental adaptations (e.g., allowing noise cancelling headphones, minimizing the number of staff, or wearing sunglasses if the lights are too bright), and communication strategies (e.g., giving time to adjust to new commands, breaking down instructions into small parts, or offering a small reward for a specific task) to support compliance Finally, a minority of children with ASD will demonstrate escalating behaviors that prohibit successful interactions with medical staff and require reactive measures (e.g., anxiolysis or restraint) to ensure patient safety and promote delivery of optimal care Engaging caregivers is the most successful way to facilitate treatment for individuals with ASD Appreciating how best to communicate, recognizing the difficulty for a particular child to maintain composure in a medical setting, and learning what reduces anxiety and alternatively what provokes escalating behaviors allow for simple accommodations to enable successful care delivery In general, communicate directly with the child using simple, concrete language, give brief instructions, warn about transitions, offer positive reinforcement, allow for frequent breaks, recognize when tasks are overwhelming, and limit unstructured time For children with limited verbal abilities and for those with significant anxiety (escalating behaviors), consider using visual supports to communicate expectations and structure the encounter Some children use specific picture systems at home Others are familiar with resources used in other treatment and educational settings that are easily adapted to hospitalbased care Among these are “if/then” cards, visual schedules, and Social Stories These can be quickly sketched at the bedside or printed from online templates “If/then” cards display two linked images revealing an action and then a reward if the action is completed (e.g., if you take the medicine, then you will get a sticker) Visual schedules organize simple words or pictures to seriate the steps of an event Social Stories explain the sequence of an action or activity in simple illustrations with or without accompanying text Just as a highly structured encounter offers significant support to individuals with ASD, flexibility and, at times, simple accommodations to the care environment, often reduces anxiety enough to gain compliance and ensure safe interactions Respecting and working around triggers for agitation often facilitates a cooperative experience Importantly, recognize that many behaviors are a reflection of significant anxiety and consider breaks in demands, positive behavioral support, flexibility with expectations, and at times anxiolysis to minimize distress SCREENING FOR MENTAL HEALTH PROBLEMS IN THE EMERGENCY DEPARTMENT Many children with psychiatric illness not present to the ED with overt psychiatric symptoms It is also clear that many patients with psychiatric disorders exhibit somatic symptoms, such as headache and abdominal pain; some chronic medical illnesses, such as asthma and diabetes, can also be exacerbated by stress and anxiety Because the ED may be the only point of contact for children with undiagnosed psychiatric illness, the American Academy of Pediatrics (AAP) has acknowledged the role of the ED as a safety net for children and adolescents with unmet mental health needs Several challenges are important to consider when screening for behavioral disorders or psychiatric illness in acute care settings Lack of an ongoing therapeutic relationship and fear of stigma may prevent an adolescent from reporting depression, substance use, or suicidal thoughts and behaviors The high stimulus setting of the ED may also discourage the disclosure of sensitive mental health matters Screening instruments need to be valid when administered by clinicians who not have specific training in psychology or psychiatry Oftentimes the behavioral health system, particularly for low-income patients, leaves physicians with limited referral options Ethical and legal concerns are also of consideration, including the need for standardized, confidential documentation for positive screens, misperceptions about mandated reporting requirements, and legal limitations of communication options with parents and other family members It is very helpful if ED and hospital leadership understand the legislative and local policies around these issues and make their faculty and staff aware of the standard of care in this regard While there are culturally sensitive and developmentally appropriate screening tools that promote the accurate detection of suicide, depression, and other psychiatric illnesses as well as substance use (e.g., the CRAFFT tool, https://crafft.org ), the need for efficiency in the acute care setting creates an extra challenge In the current medical and economic climate, busy clinicians prefer clinical innovations to be “pushbutton” in nature, creating added value while minimizing time and effort Computer technology and omnipresent mobile devices offer some solutions to these barriers, and also offer the potential for skip-logic and “computerized adaptive testing” that can maximize accuracy by adding follow-up questions only when initial, more sensitive questions are answered positively Of all screening domains, suicidality is a paramount concern for ED clinicians The key question is often distinguishing between self-harm and intent to die It should be noted, however, that previous acts of self-harm that may not have required medical attention might also be a potent indicator of suicide risk An adolescent who divulges that he/she had specific plans for suicide or a suicide attempt and a desire to kill him/herself within the past week should be deemed imminent risk and should be considered for psychiatric hospitalization or rapid, intense outpatient therapy In addition, although simply stating a belief that “life is not worth living” without having a suicide plan rarely leads to psychiatric hospitalization, these adolescents may still benefit from outpatient mental health services to prevent escalation of symptoms and subsequent suicide attempts Recent innovations have produced efficient screening instruments and processes that can be used in the acute care setting The Ask Suicide Screening Questions (ASQ) and Risk of Suicide Questionnaire (RSQ) are brief screening tools for assessing suicidal ideation in the ED The Behavioral Health Screen for Emergency Departments (BHS-ED) has successfully applied computerized technology to have adolescents self-administer suicide and depression questions, among other behavioral health domains assessed Any one positive answer to these questions should prompt consultation by social worker or psychiatrist, or referral to a crisis intervention team Similar developments have occurred in the real-time assessment of other mental health domains such as traumatic stress in pediatric ED patients Brief screening tools for acutely injured children and their families can assess previous adverse experiences as well as immediate response to an acute illness and the ED visit itself There are also resources that provide education on what to expect, how to parent a traumatized child, how to know when additional help is needed, and where to find it Information such as this can be found at sites for the National Traumatic Stress Network (https://www.nctsn.org ) and the Center for Pediatric Traumatic Stress at the Children’s Hospital of Philadelphia (http://www.healthcaretoolbox.org ) Ultimately, the ED physician bears the burden of responsibility to consult with necessary mental health and crisis professionals and make the appropriate discharge decisions Notably, the family’s experience in the ED may impact the outpatient referral process The establishment of realistic expectations about treatment follow-up and a commitment from the ... images revealing an action and then a reward if the action is completed (e.g., if you take the medicine, then you will get a sticker) Visual schedules organize simple words or pictures to seriate... expectations, and at times anxiolysis to minimize distress SCREENING FOR MENTAL HEALTH PROBLEMS IN THE EMERGENCY DEPARTMENT Many children with psychiatric illness not present to the ED with overt psychiatric... only point of contact for children with undiagnosed psychiatric illness, the American Academy of Pediatrics (AAP) has acknowledged the role of the ED as a safety net for children and adolescents