Rain Man: Autism

Rain Man: Autism

Case Presentation

Raymond Babbit: Mid-Forty year old white male. Diagnosed with Autistic Disorder, and has some savant abilities; specifically recall and mathematical calculations. Currently resides in a long-term mental health institution and has no important social interactions.

Axis

Axis I: Autistic Disorder

Axis II: Deferred

Axis III: Deferred

Axis IV: Unemployed, living in a mental institution, limited social support, inadequate social interaction

Axis V: GAF = 35 (Current)

Signs and Symptoms

• Repetitive patterns of behavior
• Inflexible adherance to routine
• Lack of social or emotional reciprocity
• Impairment in the use of non-verbal cues
• Inability to sustain conversations
• "Any break from routine and he gets terrified" -Dr. Bruener
• "When he gets nervous he does 'Whose on first?' from Abbott and Costello" - Vern
• "Hey, what meds are you on?"

Relevant History

Admitted to Wallbrook as a child, following an accident where Raymond severely scalded his brother, Charlie, in a bathtub when the two were not supervised.

Mother died early in child-hood

Father recently passed away

Impaired Social Interaction

Ineffective Coping

Risk of Self-Mutilation

At risk for deliberate self-injurious behavior resulting in tissue damage with the intent of causing nonfatal injury r/t neurological alterations and obvious indifference to environment as evidenced by inability to navigate environment safely and episodes of emotional outbursts

Impaired Social Interaction r/t neurological alteration aeb aversion to affection, lack of eye contact, and lack of facial responsiveness

Ineffective Coping r/t inadequate coping strategies and disorganized or chaotic environments as evidenced by inadequate problem solving and oppositional and defiant responses to adult requests or rules.

Short term goal

Long term goal

Short term goal

Long term goal

Client will refrain from further self-injury for the remainder of the year.

Client will utilize socially acceptable coping skills that are not physically harmful by time of discharge

Client will demonstrate ability and willingness to follow rules of the treatment center or care provider within 2 weeks

Client will demonstrate alternative behavior (such as initiating interaction between self and care giver) in response to anxiety within 1 week.

Client will demonstrate trust in nurse within 2 weeks

Client will initiate interactions with nurse and peers within 3 months

Intervention

Intervention #1

Intervention #1

Intervene to protect the patient when self-mutliating behviors, such as head banging and other hysterical behaviors, become evident

Assess family dynamics (especially with brother) and the need for family therapy and community supports.

Explore with client alternative ways of handling frustration that would be most suited to his or her lifestyle. Provide support and positive feedback to client as new coping strategies are tried.

Do not debate, argue, rationalize, or bargain with the client.

Rationale

Provide client with familiar objects such as favorite juice, favorite snack, TV, and position bed by the window.

Rationale: These items will offer security during times when patient feels distressed

The nurse is responsible for the client's safety

Identify with the client areas of social skill deficit and develop a plan for improving these areas. Include teaching the client relaxation techniques to reduce anxiety in social situations.

Rationale: Promotes clients sense of control and begins the development of alternative, more adaptive coping behaviors by increasing role competence.

Treatment generally focuses on increasing support for the client, improving family communication, and enhancing the client's sense of control over the environment.

Rationale: Ignoring these attempts may work to decrease manipulative behaviors.

Rationale: Positive feedback encourages use of the acceptable behaviors

Intervention

Intervention #2

Intervention #2

Intervention #2

Intervention #2

Explain all relevant symptoms, procedures, treatments, and expected outcomes for self-mutilation that is autism related.

Try to determine if self-mutlilative behaviors occur in response to increasing anxiety and, if so, to what the anxiety may be attributed by the end of the week.

Identify for the client the consequences of maladaptive behavior. All staff must follow through and be consistent.

Encourage use of social support resources.

Rationale

Function in a one-to-one relationship with client and spend time with him. This may mean just sitting in silence for a while.

Rationale: consistency of interaction enhances the establishment of trust

Clients prefer to participate in their treatment planning to gain a sense of control.

Mutilative behaviors may be averted if the cause can be determined

Rationale: Positive and consistent interactions with staff help promote stability of the environment for the client.

Provide opportunities for socialization and encourage participation. Develop a schedule for gradually increasing time of the client in group activities.

Rationale: Social interaction can provide positive reinforcement and opportunities for the client to practice new behaviors in a supportive environment.

Rationale: Better adjustment in children of a parent with multiple sclerosis was related to higher levels of social support and approach coping strategies

Intervention

Work on one-to-one basis with the client

Intervention #3

Provide the client and family with phone numbers of appropriate community agencies for therapy and counseling.

Intervention #3

Rationale

When Raymond exhibits symptoms of anxious behavior (i.e, head-banging, scripting, perserveration, etc.) the nurse will redirect to an established coping strategy.

Assist the client to set realistic goals and identify personal skills and knowledge.

This will establish trust with the client

Continuous follow-up care should be implemented; therefore, the method to access this care must be given to the client and his brother

Support client with your presence as he endeavors to relate to others in the environment.

Rationale: The presence of an individual with whom a trusting relationship has been established provides a feel of security

Develop a therapeutic nurse-client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard.

Rationale: These characteristics enhance establishment and maintenance of a trusting relationship and enhance the client’s feelings of self-worth

Rationale: Researchers found that participants who were four months after myocardial infarction experiencing fatigue described fumbling coping strategies. The researchers concluded that nursing interventions to assist clients to identify and reduce stressors and increase client's ability to cope with stressors would be useful.

Rationale: Prompting Raymond to alternative activities when he is anxious will help establish causal relationship between the action and the decrease of his anxiety

Ethical Consideration

Should Raymond be forced into an institution or be allowed to live in the 'outside world' where he can freely interact with society?

Nursing Implications Regarding Ethical Issue

The decision to return Raymond to the mental institution demonstrated the principle of non-maleficence.

- The doctors wanted to make sure he was not a threat to himself or anyone else around him.

Alternative Decision

Allowing Raymond to stay with Charlie under the supervision of various doctors and psychologists.

• Doctor's could monitor Ray to make sure he was not engaging in self destructive activities.
• Charlie could help introduce and familiarize Ray with society and they could continue to form a brotherly bond.
• Would fulfill principles of beneficence and non-maleficence.