Notes for the school nurse: Common challenges related to autism

Like every other kid, students with autism and other developmental disabilities are likely to visit the nurse’s office with bumps and bruises, headaches and colds and other common ailments. Due to the likelihood that they experience additional health issues, autistic students are more likely to be regular visitors.

Some of the more common co-occuring conditions with autism that may lead to frequent trips to the nurse are:

• Gastrointestinal (GI) problems
• Epilepsy
• Feeding issues
• Attention-deficit/hyperactivity disorder (ADHD)
• Anxiety and depression
• Obsessive compulsive disorder (OCD)

If an autistic student requires daily intensive care, suffers from trauma related to their medical needs or medical providers, has expected behavior, frequently or occasionally, that requires medical attention, or has any issue requiring health management, including an inability or aversion to identifying pain, an Individualized Health Plan may be a good idea. Check out our guide to establishing one here.

Regardless of an autistic student’s level of needs though, the nurse’s office should be a safe and supportive place for an autistic student. Effective interaction will require understanding the individual. To achieve this, parents/caregivers and the school nurse should have a conversation at the beginning of every school year to discuss the student, review needs and establish lines of communication. Additionally, it can be helpful for the school nurse and an autistic student to get to know each other before a medical need, illness or emergency occurs. Scheduling a tour of the nurse’s office or planning some interactions between the nurse and the student early in the school year, can help the student become comfortable with the nurse and in turn lead to better outcomes when medical needs arise.

But annually reviewing the most common challenges related to autism will also help school nurses implement support strategies that make visits to their office less stressful and most productive for everyone. Following are some considerations:

Social Communication

Some students with autism may have little to no speech, others may talk for a long period of time about certain topics, while still others will tell you what you want to hear. They may not use or read nonverbal cues like body language or eye contact. It’s also important to understand that a student’s language or behavior may not reflect their desire to engage or their ability to adequately explain why they need the nurse.

Beyond consulting with the parents to get a full understanding of how to best communicate with the student, nurses should ask each student’s teachers (general education, special education and/or paraprofessional) about specific strategies to help with communication. If the student uses alternative or augmentative communication (AAC), such as the Picture Exchange Communication System (PECS) or a communication device, they may need the support of another person familiar with the system to be able to respond. Even those who are highly verbal in some situations may have a hard time describing body sensations or using language at all when stress and emotions are running high.

Strategies to Support Communication

• Visual tools, like a visual pain scale for pain severity, a body chart to point to the location of pain, or an emergency communication board, can be helpful. You can find these available for free online.
• Consider using closed-ended (yes-or-no) questions or offering choices if the student is struggling to answer. If offering choices, end with the option of “something else.” This will require further questions but will also help bring clarity.
• It is especially important to keep your tone and volume calm and consistent.
• Allow additional wait time in conversations, especially when asking questions.
• Avoid abstract language and sarcasm.
• If engaging with other adults in the student’s life – their parents/caregiver, teachers or school administration in front of the student, include the student. Refrain from talking about them as if they aren’t there or aren’t able to understand.

Sensory

Sensory issues are common in autistic people and are included in the diagnostic criteria. These include the commonly-known five senses – sights, sounds, smells, tastes, touch – as well as balance (vestibular), awareness of body position and movement (proprioception), and awareness of internal body cues and sensations (interoception). Autistic people can experience both hypersensitivity (over-responsiveness) and hyposensitivity (under-responsiveness) to a wide range of stimuli. Most have a combination of both.

For students with sensory issues, everyday school experiences like a door buzzer, fire alarm or school bell might represent a sensory assault. Responses to sensory overload vary widely, from attempting to escape the situation by running or hiding to shutting down and not speaking to having a meltdown or showing aggressive behaviors. Students may show intense anxiety or fear if asked to take an over-the-counter medicine that tastes or smells different than the brand they have at home, or they may not tolerate adhesive bandages.

For many people with sensory issues, interoception — awareness of internal body cues and sensations — makes it challenging to recognize illness or injury. They may be hypersensitive to some sensations and hyposensitive to others. This can result in what seems like an overreaction to a minor incident, or, at the other extreme, a student who shows no sign of pain after breaking a bone.

Strategies to Support Sensory Regulation:

• The mere existence of the nurse’s office may trigger sensory overload. Consider treating the autistic student away from other people, dimming the lighting, having a white noise machine, and allowing sensory fidgets to help the nurse’s office feel safer. Ask parents/caregivers and teachers what works to combat stress.
• Accept tips and strategies from parents on helping students take medication or receive treatment.
• Allow students who have strong sensory preferences to keep their own supplies, like a specific brand of adhesive bandages or fresh clothes in case of soiling, available in the nurse’s office. 

Behavior and Safety

Autism can affect behavior in many different ways. Many individuals engage in repetitive speech or movements. They may have intense, specific interests in topics or attachment to certain objects. A strong preference for routine and difficulty with flexibility and change is common.

Some students may have behaviors related to their disability that put themselves or others at risk, including self-injurious or aggressive behavior, running away, eating non-food items, and a lack of awareness of danger. These are sometimes referred to as challenging behaviors. While these issues can be difficult for the adults who intervene or witness them, it is important to keep in mind that they often happen because a student is communicating in the only way they know how – through their behavior.

Strategies to Support Behavior and Safety Concerns

• Remember that behavior is communication. If a child has a significant new behavior concern or increase in a behavior, consider whether it could be related to pain, injury, illness, etc.
• Working with a student’s intense interests or preference for routine may be the most effective way to reduce their stress level during interactions in the nurse’s office. Knowing what to expect can go a long way. For students who see the nurse regularly, a sticker or reward chart, a daily knock-knock joke or riddle, or simply being asked about their interests may reduce anxiety.
• A familiar classroom aide, one-on-one paraprofessional, another familiar caregiver or even a peer or sibling may be able to ease anxiety when a student needs medical care.