Abstract
Introduction: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by cognitive, communicative, and social impairments, and is classified into three levels of support. Child hospitalization, in turn, impacts the child and their family in biopsycho-social aspects, related to issues of physical health, stress, adaptation to the disease, and social interactions. In the case of autistic children, the complexity of the disorder requires hospital care adaptations.
Objective: To describe the nursing care provided to children with ASD during hospitalization.
Materials and Methods: This is an integrative literature review performed in July 2024, covering articles published between 2014 and 2024. The search for articles was conducted in the PubMed, ScienceDirect, Periódicos Capes, Lilacs, and BDEnf databases, using descriptors registered in MeSH/DeCS. The inclusion criteria consisted of primary studies, while the exclusion criteria consisted of academic papers, books, and book chapters.
Results: The search and selection process for the studies in this review was organized via the Prisma flowchart, yielding 317 identified studies, of which 11 were selected. Most studies were qualitative and published in the United States. The results show the importance of individualizing care according to the specific needs of each child. In addition, visual and sensory communication strategies have been shown to be effective in reducing stress and promoting a welcoming environment. In this sense, specialized training for healthcare professionals and a multidisciplinary approach were found to be essential for improving care.
Conclusions: The analysis of the studies reviewed highlights the importance of a personalized and patient-centered approach, as well as the need for continuous training for nursing professionals. Thus, this study contributes significantly to the growth of knowledge regarding nursing care, identifying challenges and needs, as well as proposing evidence-based interventions to improve care quality.
Keywords (Source: DeCS): Autism spectrum disorder, child, hospitalized child, Nursing, nursing care.
Resumen
Introducción: El trastorno del espectro autista es un trastorno del neurodesarrollo caracterizado por alteraciones cognitivas, comunicativas y sociales, y se clasifica en tres niveles de apoyo. La hospitalización infantil impacta al niño y a su familia en aspectos biopsicosociales, incluyendo la salud física, el estrés, la adaptación a la enfermedad y las interacciones sociales. En el caso de los niños autistas, la complejidad del trastorno requiere adaptaciones en la atención hospitalaria.
Objetivo: Describir la atención de enfermería brindada a niños con trastorno del espectro autista durante la hospitalización.
Materiales y métodos: Se trata de una revisión integrativa de la literatura, realizada en julio de 2024, que abarcó artículos publicados entre 2014 y 2024. La búsqueda se llevó a cabo en las bases de datos PubMed, ScienceDirect, Periódicos Capes, Lilacs y BDEnf, utilizando descriptores registrados en los vocabularios controlados MeSH y DeCS. Como criterio de inclusión, se consideraron estudios primarios, mientras que los criterios de exclusión incluyeron trabajos académicos, libros y capítulos de libros.
Resultados: El proceso de búsqueda y selección de estudios se organizó mediante el diagrama de flujo Prisma, resultando en la identificación de 317 estudios, de los cuales se seleccionaron 11. La mayoría de los estudios eran cualitativos y publicados en Estados Unidos. Los hallazgos evidencian la importancia de individualizar la atención según las necesidades específicas de cada niño. Además, las estrategias de comunicación visual y sensorial demostraron ser eficaces para reducir el estrés y proporcionar un ambiente más acogedor. La capacitación especializada de los profesionales de la salud y el enfoque multidisciplinario fueron identificados como fundamentales para mejorar la atención.
Conclusiones: Los estudios revisados destacan la relevancia de una atención personalizada y centrada en el paciente, así como la necesidad de una formación continua para los profesionales de enfermería. De este modo, este estudio contribuye al avance del conocimiento sobre la atención de enfermería, identificando desafíos y necesidades, además de proponer intervenciones basadas en la evidencia para mejorar la calidad de la atención.
Palabras clave (Fuente DeCs): Trastorno del espectro autista, niño, niño hospitalizado, Enfermería, cuidados de enfermería.
Resumo
Introdução: O transtorno do espectro autista é um transtorno do neurodesenvolvimento caracterizado por comprometimentos cognitivos, comunicativos e sociais, e se classifica em três níveis de suporte. A hospitalização infantil, por sua vez, impacta a criança e sua família em aspectos biopsicossociais, relacionados às questões de saúde física, estresse, adaptação à doença e interações sociais. No caso de crianças autistas, a complexidade do transtorno exige adaptações no cuidado hospitalar.
Objetivo: Descrever o cuidado de enfermagem prestado à criança com transtorno do espectro autista durante a hospitalização.
Materiais e métodos: Trata-se de uma revisão integrativa da literatura, realizada em julho de 2024, que abrangeu artigos publicados entre 2014 e 2024. A busca dos artigos foi conduzida nas bases de dados PubMed, ScienceDirect, Periódicos Capes, Lilacs e BDEnf, com a utilização de descritores cadastrados nos vocabulários controlados MeSH e DeCS. Como critério de inclusão, foram considerados estudos primários, enquanto os critérios de exclusão abrangeram trabalhos acadêmicos, livros e capítulos de livros.
Resultados: O processo de busca e seleção dos estudos desta revisão foi organizado por meio do fluxograma Prisma, resultando em 317 estudos identificados, dos quais 11 foram selecionados. A maioria dos estudos era qualitativa e publicada nos Estados Unidos. Os resultados indicam a importância de individualizar os cuidados conforme as necessidades específicas de cada criança. Além disso, estratégias de comunicação visual e sensorial mostraram-se eficazes para reduzir o estresse e promover um ambiente acolhedor. Nesse sentido, a formação especializada dos profissionais de saúde e a abordagem multidisciplinar foram identificadas como fundamentais para aprimorar a assistência.
Conclusões: A análise dos estudos revisados destaca a importância de uma abordagem personalizada e centrada no paciente, além da necessidade de treinamento contínuo para os profissionais de enfermagem. Assim, este estudo contribui significativamente para o avanço do conhecimento sobre os cuidados de enfermagem, identificando desafios e necessidades, bem como propondo intervenções baseadas em evidências a fim de aprimorar a qualidade da assistência.
Palavras-chave (Fonte DeCs): Transtorno do espectro autista, criança, criança hospitalizada, enfermagem, cuidados de enfermagem.
Carátula del artículo
Nursing Care for Children with Autism Spectrum Disorder in Hospital Settings: An Integrative Literature Review
Cuidados de enfermería a niños con trastorno del espectro autista en entornos hospitalarios: una revisión bibliográfica integradora
Cuidado de enfermagem à criança com transtorno do espectro autista em ambientes hospitalares: uma revisão integrativa da literatura
Iasmin Danielle Bernardo de Oliveira iasmin.oliveira@eenf.ufal.br
Universidade Federal de Alagoas, Brazil
Ivanise Gomes de Souza Bittencourt ivanise.gomes@eenf.ufal.br
Universidade Federal de Alagoas, Brazil
Rayssa Francielly dos Santos Alves rayssa.alves@eenf.ufal.br
Universidade Federal de Alagoas, Brazil
Thaynara Maria Pontes Bulhões thaynara.bulhoes@esenfar.ufal.br
Universidade Federal de Alagoas, Brazil
Ingrid Martins Leite Lúcio ingridmll@eenf.ufal.br
Universidade Federal de Alagoas, Brazil
Aquichan, vol. 25, núm. 1, e2518, 2025
Universidad de La Sabana
Recepção: 19 Setembro 2024
Aprovação: 20 Fevereiro 2025
Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by cognitive, communicative, and social impairments, which lead to difficulty in social reciprocity, decreased non-verbal communication, and difficulties in developing and maintaining relationships. The neurodevelopmental alterations that characterize ASD are noticeable from the earliest stages of childhood development and persist throughout the individual's life. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ASD is divided into three levels of support, depending on the severity and impairment of factors related to communication, social interaction, and restricted and repetitive behavior patterns. Given the diversity of symptoms and levels of support among people with ASD, individualized interventions are necessary 1-4.
Estimates of the prevalence of autism have been rising considerably. According to the World Health Organization (WHO), there are approximately 70 million people diagnosed with autism worldwide 5. In the United States, the Centers for Disease Control and Prevention (CDC) released a report in March 2023, stating that 1 in 36 children up to the age of 8 has autism, which represents 2.8 % of the US population 6,7. A previous CDC study, released in 2021, showed that the prevalence was 1 in 44 children. In line with the data from the CDC, the incidence of ASD is four times more frequent in male individuals 8,9.
In Brazil, it is estimated that 6 million people are autistic and, according to the 2023 School Survey, released on February 22, 2024, there are 636,000 students with autism nationwide 10. The growing number of ASD cases is believed to be the result of more effective diagnostic criteria, increased awareness of the subject among parents and society, more qualified training for healthcare professionals, greater financial resources for scientific publications, and the development of specialized ASD services 8,11.
Regarding the causes of the disorder, studies suggest that ASD has a complex and multifactorial etiology, involving genetic, environmental, and behavioral factors 12. As far as diagnosis is concerned, the criteria outlined in the DSM-5 and the International Classification of Diseases are used 13,14; diagnostic assessment requires an observational clinical evaluation and detailed anamnesis by a multidisciplinary team. For this purpose, specific scales are used, such as the Modified Checklist for Autism in Toddlers, which allows screening for signs of ASD in children ideally aged from 18 to 24 months 15-17.
Child hospitalization is a critical process that affects the child-family binomial, impacting physical, emotional, and social aspects. During hospitalization, the child is inserted into a new environment and subjected to various invasive procedures that can cause pain, fear, decreased cognitive capacity, and mood swings. In this context, providing care to hospitalized children requires not only conducting the necessary procedures but also developing ludic strategies and adapting communication so that the child understands the situation and cooperates with healthcare professionals 18.
In terms of the hospitalization of autistic children, the complexity of the disorder requires the nursing team to adapt the care plan to facilitate and ensure a safe, comfortable, and effective hospitalization process 19. In this sense, it is essential that nurses perform individualized interventions focused on the particularities of autistic children, including behavioral, communicative, and sensory adaptations 16.
Law 12.764, of December 27, 2012, established the National Policy for the Protection of the Rights of People with Autism Spectrum Disorder, which establishes that people with ASD are classified as people with disabilities for all legal purposes 20 and must be included in specific legislation for people with disabilities, such as the Statute of People with Disabilities, under Law 13.146, of July 6, 2015 21.
In addition, Law 12.764 of December 27, 2012, ensures the right to specialized follow-up and comprehensive healthcare, with a focus on providing early diagnosis, multi-professional treatment, and priority access to the services within the Unified Health System 20. Thus, nursing care should be based on the individuality of patients with ASD, promoting an adapted and humanized hospital environment.
Therefore, this study aimed to answer the following guiding question: Within the scope of the research produced, what are the dimensions of nursing care for hospitalized children with ASD? In light of the above, the study aimed to describe nursing care for hospitalized children with ASD.
The relevance of this research stems from the need to produce subsidies for the dissemination of information on ASD and the potential to instruct healthcare professionals on effective nursing interventions in the hospitalization of autistic children to ensure humanized, quality, and resolutive care, allowing the child to participate in the entire process.
In general, hospitalization can cause discomfort for children, resulting in physical and emotional suffering, as well as changes to their routine. These challenges can be heightened in children with ASD, due to the characteristics of the disorder. In view of this, studies that address the role of nursing professionals in the hospitalization of children with ASD are essential to understanding the dynamics of the care provided to children and their families, as well as to develop effective interventions and care plans.
Materials and Methods
An integrative literature review was conducted to ensure a detailed and systematic process in the delimitation of knowledge 22. Therefore, the search was conducted based on six stages, defined by the aforementioned authors, as follows: definition of the review question; search and selection of primary studies; data extraction from the primary studies; critical evaluation of the primary studies; synthesis of the review result, and presentation of the review.
In the first stage, the research question was drafted-What are the dimensions of nursing care for hospitalized children with ASD?- using the PICo strategy, where 'P' stands for population, 'I' for interest of study, and 'Co' for context. Figure 1 shows how the strategy was organized.
Figure 1
Definition of the PICo Strategy
Source: prepared by the authors.
In the second stage, articles were selected from the databases PubMed, Science Direct, Journals of the Coordination for the Improvement of Higher Education Personnel (Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior [Capes]), Latin American and Caribbean Health Sciences Literature (Lilacs), and Nursing Databases (BDEnf) via the Virtual Health Library (VHL). For the search, the descriptors registered in the controlled vocabulary of the Medical Subject Headings (MeSH) and the Descriptors in Health Sciences (DeCS) were used. The terms were used in Portuguese, English, and Spanish, and then adapted to the language of each database.
Based on the selection of descriptors, specific search strategies were devised for each database, which are presented in Table 1. This data collection was conducted during July 2024.
Table 1
Search Strategies
Source: Prepared by the authors.
During this stage, the search strategy was reviewed by specialists in this field to ensure the coverage and adequacy of the terms used. We relied on the collaboration of researchers with experience in the reviewed subject, including the nurse researchers present in the study, who have expertise in providing care for children with ASD, to evaluate whether the descriptors, synonyms, and Boolean operators selected allowed the retrieval of the most relevant studies.
The adjustments performed on the basis of these contributions minimized the risk of inadvertent exclusion of relevant studies and strengthened the methodological validity of the review.
To improve data collection, in the third stage, the data from primary studies were extracted using the inclusion and exclusion criteria. The inclusion criteria consisted of primary studies published between 2014 and 2024, and the exclusion criteria of theses, dissertations, term papers, books, and book chapters.
In the fourth stage, after applying the inclusion and exclusion criteria, 317 studies were found, of which one was excluded due to being a duplicate, yielding a total of 316 studies eligible for screening. After reading the titles and abstracts, 283 articles were excluded for not meeting the study criteria, resulting in 33 studies for full reading. Of these, two were excluded due to the unavailability of the full text, and 31 articles were assessed in full. Finally, a total of 11 studies were included in the review. The Prisma diagram was used to accurately represent all the stages of the selection process.
The studies were classified in terms of methodological quality via the Critical Appraisal Skills Programme (Casp) tool, a specific scale for qualitative studies. This tool contains 10 items related to study design and results and is divided into three sections: A, B, and C 23. In addition, the scientific evidence was classified according to the levels and degrees of recommendation proposed by Bork 24.
In the fifth stage, the results of the reviews were synthesized and then, in the sixth stage, the data from the integrative review was drafted and presented.
Results
The search and selection process for the studies included in this review is presented in the figure below, according to the Prisma flowchart 25.
Figure 2
Prisma Flowchart
Source: Adapted from Page et al. (2021).
Regarding the countries of origin of the studies, seven were conducted in the United States 26-32, two in Brazil 33,34, one in Canada 35, and one in Italy 36.
To optimize the results of this review, the data identified after collection was characterized in Table 2, according to publication title, authors, and year, as well as objectives, study method, and main results.
Figure 3
Choropleth Map
Source: Prepared by the authors.
Table 2
Characterization of the Selected Studies
Source: Prepared by the authors.
Thus, the studies analyzed highlight nursing care for hospitalized children with ASD requires an individualized and multidisciplinary approach. The main findings of the review were grouped into three main categories: Care strategies, barriers to care, and professional training needs.
Therefore, they emphasize the need for nursing care based on individualization, adapted communication, and continuous training for healthcare professionals. Strategies such as adapting the environment, using visual communication methods, and partnering with the family have proved effective in improving the hospital experience for children with ASD. However, challenges such as staff overload and lack of specialized training still pose challenges to the implementation of these practices.
After analyzing the methods of each study, the quality of the evidence was analyzed via Casp (Table 3).
Table 3
Evaluation of studies via the Casp tool
Source: Prepared by the authors.
Based on the evaluation of the 10 Casp items, it can be inferred that eight studies, out of the 11 included in this review, have good methodological quality, while three others have moderate methodological quality. The analysis of the results shows that most of the studies were assessed adequately in terms of the clarity of the study objectives and the suitability of the qualitative methodology. However, there were some variations in the quality of the studies in terms of study design, recruitment, data collection, the relationship between the researcher and the participants, ethical considerations, data analysis, and conclusions.
Then, the studies were classified according to the levels and degrees of recommendation 24, with the following levels of evidence: i) Systematic review; ii) Randomized clinical trial; iii) Cohort; iv) Case-control; v) Case series; vi) Specialist opinions; vii) Pre-clinical studies (animals/in vitro). In terms of the degree of recommendation, it is classified as: i) The result recommends the intervention; b) The result is inconclusive -not enough to confirm the hypothesis; c) The result contraindicates the intervention (Table 4).
Table 4
Levels of Evidence and Degrees of Recommendation According to Bork 24
Source: Prepared by the authors.
Discussion
Children with ASD face challenges during hospitalization, including hypersensitivities, sensory difficulties, problems with communication and loud noises, invasive procedures, and multiple interviews. Hospitals can be significant sources of stress due to the uncertainty of the new environment and the difficulty of adapting to changes 29,30. Furthermore, it is suggested that this reaction is attributed to altered sensory perception, which results in hyper-reactivity to sensory and environmental stimuli 26. Therefore, most children with autism tend to adapt better to environments that are routine, comfortable, and predictable, which highlights the need for adjustments to the environment and sensory perceptions 37.
Furthermore, hypersensitivity to auditory, visual, or sensory stimuli can hinder their acceptance of equipment and procedures, such as cardiac monitors, venipunctures, and blood pressure monitors 31. There are also challenges such as interruptions in care during screening and phlebotomy 27. Deficiencies in these aspects can compromise patient safety, resulting in diagnostic errors due to a lack of accurate vital signs or difficulty in obtaining timely blood testr.
The results of the studies included in this review highlight communication barriers as a significant obstacle in the hospitalization of children with ASD. Similarly, communication difficulties can compromise the expression of pain and other physical symptoms, impairing the provision of care 31,35. It is therefore essential that the nursing team uses tools to improve communication, such as the Visual Pain Scale.
There is also the importance of dietary care interventions, due to the common food selectivity among these children, who often have hypersensitivities or rituals related to the taste, smell, appearance, and temperature of food 33. This underlines the need for a multi-disciplinary approach to ensure adequate nutrition and hydroelectrolytic balance.
Families of children with ASD also face significant challenges during hospitalization. Parental dissatisfaction with how healthcare professionals communicate with their children and the implementation of effective communication strategies has been noted 28. In addition, it has been found that the challenges faced by parents of children with ASD include the significant burden of car : managing the behaviors associated with autism, high financial burdens, and physical and mental problems such as muscle tension, gastrointestinal symptoms, anger, and depression 29.
The hospitalization of children with ASD often results in the severance of family bonds, since the main caregiver usually remains in the hospital for prolonged periods 33. This situation can generate a significant emotional burden and stress, affecting both the family dynamic and the support the child receives. The lack of constant contact with other family members can aggravate the suffering of the child and the parents, damaging the well-being of all involved.
In terms of the challenges faced by nursing professionals, studies have emphasized the nursing team's insufficient knowledge regarding ASD and limited communication strategies 27,28,34. Similarly, in terms of the professionals' knowledge of the subject, difficulties have been identifiedoregarding the etiology, signs, and symptoms, as well as therapeutic interventions for children with ASD, since the subject is not covered comprehensively during academic training 34. This can lead to feelings of helplessness and compromised care for children and their families who require specialized care. It also reflects the urgent need to improve training and support for these professionals.
Additionally, the scaling of nursing personnel has been highlighted as a significant problem 34. Several hospital nursing teams operate with a reduced number of professionals, which negatively affects the implementation of personalized interventions and the quality of care, due to time constraints and work overload.
In addition, self-efficacy among nurses is affected by feelings of inadequacy and emotional challenges, such as sadness, inadequacy, and embarrassment, which highlights the importance of an educational approach that includes not only technical knowledg, but also emotional support 36. A holistic approach to be implemented includes forming a network of healthcare professionals who collaborate and share their knowledge and functions, with the aim of promoting children's well-being and ensuring comprehensive care.
Qualitative studies have highlighted the importance of a collaborative approach between healthcare professionals and families when providing care for children with ASD 29,35. Furthermore, they emphasize that including the family as active members in the planning and execution of care is essential for personalizing care and addressing specific challenges, such as communication and managing agitation 29.
Likewise, nursing professionals should consider parents' preferences before performing any invasive procedure on their child and determine the best approach to communicate to the child, such as using images, as well as understanding the specific needs of each patient 29. The study also highlights the importance of using the hospitalization period to promote health education for family members, since hospitalization has an impact on family dynamics as a whole. In this context, it is crucial to guide family members and caregivers on techniques to reduce stress and anxiety, manage emotions, maintain health and self-care, inform them of chaplaincy services in the hospital unit, if available, and emphasize the importance of sleep for physiological health 38,39.
Effective partnerships with parents, especially in communicating special needs and interpreting signs in non-verbal children, are crucial to providing positive care experiences 35. Parents performed an essential role in helping with diagnostic hypotheses, identifying the child's specific needs and sensitivities, and providing relevant information, especially in the case of non-verbal children. This collaboration is vital for promoting positive experiences in both child and family healthcare, given that the study showed that positive experiences are associated with reduced stress and anxiety in caregivers.
Similarly, studies point to the need for specialized training to facilitate interaction between nursing professionals and family members of children with ASD 28,30. The approaches adopted should include effective communication techniques, family stress management strategies, and methods designed to create a welcoming environment; thus, studies have consistently shown that collaborating with families, understanding the child's needs through caregivers, and recognizing parents as experts in their child's needs are key aspects of establishing an effective patient-professional relationship when providing care for children with ASD 28,40.
From this perspective, the implementation of specific care plans has been shown to be effective in improving the hospital experience of children with ASD and their families 31. As a study result, parents whose children had specific care plans were more likely to report that professionals explained information more clearly, listened to their concerns thoroughly, and helped the child cope with the fear and stress related to hospitalization. In terms of care, professionals asked if there was any part of the physical examination that the child did not tolerate well, how the child expressed their needs and desires, if there was any intolerable sensory stimulation, and if there were any behaviors that required additional support from the team.
The results of the studies included in this review highlighted the importance of the strategies adapted to improve the care of children with ASD in hospital environments. Thus, the need for soft technologies was noted, such as effective communication, adaptation of sensory environments, and continuous education for healthcare professionals, pointing to practices such as the use of hospital passports and sensory kits to improve patients' experience and stress management 26.
A hospital passport is a document that summarizes essential information regarding optimal communication, pain management, sensory needs, specific interests, and possible triggers for the patient. The main aim of this resource is to ensure that healthcare professionals are aware of the patient's individual needs and to facilitate the provision of care during hospitalization. Sensory kits, on the other hand, are described in the study as tools that help in performing procedures with children with ASD, reducing resistance to cooperation and minimizing feelings of anxiety and stress 26.
These kits often include items such as noise canceling headphones, stimulation toys, anti-stress balls, and tablets. In addition, it is recommended to adjust the hospital environment, such as using private rooms and reducing the intensity of lights and noises to reduce excessive stimuli that could complicate the hospitalization process 26.
Continuous staff training and the use of behavioral reinforcement techniques to improve the quality of care and reduce challenging behaviors were highlighted 27. Similarly, the effectiveness of positive reinforcement has been mentioned as a key strategy for managing problematic behavior, thereby promoting a more positive hospital experience for children with ASD 36.
The technique of behavioral reinforcement, often referred to as "positive reinforcement", is a strategy widely used in applied behavior analysis therapy 41. This method consists of offering the child meaningful rewards, such as praise, toys, books, or access to favorite activities, such as playgrounds, after they have exhibited desired behaviors. This approach has been shown to be effective in promoting adaptive behaviors and reducing challenging behaviors, making a significant contribution to managing the hospitalization period of children with ASD 42.
Furthermore, the benefits of individualized psychosocial care plans include signaling and limiting the professionals involved in care, as well as the possibility of using comfort items preferred by the child throughout the hospitalization process 31. The interventions proposed in the study not only improved comfort and time management, but also reduced the need for sedation, as evidenced by the reduction in sedation required for laboratory tests. These findings highlighted the importance of a personalized and integrated approach, which considers both the psychosocial well-being and the specific sensory needs of children with ASD.
Furthermore, it has been noted that it is important to use soft technologies in the healthcare of children with ASD during hospitalization 34,39,43. Music therapy, for instance, promotes socialization, improves physical and mental functions, facilitates the establishment of a bond between professional and patient, and helps to reduce the stress associated with the hospital environment 44. Another tool recommended for nursing professionals is therapeutic toys 45. The use of ludic toys offers children a way of expressing themselves, relieves tension and negative emotions, and improves communication and relationships between children, families, and healthcare professionals, which is essential for providing humanized and effective care 46,47.
Studies have addressed the need for continuous training, communication strategies with the family, modifications to the environment, and interprofessional collaboration in the care of children with ASD, underlining that the effectiveness of care hinges on the repertoire of strategies available 28. To interact with a child with ASD, the use of gestures and short instructions, the incorporation of images or visual aids, and waiting an adequate period before providing new instructions were recommended 48,49.
Similarly, the importance of interprofessional support has been highlighted 28. A valuable strategy for the nursing team is to request appointments with the child's therapeutic team, which can contribute to the development of an effective therapeutic plan, tailored to the child's specific needs. In addition, the importance of interaction between professionals and matrix support was emphasized, pinpointing the Child and Youth Psychosocial Care Center (Centro de Atenção Psicossocial Infanto-Juvenil - CAPSij) as a significant reference in the care of children with ASD 28,34.
Qualitative studies have highlighted the relevance of individualized approaches and specific protocols in the care of children with ASD in hospital settings 31-33. Similarly, they have shown the effectiveness of medication compliance protocols, using positive reinforcers to improve adherence to treatment, with significant success rates 32. Collaboration with psychologists to customize reinforcers emphasizes the need for an interdisciplinary approach.
It has been noted that the implementation of a personalized care plan has a key role in providing care for children with ASD, by increasing professionals' knowledge of the disorder, improving their self-perception of their skills, and promoting more effective interactions between the patient, the family, and the healthcare team 31. The study showed that nurses were the professionals who used individualized care plans most often.
These studies have presented a specific care plan for children with ASD during hospitalization and have addressed the implementation of various nursing interventions 33. These interventions include minimizing unnecessary physical contact; using non-verbal communication during appointments, with the use of objects, toys, gestures, and images, such as visual pain scales; ensuring continuity of the caregiver or professional responsible for the child's care; establishing a connection with the child to promote a safe environment that encourages interaction; reducing the number of simultaneous procedures performed; providing comfort to the child, such as bringing familiar items into the hospital environment; avoiding the use of force or threats to perform procedures; and ensuring that the environment is adapted to the child's sensory needs. These strategies aimed to improve the nursing team's practice and promote more humanized, welcoming, and effective care 33,50.
Furthermore, feeding children with ASD during hospitalization has been emphasized 33. Given these children's tendency towards food selectivity and the possibility of refusing food in the hospital, which can lead to inadequate nutrition and a water-electrolyte imbalance, it is essential that the nursing team implement the following interventions: monitor food intake and identify the reasons for any refusals; record specific information regarding food in the patient's medical record, such as allergies, color, texture, and size of food; collaborate with the medical doctor and nutritionist to define the most adequate diet; and perform water balance checks on the patient 33.
Thus, the studies point to the importance of continued training for healthcare professionals, which not only increases their knowledge of AS, but also improves their self-efficacy and the quality of their interactions with patients and their families. The use of specific care plans is vital to meet the unique needs of each child and promote more humanized and effective hospital care.
One of the limitations of this review is the prevalence of qualitative studies, which, while enriching the understanding of the phenomenon, limits the generalizability of the findings. In addition, the scarcity of studies conducted in Brazil restricts the direct applicability of the results to the national context.
In light of this, it is recommended that experimental and longitudinal studies be conducted to evaluate the effectiveness of specific interventions in the hospitalization of children with ASD. Research aimed at creating and validating standardized protocols can contribute to the systematization of care, reducing variability in the care provided. Furthermore, research on the impact of training the nursing team on the quality of care can provide support for the development of more effective continued training programs.
Thus, this study emphasizes the need for evidence-based strategies to improve nursing care for hospitalized children with ASD, highlighting the importance of a care model that covers the child's individual needs, family support, and professional training.
Conclusions
The present study achieved its objectives by describing the dimensions of nursing care for hospitalized children with ASD, identifying inherent challenges, and proposing evidence-based interventions. The analysis of the studies reviewed shows that hospitalization of this population requires an individualized approach, which includes the adaptation of the hospital environment, the implementation of alternative communication strategies, and the development of personalized care plans. In addition, the partnership with the family and the continuous training of nursing professionals were identified as key elements for quality care.
The findings reinforce the need to invest in the training of nursing staff and expand knowledge on ASD, behavioral management, and alternative communication. They also highlight the importance of interdisciplinary collaboration and the creation of specific institutional guidelines for the hospitalization of children with ASD, thus ensuring humane and effective care.
For future research, it is suggested that experimental studies should be conducted to evaluate the effectiveness of varying care strategies in the hospital setting, as well as research into the impact of professional training on the quality of care. In addition, it would be relevant to explore the development of standardized protocols for the care of children with ASD, integrating evidence-based practices that have been adapted to institutional realities.
Therefore, the present study contributes significantly to the growth of knowledge in the field of pediatric nursing, providing theoretical and practical support to improve hospital care for children with ASD and their families.
