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The AIDEN acronym: increasing nurse anesthetists' knowledge of preoperative care for children with autism spectrum disorder

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The AIDEN acronym: increasing nurse anesthetists' knowledge of preoperative care for children with autism spectrum disorder

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Content THE AIDEN ACRONYM: INCREASING NURSE ANESTHETISTS’ KNOWLEDGE OF
PREOPERATIVE CARE FOR CHILDREN WITH AUTISM SPECTRUM DISORDER
by
Alicia Selga, Hyung Kim, & Thuong Tran
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2025

PREOPERATIVE CARE FOR CHILDREN WITH ASD ii
The following manuscript was contributed to in equal parts by
Hyung Kim, Thuong Tran, and Alicia Selga

PREOPERATIVE CARE FOR CHILDREN WITH ASD iii
Dedication
We would like to dedicate this project to all of the children and families living with
autism spectrum disorder. As Stuart Duncan said, “Autism is not a disability, it’s a different
ability.” We hope we can make the healthcare experience a little easier and a little less scary.
We would also like to dedicate this project to Dr. Calvin Sparks DNP, CRNA and his son
Aiden Sparks. Thank you for your service and hard work in the field of nurse anesthesia and
opening up your lives to make this project come to life.

PREOPERATIVE CARE FOR CHILDREN WITH ASD iv
Acknowledgements
Our research group would like to thank Dr. Paula Belson, Dr. Elizabeth Bamgbose, and
Dr. Amanda Goodrich for their guidance, expertise, and patience in the development and
implementation of this project, we couldn’t have done it without a team effort.
We would also like to acknowledge and thank our biggest personal support systems, our
families and friends. This has been a long journey, and it was only possible with all your love
and support.

PREOPERATIVE CARE FOR CHILDREN WITH ASD v
Table of Contents
Distribution of work………………………………………………………………………………ii
Dedication……………………………………………………………………………...…………iii
Acknowledgements……………………………………………………………………………….iv
Abstract………………………………….. ……………………………………………………...vii
Chapter 1…………………………………………………………………………..………………1
Introduction………………………………..………………………………………………1
Research Question and Statement of Specific Aims …………………………………...…2
Background & Significance ...……………………………………………………….……3
The AIDEN Acronym...…………………….………………………………….….4
Chapter 2…………………………………………………………………………….…………….6
Literature Review…………………………………………………………………………6
AIDEN Acronym......……...………………………………………………………6
Current Perioperative Guidelines………………………………………………….7
Interdisciplinary Approach and Environmental Control……….………………….7
Providers’ educational needs……………...…………………….…………………9
Effective Use of Preoperative Anxiolytics………………………………....…….10
Chapter 3…………………………………………………………………………………………13
Methodology……………………………………………………………………………..13
AIDEN Acronym Presentation with Pre-Post Survey………….……………….13
Sampling and Analysis………………………………………………………….14
Statistical Methods……….…………………………………………….….…….14
Chapter 4…………………………………………………………………………………………16
Results……………………………………………………………………………………16
Subject Characteristics…………...………………………………………………16
Differences in Test Scores……………………………………………………….16

PREOPERATIVE CARE FOR CHILDREN WITH ASD vi
Chapter 5…………………………………………………………………………………………18
Discussion……………………………………………………………..…………………18
Conclusion……………………………………………………………………………….19
References…………………………………………………………………………….………….21
Tables…………………………………………………………………………………….………23
Table 1: Demographic Data……………………………………………………….……………..23
Table 2: Distribution of scores (median (Q1, Q3) for each question (out of 10) and total
scores (out of 60) for pre- and post-test after being shown the AIDEN method video.……..24
Table 3: Distribution of scores (median (Q1, Q3) for each question (out of 10) and total
scores (out of 60) for pre- and post-test after being shown the AIDEN method video,
stratified by gender…………………………………………………………………………..25
Appendices…………………………………………………………………….…………………28
Appendix A: AIDEN Acronym……………………………………..……………………..28
Appendix B: PRISMA Flow Chart………………………………………………………29
Appendix C: Literature Matrix....…………………………..……………………………30

PREOPERATIVE CARE FOR CHILDREN WITH ASD vii
Abstract
Children with autism spectrum disorder (ASD) present unique challenges in perioperative care
due to sensory sensitivities, communication difficulties, and behavioral needs. This doctoral
capstone investigates whether educating nurse anesthetists on the AIDEN acronym improves
their knowledge and preparedness in providing preoperative care for pediatric patients with ASD
see Appendix A). The AIDEN acronym, which stands for Acknowledge and Assess,
Interdisciplinary Approach, Do Not Disturb, Educate Staff, and Necessity of Anxiolysis, was
presented to certified registered nurse anesthetists (CRNAs) through an educational module. Preand post- test surveys were conducted to measure knowledge changes. Results indicated
statistically significant improvements in CRNA’s knowledge and understanding of ASD-specific
preoperative care, particularly in areas related to patient assessment, interdisciplinary
collaboration, and the appropriate use of anxiolytic medications. These findings suggest that the
AIDEN acronym can serve as an effective educational tool to improve the quality of preoperative
care for children with ASD. Further studies should focus on clinical implementation and
caregiver satisfaction to evaluate its practical impact.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 1
Chapter 1
Introduction
Autism spectrum disorder (ASD) is the fastest growing neurodevelopmental disorder in
the world with a global prevalence of 1.5% (Mellado-Cairet et al., 2019). Over the last 20 years
in the United States, prevalence has grown from 1 in 150 to 1 in 44 children. Usually diagnosed
by age three, ASD occurrence is four times more common in boys than girls (Centers for Disease
Control and Prevention [CDC], 2022). ASD encompasses a broad range of conditions; the
Diagnostic and Statistical Manual 5th edition (DSM5) defines it as a persistent deficit in social
interaction and communication across multiple contexts along with a restrictive, repetitive
pattern of behaviors, interests, or activities (Taghizadeh et al., 2019). With its increasing
prevalence among children, it is likely anesthesia providers, including certified registered nurse
anesthetists (CRNAs), will encounter patients with ASD at some points during their training and
practice.
The uniqueness and complexity of each child with ASD requires the need for an
individualized plan of care (Snow et al., 2022). Antiquated concepts in the preoperative care of
children with ASD include forced pharmacologic premedication and physical restraint (MelladoCairet et al., 2019). The culture of care has since shifted focus from how to deal with a
combative or uncooperative patient to addressing the root cause of behavioral difficulties
(Mellado-Cairet et al., 2019). The goal of anesthesia providers is to deliver the most up to date,
safe and effective evidence-based care. However, knowledge and the ability to provide highquality care does not always ensure that an anesthetist feels comfortable caring for children with
autism (Snow et al., 2022). Current literature on preoperative care of the pediatric autistic
population led doctoral nurse anesthesiology student Calvin Sparks to evaluate the current

PREOPERATIVE CARE FOR CHILDREN WITH ASD 2
standards of practice and create new evidence-based guidelines to improve quality of care for
pediatric patients previously diagnosed with ASD. His novel guidelines were described by what
he called the AIDEN acronym.
The AIDEN acronym is a memory aid to help the anesthesia provider in formulating a
preoperative management plan for the pediatric patient with ASD. The components that make up
the acronym are as follows:
A: acknowledge and assess
I: interdisciplinary approach
D: do not disturb
E: educate staff
N: necessity of anxiolysis.
Research Question and Statement of Specific Aims
The research question guiding this project is: Does providing an educational presentation
on the AIDEN acronym increase nurse anesthetists’ knowledge on how to plan and participate in
preoperative care for a child with autism spectrum disorder? The Population/ Intervention/
Comparison/ Outcome (PICO) framework will be used to structure this investigation. The
population of interest will be CRNAs, and the intervention will be providing an educational
presentation on the AIDEN acronym. Knowledge levels of CRNAs regarding preoperative
planning and care for a child with ASD will be compared before and after the educational
presentation via a Likert scale survey. The outcome expected is increased knowledge after
learning the AIDEN acronym. The specific aims of this study are:

PREOPERATIVE CARE FOR CHILDREN WITH ASD 3
1. Perform a comprehensive literature search investigating anesthetic considerations for
pediatric patients with ASD.
2. Create an educational presentation of the AIDEN acronym with a detailed explanation of
each component and distribute it to CRNAs.
3. Determine if CRNAs who viewed the educational presentation increased their knowledge
of preoperative planning and care for a child with ASD by evaluating results from Likert
scale pre- and post-surveys.
Background and Significance
The surgical process is filled with fast paced interactions, multiple personnel,
unpredictable settings, bright lights, and loud sounds which may be overwhelming to a child with
ASD. Minor changes in their often fixed daily routines can cause distress and anxiety, leading to
non-compliance, aggression, or self-injury (Snow et al., 2022; Swartz et al., 2017). The
challenges pediatric ASD patients face are not only related to communication and sensory
challenges, but also to the flexibility of the hospital environment and healthcare providers
(Vlassakova & Emmanouil, 2016). Early identification of ASD patients and collecting
information from their parent or guardian regarding behavioral patterns, triggers, needs, and
previous anesthesia experiences have been successful in ensuring a smooth perioperative course
(Vlassakova & Emmanouil, 2016). Consistent recommendations among the literature support a
multidisciplinary and flexible individualized perioperative management plan with the patient’s
caregiver serving as an expert advisor (Snow et al., 2022; Swartz et al., 2017).

PREOPERATIVE CARE FOR CHILDREN WITH ASD 4
The AIDEN Acronym
The AIDEN acronym begins with acknowledging and assessing (A). Each child with
ASD has varying degrees of intellectual disability, functional deficits, and social communication
and interaction (Taghizadeh et al., 2019). It is imperative that a thorough preoperative
assessment be completed (Vlassakova & Emmanouil, 2016). The use of a preoperative clinic can
provide conditioning and desensitization by exposing the child to an environment like one they
will experience on the day of their procedure; this can help in identifying the patient’s response
to stressors and clinical triggers (Mellado-Cairet et al., 2019).
In the development of an individualized preoperative plan, it is important to have a
“team,” or interdisciplinary (I), approach; this includes everyone from the admissions personnel
to the anesthesia provider and the surgeon. At the helm of this team should be the person or
people who spend the most time with the patient. Essential information can be obtained and used
to decrease the child’s anxiety and optimize the preoperative assessment and preparation for
surgery (Snow et al., 2022; Swartz et al., 2017). Having a caregiver or comfort item present with
the patient before surgery and during induction have led to a decreased need for preoperative
sedation (Swartz et al., 2017). Another consideration is the inclusion of a Child Life Specialist.
These Bachelor or Master's prepared specialists walk children and their families through the
healthcare experience. Their goal is to help patients and families understand medical procedures
using appropriate language, teaching aids, and instructional material; they also discuss the typical
sequence of events and sensory stimulation they may encounter (Sparks, 2024).
Bright, loud, high-tech medical environments can be frightening to children with ASD
due to oversensitivity to stimuli (Snow et al., 2022). Providing an isolated area away from
sensory stimulation while waiting for the scheduled procedure can significantly reduce anxiety

PREOPERATIVE CARE FOR CHILDREN WITH ASD 5
levels. Sparks (2024) suggests placing “Do Not Disturb” signs (D) outside the patient's room or a
flag in the medical record to indicate an ASD patient. This would alert staff and decrease
exposure to unnecessary stimuli.
The next step is educating (E) staff. Anesthesia providers involved in the care of these
patients should be educated on ASD and how existing barriers regarding this population can
affect a proper pre-operative assessment and anesthetic plan (Sparks, 2024). In addition to
obtaining medical knowledge of ASD, personal knowledge about each patient can be obtained by
thoroughly interviewing the primary caregiver. The recommendation from the creator of the
AIDEN acronym is a four-hour mandatory education seminar to be completed by all staff
involved with ASD patient care (Sparks, 2024).
Finally, the acronym ends with the necessity of anxiolysis (N). Preoperative sedation
should be utilized on an as-needed basis, not as a first line treatment. Other interventions
previously mentioned should aid in the reduction of the ASD patient’s anxiety and ease the
overall preoperative process (Sparks, 2024). On occasion, premedication is unavoidable; in this
case, effective anxiolysis can be instrumental in a smooth induction of anesthesia which is the
ultimate goal (Sparks, 2024). If premedication is necessary, severity level should be considered
in determining which drug, dose, and route to use (Swartz et al., 2017).

PREOPERATIVE CARE FOR CHILDREN WITH ASD 6
Chapter 2
Literature Review
A literature search was performed utilizing online databases PubMed, Cochrane Library,
Google Scholar, Embase, Web of Science, CINAHL, and Norris Medical Library catalog
between September 16, 2022 and November 23, 2022. The following search terms were utilized:
autism, autism spectrum disorder, pediatric, anesthesia, anesthesia and autism, anesthesia
guideline for autism, guidelines of preoperative anesthesia and autism. Inclusion criteria
included publication date, source, and relevant articles. Initially, there were over 700 articles.
Duplicates were removed, search terms were revised, and the publication date was narrowed
down to seven years, resulting in over 400 articles. Exclusion criteria included articles older than
seven years, non-preoperative areas, adult patient populations, and articles not published in the
English language. After evaluation based on content and inclusion/exclusion criteria, nine
articles were selected for the capstone project including Spark’s research which is expected to be
published in Otterbein University’s Library in May of 2024 (see Appendix B).
AIDEN Acronym
Sparks (2024) conducted a systematic review of preoperative anesthesia practice
guidelines currently available for pediatric patients with ASD. Electronic database searches,
including PUBMED, CINAHL, Cochrane Library, ProQuest, and EBSCO were used to generate
over 50 articles that met the inclusion and exclusion criteria set forth by the study. Of the eligible
results, Sparks (2024) included a total of 15 publications in his research to combine current
evidence-based standards of care of the pediatric ASD patient into one, convenient acronym.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 7
Current Perioperative Guidelines
Koski et al. (2016) conducted a systematic literature review to identify the current
perioperative management practices involving pediatric patients with ASD (see Appendix
C). Using electronic databases OVID, SR, Medline, PsycINFO, AMED, PubMed, and Google
Scholar, the authors initially identified 66 non-duplicated articles published between 1997 and
2016. Publications were excluded if they exclusively focused on intraoperative surgical
interventions or preoperative sedation. A total of 11 publications were deemed relevant, meeting
criteria of being published in a peer-reviewed journal and containing primary, empirical, and/or
case report information regarding perioperative care for pediatric patients with ASD. This review
identified the lack of a comprehensive initial, pragmatic assessment for pediatric patients with
ASD in a preoperative setting. The study further mentioned the need for an individualized
approach to perioperative care and made the following recommendations: increased attention to
patient needs, early preparation and communication with parents and guardians, implementation
of an individualized care plan, and familiarization with patient’s specific behaviors including
alleviating and aggravating factors.
Interdisciplinary Approach and Environmental Control
In 2019, Whippey et al. developed a perioperative protocol for pediatric patients with
ASD and conducted a pilot study. The protocol consisted of four salient areas within
perioperative settings that were previously identified as modifiable: environmental,
pharmacological interventions, individualized order sets, and child life specialists. The study
aimed to determine if the use of the protocol was feasible preoperatively, to assess the patient’s
emotion and sedation scores before and after anxiolytic administration, and to assess the level of

PREOPERATIVE CARE FOR CHILDREN WITH ASD 8
the couplet's satisfaction. Over a period of nine months, 18 patient and parent or guardian
couplets were recruited and enrolled in the Special Accommodation Program (SAP) in a tertiary
pediatric hospital in Canada. The authors measured the feasibility of the protocol by the protocol
adherence rate (97%). Noises created by crowds accounted for 78% of modifiable environmental
factors, whereas bright lights were responsible for 56%. A total of 15 patients (83%) reported
uneventful inductions of anesthesia when accompanied by a child life specialist. Furthermore,
the study reported an increase in overall patient and parental satisfaction (55%).
Between 2012 and 2014, Swartz et al. (2017) successfully employed individualized care
plans for a sample of 246 children with ASD. A retrospective chart review was completed to
document the need for preoperative sedation which was stratified by ASD severity level,
behavior at induction, and caregiver satisfaction. What these authors found was that a dedicated
multidisciplinary and flexible, individualized care plan provides the most beneficial
perioperative management plan for children with ASD. They based this conclusion on three main
factors: the reported satisfaction level of the caregivers (98% satisfied), level of patient
cooperation at induction (90.2% overall, with or without sedation), and sedation requirements
(60% managed successfully without sedation). They also noted that knowing the severity level of
each patient may be helpful in determining the need for preoperative sedation; as severity level
increased, so did the need for sedation.
Fahy et al., (2020) conducted a study to explore the communication and sensory
challenges for pediatric ASD patients undergoing ear nose and throat (ENT) procedures over six
months. The parents of nine randomly selected patients undergoing ENT procedures were
requested to complete a post-procedure questionnaire followed by semi-structured interviews.
The 11-item questionnaire focused on the performance of the hospital and perioperative

PREOPERATIVE CARE FOR CHILDREN WITH ASD 9
management of their children. In addition, twenty-five hospital staff who participated in the care
of the children completed an adapted questionnaire.
The study revealed that the parents played an integral role as experts in understanding the
individual needs and sensitivities of their autistic children. Furthermore, it reported the
importance of cooperation between the parents and staff in caring for autistic children. While a
new environment and multiple transitions from one area to another during the perioperative
period posed challenges for both the parents and their children, postoperative recovery was
identified as the most difficult part of care. In addition, the hospital staff expressed that they felt
stressed and uneasy when caring for patients with ASD and identified the necessity of
collaboration with parents and individualized care plans (Fahy et al., 2020).
Although this study had a small sample size and did not reach statistical significance, it
supported the idea that the care of each child required an individualized care plan that includes
coordination between healthcare professionals and parents, reduction of uncertainty and
stimulation, clear communication, and a structured, low-arousal environment.
Providers’ educational needs
Berglund et al. (2017) conducted a study using the Delphi method to develop guidelines
for providing care to children with ASD undergoing surgery and radiologic procedures requiring
anesthesia. Potential participants were identified only from the departments of anesthesiology
and radiology. Subsequently, 30 were deemed experts and were included in the study. Three
questionnaires were sent to the study subjects and their responses were analyzed, leading to the
creation of an eventual guideline. The newly synthesized guidelines from the study included 14
items and a checklist of 16 factors. The authors emphasized the following five main areas in the

PREOPERATIVE CARE FOR CHILDREN WITH ASD 10
new guideline: involvement of parents, environments, time utilization, communication, and
health care professionals (Berglund et al., 2017). From the guideline, the quality of structure for
caring for children with ASD and knowledge of the healthcare providers were deemed most
crucial. The study concluded that to serve children with ASD effectively, an organization needed
to create an appropriate environment and provide competent healthcare providers who could
adjust the plan of care to the specific needs of the individual child.
Wittling et al. (2018) conducted a project to create the best practice guidelines for
perioperative staff in caring for children with ASD. An interdisciplinary team at one pediatric
hospital created a coping plan that tailored to each child’s needs. The team identified that staff
education was essential to care for ASD patients safely and effectively. Education methods
included a presentation of current guidelines on how to interact with and care for the patient’s
family and a system-wide education conducted at staff meetings. A staff satisfaction survey was
created using a standard five-point Likert scale and sent via email.
After the implementation of the coping plan, the results of surveys collected at six months
and a year follow-up demonstrated that 89 percent (n=57) of surgical services staff showed
improvement in comfort level, time management, and confidence level when caring for behavior
disorder patients. The implementation of the coping plan also improved customer satisfaction.
The surveyed staff expressed that they had a better understanding and preparedness for how to
deliver the best care to a behavioral disorder patient (Wittling et al., 2018).
Effective use of Preoperative Anxiolytics
In a case study reported by Prakash et al. (2016), a 7-year-old autistic male child with
cognitive developmental delay and hyperactive seizure disorder presented for treatment related

PREOPERATIVE CARE FOR CHILDREN WITH ASD 11
to previously diagnosed dental caries. Due to the child’s previous uncooperative behaviors, he
would need to be treated under general anesthesia. The mother forewarned the anesthesia
providers of the difficulties in obtaining intravenous (IV) access. The mother, in the presence of
qualified medical personnel, prepared 10 mg of midazolam (0.5mg/kg) syrup in a cup brought
from the child’s home. After adequate sedation was achieved, IV access was obtained and the
child was transported to the operating room without restraints or the administration of an
intramuscular injection of anxiolytics (Prakash et al., 2016). This case study is one example of
the successful and effective use of anxiolytics for pediatric patients with ASD in a preoperative
environment. It prevented any physical or psychological harm that could have been caused by
using restraints or intramuscular injections. Prakash further recommended the use of ketamine
for those with moderate to severe forms of ASD.
In 2019, Li et al. published a prospective, randomized, double-blind control study
involving 275 children with ASD undergoing either computerized tomography (CT) scan or
auditory brainstem response (ABR) test. The study aimed to evaluate the efficacy and safety of
administering intranasal dexmedetomidine with and without buccal midazolam for sedation. The
study reported a sedation success rate of 65% (89 out of 136) for children who received
intranasal dexmedetomidine and 83% (116 out of 139) for children who received intranasal
dexmedetomidine plus buccal midazolam for preoperative sedation without reports of adverse
side effects such as hypotension and bradycardia. They concluded the combination of intranasal
dexmedetomidine and buccal midazolam was a successful sedation technique and should be
considered due to the fact that it requires little to no cooperation from the child.
The aforementioned literature review revealed that by focusing on the critical areas of
personalized anesthetic approaches, interdisciplinary strategies, safe environments, increased

PREOPERATIVE CARE FOR CHILDREN WITH ASD 12
awareness and education, and anxiety management, anesthesia providers can significantly
improve the care they provide to children with ASD and their families.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 13
Chapter 3
Methodology
AIDEN Acronym Presentation with Pre-Post Survey
For this project, the authors created an educational presentation consisting of a lecture
recorded over PowerPoint slides. This presentation covered each component of the AIDEN
acronym with the goal of increasing CRNAs’ knowledge on how to plan and participate in
preoperative care for a child with ASD. To assess a gain of knowledge after exposure to the
AIDEN acronym, a pre-post Likert scale survey was sent via email with the presentation.
University of Southern California (USC) nurse anesthesia program alumni from May 2020
through May 2023 were the target audience for this presentation. To contact the participants, an
email list was gathered from the Department of Nurse Anesthesia at USC. The participants were
instructed to complete the pre-survey before watching the presentation and complete the postsurvey after. The Research Electronic Data Capture (REDCap) platform was utilized for data
collection and maintaining confidentiality of participants. The participants had one month to
complete the educational presentation and surveys. A reminder email was sent out near the end
of the month. Respondents were instructed to answer the questions based on their understanding
of caring for pediatric patients with ASD preoperatively. In addition, individual information was
fully de-identified to maintain confidentiality of participants. General questions included were
age, years of experience, and experience with pediatric anesthesia care. Likert scale will range
from 1 to 10 with 1 being “not comfortable or do not understand” and 10 being “very
comfortable or completely understand.” Participants answered the same questions before and
after viewing the educational presentation on the AIDEN method. There were six primary
questions/statements:

PREOPERATIVE CARE FOR CHILDREN WITH ASD 14
1. Do you feel you have adequate knowledge to care for a pediatric patient with autism spectrum
disorder preoperatively?
2. I understand the purpose of a thorough preoperative assessment with the use of preoperative
clinic for autistic pediatric patients.
3. I understand the need for an interdisciplinary approach in caring for a pediatric patient with
autism spectrum disorder.
4. I understand the benefit of a reduced sensory-stimulating environment preoperatively for the
pediatric patient with autism spectrum disorder.
5. I understand why staff need specific education on how to care for an autistic pediatric patient.
6. I understand when and how to use anxiolysis medications preoperatively for a pediatric patient
with autism spectrum disorder.
Sampling and Analysis
The sample included CRNAs who were alumni of USC’s nurse anesthesia program. The
sampling was chosen due to the accessibility of the population and convenience. No incentives
were offered for participation. A meeting with the Program of Nurse Anesthesia’s biostatistician
was set up to receive feedback and approval of the Likert scale survey that was to be utilized for
the measurement of CRNA knowledge. Data was then collected and sent to the biostatistician. A
statistical analysis was performed to determine if any statistically significant increase in
knowledge occurred after receiving the education on the AIDEN acronym.
Statistical Methods
Two subjects completed the pre-test but did not complete the post-test and were thus

PREOPERATIVE CARE FOR CHILDREN WITH ASD 15
excluded from analyses. Scores were summed across each of the six questions for the pre-test
and for the post-test, separately, for a total score ranging from 10-60 for each test. One-tailed
Wilcoxon signed rank tests were used to compare each question and the total scores between the
pre- and post-tests. To determine if results should be reported stratified by any of the four
demographic variables, we used two-tailed Wilcoxon rank sum tests to assess whether the
median pre-test total scores differed between strata of the demographic variables. If the median
scores differed, then results were further stratified by levels of that variable. Only gender met
this criterion. Alpha = 0.05 was used to indicate statistical significance. Stata (SE version 18.0;
StataCorp, College Station, TX) was used for all analyses.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 16
Chapter 4
Results
Subject characteristics
After a month of data collection and a total of n = 16 subjects completed both the preand post-tests. Participants were roughly evenly split between 30-35 and 36-40 years old, with
one subject < 30 (Table 1). There were slightly more male participants than female (56% vs
44%). Most subjects had 1-5 years of experience (63%), with the remainder having less than 1
year of experience. Half the participants currently treated pediatric patients.
Differences in test scores
Median scores were statistically significantly improved after watching the AIDEN
acronym presentation for the following questions: “I feel I have adequate knowledge to care for a
pediatric patient with autism spectrum disorder preoperatively.” (median score: 5.0 vs 8.0; p <
0.01), “I understand the purpose of a thorough preoperative assessment with the use of
preoperative clinic for autistic pediatric patients.” (median score: 8.0 vs 9.0; p = 0.03), and “I
understand when and how to use anxiolytic medications preoperatively for a pediatric patient
with autism spectrum disorder.” (median score: 6.0 vs 7.5; p < 0.01; Table 2). Median scores
were marginally improved after watching the AIDEN acronym presentation for “I understand the
need for an interdisciplinary approach in caring for a pediatric patient with autism spectrum
disorder.” (median score: 8.0 vs 9.0; p = 0.05). Median total scores were also improved after
watching the AIDEN acronym presentation (median score: 45.5 vs 50.0; p < 0.01).
When stratified by gender, median scores for all questions and total scores were
higher for females than for males for both pre-test and post-test scores (Table 3). Median scores
were improved for males more frequently than for females, with males showing improvement in

PREOPERATIVE CARE FOR CHILDREN WITH ASD 17
all questions except “I understand why staff needs specific education on how to care for an
autistic pediatric patient.” (p < 0.05 for all), as well as the total score (p < 0.01). Among females,
median scores were only improved for “I feel I have adequate knowledge to care for a pediatric
patient with autism spectrum disorder preoperatively.” (median score: 5.0 vs 8.0; p = 0.01).

PREOPERATIVE CARE FOR CHILDREN WITH ASD 18
Chapter 5
Discussion
With the growing prevalence of autism spectrum disorder, it is important to recognize the
uniqueness and complexity of each child with ASD and the need for an individualized
preoperative plan of care (Snow et al., 2022). Antiquated concepts in the preoperative care of
children with autism spectrum disorder include forced pharmacologic premedication and
physical restraint (Mellado-Cairet et al., 2019). There has since been a shift of care from how to
deal with bad behavior to now addressing the root cause of behavioral difficulties. In his
research, Dr. Sparks evaluated the current standards of practice and created evidence-based
guidelines that he condensed into a cognitive aid he termed the AIDEN acronym.
Our goal was to see if Dr. Spark’s acronym actually improved CRNAs knowledge on
how to care for this specific patient population. Our study demonstrated that with a short
educational presentation on the AIDEN acronym, we saw a statistically significant increase in
CRNA knowledge on how to plan and participate in preoperative care of children with ASD. A
strength of our study was the feasibility of teaching the AIDEN acronym to CRNAs, including
those who do not have much experience in caring for pediatric patients with ASD. In the future,
we hope the AIDEN acronym can be fully implemented into clinical practice and studied to see
if it is truly effective. Surveying the parents or caregivers of these children would also be
beneficial in assessing the success of utilizing the AIDEN acronym.
A limitation of this study was the small sample size due to time constraint and lack of
current contact information of potential participants. Only previous university emails were
available, and it was unknown if alumni still accessed those accounts. With up-to-date contact
information and a longer time to respond, we could have had an increased number of responses.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 19
Our participants were USC alumni who might have different pediatric clinical training and
experiences compared to CRNAs who practice in different regions of the country therefore
limiting generalizability. Also, in our sample, only 50% of respondents were currently caring for
pediatric patients in daily practice. These CRNAs might have encountered and received
departmental or institutional training with ASD patients or are already comfortable in caring for
ASD patients from previous clinical practice. Another limitation of our study was its statistical
method. We used the same set of questions for both pre- and post-tests. These questions were
more subjective rather than objective which could potentially deviate the true responses
regarding the score of the participants for the post-test. We only utilized Likert-scale survey
questions which might not truly capture knowledge of participants after watching the AIDEN
educational PowerPoint. Different tests, such as a basic knowledge test done before and after
watching the PowerPoint, could be a better choice in this study to see if the educational
presentation really increased the CRNA’s knowledge. Another potential limitation was the
format of the educational presentation. The educational materials were sent via email and
watched online and, as we know, there are many different learning styles of participants. We did
not ask the participants' learning preference in the survey which might affect the responses and
result of the study.
Our study has demonstrated that the AIDEN acronym increases CRNA knowledge. To
examine the true effectiveness of the AIDEN acronym, it would need to be implemented and
studied in a medical facility.
Conclusion
The pediatric ASD patient population has special and unique needs that require every
anesthesia provider to have a strong knowledge base when caring for these patients

PREOPERATIVE CARE FOR CHILDREN WITH ASD 20
preoperatively. The introduction of the AIDEN acronym will serve as a reliable guideline that
CRNAs can use to feel competent and confident when providing preoperative anesthesia care to
children with ASD. This new acronym will be invaluable for CRNAs during the preoperative
planning and assessment of autistic children and can potentially improve overall perioperative
care and patient outcomes.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 21
References
Centers for Disease Control and Prevention. (2022, March 2). Data & statistics on autism
spectrum disorder. Retrieved from https://www.cdc.gov/ncbddd/autism/data.html
Koski, S., Gabriels, R. L., & Beresford, C. (2016). Interventions for pediatric surgery patients
with comorbid autism spectrum disorder: A systematic literature review. Archives of
Disease in Childhood, 101(12), 1090–1094. https://doi.org/10.1136/archdischild-2016-
310814.
Li, B., Yuen, V. M., Zhang, N., Zhang, H. H., Huang, J. X., Yang, S. Y., Miller, J., & Song, X.
R. (2019). A comparison of intranasal dexmedetomidine and dexmedetomidine plus
buccal midazolam for non-painful procedural sedation in children with autism. Journal of
Autism and Developmental Disorders, 49(9), 3798–3806. https://doi.org/10.1007/s10803-
019-04095-w.
Mellado-Cairet, P., Harte, C., Séjourné, E., & Robel, L. (2019). Behavioral training and
mirroring techniques to prepare elective anesthesia in severe autistic spectrum disorder
patients: An illustrative case and review. Pediatric Anesthesia, 29(3), 226-230.
https://doi.org/10.1111/pan.13566.
Prakash, S., Pai, V. K., Dhar, M., & Kumar, A. A. (2016). Premedication in an autistic,
combative child: Challenges and nuances. Saudi Journal of Anesthesia, 10(3), 339–341.
https://doi.org/10.4103/1658-354X.174917.
Snow, S. L., Smith, I. M., Latimer, M., Stirling Cameron, E., Fox, J., & Chorney, J. (2022). A
balancing act: An interpretive description of healthcare providers’ and families’
perspective on the surgical experiences of children with autism spectrum disorder. Autism
26(4), 839-848. https://doi.org/10.1177/13623613211034057.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 22
Sparks, C. (2024). Evidence based practice guidelines for the pediatric autistic spectrum disorder
population [Unpublished doctoral dissertation]. Otterbein University.
Swartz, J. S., Amos, K. E., Brindas, M., Girling, L. G., & Graham, M. R. (2017). Benefits of an
individualized perioperative plan for children with autism spectrum disorder. Pediatric
Anesthesia, 27(8), 856-862. https://doi.org/10.1111/pan.13189.
Taghizadeh, N., Heard, G., Davidson, A., Williams, K., & Story, D. (2019). The experiences of
children with autism spectrum disorder, their caregivers and health care providers during
day procedure: A mixed methods study. Pediatric Anesthesia, 29(9), 927-937.
https://doi.org/10.1111/pan.13689.
Vlassakova, B. G., & Emmanouil, D. E. (2016). Perioperative considerations in children with
autism spectrum disorder. Current Opinion in Anesthesiology, 29(3), 359-366.
https://doi.org/10.1097/ACO.0000000000000325.
Whippey, A., Bernstein, L. M., O’Rourke, D., & Reddy, D. (2019). Enhanced perioperative
management of children with autism: A pilot study. Canadian Journal of
Anesthesia/Journal canadien d'anesthésie, 66(10), 1184-1193.

PREOPERATIVE CARE FOR CHILDREN WITH ASD 23
Tables
Table 1. Demographic Data
N = 16
Age
< 30 1 (6.2%)
30-35 7 (43.8%)
36-40 8 (50.0%)
> 40 0 (0%)
Gender
Male 9 (56.2%)
Female 7 (43.8%)
Non-binary 0 (0%)
Years of Experience
< 1 6 (37.5%)
1-5 10 (62.5%)
6-10 0 (0%)
11-15 0 (0%)
16-20 0 (0%)
>20 0 (0%)
Currently treats pediatric
patients (% yes)
8 (50.0%)

PREOPERATIVE CARE FOR CHILDREN WITH ASD 24
Table 2. Distribution of scores (median (Q1, Q3) for each question (out of 10) and total scores
(out of 60) for pre- and post-test after being shown the AIDEN method video
Pre-test
Median (Q1, Q3)
Post-test
Median (Q1, Q3) p-value
I feel I have adequate knowledge to
care for a pediatric patient with
autism spectrum disorder
preoperatively.
5.0 (3.5, 7.0) 8.0 (7.0, 9.0) < 0.01
I understand the purpose of a
thorough preoperative assessment
with the use of preoperative clinic
for autistic pediatric patients.
8.0 (6.0, 9.5) 9.0 (7.0, 10.0) 0.03
I understand the need for an
interdisciplinary approach in caring
for a pediatric patient with autism
spectrum disorder.
8.0 (6.5, 10.0) 9.0 (7.0, 10.0) 0.05
I understand the benefit of a
reduced sensory-stimulating
environment preoperatively for the
pediatric patient with autism
spectrum disorder.
8.0 (5.5, 10.0) 8.0 (7.0, 10.0) 0.11
I understand why staff needs
specific education on how to care
for an autistic pediatric patient.
9.0 (8.0, 10.0) 9.0 (7.5, 10.0) 0.24
I understand when and how to use
anxiolytic medications
preoperatively for a pediatric patient
with autism spectrum disorder.
6.0 (5.0, 8.0) 7.5 (7.0, 9.5) < 0.01
Total Score 45.5 (33.5, 51.0) 50.0 (44.0, 57.0) < 0.01

PREOPERATIVE CARE FOR CHILDREN WITH ASD 25
Table 3. Distribution of scores (median (Q1, Q3) for each question (out of 10) and total scores
(out of 60) for pre- and post-test after being shown the AIDEN method video, stratified by
gender.
Male (N = 9) Female (N = 7)
Pre-test
Median
(Q1, Q3)
Post-test
Median
(Q1, Q3)
pvalue
Pre-test
Median
(Q1, Q3)
Post-test
Median
(Q1, Q3)
pvalue
I feel I have adequate
knowledge to care for a
pediatric patient with
autism spectrum
disorder preoperatively.
4.0 (3.0,
5.0)
7.0 (7.0,
8.0)
<
0.01
5.0 (4.0,
10.0)
8.0 (7.0,
10.0)
0.01
I understand the
purpose of a thorough
preoperative
assessment with the use
of preoperative clinic
for autistic pediatric
patients.
7.0 (3.0,
8.0)
8.0 (7.0,
9.0)
0.04 9.0 (8.0,
10.0)
10.0 (9.0,
10.0)
0.27
I understand the need
for an interdisciplinary
approach in caring for a
pediatric patient with
autism spectrum
disorder.
8.0 (5.0,
8.0)
8.0 (7.0,
9.0)
0.01 10.0 (8.0,
10.0)
10.0 (7.0,
10.0)
0.54
I understand the benefit
of a reduced sensorystimulating
environment
preoperatively for the
pediatric patient with
autism spectrum
disorder.
6.0 (5.0,
8.0)
8.0 (7.0,
8.0)
0.04 10.0 (10.0,
10.0)
10.0 (8.0,
10.0)
0.84
I understand why staff
needs specific
education on how to
care for an autistic
pediatric patient.
8.0 (7.0,
9.0)
9.0 (7.0,
9.0)
0.25 10.0 (9.0,
10.0)
10.0 (9.0,
10.0)
0.35

PREOPERATIVE CARE FOR CHILDREN WITH ASD 26
I understand when and
how to use anxiolytic
medications
preoperatively for a
pediatric patient with
autism spectrum
disorder.
5.0 (3.0,
7.0)
7.0 (7.0,
9.0)
<
0.01
7.0 (6.0,
10.0)
8.0 (7.0,
10.0)
0.12
Total Score 37.0 (29.0,
45.0)
48.0 (42.0,
51.0)
<
0.01
50.0 (46.0,
56.0)
56.0 (47.0,
60.0)
0.10

PREOPERATIVE CARE FOR CHILDREN WITH ASD 27
Appendix A
AIDEN Acronym: Evidence Based Practice Guidelines for the Pediatric ASD Population
Letter Meaning
A Acknowledge and Assess
I Interdisciplinary Approach
D Do Not Disturb
E Educate Staff
N Necessity of Anxiolysis

PREOPERATIVE CARE FOR CHILDREN WITH ASD 28
Appendix B
PRISMA Flow Chart

PREOPERATIVE CARE FOR CHILDREN WITH ASD 29
Appendix C
Literature Matrix
APA Reference Study
Aim/Design/Method
Summary of Main
Concepts
Main findings and
Relevance
Berglund, I. ,
Björkman, B. ,
Enskär, K. , Faresjö,
M. & Huus, K.
(2017). Management
of Children with
Autism Spectrum
Disorder in the
Anesthesia and
Radiographic
Context. Journal of
Developmental &
Behavioral
Pediatrics, 38 (3),
187-196. doi:
10.1097/DBP.000000
0000000432.
To develop
guidelines to better
care for children with
ASD undergoing
anesthesia and
radiologic procedure
Using a Delphi
method with an
online distribution of
questionnaire,
guidelines for caring
for children with
ASD
5 main areas:
planning involving
parents/guardians,
features in the
environment, and use
of time,
communication, and
the healthcare
professionals
Interdisciplinary
team member: health
care professionals
and parents/guardians
Caring for children
with ASD in the
anesthesia and
radiology contexts
requires advance
planning, catered
specifically to the
individual needs of
each child
Health care
professional require
general knowledge
regarding ASD and
ASD’s particular
manifestation in the
child entrusted their
care
Fahy, R., Corbett,
M., & Keogh, I.
(2020). Improving
peri-operative
psychosocial
interventions for
children with autism
spectrum disorder
undergoing ENT
procedures. The
Journal of
laryngology and
otology, 1–7.
Advance online
publication.
https://doi.org/10.101
7/S00222151200020
29
To understand the
communication and
sensory challenges of
ASD children
undergoing ENT
procedure and
improve services for
children with ASD
Thirty-four
individuals
participated,
comprising 9
caregivers and 25
staff members.
Parents and staff
stressed the
importance of a
partnership role that
required about unique
needs, leading to
environmental
modifications for
individual children
The importance of
listening to and
involving caregivers
is a fundamental
tenet, and parents
must be recognized
as the experts.
Uncertainty must be
kept to a minimum,
with clear
communication in a
structured, lowarousal environment
for these children
Koski, S., Gabriels,
R. L., & Beresford, C.
Comprehensive
literature review and
This study performed
a comprehensive
* Lack of
comprehensive initial

PREOPERATIVE CARE FOR CHILDREN WITH ASD 30
(2016). Interventions
for pediatric surgery
patients
with comorbid autism
spectrum disorder: A
systematic literature
review. Archives of
Disease in
Childhood, 101(12),
1090–1094.
https://doi.org/10.113
6/archdischild-2016-
310814.
analysis of content by
experts to identify the
current perioperative
management practices
involving children
with ASD
literature review and
deemed 11 articles
appropriate for
review. This review
identified the lack of
comprehensive initial
and pragmatic
assessment for
pediatric patients with
ASD in a
preoperative setting.
It also mentioned a
need for an
individualized
approach.
and pragmatic
assessment.
* Need for an
individualized
approach.
* Familiarization with
a patient's specific
behaviors.
* Identification of
alleviating and
aggravating factors.
Li, B., Yuen, V. M.,
Zhang, N., Zhang, H.
H., Huang, J. X.,
Yang, S. Y., Miller,
J., & Song, X.
R. (2019). A
comparison of
intranasal
dexmedetomidine and
dexmedetomidine
plus buccal
midazolam for nonpainful procedural
sedation in children
with autism. Journal
of Autism and
Developmental
Disorders, 49(9),
3798–3806.
https://doi.org/10.100
7/s10803-019-04095-
w
Prospective,
randomized doubleblind control trial to
compare success rate
of intranasal
dexmedetomidine
with and without
buccal midazolam in
autism children
undergoing CT and
ARB test
A total of 275
participants. 136
children received
intranasal
dexmedetomidine and
139 children received
intranasal
dexmedetomidine in
addition to buccal
midazolam for
preoperative sedation
*The study reported a
sedation success rate
of 65% (89 out of
136) of children who
received intranasal
dexmedetomidine and
83% (116 out of 139)
children with
intranasal
dexmedetomidine in
addition to buccal
midazolam for
preoperative sedation
without reports of
adverse side effects
such as hypotension
and bradycardia.
Prakash, S., Pai, V.
K., Dhar, M., &
Kumar, A. A. (2016).
Premedication in an
autistic, combative
child: Challenges and
Case study to
describe effective
management of
children with ASD in
preoperative setting
without physician
A case study of a 7-
year-old autistic male
with concurrent
seizure disorder was
able to be safely
delivered sedation by
*Successful and
effective use of
anxiolytics for
pediatric patients with
ASD in preoperative
environment without

PREOPERATIVE CARE FOR CHILDREN WITH ASD 31
nuances. Saudi
Journal of
Anesthesia, 10(3),
339–341.
https://doi.org/10.410
3/1658-354X.174917
restraint and
medication through
invasive routes
adjusting the delivery
of the medicine. It
was given by the
mother under the
guidance of
authorized personnel
in the boy’s familiar
cup. It was ingested
without incident.
inflicting potential
physical and
psychological harm
caused by using
physical restraints or
more IM injections.
Sparks, C. (2023).
Evidence based
practice guidelines
for the pediatric
autistic spectrum
disorder
population
[Unpublished
doctoral dissertation].
Otterbein University
Comprehensive
literature review of
preoperative
anesthesia practice
guidelines currently
available for pediatric
patients with ASD
An extensive
literature review was
completed to gather
the most current data
on the best way to
care for children with
ASD. This
information was then
stratified into five
groups that became
the AIDEN acronym.
* Study identified the
lack of evidencebased standards of
care in place, the need
for anxiolytics,
individualized care
plans, and
interdisciplinary
approaches
* Study created and
developed the
AIDEN acronym.
Swartz, J. S., Amos,
K. E., Brindas, M.,
Girling, L. G., &
Graham, M. R.
(2017). Benefits of an
individualized
perioperative plan for
children with autism
spectrum disorder.
Pediatric Anesthesia,
27(8), 856-862.
https://doi.org/10.111
1/pan.13189.
Retrospective chart
review of all children
with ASD scheduled
for a diagnostic or
surgical procedure
from 2012-2014. The
primary goal of the
study was to
determine the
usefulness of an
individualized plan
based on the decision
to provide
preoperative sedation
stratified by ASD
severity level.
Individualized care
plans were developed
for each child with
ASD scheduled for
anesthesia. A
retrospective chart
review was
completed to
document the need
for preoperative
sedation, sedation
stratified by ASD
severity level,
behavior at induction,
and caregiver
satisfaction.
* An individualized
plan is helpful in the
perioperative
management of
children with ASD.
* Knowledge of ASD
severity level may be
helpful in
determining the need
for preoperative
sedation.
* Parental presence
on induction without
sedation effectively
achieved cooperation
at induction in 75%
of cases
Whippey, A.,
Bernstein, L. M.,
O’Rourke, D., &
Reddy, D. (2019).
Pilot study to
determine if the use
of the protocol
previously developed
In 2019 Whippey et
al. developed a
perioperative protocol
for pediatric patients
* The use of protocol
is feasible (97%)
* Noise contributed
78% of modifiable

PREOPERATIVE CARE FOR CHILDREN WITH ASD 32
Enhanced
perioperative
management of
children with autism:
A pilot study.
Canadian Journal of
Anesthesia/Journal
Canadien
d'anesthésie, 66(10),
1184-1193.
was feasible, to assess
patient’s emotion and
sedation scores before
and after anxiolytics,
and to assess
patient/parent’s
satisfaction
with ASD and
conducted a pilot
study
environmental factors
and bright lighting at
50%
* Uneventful
anesthetic inductions
followed by preop
anxiolytics (83%)
* Overall participants
satisfaction (55%)
Wittling, K., Dufur,
J. P., McClain, A., &
Gettis, M. (2018).
Behavioral Coping
Plans: One
Inter-Professional
Team's Approach to
Patient-Centered
Care. Journal of
pediatric nursing, 41,
135–139.
https://doi.org/10.101
6/j.pedn.2018.05.004
To optimize best
practices for
perioperative staff in
caring for children
with ASD through a
target, individualized
plan of care for the
autistic child and his
or her family
Psychosocial and
medical care
strategies were
utilized to create a
coping plan with
standardized question
The coping plan is a
formalized summary
aimed at helping
health care providers
give individualized
care, and decrease the
anxiety of both the
parent and child
The evidence-based
practice was initiated
in response to the
needs of a select
group of children
with ASD
Evidence based
practice outcome
indicated this project
was successful in
meeting the needs of
the children with
ASD and their
families
Nurses engaged in
this project reported
their positive
response to this
change in practice

Abstract (if available)

Abstract Children with autism spectrum disorder (ASD) present unique challenges in perioperative care due to sensory sensitivities, communication difficulties, and behavioral needs. This doctoral capstone investigates whether educating nurse anesthetists on the AIDEN acronym improves their knowledge and preparedness in providing preoperative care for pediatric patients with ASD see Appendix A). The AIDEN acronym, which stands for Acknowledge and Assess, Interdisciplinary Approach, Do Not Disturb, Educate Staff, and Necessity of Anxiolysis, was presented to certified registered nurse anesthetists (CRNAs) through an educational module. Pre- and post- test surveys were conducted to measure knowledge changes. Results indicated statistically significant improvements in CRNA’s knowledge and understanding of ASD-specific preoperative care, particularly in areas related to patient assessment, interdisciplinary collaboration, and the appropriate use of anxiolytic medications. These findings suggest that the AIDEN acronym can serve as an effective educational tool to improve the quality of preoperative care for children with ASD. Further studies should focus on clinical implementation and caregiver satisfaction to evaluate its practical impact.

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Creator Kim, Hyung (author)

Core Title The AIDEN acronym: increasing nurse anesthetists' knowledge of preoperative care for children with autism spectrum disorder

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2025-05

Publication Date 11/22/2024

Defense Date 11/21/2024

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