Clinical Practice Guideline for the Assessment and Management of Preterm Birth and Autism
Autism spectrum disorder (ASD) is a form of brain dysfunction that is associated with cognitive restraints, which negatively affect the processes of thinking and socialization. As a result, early assessment and management of this condition are critical, as there is a potential of at least partial mitigation of the negative factors of the development of ASD. The analysis of the contemporary literature demonstrates that preterm birth is one of the predictors of ASD, considering the negative factors that affect the early stages of gestation. Therefore, this proposal analyzes the theoretical and practical evidence of the correlation of ASD and preterm birth suggesting several procedures of the assessment and management of ASD. The proposal is a significant document because it adds to the methodological approaches that allow to successfully assess ASD at its earlier stages of development, which positively affects the processes of brain formation. Consequently, potential implications of this research include both reduction of the negative factors associated with the development of ASD in children as well as an increase of preventive strategies that help avoid the development of the disease.
The analysis of the theoretical and practical evidence associated with the development of ASD in premature children reveals that there are various theories aimed at explaining the predictors of this condition. For instance, recognizing that ASD is a brain development disparity, experts have been considering genetic mutation and other deviations of a fetus's genetic development as the core factors leading to it (Ronemus, Iossifov, Levy, & Wigler, 2014). Partially, they considered the role of the exterior factors that create a negative physical and physiological environment for the development of a fetus's brain. One presumes that their negative role included the reduction of the access of oxygen to the brain tissue, overall poisoning of the tissue, damage to the formation of proteins, and so on. Moreover, additional negative physiological conditions include cerebellum injury, low birth weight, and intrauterine infection of a mother (de los Reyes & Gardner, n. d.). Therefore, the absence of the natural immunological protection of the human organism at its early stages of development and the overall invulnerability to the mentioned physiological conditions and physical factors are potential predictors of ASD. The presence of these factors allows to state that the research should consider the adaptation model developed by Callista Roy.
The reason for implementing Callista Roy's theory in this research is that patients with ASD have significant problems with social adaptation, which is why one presumes that the adaptation theory allows to detect and mitigate the issue. Thus, in Roy’s Adaptation Model, humans are recognized as a “holistic adaptive system who copes with environmental changes to maintain adaptation, to promote individual and environmental transformation” (Shah, 2015, p. 39). According to this model, there are four modes of adaptation, which require focus, revision, and validation: physiologic-psychosocial, self-concept, role function, and independence mode (Maslakpak, Maghsoodi, & Sheikhi, 2015). However, the model requires adaptation to the framework of the study because it includes the factor of individual adaptation whereas a child at various gestation stages is unable to adapt to various conditions autonomously requiring nursing assistance.
The first mode considered by Roy’s Adaptation Model is physiologic-psychosocial as it affects physiology and chemistry that are associated with the function of a human organism. Considering this aspect, a nurse has to assure that the patient has physiologic integrity that adds to the total wholeness of a future person (Maslakpak, Maghsoodi, & Sheikhi, 2015). Furthermore, a nurse should consider the self-concept and role function elements of the model; however, they require transformation due to the fact that the patient is not an autonomous individual until his or her birth and the formation of individuality. As a result, these elements should be revised with the accent on the fact that a patient is a potential component of the society, who obtains psychological and spiritual integrity allowing him or her to be a natural part of the community. Thus, ASD is a factor that prevents a person from fulfilling this role, which is why it requires assessment and management at the early stages of human development. Last, a nurse should recognize the importance of independence mode (Maslakpak, Maghsoodi, & Sheikhi, 2015) with regard to the future implications of early assessment and management of ASD. Thus, mitigation of ASD or bypass of its development has potentially positive implications for a child in terms of his or her becoming an independent individual, who is capable of autonomous adaptation to life conditions.
It is critical to note that according to the model of Callista Roy, nurses should use the nursing process for the promotion of each of the adaptive modes. As a consequence, there is a need for the development of strategies, which allow to consider the problem of detecting the early predictors of ASD and their mitigation. These measures would allow a nurse to promote adaptation for individuals, thereby contributing positively to a patient’s health and quality of life (Maslakpak, Maghsoodi, & Sheikhi, 2015). Therefore, the reason for validating this model in the framework of the research proposal is that it is relevant to the needs of a patient as it contributes to his or her adaptation, individuality, autonomy, and social integration.
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Proposal and Validation
The purpose of this proposal is to reveal the factors that allow to successfully assess ASD at its earlier stages of development, thereby positively affecting the processes of brain formation. The study will gather data using the surveys of pregnant women and nurses assisting them, as well as observations charts that include the assessment of a fetus's characteristics. This research will gather critical data that enhances empirical evidence, reviewing and identifying the role of preterm birth as a critical ASD predictor. The research question of the study is: What physiological and environmental characteristics in the process of development of preterm birth children potentially lead to the formation of ASD?
The specific objectives of the study are: (1) to reveal the role of a mother's behavior on the development of ASD in preterm birth children; (2) to identify the correlation of specific psychological characteristics of a preterm-born child with ASD; (3) to reveal methodological tools that allow a nurse to bypass the role of the exposed negative factors in the development of ASD. The methodological procedures allowing to perform research include such stages as conducting weekly surveys and the assessment of the physiological characteristics of a child and his/her mother. These interventions would help form a comprehensive medical chart that would include a wide range of factors associated with the development of ASD in preterm-born children. Furthermore, comparative statistical analysis is expected to reveal the most critical factors that lead to the restraints in the brain formation of a fetus and further development of ASD. Currently, recent studies demonstrate that prenatal and neonatal complications in preterm infants have a strong correlation with the further development of ASD (Buchmayer, Johansson, Johansson, Hultman, Sparén & Cnattingius, 2009). At the same time, due to recent evidence, scholars tend to exclude such factors as parental age and the weight for gestational age from the list of ASD development predictors (Larsson, Eaton, Madsen, Vestergaard, Olesen, Agerbo, . . . Mortensen, 2005). However, one presumes that there is a need for revealing the role of these factors because they may lead to extremely preterm birth. In its turn, they are major factors resulting in cognitive delay and ASD-related behavior (Hollander, Kolevzon, Coyle, 2011, p. 243). Considering the patterns of treatment, due to the exposed evidence, the proposal considers such perspectives as overall screening and preventive genomic screening. The reason for this is the suggestions that ASD is caused by “incomplete or inadequate transition to mature electrical patterns of activity”, which negatively affects the brain functions, in particular, “excitatory-to-inhibitory GABA sequence that occurs during development” (Ben-Ari, 2015). In addition, recent experiments have proved that there is an increased prevalence of ASD in preterm born children with the birth weight less than 1,500 g (Dudova et al., 2014). At the same time, the literature review has revealed that there is no evidence proving that any particular form of medication treatment can improve or bypass the development of ASD in preterm born children.
Diagnosis and Prevention
The procedures for diagnosing ASD and its prevention in preterm born children are strongly associated with early screening. For instance, experts propose using ultrasonic screening of a fetus's brain with the aim of revealing the patterns of the formation of brain tissue (Movsas et al., 2013). In this sense, scholars have experimentally proved that the physical predictors of ASD include “ventricular enlargement (indicative of diffuse white matter injury), parenchymal lesions (indicative of focal white matter injury) and isolated germinal matrix/intraventricular hemorrhage (GM/IVH)” (Movsas et al., 2013, p. 1). Therefore, one recognizes that brain-screening procedures are critical for the early detection of ASD development in potentially preterm born children. For instance, such evidence as more cystic lesions in the cortical white matter at TEA and smaller cerebellar volumes are the evidence of potentially developed ASD (Ure at al., 2015). At the same time, the research has revealed no data that indicates the existence of the means of adequate treatment of ASD in preterm born children. One of the possible ways of avoiding the risk of ASD in preterm born children is the examination of DNA methylation patterns of OXTR gene because the deviations in its methylation and regulation are associated with “an in utero programing of this gene” to lead to ASD (Behnia et al., 2015). Therefore, its exclusion or modification may allow to bypass the risk of ASD development in preterm born children.
Summarizing the presented information, the paper arrives at the conclusion that the proposed research would allow to detect physiological and environmental factors that lead to ASD development in preterm children. Using Callista Roy’s Adaptation Model, the research proposes to answer the question: What physiological and environmental characteristics in the process of development of preterm birth children potentially lead to the formation of ASD? It is suggested that the surveys of the medical staff and pregnant mothers together with weekly screening results of the fetuses would provide critical data used for further statistical analysis. The proposal reveals that there is no evidence supporting the view that any medication can allow to avoid the development of ASD in preterm born children. At the same time, researchers claim that ASD in preterm-born children has a strong association with extremely low birth weight. In addition, it has specific genetic predictors, which is why early screening and assessment of the fetus with further genetic modification may be a valid option for bypassing the development of ASD.