What are the discharge criteria for a child with autism spectrum disorder in an inpatient or intensive outpatient program, including medical stability, therapeutic psychotropic medication dosing, caregiver competence, comprehensive discharge summary, community support arrangements, functional safety at home, and a written crisis plan?

Discharge Criteria for Autism Spectrum Disorder from Inpatient or Intensive Outpatient Programs

Children with autism spectrum disorder should be discharged from inpatient psychiatric care when dangerous behaviors (aggression, self-injury) have decreased to manageable levels, psychotropic medications are optimized and stable, caregivers demonstrate competence in behavioral management strategies, and a comprehensive outpatient plan with specialized autism services is secured. 1, 2

Medical and Behavioral Stability Requirements

Core Behavioral Targets

• Irritability and aggression must be reduced to levels that no longer pose imminent risk of injury to self or others 1, 2
• Severe impulsivity should be controlled sufficiently that the child is not at immediate risk of losing access to community services 3
• Behavioral disturbances should respond to the treatment plan implemented during hospitalization, with caregivers able to replicate interventions at home 1, 4

Medication Optimization

• Psychotropic medications targeting comorbid psychiatric conditions (ADHD, anxiety, mood dysregulation) must be at therapeutic doses with stable response 3, 5
• If risperidone or aripiprazole were initiated for severe irritability/aggression, adequate trial duration (typically 4-6 weeks) should demonstrate response before discharge 6, 3
• Medication side effects (appetite changes, weight changes, sleep disturbances) must be identified, monitored, and managed with a clear outpatient monitoring plan 5
• Avoid discharging during active medication titration unless specialized outpatient psychiatric follow-up is immediately available 3

Caregiver Competence and Home Safety

Required Caregiver Skills

• Caregivers must demonstrate proficiency in implementing behaviorally-informed interventions taught during hospitalization 1, 2
• Parents should understand and be able to execute the behavioral crisis plan, including de-escalation techniques and environmental modifications 1, 4
• Caregivers must recognize early warning signs of behavioral escalation and know when to seek emergency intervention 7

Home Environment Assessment

• The physical home environment must be assessed for safety, with removal or securing of dangerous items if self-injury or aggression occurred 7
• Adequate supervision must be available at home—discharge should not occur if the child will be unsupervised for extended periods 7
• Functional capacity of the home to support the child's needs should be verified, including space for sensory regulation and behavioral interventions 7

Comprehensive Discharge Planning

Outpatient Psychiatric Care

• A child and adolescent psychiatrist or psychiatrist with developmental neuropsychiatry training must be identified for ongoing medication management 3
• First outpatient psychiatry appointment should be scheduled within 1-2 weeks of discharge, with closer follow-up if medications were recently adjusted 7, 3
• For children on risperidone or aripiprazole, metabolic monitoring (weight, glucose, lipids) must be arranged in the outpatient setting 5

Specialized Autism Services

• Applied Behavior Analysis (ABA) or other intensive behavioral intervention services must be arranged prior to discharge 6, 8
• School-based services should be coordinated, with an Individualized Education Program (IEP) updated to reflect current behavioral needs and strategies 1, 4
• Social skills groups, occupational therapy for sensory issues, and speech therapy should be in place as clinically indicated 6

Crisis Planning

• A written crisis plan must be provided to caregivers detailing specific triggers, early warning signs, de-escalation strategies, and when to seek emergency care 7
• Emergency contact numbers for the outpatient psychiatrist, crisis hotline, and nearest emergency department should be documented 7
• Caregivers should understand that the crisis plan is not a "no-harm contract" but rather a practical action plan for managing escalations 7

Discharge Documentation Requirements

Comprehensive Discharge Summary

• The discharge summary must include admission behavioral concerns, diagnostic clarifications made during hospitalization (including newly identified comorbidities), and response to interventions 7, 4
• All psychotropic medications with specific dosing, rationale, target symptoms, and monitoring parameters must be clearly documented 7, 3
• Behavioral interventions that were effective should be described in sufficient detail for outpatient providers and caregivers to replicate 1, 2

Communication with Outpatient Providers

• Direct communication (phone call or secure message) with the outpatient psychiatrist and primary care physician should occur before discharge 7
• The discharge plan should explicitly state which provider is responsible for each aspect of care (medication management, behavioral therapy, medical monitoring) 7

Special Considerations for Autism Population

Avoid Common Pitfalls

• Do not use implicit coercion such as "you cannot be discharged until you promise not to be aggressive"—this encourages deceit and impairs therapeutic alliance 7
• Screen comprehensively for comorbid conditions (ADHD, anxiety, depression, sleep disorders, GI problems, epilepsy) as approximately 90% of children with ASD have at least one additional condition 6, 5
• Avoid "diagnostic overshadowing" where all symptoms are attributed to autism and treatable psychiatric conditions are missed 6

Specialized Unit Advantages

• Children treated in specialized autism inpatient units have lower irritability scores at discharge and 2 months post-discharge compared to general psychiatric units 2
• Specialized units demonstrate reduced emergency department utilization within 2 months of discharge (significantly lower recidivism) 2, 4
• If the child was hospitalized on a general psychiatric unit, more intensive outpatient follow-up may be needed to compensate for less specialized inpatient treatment 2

Timing Considerations

• Average length of stay in specialized autism programs ranges from 26-45 days, significantly longer than general child psychiatric admissions 4
• Premature discharge before behavioral interventions are established and caregiver training is complete increases risk of readmission 2, 4
• Discharge should not be delayed solely for administrative reasons (insurance authorization, placement availability) once clinical criteria are met 7