**2. Methods**

A search was conducted in the MEDLINE, PubMed, CINHAL databases, using a search strategy to identify studies published between January 2019 and December 2020, in Portuguese, English and Spanish. Studies that described interventions in children with autism spectrum disorders in the context of a pandemic by Covid-19 were included. 21 articles were selected using the PRISMA method. Gray literature and other articles researched in the Google Scholar, were also included.

### **3. The impact of environmental changes and disrupted routines during the COVID-19 pandemic**

Children and young people with autism spectrum disorder are vulnerable to the effects of prolonged isolation or quarantine, and may have difficulties adapting to this new routine, especially since inflexibility and a great reluctance to change are hallmarks of this disorder [20]. All of these practices leading to decreased

transmission of the coronavirus (SARS-CoV-2) negatively affect children and young people with autism spectrum disorder, but also their families, including siblings. Prolonged isolation increases the risk of losing daily practical skills; in the case of children with Autism Spectrum Disorder, it can also lead to an increased risk of disruptive behaviors such as depression and anxiety, and difficulty in relationships with peers, manifested by isolation, anger and aggression [20]. It is known that physical contact and socialization are fundamental to the well-being of all human beings, but children with ASD are particularly vulnerable because harmful changes in the environment can negatively affect their social, cognitive and emotional development. Children with special educational needs may need additional support to adapt to new routines and to understand changes. The most susceptible youth may develop symptoms of anxiety, depression and, in some cases, obsessive–compulsive behaviors.

Some authors recommend that you can combat the adverse effects of isolation through [7, 20, 21]:


In a study of 527 parents of children with autism spectrum disorder, with the aim of investigating the impact of the COVID-19 outbreak on these children, carried out in northern Italy, one of the most affected European regions, concluded that the majority of children who had 13 years old showed a decrease in autonomy and in the ability to carry out structured activities. After COVID-19, parents reported that their children had more intense (35.5%) and more frequent (41.5%) behavior problems, with about 20% having to go to health institutions [22].

#### *Autistic Spectrum Disorder in the Context of Pandemic by Covid-19: Caring for Children… DOI: http://dx.doi.org/10.5772/intechopen.96583*

During the COVID-19 pandemic, strong attention should be paid to the potential and resources existing in the communities and not to their weaknesses and vulnerabilities. In this regard, efforts should be made to create or maintain safe and protected environments for children/young people with autism spectrum disorders. One of the measures is the use of masks; DGS recommends its use from the age of 10 [23]. These children may have difficulty accepting and/or using masks appropriately and continuously, which are a fundamental health and hygiene rule for outings and activities carried out outside the home. To get used to its use, it may be useful to adopt a gradual approach to the use of these articles, progressively increasing the time of use and resorting to positive and motivating reinforcements for their use. As for the masks, if a person does not accept to use anything strange on the face, it is suggested to introduce the use of it in regular activities, applying it gently over the nose and mouth without squeezing. When the child/young person accepts its use, their behavior should be reinforced, for example, praising. As time goes by and the child/young person feels more familiar with the use of the mask, it can adjust to the proper position of total protection of the nose and mouth. It is recommended that the intention to use the mask be repeated several times a day, explaining in advance the need for its use (for example, communicating that it is a new way of preparing to leave) or creating a situation in which you remember when it is necessary to wear the mask outside the home. The forms of communication should be adjusted as closely as possible to the person's support needs (pictograms, objectives, verbal information, …). It is also essential that professionals and teachers use their own mask to show the child/youth how it should be used, acting as a reference and motivating element [24]. As for hand washing and respiratory etiquette, the child/ young person with autism spectrum disorder should be advised on specific actions and behaviors for controlling the pandemic. Visual support can be used to complement the parents' explanations. It is important to develop a routine with the child/ young person and make hand washing a priority. Parents need to be aware that this activity will take some time to make it an habit, but children/young people learn when taught by example. This measure should be considered a family activity and the parents' participation in this routine is very important. The norm of hand washing can be difficult for children/young people with autism spectrum disorder, because the process generates some confusion, either due to the increase in the time it takes, as the steps involved in the technique, result in increased stress in children/ young people and the desire to avoid the process [25].

## **4. Caregivers of children with autism spectrum disorder in the context of COVID-19**

As for the family of the child/young person with autism spectrum disorder in the context of COVID-19, parental stress is greater in parents of children/young people with autism spectrum disorder when compared to parents with children who show typical development [26].

In a study by Colizzi, Sironi and Antonini in 2020 it was concluded that parents' stress was still related to the risk of job loss, economic uncertainty, lack of adequate health resources, and increased time to access intervention programs could impair the ability of the caregiver or parents to deal with the child/young person in the context of Pandemic [22].

Parents face several challenges generated by COVID-19. One is the transitions in lifestyle changes caused by social isolation and the adoption of new routines that the child/young person with autism spectrum disorder was not used to. These transitions and changes in routine can be very disturbing, aggravating the behavior of children/young people, such as the increased frequency of crying and aggressive behaviors such as reactive strategies and even the refusal to transition [27]. While some parents reported that their children adapted without major problems, thinking of this period of the pandemic as a break from school or vacation, other parents reported that their children were uncomfortable with the transition. Other parents also reported that their children immediately felt the effects of the interruption in their routine as an impossibility to go to school, to see teachers and friends. The mood and behavior of children/young people changed immediately, showing anger, confusion, sadness and exhibiting more hyperactivity [26].

While we can predict that parents' stress will be greater during the pandemic, we also recognize that there are ways for parents to combat and deal positively with daily stressors. Pottie and Ingram in 2008, identified coping responses that can elevate the parents' mood: social support, positive restraint, focus on the problem, emotional regulation and making a commitment. Simultaneously, the authors identified four coping responses that reduced positive mood: escape, guilt, inhibition and lack of support [28].

In Italy, parents, due to the suspension of educational and rehabilitation services during confinement caused by the pandemic and the consequent isolation, expressed having experienced some challenging situations, namely problems with Internet connection (19%), ignorance about the use of the web (17%) and difficulties in following the instructions given by health professionals (22%). The emotional burden faced by parents during the pandemic involved mainly the fear of being alone and caring for children with special health needs without the support of an expert [29].

In the study by Parenteau, Bent and Hossain in 2020, parents reported positive and negative techniques for dealing with COVID-19. To face the transitions that the pandemic caused in their family routines in a healthy way, parents resorted to: exercise (walking, cycling, yoga), meditation, prayer, reading the newspaper, participating in virtual groups to connect with the community, friends and therapists. For families who had more than one caregiver at home, some parents suggested the idea of alternating between rest intervals so as not to get too overwhelmed [26].

Finding positive ways to cope with illness and isolation can be beneficial for parents and children/young people with autism spectrum disorder.

With the challenges that arise for children/young people with autism spectrum disorder and that they have online support/classes, many families have decided to concentrate their efforts to work on the skills of daily living. With more time at home, families can start or deepen the development of self-care activities in children/young people, be present to reinforce and clarify doubts and provide reminders [27].

In an observational, cross-sectional and analytical study carried out in Portugal by Amorim, Catarino and Miragaia in 2020 to a total of 99 parents of school-age children, two groups were formed: one of parents of children with ASD and the other of parents of children without neurodevelopmental problems. The average age of the children participating in the study was 10.75 ± 3.13 years and 68.7% male. Most fathers had university degrees (62.9% of mothers and 61.1% of fathers). Emotional dysregulation was also a common problem experienced by children with ASD and was associated with problems of inadequate adaptation. In addition, anxiety and depression were the most prevalent affective disorders in these children. It is also known that school demands and social commitment are stressors for children with ASD. So you can imagine that staying at home during quarantine, away from these challenges, can comfort these children. However, in that period, these children had to live with a great stressor for them: the change of routines [30].

#### *Autistic Spectrum Disorder in the Context of Pandemic by Covid-19: Caring for Children… DOI: http://dx.doi.org/10.5772/intechopen.96583*

For parents with children/young people with ASD, quarantine means not only serving as their child's teacher, but also serving as a special educator, social skills trainer, speech therapist or behavioral/mental therapist, sometimes with little support from professionals [31]. Children with ASD generally require more intensive services and support than children with typical development, which can intensify parents' tension during the pandemic.

The pandemic is changing several factors closely associated with person-environment suitability. These factors include balancing the needs of children/young people with autism for routine and environmental predictability versus the unpredictability associated with the pandemic; learning or working styles of autistic individuals versus opportunities available at this time; and the living environment or activity schedules among family members.

As we have seen, changes in daily routines and restrictions on the regular environment interrupt a number of domains as physical health, mental health and family factors. For example, sleep dysregulation, reduced access to specific foods will impact selective feeding by children/young people with ASD, which may lead to reduced food intake, poor nutrition or worsening problems of elimination and constipation. Restricted access to regular programming, activities and preferred locations contributes to the decrease in physical activity, which is already a concern among children/youth/family, as well as higher rates of obesity [32].

Maintaining typical routines as it has already been demonstrated is impossible during the COVID-19 pandemic. However, the impact of changes in routines can be mitigated by the joint creation and implementation of alternative routines, incorporating regular bedtime and morning hours, attention to sensory stimulation, adequate but limited exposure to the media, regulated times of watching TV and game viewing and attention to regular hygiene, food and water intake, daily exercise and sleep. Maintaining social networks (even if the only viable option to do this is online) is essential for children/young people/autistic and their families [33].

COVID-19 has become a pandemic and many governments have declared restrictive measures to prevent its spread. For parents and children, staying at home is one of those measures. In this situation, the treatment of young children with special needs, such as autism can be a challenge for families and caregivers.

Autism is increasingly among us and close to all of us; at home, in schools, in families, in society and in the world in general. What is extraordinary about the times in which we live due to the public health situation by Covid-19 and because of quick action to prevent and minimize a major outbreak of infection and contagion, leads us to rethink the school, the reality, our actions, our priorities, the different ways of acting in order to minimize a worsening at the psycho-emotional level and behavioral responses in children and young people and other population that are part of a group, which is no longer as a minority, as was initially believed by the statistical data, for the researches presented of the significant increase of children with Autism Spectrum Disorder, in the current world.

Families with children with autism spectrum disorder face a number of challenges with the rise of the COVID-19 pandemic, including the explanation of the pandemic and the need to ensure and monitor safety measures for children in an understandable way, building a structure at home to minimize social isolation. These children usually have to undergo specific interventions by health professionals. However, at this moment, due to contention measures, both families and children with autism are limited in face-to-face professional support.

These routine changes can cause them profound suffering. For this reason, all of us (parents, nurses, other health professionals and researchers) must be united and quickly establish new methods and functional routines to enable children with autism spectrum disorder to be safe and at peace.
