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EMSWORLD.com | NOVEMBER 2017 41 level of comfort with the diagnosis of ASD using a Likert scale (0–10, with 0 being very uncomfortable and 10 being very comfortable with the diagnosis) in both the pre- and post- tests. Summary test results collected from 50 participants (fire and rescue personnel from Shenandoah County) are in Table 2. While the results were not statistically significant due to the limited number of par- ticipants, the difference between pre- and post-test responses demonstrated a gen- eral improvement in knowledge and increase in responders' comfort with the diagnosis of ASD. Although the sample was limited to indi- viduals from one county and included both paid and volunteer staff, the gain in reported level of comfort and reduction in the number of incorrect questions demonstrates the benefits of training for first responders. The Second Phase Over a number of years, students from Shenandoah University have continued to assist in research around implementing this program to fire and rescue agencies to better identify learning needs and gaps within the program. The second phase of the study, looking to measure changes in training participant empathy, was conducted in 2010 and 2011. It sought to identify an increase in knowl- edge measured through a pre- and post-test composed of multiple-choice, true/false and problem-based questions. This phase of the study also looked at self- perceived empathy using a Likert scale (0–10 ranking) to allow participants to rate their own level of empathy for individuals with the ASD diagnosis. The third aspect investigated by the study was also participants' self-perceived ability to identify an individual with autism, which was again measured using a Likert scale. The final measurement assessed was self- perceived ability to successfully perform job duties during a call for someone with autism. Participants demonstrated an increase in per- ceived confidence in this ability. Participants in this second phase of the study included 45 paid fire and rescue per- sonnel from Shenandoah County. Thirty-five participants were male and 10 were female. As with Phase I, the educational background of participants ranged from high school diploma to master's degree. The results for the second phase of the study looking at change scores can be found in Table 3. This study also considered changes in scores pre- and post-test. Although the gen- eralizability of this research is limited due to the small sample size and because the study was limited to one county agency, the results demonstrate an increase in all target areas, including increased knowledge about autism, self-reported empathy, self-perceived ability to identify characteristics of autism and self- perceived confidence to perform job duties following completion of the training program. The results of this study then opened the door for a third study to identify ways to improve first responder interaction with individuals with ASD during emergency situations. The Third Phase In 2011 and 2012, a third study phase was conducted to determine whether adding role-play to the education training program would increase change scores demonstrating knowledge gained and improve understanding about individuals with autism. First responders from Shenandoah County participated in the autism education course and were provided a pretest, an immediate post-test and a three-week follow-up post- test. Approximately half of the 23 participants were excused after the training program to take the post-test, while the other half took part in a role-play activity followed by a post- test. The role-play activity involved an injured child with autism, a frantic parent and a three-person rescue team. Individuals from the class played the first responders, mother and child, and the remaining individuals in the class were in the audience and provided input into decision-making. As the results in Table 4 indicate, adding role-play did not result in a significant increase in change scores in relation to participant assessment scores. As this was only one sample, it is impossible to make generalizations regarding this data. Further study is warranted to determine the true impact of role-play on adult learning for first responders in relation to this specific edu- cational program. The unique job conditions and duties of fire and rescue personnel must be considered when designing and imple- menting an educational program. Conclusion The use of didactic instruction from a struc- tured lecture demonstrates the ability to increase the comfort level of fire and rescue personnel in assisting individuals with ASD. However, further study is warranted to better understand which teaching techniques pro- vide the most beneficial learning experiences. Consider again the scenario at the beginning of this article. Had officers allowed the boy to continue to pace, he would likely have been able to self-regulate through calming tech- niques and reduce his anxiety to a level where care could be provided. Looking even deeper, the officers might have found that the 13-year- old did not want to get dressed because the tag in the shirt his mother wanted him to wear was bothering him. Although this seems like a major overreaction to the outside observer, had the officers understood the patient's trig- gers and calming techniques, they likely could have avoided this individual's elopement. REFERENCES 1. Xiang H, Stallones L, Chen G, et al. Nonfatal injuries among U.S. children with disabling conditions. Am J Public Health, 2005 Nov; 95(11): 1,970–5. 2. Sinclair SA, Xiang H. Injuries among U.S. children with dif ferent types of disabilities. Am J Public Health, 2008 Aug; 98(8): 1,510–6. 3. Centers for Disease Control and Prevention. Autism Spectrum Disorder (ASD): Data & Statistics. http://www. startribune.com/paramedic-dies-when-ambulance-hits- stalled-semi-on-i-694/450238853/ A B O U T T H E A U T H O R Alicia Lutman, OTD, MS, OTR/L, ATC, is an associate professor in the Division of Occupational Therapy at Shenandoah University in Winchester, Va. She has been educating first responders about providing care for individuals with autism and mental health conditions during emergency situations since 2009. Table 4: Phase III Study Results Measured Component Score Pretest control group assessment score 367 Pretest role-play group assessment score 331 Post-test control group assessment score 464 Post-test role-play group assessment score 425 Overall increase, control group 97 Overall increase, role-play group 94