My daughter with autism was very resistant during her first dental visit. Are there any steps we can take to help her tolerate a dental exam? We were actively involved in her home-based early intervention program for the last two years and have a working knowledge of ABA. Our daughter’s program is overseen by a board certified behavior analyst.
Answered by Jennifer Hieminga, MEd, BCBA Associate Director
New Haven Learning Centre
First and foremost, since you both have assumed an active role in your daughter’s intervention and have supervision by a BCBA, there are definitely steps that you can take to address your concern. Dental visits can be a very common challenge for families of children with autism. In fact, for many individuals with autism, other routine appointments such as medical visits, and haircuts can be extremely difficult to tolerate as well.
There are many factors that may contribute to this intolerance such as novel settings, unfamiliar adults, new or unpleasant sounds, bright lights, foreign tastes, painful sensations, awkward positions, sitting for long periods of time and physical touch. As a result, many children with autism display noncompliance or avoidance in response to these stimuli or events.
Fortunately, there is a growing body of research published in peer-reviewed journals describing effective strategies based on the principles of applied behavior analysis (ABA) to target dental toleration (Hernandez & Ikkanda, 2011; Delli, Reichart, Bornstein & Livas, 2013). Several different behavior analytic interventions have been used to increase an individual’s tolerance of or proximity to an avoided stimulus or event, such as a dental exam. For example, the use of escape and reward contingent on cooperative dental behavior was shown to be effective for some individuals (Allen & Stokes, 1987; Allen, Loiben, Aleen, & Stanley, 1992; Virdi, 2011). Non-contingent escape, in which the child was given periodic breaks during the dental exam regardless of his/her behavior, was also effective in decreasing disruptive behavior (O’Callaghan, Allen, Powell, & Salama, 2006; Allen & Wallace, 2013). Other strategies such as using distraction and rewards (Stark et al., 1989; Fakhruddin, Yehia, & Batawi, 2017), providing opportunities for the individuals to participate in the dental exam (Conyers et al., 2004), using stories or video modeling in advance of the appointment (Nelson, Sheller, Friedman, & Bernier, 2015) and employing systematic desensitization procedures (Altabet, 2002; Nelson et al., 2017) have also been shown to be effective. Cuvo and colleagues (2010) used a combination of interventions including a priming video model, escape extinction, stimulus fading, and distracting stimuli. The board certified behavior analyst overseeing your daughter’s program is likely familiar with these procedures.
Clinical practice suggests that dental exams can indeed be modified to teach children with autism component skills related to dental exams (Blitz & Britton, 2010). However, a major challenge when implementing such skill-acquisition programs is the reduced opportunities to actually target these skills, particularly given the limits imposed by insurance reimbursement. One highly effective way to address this is to create a mock dental exam scenario in your home, as it provides opportunities to teach and practice the skills consistently and frequently. These scenarios should approximate, as best as possible, an actual dental office (e.g., similar tools, sounds, light, reclining chair), making it easier for the skills mastered in the mock teaching scenario to generalize to the dental office exam as a later time.
Developing a “Cooperates with a Dental Exam” Skill Acquisition Program
What follows are some steps needed to create and implement this program.
- Speak to your family dentist to identify all the components of the exam with which your child will be required to participate.
- Collect necessary materials required for the exam. Many of these items may be obtained or borrowed from your dentist and may include:
- Reclining chair (e.g., lazy boy)
- Dental bib
- Electric Toothbrush with round head (to approximate polishing)
- Dental mask
- Dental mirror
- X-ray plates
- Flossing pics
- Based on the dentist’s input, develop a detailed task analysis outlining each step of the dental exam. See sample task analysis provided in the next section below.
- Collect baseline data to determine your child’s ability to cooperate with each step of the exam and to identify skills that need to be taught. For example, baseline data may indicate that your child may have difficulty tolerating novel sounds at the dentist’s office but not with the exam itself. In this situation, a specific program for tolerating novel sounds found in the dental office should be introduced. It cannot be overstated that an intervention to address this area would need to be individualized. However, for the purpose of this reply it will be assumed that your daughter presents with difficulty in all, or the majority of the steps involved in a dental exam.
- Lastly, before starting the program, identify highly potent reinforcers/rewards that your daughter will access for tolerating the mock or actual dental exam.
Sample Task Analysis
A comprehensive task analysis for your daughter may include the following steps; however, the behavior analyst overseeing your daughter’s program will be able to develop a more relevant and individualized task analysis based on the baseline data and skills assessment.
Mock Dental Exam at Home:
Please note this program is taught as a chain (i.e., each step builds on the previous step).
- Sits in a mock dental chair
- Wears a dental bib
- Tolerates the light needed for the exam
- Tolerates the instructor wearing a dental mask and gloves
- Tolerates the instructor using a dental mirror in her mouth
- Tolerates the instructor counting/touching their teeth with a rubber tip
- Tolerates a mock dental exam for 1 minute
- Tolerates a mock dental exam for 2 minutes
- Tolerates the instructor gently flossing her teeth with pic
- Tolerates an x-ray plate being inserted into her mouth
- Bites down on an x-ray plate for 15 seconds (be aware that this may occasion a gag reflex in some children)
- Tolerates a mock dental exam for 5 minutes
- Tolerates a mock dental exam for 10 minutes
- Tolerates a mock dental exam for 15 minutes
- Tolerates a mock dental exam for 20 minutes
Dental Exam at the Dentist:
Prior to the next actual dental exam, have an in-depth conversation with the provider about your daughter’s diagnosis, strengths, and possible challenges. Ask questions about the components of the exam, as well as other details such as the size and layout of the waiting room, presence of electronics in examining room, etc. Try to schedule an appointment to bring your daughter to the dental office so that you, or one of your instructors, can do several short practice visits to promote the generalization of mastered skills in the actual setting. Many dental offices are amenable to booking an appointment, either after hours or when they are not busy, to allow you use of the office and chair. Dentists with extensive experience with young patients with ASD will likely welcome these visits to the extent feasible within their busy practices.
Again, the task analysis will need to be tailored to each individual. Some learners with autism will not require a task analysis as detailed as the example above, while others may require an even more detailed and systematic (e.g., increase time intervals in 1 minute increments) task analysis. There are a number of additional strategies which may enhance the overall success of your efforts. These include:
- Making toothbrushing a priority and using visual supports as needed. Many children respond well when parents make routine as fun as possible.
- Withholding a highly potent reinforcer(s) that your daughter is able to access only for success in this program and at no other time.
- Gradually increasing the amount of time that your daughter has to cooperate with a particular procedure. In fact, it may be beneficial to target duration during your practice sessions that exceed that of an actual exam.
- As the time you are expecting your daughter to tolerate a mock exam increases, you may want to consider offering breaks following cooperative behavior.
- Using a timer to indicate how much time your daughter has left until the exam will end.
- Modeling the actions that your daughter is to complete (e.g., opening your mouth). In some cases, it may be helpful to allow her to perform some of the actions on an adult in a turn taking format.
- Using shaping strategies by differentially reinforcing close approximations to the target that you are trying to teach.
- Teaching compliance with one step directions (e.g., turn you head this way, look at me, open mouth)
- Provide more frequent or higher-level reinforcement for aspects of the sequence with which your daughter is struggling.
- As mentioned earlier, the use of distraction can be helpful in promoting tolerance. Allowing your daughter to watch a preferred video clip (e.g., movie) is a form of distraction during the dental exam.
- If already demonstrated to be effective during your practice sessions, consider removing the preferred video if and when she is engaging in noncompliance and allow her to gain access to it again when the behavior has ceased. If this consequence is not well tolerated during practice sessions, then using it in the dental office is strongly discouraged.
Teaching children to tolerate all of the noises, the tastes, the touch, and the sensations involved with a dental exam can be very difficult. However, taking the time to teach the skill systematically can prove highly effective and contribute to better oral hygiene over their lifespan! Given that your daughter will require routine dental care for the rest of her life, your efforts are a very worthwhile investment.
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Allen, K. D., & Stokes., T. F. (1987). Use of escape and reward in the management of young children during dental treatment. Journal of Applied Behavior Analysis, 20, 381-390.
Allen, K. D., & Wallace, D. P. (2013). Effectiveness of using noncontingent escape for general behavior management in a pediatric dental clinic. Journal of Applied Behavior Analysis, 46(4), 723-737.
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Citation for this article:
Hieminga, J. (2019). Clinical Corner: Cooperating with dental exams. Science in Autism Treatment, 16(2).