Carter, L., Harper, J. M., & Luiselli, J. K. (2019). Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement-fading. Journal of Developmental and Physical Disabilities, 31(2) 1-10.

Reviewed by: Roxanne Gayle, PhD, BCBA-D and Mary Jane Weiss, PhD, BCBA-D, Endicott College

Why research this topic?

Procedures to teach specific skills for individuals with autismAs we saw in the previous article, a well crafted exposure procedure can be beneficial to teach receiving a haircut. In this study, the authors focused on another significant problem for a number of families: Problems with dental procedures. Children with autism often have difficulty completing health care routines such as dental procedures. They engage in behaviors such as noncompliance, aggression, and self-injurious behavior, resulting in safety concerns for both the child and the health care provider. Delays and avoidance of dental visits are common, and reduced dental health can result from inadequate preventative treatment. In order to provide care for these individuals, dentists may use sedation or restraints, which are more invasive approaches to treatment. Researchers should attempt to find less invasive and more efficient approaches to increase tolerance of dental procedures by children with autism.

What did the researchers do?

The researchers addressed noncompliance with dental procedures in two participants (ages 10 and 18). Problem behaviors included noncompliance, dropping to the floor, refusal to open the mouth, and the need for extensive physical prompting. The participants were gradually exposed to the 38 steps of a dental cleaning procedure, and provided edibles when they tolerated those steps without engaging in aggression or self-injurious behavior. All of the treatment was done in an analog environment, in a room at the learners’ school. Additional steps of the procedure were introduced based on the participant’s success with the previous step criteria. This continued until both participants were exposed to all 38 steps within the dental procedure. (For a complete list, consult the article, hyperlinked above.) On day 1, the participants started with steps 1 through 7 of the dental procedure. If the participants met criteria then, on day 2, additional steps were introduced. (The number of added steps was individualized; one client had only one step added.) Once compliance was established with the procedure, the use of edibles was then discontinued to assess if the participants would complete the procedure without the need for edibles as an incentive.

What did the researchers find?

Both participants were able to tolerate each step within the dental procedure without the need for the delivery of edibles throughout the procedure by the end of the experiment. One of the two participants was able to complete a dental cleaning at the actual dentist’s office, while scheduling difficulties precluded generalization training with the other participant.

What are the strengths and limitations of the study?

The protocol demonstrated an efficient approach to address tolerance of dental procedures. The grouping of steps also made the intervention less time consuming; the number of sessions was significantly less than in the haircut study, possibly because steps were grouped to speed tolerance. It also represents a far more humane and far less intrusive procedure than restraint or sedation. A limitation of the study was that the participants were not exposed to an environment that was completely identical to an actual dentist’s office. It did not have an overhead lamp, sounds of suction tools, or other features that are key components in a dental procedure. These omissions may decrease the likelihood that future participants will be able to complete the dental procedure at the actual dentist’s office, failing to generalize their responses when these new stimuli are present. Another limitation of the study was that the researcher provided an edible for each step the participant tolerated. For dental procedures, it would be preferable to not use edibles as they may interfere with the process; other kinds of incentives could be explored.

What do the results mean?

Practitioners may adopt this protocol into treatment for children with autism and other developmental disabilities who demonstrate noncompliance with dental procedures. Future researchers should structure their teaching environment to more closely match the actual dentist office, as well as consider using alternative reinforcers than edibles.

Citation for this article:

Gayle, R., & Weiss, M. J. (2021). Research synopsis: Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement-fading. Science in Autism Treatment, 18(7).

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