How can you deliver effective oral hygiene instruction to children with autism?
This question was submitted by a general dentist: “How can we deliver effective oral hygiene instruction to children with autism?”
Dr. John O’Keefe, Director of Knowledge Networks at CDA interviewed Dr. Clive Friedman, past President of the International Association for Disability and Oral Health (IADH) and current member of IADH Education Committee
Understanding your patient is crucial
The key to success in treating an autistic child is to follow an approach based on understanding the patient, not only in terms of their diagnosed condition, but also of their psychosocial environment.
It is important to understand where a child fits on the PDD spectrum, from mild through to severe, and the impact this may have on your approach. However, it is the psychosocial factors that are absolutely key to understanding the child and determining your approach to caring for them in the dental clinic setting.
From the beginning of the relationship with the child, you will need to understand the severity of the condition, the child’s self-perception and whether they have a hypersensitivity disorder. Are they sensitive to light touch or deep pressure, do they react to taste, texture or sounds, male or female voices? Understanding how the child reacts to new environments and determining whether or not there needs to gradual integration into the clinic setting in order to desensitize them is crucial.
The solidity of the autistic child’s support system, including the parents’ or caregivers’ level of engagement and knowledge, as well as their interactions with siblings and other family members, will be very important if there is to be any possibility of success with an oral care program.
The child’s parents are your best allies
When a parent tells you, “My child has autism”, there is a great opportunity for the dental team to respond with, “tell me more”. This opens us up to understanding the child’s daily-life activities and the impact that the condition has on the supporting individuals.
Any strategies that enable the successful implementation of the child’s other daily activities will most likely facilitate the success of oral hygiene practices. Parents know the child best and how their child’s autism impacts on their own daily life. Thus, parents are your best allies in the provision of effective oral health care.
To look into oral health maintenance, ask the parent or guardian: “What is currently working or not working for you?” It is essential that the dental professional make no assumption that they know best.
Practical guidelines for initial oral hygiene instruction
Always ask permission to initiate oral hygiene instruction: “would you like me to give you advice on oral hygiene care?” This is an important question as it opens the conversation and gives the parent a choice. If the parent responds that they know exactly how to care for the child, but it is evident that the current oral hygiene practices are not effective, respond sensitively with, “I am curious. Help me to understand your current oral care as there seems to be a gap between your knowledge and your child’s oral health.”
Many children with autism are involved in behavioral programs, whether in a school setting or initiated by the parents, and which often involve repetitive tasking activities. When applied in a consistent manner, the same programs are also very successful in the clinic setting. What that entails is introducing specific tasks and then noting the child’s ability to accept these tasks. Continue to repeat the same task and add new ones, slowly increasing the intensity of the activity.
Use the strategy of “successive approximations” which is a gradual learning process, which tests the child’s limit to learn a new activity and then temporarily backing away from the activity when the limit is reached. This allows the child to process the information. Having a clear sense of time is critical. Counting to 5 gives the child a sense of a start and finish to each task.
It is also essential to prepare the child to accept oral care as it may be perceived as an invasion. Much of the preparation can be done by the parent, using photos or a “pix program”. Again, getting the parent on your side is key to success, as they know what may or may not work. Sound is often a trigger for anxiety or negative responses; hence, maintaining a calm, quiet environment can be effective. Also, singing in a low tone can help to pave the way for a successful intervention. For some children, certain types of deep pressure on head and neck can help to prepare them for the intrusion into their personal space.
Treating a child with Autism is much like treating any other patient. What works today might not work tomorrow. Success is an evolution; however, listening to the parents and using the information that they give you is the key to success.
Individualizing Dental Care for Children and Youth with Autism Spectrum Disorders
Determined Program Questionnaire for Parent/Guardian (Interactive PDF form)
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