March 2017 Volume LII Number 2
Treatment Considerations for Patients with Autism Spectrum Disorder
By Nidhi Taneja
The term Autism describes a complex disorder of brain develop- ment that affects social interaction and communication which often results in repetitive or stereotyped behavior. Autism may refer to a specific diagnosis that is consistent with a number of specified symptoms. Autism may also be used as a general term to describe other Pervasive Developmental Disorders (PDD) which can include Autism, Asperger syndrome, Rett syndrome, Childhood Disintegra- tive Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS). Children with these disorders are considered to be on the Autism Spectrum, and in addition are considered to have an Autism Spectrum Disorder (ASD).
According to literature, children with ASD are more likely than others to have unmet dental needs. The reasons for this under- treatment may be related to the difficulties involved in treating these children, as well as the perceived and barriers to treatment encoun- tered by caregivers and dentists alike. The increasing prevalence of ASD suggests that dental practices will be seeing patients with this diagnosis more frequently in the future. Although these patients have dental needs similar to those of other patients, the symptoms of the disorder may influence the ability of dental practitioners to provide necessary care.
Though many patients are referred to a hospital setting for their behavior and/or medical management, there are many patients on the spectrum who are cooperative enough where they can be seen in dental offices regularly for preventative care. As these families already face enormous emotional and financial challenges, allowing for early intervention and preventative care for these more cooperative patients can have a significant impact on the overall health and well being of these patients and families. Currently, I am a second year pediatric dental resident at Univer- sity of Connecticut, where we see children with ASD almost every other day. Based on my and other practitioners’ experiences in our clinic, I have accumulated some strategies and experiences regarding treatment considerations specific to autistic children.
One of the most challenging behavior issues for children with autism is that they are unable to adjust to new situations. A dental visit can trigger uncooperative to aggressive behaviors for children depend- ing on where they are on the spectrum. To help prevent some of these behavioral issues, it is helpful to call the parents before their appoint- ment to receive as much information as possible about their child’s medical history and behavioral habits in order to help the visit run as smoothly as possible. During the phone conversation, ask if the patient has any comforting items such as a stuffed animal or a music device, and encourage the parent/guardian to bring it with them to the visit.
Using a picture book to familiarize the child with the dentist, staff, office space and basic dental instruments can go a long way if it is mailed to the patients in advance or given at the first appointment. Parents could be utilized to prepare the child a few days in advance before their appointment to talk to the child and remind him about his dental appointment where he/she will open his/her mouth and the dentist will clean their teeth. On a case by case basis, it is good to utilize the behavior/occupational therapist of the child to work on tooth brushing at home as well.
Schedule appointments during the least busy time of day (perhaps the first or last appointment of the day) for patients who react to a busy office environment. Even though ours is an open bay clinic, we almost always utilize quiet rooms for children with autism to keep the distractions to a minimum. Avoid scheduling these patients with other highly active patients. For example, avoid scheduling with a pediatric patient who may be very vocal during care. These patients are very sensitive to loud noise.
Many children with autism are non-verbal but good with receptive communication. Others can be aggressive and for the same reason, avoid too many new people as it can aggravate a child to act up out of insecurity. In rare instance of severe aggression, a plan of restraint should be worked up in advance in confirmation with the parents. Caregivers of children with autism are concerned about both the child having an unpleasant experience and about their own embarrassment in the event the child is not compliant or having a behavioral outburst. It is important to provide some reassurance to parents to make them comfortable. Inform the parents how the appointment will go and what their role will be in advance to avoid overwhelming them during the visit.
In an ideal circumstance, scheduling the first appointment as an introduction appointment to the dental team and the physical space is preferred. Consider giving an office tour. This appointment should be kept short and positive. Do not render oral care during this appoint- ment. Though desensitization appointments are most valuable for this population, it is important to keep in mind that sometimes it might not be possible for the patient/caregiver to return for a while due to other medical needs or logistical reasons. In such instance, it is important that the patient is evaluated for any emergent care or acute infection. At the same time it is important to address parents’ concerns and develop a relationship so the caregiver feels comfortable in returning to the clinic to establish a dental home for the patient.
Schedule short appointments. As for any healthy child, a short, non-threatening appointment always builds trust and increases compliance. If possible, discuss desensitization appointments and role of home care instructions with parents to improve compliance for potentially coopera- tive patients. Children with spectrum disorder have altered sensation and many times oral aversions. A good home care regimen with regular tooth brushing helps the patient to get used to the oral sensation of toothbrush and paste.
Wear a protective coat of a different color for the patient who responds negatively to the traditional doctor’s white coat. This could help reduce the trigger of a negative doctor’s appointment or in general have a more friendly environment for a child. The doctor could also introduce himself/herself in the waiting area a few minutes before the patient is brought in, to prepare the patient in increments.
Consider utilizing the toothbrush prior to any other instrumentation. Many a times parents or caregivers help children at home with brushing. Introducing familiar objects by familiar figures help to develop trust. While the caregiver brushes the teeth, a quick exam and slow transition to the provider could be helpful in letting the patient allowing the dentist to do a thorough exam. Help parents with various techniques to help brush their child’s teeth.
Tell, Show, Do—the classic technique of behavior management—works well for chil- dren with autism as well. Slow introduction of new stimuli and preparing the child how they will feel with different instruments can improve in better compliance.
Sensory overload leads to overstimula- tion for most patients with ASD. Minimize heightened activity in the treatment room by minimizing introduction of too many new people in the room. Minimize noise from un- wrapping autoclave packages, or other avoid- able sources. Minimize use of overhead light if possible as some patients can get extremely reactive to bright light. When interacting with the patient, avoid rapid movements or rapid speech; rather, move and speak in a calm manner. Sometimes comforting items like lead apron can be used if patient allows it to relax them. Parental presence/absence: Caregivers and parents play a pivotal role in manag- ing the behavior of a special needs patients. They spend a lot of time with them and can provide helpful cues in managing their behavior. Thus typically it is a good idea to utilize the caregiver actively/passively while treating the patient. It should be discussed in advance with the parents, their expectations from the appointment for both the child and the appointment.
Self injurious habits are commonly noted in children with autism. It is important to be observant of any such injury and distinguish it from child abuse. According to literature, children with special needs are more prone to child abuse. Many patients have co-morbid conditions including seizures and thus dental trauma may be noted. Educate parents about management of dental trauma and how to utilize emergency department in case of need. These patients are reported to have a higher pain tolerance and some are non verbal. Thus a thorough exam is even more imperative to rule out any source of pain or active infection.
Despite all efforts, sometimes we are not able to deliver the planned care for the child, owing to behavioral or other factors. It is important to be patient and not dismiss the patient without encouraging parents and being considerate of their efforts at home. Be flexible and willing to modify the treatment goals for each appointment.
For children on the spectrum who are ab- solutely uncooperative or medically complex and needing significant dental work, always try to collaborate with other medical speciali- ties. If possible, and time permits, a thorough exam and radiographs for patients who are going for any other procedures under seda- tion can go a long way in helping the patient to eliminate any developing dental disease.
Routine and consistency is a well documented strategy in the management of children with ASD. Maintaining a continuity of care using the same dental team members and treatment room on each subsequent ap- pointment for these patients can be noted for a more successful following appointment.
Reinforce to the parents the need of regu- lar home care and its role in make the patient more compliant during the dental visit. Give small goals to parents like brushing for 5-10 seconds to 2 min paired with activities that child likes. For example they can try brushing while watching TV. Children with ASD often have food based reward system as a part of behavior therapy. Emphasis should be made to address carious process with frequency of food. Some patients like vibration feelings with power brush so we can recommend electric toothbrush. Three sides toothbrushes can also help parents for cleaning all surfaces if the teeth at once.
Use of pictograms, video modeling and dental social stories can be helpful. Behav- ior specialists work with these children for various social situations. These tools can be helpful in preparing a child for a visit to the dentist. Thus establishing a plan with the be- havior specialist or occupational specialist can be a unique approach but very helpful. Simi- larly, tooth brushing techniques can be taught to the child during the physical therapy ses- sions if the child takes those at school.
In the end, "if you have seen one child with autism, you have seen only one child with autism." This is very true as the ASD has a wide spectrum. We need to be creative and flexible in treating these children. One technique that worked for one child dur- ing an appointment, might completely fail another time. Thus it is important to always keep an open mind and patience. It is impor- tant to remember the struggles the parents have to go through every single day and its worth spending a few minutes to check with them if they have any concerns we can help with. The satisfaction of getting a successful visit for these patients is not only a relief for parents but a sense of self satisfaction non parallel to any other.
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