BY Josalyn Sewell, RDH, OMT
You are a good hygienist. You keep up on current research, read your monthly publications, and pay attention during CE courses. You have a basic, working knowledge of many health conditions and disorders, including diabetes, addiction, mental illness, high blood pressure, and developmental disorders (including autism). You know that autism is complex, involves sensory challenges, and that communication is difficult.
However, today is Friday, and your first patient on Monday morning is a child with autism who has never been to the dental office. The entire office and the family is counting on you to try to make this appointment successful. Are you ready?
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- The world of autism: Treating patients with autism can be very rewarding for the dental hygienist
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Are you ready if the patient is nonverbal? Are you ready if they have a meltdown? Are you ready if they find noises difficult to deal with? Are you ready if they refuse to get near the dental chair?
If you are not currently ready, don't panic. I am going to walk you through some simple, practical strategies that will prepare you. I have confidence you will be able to answer the question with a confident "Yes, I am ready."
You might even love this article so much that you frame it and we become social media BFFs. OK, I'm exaggerating a little but the truth is your doctor will love you, your patients will adore you, I will love you, and you will feel so good about making a positive difference that is about so much more than removing plaque and calculus.
Do your homework
Ideally, the medical and dental history should be done beforehand. I find it important to have a medical history that is more specific to autism. The medical history should include information about sensory challenges, communication abilities, and a section for parents to share what the child is interested in. If the family cannot bring the paperwork in beforehand, I will call to interview them and take notes. The parents really appreciate it. I like to know beforehand if a child is sensitive to lights or sounds rather than finding out by accident and upsetting them during the appointment.
I have created a free, downloadable autism specific medical history form on my blog just for you. Visit AutismAintForSissys.blogspot.com.
Build a relationship of trust-It is not uncommon for us to come in scalers-a-blazing and jump right into somebody's personal space within minutes of the greeting.
The greatest tool you have when working with patients with autism is time. I understand the ticking time bomb on the wall and the schedule you are required to keep, but please try to slow down and spend a little quality time with these patients, especially the first visit. You should already know a little about the patient if you have the medical history filled out. Talk about the characters, shows, or activities the patient enjoys. Use creative ways to incorporate these interests in the appointment. If the autistic patient favors a certain character, I try to have stickers or a picture available. Often, that is how I can break the ice and connect with the patient.
Aim for the least restrictive strategies - People with autism generally have incredible memory. If you traumatize them by holding them down and clean their teeth even while they are screaming and kicking, they may never forget it or overcome their fear of the dental setting. It is better to take things slow-even very, very slow. Once they gain the skills it takes to behave appropriately in the dental chair, they often become the easiest patients.
These patients thrive on structure. Once they understand what the routine is for at the appointment, they will not budge until it's done. It is more difficult to work with a patient who has been previously traumatized than it is to work with a patient who is fearful because they have never had a dental appointment.
If there is a true dental emergency such as trauma, the situation may then require the parents to restrain the child in order to help them get out of pain. Thankfully, for dental hygiene, plaque and calculus are not reason enough to traumatize an individual. Our job is not just to render a mouth free of plaque; it is to teach appropriate behavior and encourage independence-both of which have the potential to carry over in positive ways in other areas of the patient's life.
Clear, concise, and consistent - Large portions of the autism population have auditory processing challenges that may also be accompanied by a sensory processing disorder.
The buzzing of the ultrasonic cleaner at the end of the hall may agitate them and keep them from attending to or understanding the person two feet in front of them. When you speak a sentence, it may take longer for them to process the words. As I result, if you say, "Open your mouth," followed immediately by, "Open, open, open," the patient start over at the beginning each time you speak a word in the effort to decipher what you am asking.
This means you should say, "Open your mouth" just once and then wait a few seconds. Often, just when you feel that need to repeat yourself, the patient will open. Keep your sentences clear, concise, and consistent. Individuals with autism are very literal. Statements such as, "Open like an alligator," may not have any meaning to them. Pick the phrases you will use and stick to them. Do not say, "Open up" followed by "Open your mouth," followed by, "Big, big, big ..." or whatever you typically communicate to little children. Pick one phrase and stick to that. Consistency is key.
The tone of your voice is really important. For many individuals with autism, such my son, words are not functional. The tone of my voice is an important clue in the puzzle of communication. If I talk in a high-pitched, happy voice, all my son hears is that I am happy, and he can keep doing whatever he is doing. If I speak to him in an even tone and more directly, he knows I am asking him to do something.
I often use a key word that alerts him to know I need him to pay attention. For Ethan, I may say, "Ethan. Focus. (pause) Open your mouth," in a very clear, calm tone.
Ask the parents or caregivers what works best to get the patient's attention. Be sure to make notes in the patient's chart and coach the other members of the team to use the same language.
Make it visual - People with autism are highly visual. If you can show the task in pictures or video, you will increase understanding immensely. A instruction can immediately be ineffective. Pictures are static; they can be held and looked at for much longer. Implementing a visual schedule is easy, and many children on the autism spectrum use visual schedules at home or at school.
A visual schedule is exactly like your to-do list-just in pictures. The schedule can be a set of photographs of different aspects of the dental appointment (sit in the chair, having radiographs, polish, fluoride varnish, etc.) on a ring. Show the patient the photograph, complete the treatment in that image, and move on to the next photograph. It is also nice to have the presentation on poster board and attach the images with Velcro. When the task is completed, the patient pulls the photograph off and sets it aside, signaling that it is done. When the patient can see what will happen next, it takes a lot of anxiety out of the appointment. I recommend laminating the photographs so that they can be wiped clean and will not get crumpled or wet.
Practicing at home
I like to give my patients a few disposable items to practice with at home before the appointment. I include a pair of gloves, a mask, saliva ejector, fluoride brush, and a prophy angle. I explain to the parent what they are for and what to do with them. Most importantly, this allows the patient to touch the items and become comfortable with having them in the mouth. I also encourage the parents to brush the child's teeth while they are lying down a few times a week before the appointment. The actions of brushing and lying down can make the appointment easier.
Count to ten - A simple practice that has helped me tremendously is counting to 10. It takes a few times for the patient to understand what I expect, but once they understand it works beautifully. If I am polishing and they want me to stop I will agree to polish for 10 seconds only.
As soon as I start polishing I start counting, and I do not stop polishing until I reach ten. I need them to understand that I will stop but not until I say "10." If you automatically give up at two or three you will never get to ten. If the patient is struggling, I count really fast; if they are doing well, I can drag out the count. If the child closes, I do my best to not appear to have stopped until I get to ten to reinforce the behavior.
With sharp instruments it becomes more difficult because you will have to quickly remove the instrument if the patient closes down. Just keep trying. This works great for typical kids too.
Short, frequent visits - When introducing a patient to the dental setting, it is best to have them come for several short, frequent visits. The first visit is almost always a happy visit. If the patient is willing and ready, I am prepared to provide treatment but do not put the pressure on my patient or myself, if the first visit is just an introduction.
Always make the first visit enjoyable and fun so that the patient and parent will be eager to return. I have found that with the really difficult patients a series of two or three appointments about a week apart seems to work well to help patient's master the appointment.
Sensory friendly office - The first appointment of the day seems to work well. The patient is rested, has had breakfast, and is not worn out from school or therapy. It also means that I can leave the radio off, and the autoclave and the dental drill are not buzzing yet. The office is calmer and quieter. It also means that I am fresh and can roll with the punches more freely than when I am tired and ready to go home.
It is just as easy to turn off the overhead sounds and wait to turn the autoclave on any time during the day as it is in the morning; it will be your preference. Lastly, you have a great sensory tool hanging right behind your head-the lead apron. Lay it on the patient for the entire appointment. It is comforting and calming.
Useful apps - I recommend one video and the use of one app for all my patients. The app I like is called, "My Healthy Smile" and is available only at the app store (iPad, iPhone). There are short social stories with pictures that walk the patient through various dental procedures (radiographs, prophy, exam, braces, for example). It also has a section for home care that talks about eating healthy foods, brushing twice a day, etc. It is $1.99 and worth much more.
I also use this app with typical kids who are anxious. Sometimes I pull it out and use it chairside. I strongly recommend the use of a self-modeling video. Look At Me Now is a company that has videos of a child doing a number of things: going to the doctor, going to the dentist, getting nails trimmed, etc. The parent uploads a picture of the child and the company transposes the patient's head onto the child's body in the video. The child can now visualize going to the dentist and behaving appropriately. This has changed the way I practice. I hope you look it up and use it.
So, let me ask the question again. It's Friday afternoon, and your first patient on Monday morning has autism. Are you ready? I have confidence if you implement one or all of these strategies you will be successful in your treatment.
Let us not forget that success can be measured in many ways. When you can help a patient overcome fear, anxiety, and sensory challenges to lay in a big chair with a bright light shining on them, you will feel like you passed your clinical boards with a 100%. You will also want to be my social media BFF. So get out there and give it your best shot. If you think about it, reach out to me and tell me how good it feels. RDH
Use Rewards Appropriately
You will witness a combination of good and negative behavior within a single appointment, especially if the patient is new to the dental setting. It is critical to manage that behavior to the best of your abilities. Drawing attention to negative behavior will often increase the likelihood that it will happen again. Ignore the negative behavior. If the child acts inappropriately, simply turn your head away and wait until a few seconds after the behavior has stopped to turn around.
Concentrate instead on the behavior you want to continue. Some patients may be motivated by cheering and a robust, "Way to go!" with a high five. For some, that kind of enthusiasm will be detrimental. The first time my son urinated in the toilet I cheered and yelled and hugged him with a loud "Good job, buddy! You did it!" It turned out to be too much for him because he remembered the overwhelming excitement, and he didn't do go in the toilet again for a year and a half. I had to learn to curb my excitement.
Follow the parent's lead and ask before you get started. I like to have a few things in my drawer that I find most of my patients with autism enjoy-little fidget toys, stickers, small puzzles (not the jigsaw kind, I prefer the ones where you have to move a bead through a maze, or get a ring on a stick suspended in water), and anything with flashing lights is always a winner. Avoid items that make noise. I look for items that offer a lot of sensory information: bright colors, flashing lights, different textures. I've never met a kid that didn't like bubbles.
Take a photo of the rewards and use them in the visual schedule. For example, if you know that rinsing after polishing is especially hard for that patient, put a reward card following that activity. The patient will have something motivating to get them through a difficult task.
Learn when to fade out rewards. The goal is to get through the entire appointment with a single reward at the end. To get there will take lots of practice. Tackle one challenge at a time. Let's say you have a new patient that is "pre-cooperative" and will not sit in the chair. Ask them to sit in the chair, and, even if they sit down for half a second at the end of the appointment, reward them immediately for the attempt. Say something like, "Yes! You sat in the chair. Good job. You get bubbles for sitting in the chair." Blow one wand full of bubbles and give the direction again. If the bubbles are motivating enough, the patient will try again.
As the patient masters the task, it is important to fade out the rewards. If they sit in the chair without a problem, there will be no need to offer a reward. The key to a successful reward is that it should be highly motivating and of short duration. If it lasts more than a couple of minutes, it makes getting back to the appointment difficult. The patient will forget why they were given a reward in the first place.
Josalyn Sewell, RDH, OMT, enjoys many aspects of a dental hygiene career, including clinical work, teaching, speaking, writing, and sales. She is a member of both the ADHA and CareerFusion. Josalyn's full-time position is in domestic management (stay-at-home-mostly-mom) in a rural town in the mountains of eastern Arizona. She blogs about what it is like to raise a child on the autism spectrum. You can find her blog at: autismaintforsissys.blogspot.com or on Facebook: Autism Ain't for Sissys.