Mastering the Spectrum of Care by Cheryl DiVita, RDH, and Katie Zoratti, MS, MBA

Patients on the autism spectrum
For children with autism spectrum disorder and developmental delays, oral health is a different kind of challenge. These children are often nonverbal and have sensitivities to light, sound and touch, which are all factors that need to be considered when caring for and treating children with autism.

Autism affects 1 in every 68 children in the U.S., mostly in three key areas of their life: social interaction, communication, and behaviors and interests.

To have successful dentist visits, many children with autism need help coping with and familiarizing with their surroundings—but this takes time, patience and many visits to achieve. Planning with your staff and parents is important.

Scheduling appointments and "meet-and-greets"
When scheduling, recommend that parents submit all paperwork ahead of time so they won't need to tackle this in the waiting room. If they sound uneasy, have them speak with the hygienist before the visit. Also, encourage parents to bring children for a "meet-and-greet" visit to the office during quiet time (i.e., lunchtime) before the day of the actual appointment. This will help children acclimate to the new environment.

Have a specific operatory picked out that will used every time the child visits. The ideal operatory will be private and have a neutral paint color and limited wall hangings. Having a familiar and consistent process and location with limited distractions can help put children at ease. Let children explore the entire office if needed, and let them sit in the chair to encourage a positive experience.

Planning ahead with the families
In preparation for the visit, encourage the families to plan ahead on their end, too. Have families create visual supports such as social stories or visual schedules to help prepare children. Social stories are visual stories to show children where they're going. It may include a picture of the building, the reception desk, the staff and someone in a dental chair—essentially telling a story as to what children should expect on the visit. Also, have a visual schedule to use during the visit to show the process step by step, which helps children understand what activities are going to take place.

If children are involved with applied behavior analysis (ABA therapy), the use of visual supports showing the difference between "work time" and "play time" can be helpful. This can help to get children to sit down and stay in the chair.

Also, the use of a token board can assist with the process, incentivizing children to follow directions. Both supports offer children guidance and a system of reward for their participation.

If sensory inputs are needed to get children to sit in the chair or have them feel more comfortable, have parents bring a special toy, blanket, stuffed animal or tablet with a favorite video.

A "visual schedule" shows children with autism spectrum disorder the series of steps they'll be involved in during their dental visit, such as lying in the chair, opening their mouth and brushing their teeth.

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  Step 1

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  Step 2

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  Step 3

Tips for a smoother visit
When the child arrives, be ready and immediately take him or her to the designated operatory room. It's not that these families aren't willing to wait—it's that they physically can't in many cases, because of being overly stimulated in new situations.

Moving quickly to a private room can also help keep children more calm (and parents less stressed).

Take a slow, gentle approach to gain trust and confidence. The more children can trust you as their dental provider, the more they'll allow more dental procedures as they grow.

When greeting children, be mindful of their sensitivities. For example: With typical kids, we tend to enter the room and say "Hi!" With autistic children, however, your normal voice can often be perceived as too loud—or even yelling—so it's recommended to ease into the initial greeting. Other recommendations include putting yourself at the child's eye level and keeping your expressions soft.

Refrain from calling yourself "doctor" when introducing yourself. Instead, go by "Mr." or "Mrs.," or just your first name. Show children you're their friend to help put them at ease and feel relaxed, ultimately gaining their trust.

Also, keep the number of people involved with the visit to a minimum, because too many people in the room can be intimidating and overwhelming. Doctor's offices can be a revolving door for many children with special needs, so knowing one fewer doctor and gaining one more friend could just be the trick to a successful visit.

Finding the right balance
Each child is wired differently. Some kids do better sitting on Mom or Dad's lap before acclimating to the dental chair. Always start with a toothbrush or something familiar from home. Remember, your touch and your instruments such as brushes, flossers and the light are things that many of these children find difficult to deal with (or they're just new to them). Again, it's important to just ease into it and find that balance.

Learning likes and dislikes
Parents should communicate their child's likes or dislikes such as sensitivity to lights, or the fact that loud noises can be upsetting. Many children with autism are nonverbal, so their reaction to these may often be shown with behaviors such as covering their heads, running away, kicking or crying. However, it's just them trying to tell you they can't handle all of these inputs at once. Often, they need to be introduced or eased into them more slowly.

Using successful techniques
During the visit, playing music or singing a favorite song like the ABCs while you're brushing can be calming to a child. Visual supports are very important during this part of the visit. Encourage parents to stand chairside if needed, and bring visual supports that show the child each step of the process. (Example: "Open your mouth, so a mirror can be used to count your teeth.")

Also, use this time with the parents to educate them on the importance of brushing their children's teeth and work on brushing techniques that work for the child, whether with a cloth or a baby toothbrush. A lot of parents do not brush their child's teeth because of sensory issues. Even if parents get resistance, it's important to keep trying to brush their child's teeth every day. The earlier they start, the better the child will adjust and make it a routine.

Scheduling frequent follow-ups
Don't be discouraged if a child's first few visits with you are filled with crying and resistance, or you only get as far as having him or her sit in the chair. Work with their families and encourage them to come every three months, instead of six—the extra visit is strictly a checkup to get the child comfortable with the dental visit process: sitting in the chair, becoming familiar with the instruments, understanding the steps, seeing consistent people involved in the process, etc.

Treating children with autism and developmental delays can be very rewarding,­ and can also carve a niche for your practice in your local marketplace as other parents hear how deft and skilled you are. The key to success is planning with staff and families, establishing familiarity and routines—and, of course, patience, patience, patience!