Most clinicians have or will treat a patient who has special needs, whether those special needs are easily recognizable physically or come in the form of a developmental disability such as autism. What may be a routine dental visit for us or for another child can be a stressful event that incites an emotional tailspin for others.
Autism spectrum disorder is a variable condition on the rise in the United States, and it affects our children in mysterious ways. In April 2018, the Centers for Disease Control released new statistics on autism spectrum disorder. The newest studies indicate that, in the United States, one in 59 children is on the autism spectrum, up from the previous figure of one in 68.1 A government survey of parents revealed that one in 45 children has been diagnosed with autism.2 The prevalence of the disorder is greater among boys than girls: one in 37 and one in 151, respectively.1 There is speculation about the cause of autism, although it still remains unknown.
Autism can manifest in a multitude of ways; every child it affects is different. From those mildly affected to those who have a profound disability, each individual has unique triggers and coping mechanisms. In many cases, early intervention and therapy have improved the ability of children to learn and communicate with others and to learn social skills that don’t come naturally to them. Some of the more common manifestations of autism include repetitive movements such as rocking back and forth, avoiding eye contact and touch, struggling to understanding others’ feelings and emotions, delayed or undeveloped language, and upset over changes in routine. Most children who have autism have intense reactions to textures, smells, sounds, lights, or colors. Shifts in routine and new environments or faces can cause anxiety in these children, often making them less cooperative as patients.
Parents often expect to bring home perfect bundles of joy and are eager to watch them grow and experience the world around them. In our daughter’s early years, she was a difficult child, and we knew something was not quite right. She hit all the milestones as an infant, such as talking and walking, but she wasn’t like the other little ones at daycare. We were urged to get an evaluation, and then we were given the heart-wrenching news of her diagnosis: autism in conjunction with ADHD. Although she is considered high functioning, she will likely always need some form of support. Through the help of therapies, she is learning to function outside of the home, which is what every parent of a child with special needs hopes for.
The patience and compassion required to raise a child with special needs have made me a better clinician on many levels. I have been able to treat patients with special needs when others have failed, and much of that success has come from recognizing triggers in my most severely affected patients. I have been blessed to treat Ian, who is 6 foot 3 inches and nearly 300 pounds at the age of 19, and who has severe autism. I had seen Ian’s parents and brother for years while Ian was treated by a pediatric dentist—then he came to my chair. His mom was a source of information and support for me when we first faced our daughter’s diagnosis, and in turn, she felt that I knew enough about the condition to attempt to treat Ian.
The first few times he was in my chair, he wore a head-to-toe body sock for comfort and earphones for noise. With his family’s help, I learned his signs of excitability and agitation. Ian spoke very few words and lacked the ability to express himself when something was not right. He would bring a book and repetitively tap a finger on a certain picture until there was a hole in the page. I never asked Ian to put his book away during treatment; he was able to hold it mostly out of the way. He needed this outlet for anxiety, and it didn’t prevent me from completing his treatment.
Fortunately, he was not caries prone, although brushing was difficult for him. Like many autistic patients, he was hypersensitive to sensations. Sometimes patients will not allow polishing paste if the taste or texture is too foreign. Using a power brush was not an option for Ian, and his family had a difficult time helping him use a manual brush. The Super Brush by Paro is a favorite of mine for patients with limited dexterity or special needs. It brushes the buccal, lingual, and occlusal surfaces all at once, which is helpful in cases where cooperation is limited, as it is efficient and quick.
Often, patients who have autism are on medication to help manage the manifestations of the disorder. With a combination of less-than-ideal home care and medications, they are often more prone to xerostomia and caries than their peers. Many of the commonly used medications for autism treatment are also used for ADHD (Concerta, Adderall, Vyvanse). However, many patients who have autism are also on medications that help control anxiety, which often comes with the disorder. Anxiety in the dental chair typically stems from the deviation from routine.
Treating patients with special needs poses its own challenges in the dental office, but there are techniques that can help to minimize distractions in order to make the appointment easier on all parties. When scheduling dental visits, be considerate of the best time of day for the patient—is this patient more comfortable and cooperative in the morning or afternoon? If at all possible, try to schedule patients with autism for times when the office is quiet to help avoid extra stimulation—or to avoid disrupting others if your patient is noisy and vocal.
It’s also helpful to speak with the parent or caretaker ahead of time to inquire about actions, sounds, or sensations that may trigger the patient. Most people affected by the disorder have a comfort mechanism or action that helps them cope in stressful environments. For my daughter, being in a dental office is no problem, but the sound of the handpiece humming brings her stress. She hums throughout her entire appointment in order to comfort herself, even when she is feeling particularly cooperative.
Noise-canceling earphones are common tools in helping individuals who have autism dull the overpowering stimuli of daily life. Many patients with autism will find comfort in the use of a weighted blanket; try offering to drape your lead apron over the patient during the procedure if needed. The weight and pressure can help calm the overstimulated nervous system. My daughter’s therapist recommended the WatchMinder, a wristwatch with programmable and customizable reminders and alarms that can be set to vibrate on her wrist at intervals. The pressure of the band and the physical stimulation from the vibration provide her with a sense of comfort. For a child who is easily distracted and off in her own world, the watch has proven to help her tremendously in staying on task at school.
In most cases, the calmer and more soft-spoken the clinician is, the easier it is for the patient to cooperate. Explaining the process step-by-step may also help ease the anxiety brought on by the procedure. If your patient is verbal, find out what subjects motivate him or her; finding common ground will help ease the anxiety. Many people who have autism are incredibly intelligent and have vast knowledge of certain subjects. You are likely to learn something from them.
Autism spectrum disorder and the stress it produces for parents and caretakers often create a heavy emotional burden. On the flip side, children who have autism are often classified as “bad kids” when they act out if others are unaware of their neurological condition. We discuss autism using a spectrum because the range of disability is broad, and the manifestation of symptoms can vary as time goes on. When a child is diagnosed with autism at a young age, he or she can receive therapies to help with the development of necessary life skills. Therapies often focus on daily living skills and can take several hours each week and multiple trips to doctors and clinics. Discuss with the parent and caretaker their concerns, and remember that, although patients with special needs may not always be as compliant as their peers due to forces beyond their control, you can work on finding a solution together.
References
1. CDC increases estimate of autism’s prevalence by 15 percent, to 1 in 59 children. Autism Speaks website. https://www.autismspeaks.org/science/science-news/cdc-increases-estimate-autism%E2%80%99s-prevalence-15-percent-1-59-children. Published April 26, 2018. Accessed August 7, 2018.
2. Behind the science: New 1 in 45 autism prevalence survey. Autism Speaks website. https://www.autismspeaks.org/blog/2015/11/16/behind-science-new-1-45-autism-prevalence-survey. Published November 16, 2015. Accessed August 7, 2018.
Jamie Collins, RDH, CDA, is a practicing clinical hygienist in Idaho and Washington states. She has been in the dental field for nearly 20 years, both as an assistant and hygienist. With a passion for patient care, especially for those with higher risk factors, she enjoys sharing the tips and tricks of the dental profession through speaking and writing. In addition to being in clinical practice, she is also an educator, has contributed to multiple textbooks and curriculum development, and is a key opinion leader. She can be contacted at
[email protected].
