Oral Health Conference

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Developing a Desensitization Program

• to Teach Children with an Autism Spectrum
  Disorder (ASD) to Tolerate Dental Procedures
• An Oral-Behavioral Model

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• Ronda DeMattei, RDH, PhD
• Assistant Professor of Dental Hygiene
• rondad_at_siu.edu
• Rachel Huckfeldt, BCBA,MS
• Behavior Analyst
• Anthony Cuvo, PhD
• Professor of Behavior Analysis Therapy
• Director of the SIUC Center for Autism Spectrum
  Disorders
• acuvo_at_siu.edu
• Jenny Sulllivan, BS
• Graduate Student of Behavior Analysis

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Funding for this project was provided in whole or
part by

• Illinois Childrens Healthcare Foundation
• The Autism Project
• Southern Illinois University Carbondale

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Collaborative Approach to Person-Centered Oral
Care
Dental Hygiene
The Child
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Behavior Analysis Therapy
Communication Sciences Disorders
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Acquiring oral care for children with an ASD is a
difficult problem.

• Multifactorial reasons for lack of adequate oral
  care for this population
• Inadequately trained dental personnel
• Lack of reliable funding for treatment
• And, the most prohibitive problem is

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The childs behavior.
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Typically, individuals with an ASD

• Are dependent upon routines
• Are hypo-or hyper-sensitive to some aspects of
  their environment
• Lack age appropriate communication skills

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Diagnostic Criteria from the DSM IV TR (2000)
forPervasive Developmental Disorders (PDD)

• Autism Spectrum Disorders (ASD)
• Autistic Disorder (AD)
• Childhood Disintegrative Disorder (CDD)
• Retts Disorder
• Aspergers Disorder
• PDD-NOS (Not otherwise specified)

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DSM IV TR Diagnostic Criteria for Autism Disorder
(AD)

• A total of at least six items from categories 1,
  2, 3.
• With at least two from category 1, and
• one each from categories 2 3.
• (1) Qualitative impairment in social interaction
• (2) Qualitative impairment in communication
• (3) Restricted, repetitive, and stereotyped
  patterns of behavior, interests, and activities.

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1. Impairments in Reciprocal Social Interaction

• Marked impairment in the use of multiple
  nonverbal behaviors
• Failure to develop peer relationships appropriate
  to developmental level
• A lack of spontaneous seeking to share enjoyment,
  interests, or achievements with other people
• Lack of social or emotional reciprocity

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2. Impairments in Communication

• Delay in, or total lack of the development of
  spoken language
• When speech is present, inability to initiate or
  sustain conversations
• Stereotyped and repetitive use of language or
  idiosyncratic language
• Lack of varied spontaneous make-believe play or
  social imitative play appropriate to
  developmental age

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3. Restricted, Repetitive Behaviors, Interests or
Activities

• Encompassing preoccupation with one or more
  stereotyped and restricted patterns of interest
  that are abnormal either in intensity or focus
• Apparently compulsive adherence to specific,
  nonfunctional routines or rituals
• Stereotyped and repetitive motor mannerisms (e.g.
  hand flapping)
• Persistent preoccupation with parts of objects

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Basis for Developing the Desensitization Project

• Past research has shown that compliance of
  individuals with developmental disabilities with
  dental procedures can be improved.
• Shaping, reinforcement, fading (Kohlenberg et
  al., 1972)
• Visual schedules (Backman, Pilebro, 1999)
• Desensitization (Altabet, 2002 Luscre, Center,
  1996 Conyers et al., 2004)
• Video modeling (Conyers et al., 2004)
• Little research has focused specifically on
  children with autism

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Prerequisite Child Skills

• Joint attention
• Responsive to reinforcement
• Ability to follow a routine
• Ability to self-regulate
• Communication skills
• Ability to follow simple instructions
• Ability to hold mouth open for 10s at a time

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Desensitization

• means that aversive stimuli are gradually
  introduced to people who tend to have phobic
  reactions to the stimuli.
• involves behavioral demonstrations of increased
  tolerance to the stimuli that is reinforced with
  praise or tangible objects identified in a
  preference assessment.

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Mock Dental Office atCenter for Autism Spectrum
Disorders
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Example of Desensitization Hierarchy

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Desensitization DVDs
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Desensitization Program

• Consisted of
• Baseline
• Priming DVD
• Desensitization/Picture Cues
• Differential Reinforcement of Other Behavior
• Using Escape Extinction
• Posttest-Returning to the Dentist
• Settings
• Dental clinic
• CASD
• Childs home

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Baseline

• Dependent variable childs progression through
  desensitization hierarchy
• Performed at the SIUC Dental Hygiene Clinic
  (dental office)
• Targeted stimuli that were aversive at the dental
  office
• Clinician presented each step in hierarchy
• Compliance next step
• Noncompliance removal of stimulus

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Desensitization/Picture Cues

• Same conditions as baseline EXCEPT
• Compliance at target level access to preferred
  items (identified by a preference assessment)
• Noncompliance escape extinction
• Differential Reinforcement of Other Behavior
• After 3 consecutive sessions at target level, a
  probe occurred to see if subsequent steps needed
  to be directly taught
• Next target was . . .
• Step prior to occurrence of problem behavior
• Next step in hierarchy

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DVD Priming

• Not modeling because
• Too long between viewing emitting behavior
• Puppet narrator makes it unlike real situation
• Priming exposing child to salient stimuli
  associated with an upcoming event
• Not intended to teach a skill to mastery
• After mastering target desensitization
  hierarchies, child watched movie at CASD twice
  and several times at home before visiting dentist
• Parents recorded data on childs watching on a
  1-3 rating scale

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Example of ResultsPre- Posttest
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• Thank you for your time.
• Questions?