Autism, or autism spectrum disorder (ASD), refers to a wide range of conditions that can cause social, communication and behavioral challenges.1 There has been a significant increase in the number of people with ASD over the past few decades with approximately 1-2% of the Canadian population being diagnosed. This translates to approximately 135,000 Ontarians on the autism spectrum.2 Although the symptoms and severity of autism may vary among children, the impact on their families’ daily life is meaningful. A simple dental visit can be overwhelming and stressful to an autistic child and their parents. This may be related to intense sensory experiences (e.g. noises, odors, lights, and invasion of personal space) and a lack of knowledge about what to expect during a dental visit. To provide successful care to children with autism, dentists cannot simply deploy their usual techniques. They must adapt to the unique needs of the ASD patient population.
Children with autism often desire routine and familiarity. New settings and situations can be stressful and result in maladaptive behaviors.3,4 Preparation prior to the appointment can lay the groundwork for a more successful dental visit. There have been various forms of social skills training for children with ASD. Social stories can help a child with ASD understand social contexts that they might otherwise find difficult to interpret. These stories include pictures and descriptive, perspective and directive sentences to outline the steps involved in a task.5 Studies have shown that social stories can increase frequency and length of positive interactions and modify inappropriate behaviors.6 At Holland Bloorview Kids Rehabilitation Hospital we have created a social story specific to our dental environment. It was developed in collaboration with autism play therapists and Holland Bloorview families. We provide the social story prior to appointments and recommend families read the story once a day each day of the week leading up to the dental appointment. Many of our patients, particularly younger children, respond positively to the story, and it has proven to sufficiently prepare some patients for their upcoming appointment. However other patients require more immersive approaches.
Fig. 1
Intervention therapies for autism are based on behavioral analysis and positive reinforcement of desired behaviors. One such method is applied behavioral analysis (ABA) which focuses on how changes in the environment might influence behavior. This approach is rooted in the principle that children’s learning is encouraged by their position as active participants in the environment.7 In the past, the Holland Bloorview dental department used a strategy of repeated exposures to the dental clinic combined with ABA principles to establish positive appointment behaviors. While effective, this approach is time consuming (four visits per year for approximately two years to improve comfort level and compliance). This places a heavy burden on families and impacts clinical resources and access to services within the department. On top of this we have seen a 116% increase in the number of referrals (193 in 2014 to 418 in 2018), which further challenges our resources. This combination of factors led to the search for digital intervention tools that can relieve the demands on families and practitioners.
Today’s world of ever-present screens and digitally adept children make technology like virtual reality (VR) a promising solution to these challenges. VR is a computer-generated simulation that allows the user to interact with an artificial three-dimensional environment.
Fig. 2
VR systems have many features that can help children cope with unfamiliar situations. In particular, they offer a high level of authenticity and realism, allowing children to explore new and stressful settings in comfort prior to the actual experience.8 VR can be presented to the user through head-mounted displays, wall projection systems, computers or tablets. The autism research group at Holland Bloorview has previously developed a VR product to help children with ASD prepare for the bus ride to school. This pilot project demonstrated the safety and usability of VR equipment in kids with autism. Further, ⅔ of participants reported that they felt the VR experience could help other children feel less nervous about riding the bus.9,10 To explore the potential for virtual reality to help children with ASD cope with the dental environment we have partnered with Shaftesbury Films to develop and test a new virtual reality product (a 360° video) developed for the dentist’s office.
The product aims to reduce pre-visit dental anxiety for children with ASD, improve their dental visit experience and reduce the costs associated with disrupted or multiple dental visits. Through the VR program, variables can be adjusted to progressively desensitize the child to the dental environment. For example, the volume of equipment and the number of steps of the appointment. As well, interruptions such as a child crying in another room can be introduced to intensify the experience as needed. By using a 360° video the experience can be presented on a tablet, making it a relatively inexpensive tool for families. A randomized control trial will be carried out to determine the effectiveness of the product. The ultimate goal is to develop a commercial 360°
video product that can be used beyond the Holland Bloorview community.
References
- Lord C, El+sabbagh M, Baird G, Veenstra-VanderWeele J: Autism Spectrum Disorder. The Lancet 2018; 392: 508-520.
- Anagnostou E, Zwaigenbaum L, Szatmari P, Fombonne E, Fernandez BA, Woodbury-Smith M, Brian J, Bryson S, Smith IM, Drmic I, Buchanan JA, Roberts W, Scherer SW. Autism spectrum disorder: advances in evidence-based practice. CMAJ 2014: 186(7):509-19.
- Stoner JB, Angell ME, House JJ, Bock SJ: Transitions: Perspectives from parents of young children with autism spectrum disorder (ASD). J Dev Phys Disabil 2007;19(1):23-39.
- Gomot M, Wicker B: A challenging, unpredictable world for people with autism spectrum disorder. Int J Psychophysiol; 2012: 83(2):240-247.
- Scattone D, Wilczynski SM, Edwards RP., et al: Decreasing Disruptive Behaviors of Children with Autism Using Social Stories. J Autism Dev Disord: 2002: 32, 535–543.
- Aldabas R. Effectiveness of social stories for children with autism: A comprehensive review. Technology and Disability: 2006; 31: 1-13.
- Roane HS, Fisher WW, Carr JE. Applied Behavior Analysis as Treatment for Autism Spectrum Disorder. J Pediatr 2016 ; 175:27-32.
- Newbutt N, Sung C, Kuo HJ, Leahy MJ. The acceptance, challenges and future applications of wearable technology and virtual reality to support people with autism spectrum disorders. Recent Advances in Technology for Inclusive Well- Being; 2017: 221-241.
- Malihi M, Nguyeen J, Kushki A. A Physiologically- Mediated Virtual Reality Experience for CHildren with Autism Spectrum Disorder. In: Poster Presentation. International Society for Autism Research, Annual Conference 2019.
- Malihi M, Nguyen J, Cardy RE, Eldon S, Petta C, Kushki A. SHort report: Evaluating the safety and usability of head-mounted virtual reality compared to monitor-displayed video for children with autism spectrum disorder (ASD). Autism. Published online (in press).doi:10.1177/1362361320934214.
Oral Health welcomes this original article.
About the Author
Dr. Molly Friedman is co-director of the dental residency program at Holland Bloorview Kids Rehabilitation Hospital. She also maintains a private practice in Toronto dedicated to children’s dentistry. She can be reached at mfriedman@hollandbloorview.ca
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