January 1, 2013
by Robert P. Carmichael, BSc, DMD, MSc, FRCD(C)
Being a child with a special health care need (SHCN) places you in one of Canada’s largest minority groups. According to Human Resources and Skills Development Canada, in 2006 there were 202,350 children (3.7% of children) between the ages of 0 and 14 years with a disability in Canada.
Oral health issues are more prevalent and likely to be more serious but also more likely to go untreated in low income children with SHCN than in low income healthy children. Barriers to care for children with SHCN include inadequate physical access, scheduling complications, erratic attendance to appointments, inadequate reimbursement, behavioral problems, a paucity of dentists competent to provide care and onerous paperwork. Though these are all real obstacles to care that need to be removed, bringing about disability equality involves more than installing a wheelchair ramp or demonstrating a willingness to accept lower reimbursements from government sponsored disability support programs. What is needed is to recognize the biases that children and youth with SHCN face when trying to access oral health care. These are more often attitudinal, arising from underdeveloped disability awareness, but the net result is an indifference or reluctance to treat children with SHCN.
Physical or mental impairment will always guide treatment, but a patient- and family-centered approach is necessary to guarantee that children and youth with SHCN receive the same access to care as healthy ones. Thus, the social model of disability de-emphasizes the impairment and emphasizes the environmental barriers to oral health care. Accordingly, while the necessary clinical skill set and knowledge-base required to treat kids with SHCN may require special training, and as proficiencies need to be incorporated into the dentist’s skill set, disability awareness training is vital to attaining disability equality.
Dentistry has already embraced a willingness to respect the needs of children and youth with disabilities. Some elements of special care in dental school curricula now align with the ethos of the social model approach to SHCN, and there are numerous examples across the profession demonstrating its general acceptance. It is nevertheless evident that negative attitudes, cultivated by dentists and their teams and within society, persist to block access to dental services. Ontario is taking steps to improve accessibility under legislation that is the first of its kind in Canada. The Ontario Legislature has passed into law The Accessibility for Ontarians with Disabilities Act, 2005 (AODA) that lays the foundation for mandatory standards designed to identify and eliminate barriers — including attitudinal — to accessibility. On January 1, 2012, the first of five Accessibility Standards — the Customer Service Standard —came into force. All organizations — including dental offices — with at least one employee must establish and train staff in policies, practices and procedures governing the provision of its goods or services to persons with disabilities. The AODA will also be applied soon to employment, information and communications, transportation and the built environment, and in doing so aims to create a “fully accessible Ontario” by the year 2025. New government policies notwithstanding, there will continue to be a need within dentistry and society in general to dispel negative attitudes towards disability by promoting a social model approach to SHCN.
This issue of Oral Health magazine features articles linked by a common theme – eliminating barriers to oral health care in children and youth with SHCN, and written by dental staff at Holland Bloorview Kids Rehabilitation Hospital and the Department of Pediatric Dentistry at University of Alberta where the social model of care is well entrenched. Most children and youth with SHCN will, however, seek dental care in the community, and whether their dental home is a pediatric or general dental practice, a hospital outpatient clinic or an emergency room, they will encounter various barriers to services the rest of us take for granted. If dentistry can uniformly adopt a social model approach to disability that eliminates the barriers faced by children and youth with SHCN in accessing these services, we as a profession have the opportunity to lead the advance to disability equality in health care. OH