Fabricating an Interproximal Strip Holder

Applied Behavioral Analysis (ABA) has become the preferred learning method for many educators and specialists in preparing children with ASD for specific procedures. According to Maurice and colleagues, ABA helps these children to "build socially useful repertoires" of observable behaviors and to reduce or extinguish "socially problematic ones".⁸ One way to apply the method is through the use of a Picture Activity Schedule, a series of pictures representing the action or procedure to be learned. Several studies have suggested that children with ASD respond well to behavior modification using visual prompts. Krantz and colleagues demonstrated that photographic activity schedules depicting a variety of home-living tasks could enhance the engagement and social interactions of children with ASD while reducing their disruptive behavior.⁹ Luscre and Center combined desensitization, modeling, and reinforcement to improve the ability of autistic children to undergo dental exams.¹⁰ Nevertheless, a recent literature review found no evidence-based procedural recommendations that could address the behavioral characteristics and problematic behaviors of children with ASD in a dental environment.¹¹

The present study was designed to evaluate the effectiveness of a Picture Activity Schedule in managing children with ASD in an orthodontic examination, using the principles of ABA.

Materials and Methods

The study was conducted at the Nassau Suffolk Services for Autism (NSSA) Martin C. Barrell School in Commack, New York. After Institutional Review Board approval was obtained, a mock orthodontic office was created in a converted storage room, with donated dental equipment including a fully operational dental chair.

All 24 students enrolled at the school were eligible for the study, but informed consent was obtained for only 16 (11 males and five females). Since ASD is a complex and multifaceted condition with inherent individual differences, no control group was used; each child's baseline results were compared to his or her post-ABA results.

To obtain the baseline data for each subject, we attempted to complete an orthodontic exam in the mock office, consisting of these 13 individual steps:

1. Patient enters room.
2. Picture taken of face with lips relaxed.
3. Picture taken of face with smile.
4. Picture taken of face from side with lips relaxed.
5. Patient sits in dental chair.
6. Patient opens mouth for count of five seconds.
7. Teeth counted individually and evaluated with mirror and explorer.
8. Patient bites and holds teeth together (occlusion evaluated with mirror).
9. Anterior picture taken with teeth together (cheek retractors used).
10. Picture taken of right occlusion (cheek retractors used).
11. Picture taken of left occlusion (cheek retractors used).
12. Picture taken of upper teeth with mouth open (cheek retractors and occlusal mirror used).
13. Pictures taken of lower teeth with mouth open (cheek retractors and occlusal mirror used).

A conventional "tell-show-do" technique was used to explain each step to the student. A subject was given three chances to complete a step before the sequence was discontinued. The number of steps completed and the time required for completion of each step were documented.

Six senior NSSA teachers, all certified ABA instructors, then prepared the subjects for reevaluation. The teachers were given their own sets of dental instruments and underwent a training session for the mock exam with Drs. Schindel and Chahine. They were also provided with a Picture Activity Schedule illustrating each of the 13 individual steps. The teachers trained with the students for 15 minutes twice a day for two weeks (nine school days), reviewing the Picture Activity Schedule in conjunction with the dental instruments. In the beginning of training, the teachers stood behind the subjects, using hand-over-hand assistance as needed, to ensure that the Picture Activity Schedule, rather than verbal or visual cues from the teacher, was used as the prompt for each step. Praise was offered using individual reward systems for compliance. As the training progressed, the teachers began to withdraw their physical guidance until the student was following the schedule independently.

At the end of the two-week training period, the original sequence of steps was repeated in the mock orthodontic office, with only the student and authors present. If a subject was reluctant to complete a step, the Picture Activity Schedule was held up to demonstrate it. As before, each student was given three attempts to complete a step before the sequence was discontinued. The number of steps completed and the time per step were again recorded.

Results

The 16 students' length of enrollment at the school ranged from one to 19 years (mean 8.9 years); their ages ranged from 10 to 23 years (mean 14.4 years). According to a weighted chi-square analysis (four males per one female), the gender distribution was not significant (x2 = 1.27; p = .261).

In the baseline exams, five students completed all 13 steps, 10 completed at least some of the steps, and one was unable to undergo any steps (Fig. 1).

After the ABA intervention, 13 subjects completed all steps, two completed some steps, and the same student failed to undergo any steps. The mean completion times were significantly faster for 11 of the 13 steps, and the total time required to complete all 13 steps was reduced (Table 1). Paired t-tests of the five students who completed all 13 steps in both the baseline and post-intervention exams also showed significantly faster times for 11 of the 13 steps. (Click here for additional data in Tables 2 and 3). No relationship was found between the student's length of enrollment and the ability to complete steps or the time per step.

Discussion

Treatment of children with ASD can be a challenging experience for the orthodontist due to their compromised ability to communicate. Traditional methods of behavior management such as "tell-show-do" have limited effectiveness with these patients, who respond better to visual forms of learning than to verbal instructions. The aim of our study was to determine whether the use of a Picture Activity Schedule, based on the principles of ABA, would increase compliance with an orthodontic exam that included clinical photography. Although the first author has had success using this technique in treating autistic children with full fixed appliances and with palatal expanders, a less complicated procedure was chosen for our initial project.

The significant improvement we recorded in the time required to complete each step of our mock exam, as well as the increased number of subjects able to undergo all 13 steps, suggest that a Picture Activity Schedule can be an effective method of preparing patients with ASD for orthodontic procedures. Since there are multiple steps involved in most procedures, it is crucial that the steps can be carried out in a repeatable sequence within a reasonable amount of time.

There were several limitations to this study, including the small sample size, the absence of a standardized control group, and the lack of individual diagnostic criteria based on the severity of disorder. The subjects had varying skills for learning a procedure with a Picture Activity Schedule, including the ability to follow single- and multiple-step directions, the capacity for picture-object correspondence, and the level of receptive language. The degree of maladaptive behavior could also affect a student's acquisition rate. Given the positive outcome of this study, however, we recommend further research involving more students from this school and from other facilities that teach children with ASD.

Picture Activity Schedules in Private Practice

Picture Activity Schedules have been successfully used to prepare children with ASD for various orthodontic procedures--including full diagnostic records, banding, bonding, wire placement, and palatal expansion--at the School of Dental Medicine at Stony Brook and in Dr. Schindel's private practice. (downloadable picture activity schedule and book)

To produce Picture Activity Schedules, the orthodontic office needs to break down each treatment procedure into individual steps. These steps are then photographed using a model patient who is cooperative and who will be available if additional photos are needed (Fig. 2AB, CD).

In our experience, the sex of the child shown in the picture books does not make a difference to the patient. Simple explanations should be written to accompany the photographs. Ideally, a repertoire of procedures will be prepared and stored digitally, ready to be assembled into customized Picture Activity Schedules depending on particular treatment needs. For example, if a patient with ASD requires palatal expansion, the pages with sequences for fitting bands and taking an impression are selected and merged.

Once the individualized Picture Activity Schedule is prepared and printed, it is reviewed in the office with the patient and parent. If the patient's teacher will be involved with the training, he or she could also be present; we have seen equally good results with either teachers or parents. It is important to review the Picture Activity Schedule every day with the patient. Although there are no specific guidelines as to the length of preparation, we have found success with a two-week training period.

On the day of the patient's appointment, the procedure is reviewed with the orthodontist in the operatory, using the Picture Activity Schedule. When the procedure begins, the parent or teacher positions the schedule so the patient can utilize it as a visual prompt. We have found a diminished need to use Picture Activity Schedules over the course of treatment: new procedures are more easily introduced, often without prior training.