October 24, 2013
« AT THE UNIVERSITY OF WASHINGTON, THE CENTER FOR PEDIATRIC DENTISTRY DEVELOPS PROGRAM FOR PATIENTS WITH AUTISM »
Dedicated to making a difference in children’s oral health, Dr. Travis Nelson created a unique tool a year ago to serve that goal: an autism clinic at The Center for Pediatric Dentistry. “I read everything I could about designing an ideal dental experience for these kids,” says Dr. Nelson, Acting Assistant Professor of Pediatric Dentistry and head of The Center’s sedation clinic. “Treatment of children with autism requires a lot of flexibility, but we felt that there was an advantage in creating an organized approach to care. We put a protocol on paper and systematized it.”
An academic interest in autism and his desire to help children led Dr. Nelson to develop ways to make pediatric patients feel safe and comfortable enough to undergo oral exams and, in some cases, treatment. To help prepare children for their first visit to The Center, Dr. Nelson worked with experts from the Autism Center at Seattle Children’s hospital to create a “social story” that depicts, with simple language and illustrations, a visit to the clinic. “It’s low-tech, but it’s dynamite,” says Dr. Nelson. His website photos with and without a procedure mask also help ease children’s fears, and his “gold standard” in the clinic is completing an exam with a mouth mirror. “If you are an adult with autism and won’t allow a dental examination, the chances are unlikely that you will get needed dental care,” he says. “We are working to develop these abilities in childhood. Simply sitting in a dental chair for a mirror examination is a huge life skill.”
Growing up in Northern California, Dr. Nelson spent hours trailing his dad, a pediatric dentist whose practice was focused on Medicaid patients and children who could not get care elsewhere. “I saw kids with lots of problems, and that had an impact on me,” says Dr. Nelson. During his UW pediatric residency, he often saw youngsters with special needs at Children’s Hospital, many of them with autism. He also traveled to Alaska and Peru and found funding for his interests through the UW’s Global Health Practicum program. Autism spectrum disorder (ASD) is “primarily a communication disorder… one of the most challenging in pediatric dentistry,” he says. “Your primary tool in getting that child through a dental procedure is communication.”
Dr. Nelson looked to the families he met to understand more about ASD and how to help their children. “There’s such an amazing opportunity with these families and their children,” he says. “For example, I took up a video cam to document behavior in the clinic. When asked to consent, every parent said, ‘Yes, if it will help another child with autism.’"
"In some ways, autism is a catch-all diagnosis. There are thousands of genes that code for neurologic functions. An alteration, (and) any one of them could cause the symptoms of autism.” Symptoms vary widely. Some children shun sensory stimulation or oral contact; others crave particular sensations. Children can feel like they’re free-falling or exhibit combinations of behavioral mannerisms and fears. To work effectively, Dr. Nelson relies on the detailed responses from parents in a 10-page new-patient packet he created. “The questions are designed to reveal who the child is, his strengths and challenges with previous dental visits,” he says. “What is the best reward for good behavior?” One child gets to toss rocks in a lake. Others love shiny tokens. One lad receives an empty recyclable container each time he cooperates. “He likes the smell of them,” says Dr. Nelson, who keeps a stash of empty clothes detergent and dishwashing bottles for these visits. “His mom brings a duffel bag filled with containers. If he sits in the chair, he gets a container.”
The lead radiograph protective vest gives some children the sensation of pressure they crave. One child will open his mouth only when standing in the corner, and that’s fine with Dr. Nelson. For some children, none of these techniques are effective, and protective stabilization may be used after consulting with the parents. The information packet also reveals what the parents want, and helps Dr. Nelson determine the starting point for the first visit, which is strictly noninvasive. The examination room has no dental chair, just toys to play with in a quiet space with a door. Here Dr. Nelson or one of the pediatric dental residents talk things over with the parents and set a goal for the child. “Parents will guide you,” says Dr. Nelson. “We just have to listen. Parents do a lot of the work. They practice at home with the kids. It’s not a lot of dentistry. It’s a lot of time and behavior.”
Families with children who have autism can see Dr. Nelson or a resident each Monday and Tuesday. Referrals are chiefly word-of-mouth via families and from the UW Autism Center and Seattle Children’s hospital, though parents can just call for an appointment. Dr. Nelson typically sees 15 patients in an afternoon and says the clinic can handle more. The glue holding everything together is consistency, from the dental assistants on up. “Kids with autism have been on the website, they’ve seen my picture,” says Dr. Nelson. “I check in with all the families each time, introduce myself and the resident. They’re seeing a consistent face.” He acknowledges that this work can be frustrating: “Some children make a lot of progress and their parents are thrilled. That won’t happen for a lot of others. “My goal is to be able to provide families with their best version of what a dental visit can be. We are trying to establish best practices for dental treatment of children with autism.”
Used by permission of the Dental Alumni News.