Behavioral procedures to increase cooperation of developmentally disabled children with dental treatment

This study evaluated the effectiveness of reinforcement procedures in increasing cooperation and reducing disruptive behavior during restorative dental treatment. Four mentally retarded children received praise and tokens for cooperating with direct requests From the dentist and for sitting quietly in the chair; tokens could later be exchanged for toys. A multiple-baseline, across-subjects design was used to assess levels of cooperation during varying length baselines and during the intervention. Uncooperative behavior decreased in all children (substantially in three subjects) Following implementation of the reinforcement-based intervention. Comparing the subjects" baseline and intervention sessions showed a statistically signih’cant decrease in the level of uncooperative behavior during the intervention. Issues relating to generalization of the Findings and Factors influencing maintenance of treatment effects are discussed. Behavior management procedures to increase cooperation during dental treatment are being used increasingly by pediatric dentists. 1’’~ Recent research has shown that a number of behavioral technics are effective in reducing fear and uncooperative behavior during dental treatment of normal children using modeling procedures, ’~-8 modeling plus reinforcement, 9 and desensitization. 1° However, research in the application of behavioral technics with developmentally disabled children has been limited. Management of the mentally retarded child during dental treatment is more complex. The pedodontist is more likely to encounter aggressive behavior, behavior that is physically dangerous to the child, and poor cooperation, which can result in inefficient and lengthy treatment. 11 Kohlenberg et al. ~2 used fruit juice squirted into the mouth as a reinforcer to encourage severely retarded individuals to sit quietly in the chair, attend to the dentist, and keep their mouths open. They found that two 45-minute training sessions resulted in more cooperation and less need for physical restraint compared to a control group. Unfortunately, the reinforcement procedure was only evaluated during examination--not during restorative treatment. Savide et al. ~’~ used a combination of reinforcement and systematic desensitization to complete eight sessions of restorative treatment in a 13-year-old mildly retarded individual. However, this program required three sessions per week of relaxation training and systematic desensitization to dental procedures for 14 weeks before restorative treatment could proceed. Behavioral interventions also have been shown to be effective in teaching oral hygiene skills in an effort to reduce the need for restorative treatment. Horner and Keilitz ~4 used tokens and praise as reinforcers to teach toothbrushing skills to eight mild to moderately retarded children. The behavioral performance sequence of toothbrushing was analyzed, and 14 sequential components were identified. Six of the children were successfully taught the step-by-step sequence in from 20 to 30 sessions, and their oral hygiene improved considerably. The present study attempted to extend the application of behavioral procedures in pediatric dentistry, particularly during restorative treatment of developmentally disabled patients. Uncooperative mentally retarded children were selected for whom restorative treatment posed an increased risk. These children previously had been so disruptive during dental examinations or treatment that sedation, including general anesthesia, was recommended or required before treatment could proceed. The procedures were designed to be implemented by a dentist and a dental assistant with a minimum amount of instruction, using common apparatus and materials, and to obviate the need for premedication or physical restraint. The present study also was designed to evaluate the effectiveness of a procedure known as differential reinforcement of other behaviors (DRO) in reducing uncooperative behavior during restorative treatment. ~5 The PEDIATRIC DENTISTRY:Volume 4, Number 4, 31 7 DRO procedure involves reinforcing the first neutral or desirable response that is emitted following a set interval in which another, usually undesirable, response has not occurred. Pilot research revealed that successful completion of restorative treatment requires that the child cooperate with direct requests such as to open his/her mouth, and to cooperate passively by sitting quietly in the chair. Much of the disruptive behavior observed occurred during periods when the child should have been sitting quietly. During intervals when the child was actually sitting quietly, the dentists tended to infrequently reinforce this cooperative behavior. Understandably, the dentists involved were interested in completing treatment carefully but quickly in response to the child’s lack of cooperation. Therefore, in addition to reinforcing cooperative responses to direct requests, a DRO procedure was implemented to systematically reinforce passive cooperation in fixed, short intervals. The net effect of a DRO procedure is to decrease the frequency of undesirable behavior by reinforcing behavior which is not disruptive. Videotaping the sessions allowed a detailed analysis of the topography of the behaviors being studied and assessment of the effectiveness of the experimental procedures. Methods and Materials Subject and Setting Four mild to severely retarded children were selected on the basis of poor cooperation during previous dental examinations. Three of the subjects were extremely uncooperative and disruptive during the initial examination. Previously, such behavior resulted in excessively long examinations and the use of sedation. The fourth subject previously had required a muscle relaxant, 3050% nitrous oxide, and containment in a Pediwrap® on five occasions, and general anesthesia on another occasion before restorative treatment could be completed. It was recommended that future examinations or restorative treatments to these subjects involve sedation or, in one case, general anesthesia. Subjects ranged in age from 6 to 8 years, had a mean IQ of 45 (range: 38 to 60), and exhibited behavior problems. Normally the subjects lived at home and attended special education classes in the public school system. However, for the three weeks of the study, they were hospitalized in the behavior unit of the John F. Kennedy Institute for Handicapped Children, Baltimore, MD. They were studied in one of the dental operatories of the Institute’s Division of Pediatric Dentistry. There were two reasons for this. First, all subjects required extensive restorative treatment with moderate to severe caries involvement.~6 It was felt that restorative treatment could best be accomplished if they were inpatients. Second, the subjects presented with general behavior problems including hyperactivity, aggressiveness, noncompliance, and frequent tantrums. Both the school system and the subjects’ parents requested further evaluation and behavioral programs to manage these problems. Previous attempts to develop behavioral programs for these other problems on an outpatient basis largely had been unsuccessful and more intensive evaluation in the behavior unit was indicated. The subjects were able to continue with academic activities in a fully accredited special education program at the Institute. Measurement The uncooperative behavior of the subjects during restorative dental treatment was assessed by trained observers who viewed videotapes of experimental sessions. The observers did not participate in the planning or execution of the study. Five uncooperative behaviors were selected for evaluation based on observations of other children undergoing restorative treatment and discussions with dentists at the Institute. The following definitions were used to score uncooperative behavior during each session: 1. Attempts to dislodge--an attempt to remove or to expel dental instruments, materials or the dentist’s fingers with the hands, tongue, or by spitting 2. Inappropriate mouth closing--any time the subject closes his/her mouth during the session without previously being instructed to do so 3. Inappropriate vocals--crying, verbal requests to terminate, expletives, groaning, whining, and any speech not directly in response to a question 4. Restraint--any head, hand, leg, or body movement that requires physical restraint and causes a delay in dental work for a 5-second period or longer 5. Aggression--acts of biting, hitting, or kicking the dentist or assistant. The five categories were scored using a 1-minute interval recording procedure. An occurrence of one or more of these behaviors was noted by checking the appropriate category within the interval on a data sheet. Attempts to dislodge, inappropriate vocals, and mouth closing, and aggression were scored in the interval in which they occurred or, if there was overlap, in both intervals. Restraint was scored in the interval in which the definition requirements were fulfilled. Observation began when the subject was asked to sit in the dental chair and ended when the chair was raised to a sitting position and the napkin removed. Data are presented as the percentage of 1-minute intervals in which one or more of the five categories of uncooperative behavior occurred. Percentages were calculated based on the total number of minutes each subject spent in the baseline and treatment conditions, respectively.