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Systematic desensitization  can be used to help children or adults with autism effectively overcome phobias and other anxiety disorders. 

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Systematic desensitization  can be used to help children or adults with autism effectively overcome phobias and other anxiety disorders. 

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A guide to on what reasonable adjustments are, what adjustments have helped other autistic people, and how to ask for adjustments you might need.

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1. What is systematic desensitization (SD)?
Systematic desensitisation helps people learn that something is safe or manageable. This happens with professional support, by taking small, predictable steps at the persons' own pace, to help them feel more comfortable with a feared situation (e.g., visiting the dentist).

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A calm down kit is a set of materials put together in a box, bag, or corner of a room that children can use to calm down or distract themselves when their emotions might overwhelm them.

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What is a Calm Down Kit?

A Calm Down Kit, or Calm Down Box, is a container with sensory featured items meant to calm someone down. People diagnosed with different anxiety disorders, Autism or other sensory-related disorders often feel overwhelmed by things that they may encounter in the span of a day. A Calm Down Box has toys and fidget spinners to distract the child's attention while they cool down from an episode. Your child can customize their box by picking the things that are the most pleasing aesthetically to them and finding a place for it, so they consciously learn where to go and how to handle panic attacks or anxiety-induced episodes.

Expected Outcome of using a Calm Down Box

The purpose of having a Calm Down Box available for sensory-sensitive kids is to have the right tools ready to deescalate stressful situations. The items in the kit work almost like a pacifier for emotions. By occupying a child's senses with pleasing aesthetics, these objects help them relax and forget about what caused the problem.

If a child is sensitive to sensory stimulus, different experiences have a greater effect on his or her sensory perceptions. Things that most people can process quickly might overload someone with sensory sensitivity. If an experience is too much to handle for someone, ideally, they would be able to escape with their Calm Down Box and occupy their physical energy while the sensory neurons in their brains get time to cool down. It creates a sensory safe space where the child can find sanctuary and regain control of their thoughts.

Calm Down Kits teach self-regulation and can also promote better habits. These kits do not only work for a crisis. Children can make using their fidget toys a part of their routine by using them to ease any tension while waiting to leave for school or a doctor's appointment or helping them decompress at the end of the day before bed. Screen time on tablets or computers can have similar effects calming down certain kids, but the light given off by screens is actually stimulating. This makes Calm Down Boxes ideal for before bed.

How to Use a Calm Down Box

There are a few ways to implement a Calm Down Box for your child. Depending on your child's needs, you may want to have a Calm Down Box and a smaller mobile kit to take with you outside the house. Especially for the kit at home, it should be able to be accessed by the child easily, without help. If there is a tantrum or crisis, they will know exactly where to go to manage it. If you would like to make it a fixture in your child's schedule, like before bed for example, having a timer close by could help.

As for the contents of a Calm Down Kit, they can be customized by the child. Try objects that appeal to all five senses. Putty, clay, sand, stress balls and fidget toys are all excellent for the tactile senses. Hard candy to suck on can occupy taste and maybe some olfactory senses. Oils the child can smell, like lavender, also soothe olfactory senses. Kaleidoscopes or possibly stereoscopes can appeal to visual senses. A music box, or a good enough seashell can calm auditory senses. Even if the shell echoes a softer ocean, concentrating on listening for the sound can help.

What Kinds of Children Can Benefit from a Calm Down Kit

Calm Down Kits are helpful for children learning to self-regulate emotions. Whether or not a child has a disorder that affects their sensory perception, they are growing up in a technological age where their brains can easily be over-stimulated. Calm Down Kits give children breaks as needed to relieve anxiety, stress, anger and other unwanted emotions.

They specifically help children that cannot easily process senses and emotions. This can mean being distracted or overwhelmed by external stimulus. That makes Calm Down Kits beneficial for children dealing with Attention Deficit Hyperactivity Disorder, Generalized Anxiety Disorder, Autism Spectrum Disorder or posttraumatic stress disorder.

Benefits of Utilizing a Calm Down Kit

Using a Calm Down Box is a form of treatment. Your child will be able to relieve symptoms while also learning self-care strategies. The ability to keep calm in the face of stress and manage it is one of the hardest skills to master. The act of walking away to the kit creates the habit of taking a step back from overwhelming problems before facing them, so your child will be essentially practicing emotional self-regulation skills.

Calm Down Kits are also essential for emergencies. If your son or daughter is prone to violent tantrums, preparing a kit can prevent them from hurting themselves, hurting others or breaking something. A mobile kit might even save a night out. You can help your child cool off somewhere and readjust to the surroundings without going all the way home to feel safe.

Where to Buy a Calm Down Kit

You can collect materials individually and build your own Calm Down Box with the right sensory objects. There are also preprepared kits available online. You can build your own kit or find the right combination of tools in a premade package. The box itself does not have to be made a certain way. The objects it holds should be chosen to meet the needs of the Calm Down Kit's owner.

How to Create Your Own Calm Down Kit

You can create your own Calm Down Kit with sensory objects that appeal to your child. Let them decide which things ease their nerves the most and collect them in a container. The more the child customizes their Calm Down Kit, the better, because it shows them taking ownership. The kit and self-regulation practices become a part of your child's life and daily routine.

When making a mobile kit, make sure the container is easy to conceal, and pack light. Only stick to your child's favorite objects, or you can have them pack their Calm Down Box themselves.

Conclusion

A Calm Down Box is an important tool for any child learning to manage their emotions. It's crucial for kids with sensory sensitivity because it is impossible for them to live independently without learning to manage overwhelming experiences. Calm Down Kits guide children through tantrums, panic attacks, and managing self-regulation of their thoughts and mood. Calm Down Kit users are encouraged to personalize their kits as much as possible, because they will know what works best for them.

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Want to help your sensory-sensitive child calm down? Learn about the uses and benefits of calm-down kits for overwhelmed children, and how to make your own.

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Visual stories are a useful tool to support learning for autistic young people. Explaining what is going to happen, and when, can help young children manage anxiety, know what to expect and help them stay engaged in doing tasks and activities. All you need is a pencil and a notebook or our helpful templates.

Why are visual stories helpful?

We know that consistency and routine are important to autistic children and young people. A visual story is a simple and predictable visual support tool that helps a child or young person move from one activity to another.

Visual support is about using pictures and time frames to help your child understand what is happening.

Visual stories can support children and young people of any age or ability. They can be used to help children communicate while their speech is developing or as a tool to predict tasks and activities throughout the day.

A visual timetable

A visual timetable uses pictures and symbols to help a child or young person know what is going to happen next. The predictability of events can help with the transition from one activity to another.

A visual timetable, like our daily planner template, has space for different images to represent the sequence of activities for the day. You can use them to explain what is going to happen, for example: "Today we are going eat breakfast. Then we will walk the dog at the park. Then we will come home and do another worksheet. Then we will play a game. Then we will each lunch," and so on.

Some might find it reassuring to see the whole day at once - but for others this could be overwhelming. It may be helpful to 'start small', with a few activities at a time, and then to gradually extend the length of the sequence you use as you and your child become familiar with the visual timetable system.

A 'Now and Next' visual

Our 'Now and Next' templates have two columns- one for 'now' and one for 'next' with space to draw a picture, stick a symbol or a photo. By placing an image under each heading and showing this to your child, you are helping them to understand the process of activities or tasks.

By pointing to the picture and using simple instructions, you are reinforcing the message. For example: "Brush your teeth now, put your pyjamas on next" while pointing to each image in turn. When the first activity is finished, you can inform them by saying "brushing finished, put your pyjamas on now" while pointing to the next picture.

It is helpful to use the 'next' side of the visual tool, to place an activity that your child enjoys, something that will motivate them to act or complete the first activity.

Here are our tips to use visual stories successfully.

Keep it brief and keep it simple.

Describe everything in a positive and patient tone.

Have a dedicated space where your child can see the visual story easily and often.

Actively show that an activity has finished by ticking or removing the symbol or picture.

Review the timetable at the start and end of each day.

If possible, ask them to repeat the story or share it with others.

Present the story in a simple format. Black ink on white paper works well but some children find coloured paper easier.

Stress the steps that you know are going to pose challenges.

Try to incorporate the full range of 'who, what, when, why, where and how?' by explaining the visuals as you go

Use reward activities at the end of challenging events or tasks. For example: 'If you brush your teeth, you can play on the Nintendo for one hour'.

Reflecting on visual stories

This may be new to you and your child and it might take a few attempts for you to both feel comfortable with it. If it doesn't work first time, that doesn't mean it won't work at all.

At the end of an event or day's activities, go over the visual story together. You can look at how everything you talked about happened and how much better things were because you had both been able to prepare and feel ready for what was going to happen next.

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Ambitious about Autism is the national charity for children and young people with autism. We provide services, raise awareness and understanding, and campaign for change. Through TreeHouse School, The Rise School and Ambitious College we offer specialist education and support.

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Advice about taking medicines and medical appointments if you're autistic

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Advice about taking medicines and medical appointments if you're autistic

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Advice about taking medicines and medical appointments if you're autistic

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Advice about how to make medical appointments and taking medicines less stressful if you or your child are autistic.

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Systematic Desensitization for Trips to the Doctor, Dentist and Haircuts for Kids with Autism 

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Systematic Desensitization for Trips to the Doctor, Dentist and Haircuts for Kids with Autism 

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Systematic Desensitization for Trips to the Doctor, Dentist and Haircuts for Kids with Autism - Dr. Mary Barbera

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Dr. Mary Barbera discusses systematic desensitization tips for children with autism. Desensitizing such trips and procedures can make trips to the doctor, barber, and dentist much less stressful, and more tolerable for your children or clients with autism.

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How to prepare an autistic child for a blood test?

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How to prepare an autistic child for a blood test?

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Talk with your pediatrician about whether numbing cream or relaxing medication should be used. Take a tour of the office where the blood test will take place and plan a reward after blood draw visit. Pack a bag with comfort items, favorite toys, communication device, internet device, or favorite foods

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Supporting a Young Person Struggling with Anxiety

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Supporting a Young Person Struggling with Anxiety

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Repeating certain behaviours, actions or rituals (these are often called obsessive compulsive behaviors and can be a symptom of obsessive compulsive disorder (OCD)).
A change in eating habits
They might start to refuse snacks or food during a session. Alternatively they may start always carrying food on them, or be eating throughout sessions.
Self-harming
Purposefully harming themselves can be a coping technique for anxiety. If you're worried that the young person you are supporting is self-harming, we have some information and advice that can help.

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Supporting a Young Person Struggling with Anxiety

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Repeating certain behaviours, actions or rituals (these are often called obsessive compulsive behaviors and can be a symptom of obsessive compulsive disorder (OCD)). A change in eating habits They might start to refuse snacks or food during a session. Alternatively they may start always carrying food on them, or be eating throughout sessions.

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If you're looking for a doctor or dentist for the autistic person you support, it's good to phone ahead to check if the practice is autism-friendly and can offer the adjustments you may need. Many GP practices also offer online and telephone consultations.

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Self-regulating strategies include deep breathing, relaxation exercises, and other sensory activities. Favorite music, books, and even electronics can reduce anxiety and help a child tolerate small amounts of exposure to the feared situation. Self- and co-regulating strategies can also be combined.

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Self-regulating strategies include deep breathing, relaxation exercises, and other sensory activities. Favorite music, books, and even electronics can reduce anxiety and help a child tolerate small amounts of exposure to the feared situation. Self- and co-regulating strategies can also be combined.

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No one likes to imagine that their child will get ill. However, it's sensible for families of autistic children and young people to consider making preparations for a hospital trip, just in case.

We know for many of autistic young people, seeking medical help can induce anxiety. Read our advice on preparing for hospital visits to help reduce some of this stress and worry.

Preparing your child for a visit to the hospital

Talking to health professionals

It's really important that health professionals have as much information as possible, so they can best support any additional needs. We've listed the important information that parents should tell health professionals.

Explain when you first noticed the illness.

Describe what has happened since.

Say what you believe the problems are.

Know your child/young person's weight (for working out any emergency medication dosage).

Ask for reasonable adjustments. These could include asking for a health professional by gender, taking blood samples by thumb prick rather than needle or asking for a quiet space away from excess noise and activity.

You may also need to help the health professional understand the difference between behaviours that relate to your child's autism, and those that you believe are because they are ill.

You can contact the Acute Hospital Learning Disability Liaison Team at your local hospital. They will provide expert advice to the frontline team caring for your child or young person.

Where relevant, also ask the health professional to use communication aids.

Prepare a health passport

A health passport is a document designed to support health professionals care for someone who finds it difficult to communicate for themselves.

The passport covers information about how your child/young person behaves when they experience pain, how best to communicate with them and how to avoid causing distress. It also includes information about any medical conditions they might have.

To complete a health passport you can download our template.

Individual health care plan

Some children and young people with ongoing health conditions (such as asthma, epilepsy, diabetes, allergies etc) have an individual health care plan. This is not the same as an education, health and care (EHC) plan and is different to the health passport described above.

An individual health care plan is an agreement drawn up between parents, carers, a school or college and healthcare professionals about what healthcare is needed to support the child or young person. If your son or daughter has an individual healthcare plan, make sure this is available for any health professionals.  If you think your child or young person needs a healthcare plan, then contact your GP for advice and support.

What to pack in your hospital bag

One-page profile.

Health passport.

Communication support or visuals.

Healthcare plan (if applicable).

Medications clearly labelled with dosage.

Comfort items, for example photo of the family, favourite sensory objects, or a special toy. It might be helpful to include instructions about how to use them with your child/ young person in case you get separated.

Further information

Here are other useful resources to help with hospital trips.

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Ambitious about Autism is the national charity for children and young people with autism. We provide services, raise awareness and understanding, and campaign for change. Through TreeHouse School, The Rise School and Ambitious College we offer specialist education and support.

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Having an activity to complete can really help you self-soothe. Reading and colouring in are the more obvious options and both of these work for me. You can find plenty of inexpensive beautiful colouring books, pretty much anywhere nowadays - The Works, Amazon and Waterstones all have a good variety to choose from. You can also find a lot of printable colouring sheets online. I keep some colouring pencils and a pad to fill in.

Colouring is a very simple task and having something beautiful that you made can feel very rewarding. You might like to write about how you are feeling, or try some creative writing or poetry; for that you can include a pen and notepad. I also keep a book that is an easy, light read.

I would recommend avoiding books that could be potentially triggering, particularly if you are in a vulnerable mindset. However, this can vary from person to person. I know for some people, emotionally dense poetry or literature can help reduce feelings of loneliness or isolation. Other activities can include: word searches, word games, sudoku, knitting, crocheting, collaging, games on your phone etc.

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Having an activity to complete can really help you self-soothe. Reading and colouring in are the more obvious options and both of these work for me. You can find plenty of inexpensive beautiful colouring books, pretty much anywhere nowadays - The Works, Amazon and Waterstones all have a good variety to choose from.

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Appointments: autistic children and teenagers

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Appointments: autistic children and teenagers

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Why appointments can be challenging for autistic children and teenagers

Many autistic children and teenagers have social and communication difficulties, a preference for routines and sensory sensitivities. This means that appointments with unfamiliar people in unfamiliar, busy or noisy places can be stressful for them.

Appointments can also be confusing for autistic children and teenagers. For example, your autistic child might not understand why they're attending the appointment or what's happening. Your child might feel very anxious and have trouble understanding and expressing their anxiety. And your child might express their anxiety by getting upset or frustrated, crying, hiding or trying to avoid the appointment.

Appointments also often mean changes in routine, which can be difficult for autistic children and teenagers to cope with. For example, your child might feel upset if you take them to an appointment when they should be at school.

Before appointments with autistic children and teenagers

If you prepare your autistic child for appointments, this can reassure them that they'll be safe in unfamiliar or confusing situations. Here are strategies you can use.

Develop skills
Make sure your child has the skills for a positive and successful appointment. For example, can they sit in a chair that reclines? Can they follow simple instructions like 'Open your mouth' or 'Look at the light'? You can help your child learn or practise any skills they need before the appointment.

Prepare the professional
Talk to your GP, dentist or hairdresser about your child's needs before the appointment. Older children might like to speak to the professional themselves.

When you talk to the professional, you can explain your child's sensory sensitivities, preferences and interests. If your child has trouble understanding what people say, you can mention this too. For example, you might say, 'It helps if only one person speaks at a time. Please speak slowly, clearly, softly and calmly, and use simple language'.

Gradually introduce your child to the clinic or salon
Consider showing your child pictures of the clinic or salon before the appointment. Your child might be interested in seeing where it is on a map or driving past a few times before the appointment. You could say, 'There's the hairdresser. You're going there on Wednesday'.

If possible, ask the professional whether you can visit briefly before the appointment to see the clinic or salon and meet the professional.

Choose an appointment time
If your child finds waiting or busy spaces difficult, try to book the first appointment of the day. If your child needs time to settle before the appointment starts, you could ask for a longer appointment. You could also ask for an appointment on a quieter day or time in the week.

If your child copes better knowing about things in advance, mark the appointment in a calendar so they can see when the appointment will happen. If your child can't read, use visual cues or pictures.

Use social stories
A social story can help your child understand what's going to happen. You could read the story with your child every day for a few days before the appointment.

At the bottom of this article there's an example of a social story for going to the hairdresser.

Use pictures, visual supports and video-modelling
You might use photos, videos, symbols, pictures, words or other visual supports to show your child what's going to happen at the appointment.

For example, you could make a visual support with photos to show your child what will happen at the dentist. You might take photos of the dentist's front door, waiting area, treatment room and a dental examination. Before you go, you can show this to your child.

You can also use this strategy during the appointment to show your child what will happen next. Ask the professional to put a sticker on the schedule at the end of each step and praise your child.

Video-modelling can help too. You could try looking at YouTube videos of people going to the dentist or hairdresser. Just remember to watch them yourself first to check they're suitable for your child.

Read about where you're going
There are many storybooks that can help you talk about going to the GP, dentist and other places. You should be able to find some at your local library or bookshop. For older children or teenagers, you could look at the hairdresser's or dentist's website.

Watch someone else
You can help your child understand what's going to happen by letting them watch someone else first. For example, they could watch a sibling or friend have a haircut. You might need to do this several times before your child feels comfortable to stay in the room or get into the hairdresser's chair.

Visit an autistic-friendly provider or arrange a home visit
Consider choosing a hairdresser or other professional who regularly works with autistic children and teenagers.

A mobile hairdresser who comes to your home might also be a good idea. Your child can get their hair cut in a familiar place, without the sensory overload of a salon.

Consider using a sedative
Sometimes dentists can prescribe a mild sedative for children and teenagers who get distressed during dental appointments. Children and teenagers who might get very distressed and hurt themselves or others accidentally might be able to have work done under a general anaesthetic.

Get professional help
Psychologists and other professionals with experience in positive behaviour strategies and supports can work with your child to help them feel comfortable about going to an appointment.

While you're waiting with autistic children and teenagers

Waiting to see a doctor, dentist, hairdresser or other professional can be boring and frustrating. It can help to take a bag of things to do - for example, a couple of favourite small toys, a book or audiobook, favourite music, or apps on a phone or tablet. A snack and a drink are good ideas too.

You can also use these strategies during the appointment to distract your autistic child and help them feel more comfortable.

During appointments with autistic children and teenagers

Remain calm
Try to stay calm, if you can. This will help to reassure your autistic child that everything is OK.

Be creative
Think about strategies that might help your child feel more comfortable during the appointment. For example, they might be able to sit on the floor or on your lap, wear headphones or sunglasses, sing their favourite song or talk about their special interest. Depending on the situation, you or the professional might be able to play a game like 'I spy' to distract or calm your child.

Manage stress
If you notice that your child is becoming overwhelmed, take a step back and think about the environment.

Are there any sensory triggers like overwhelming smells or sounds or too much talking? In this situation, let your child have a break while you think of a strategy with the professional.

A sensory item or toy like a soft teddy or a Rubik's Cube might calm your child. It can also help to let them know how long the appointment will take.

If your child gets too distressed during an appointment, it's OK to stop and try again another day.

A social story for going to the hairdresser

Here's an example of a social story for going to the hairdresser.

Everyone's hair grows and needs cutting every few weeks. Usually, they go to a hairdresser to get their hair cut.

Many people I know get their hair cut, like Sam. Sam goes to the hairdresser every month.

At the hairdresser's, people get their hair washed while sitting in a special chair, not in the bath like at home. Then the hairdresser asks them to sit in another chair and starts cutting their hair with scissors.

Sometimes the hairdresser uses clippers to cut people's hair. These make a funny buzzing sound and can tickle. This is OK. The clippers don't hurt.

The hairdresser will talk to me while they're cutting my hair, and I can look at my reflection in the mirror.

When my haircut is finished, I will look fantastic.

You can personalise the story for your child and use language your child will understand. You can also build in possible changes in plans. For example, 'I might have to wait until the hairdresser is ready to cut my hair'. This gives your child an idea of what to expect.

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Appointments: autistic children and teenagers

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Appointments with dentists, doctors and hairdressers can be difficult for autistic children and teens. Social stories, visual aids and preparation can help.

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Preparing a Child with Autism for Doctor or Dentist Appointments

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Preparing a Child with Autism for Doctor or Dentist Appointments

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Categories: ASD and DD, Child-focused

By Erica Kearney, M.A, LABA, BCBA

Children with autism spectrum disorder (ASD) and other developmental disabilities often have a difficult time during visits to the doctor or the dentist. This is understandable. Most of us do not look forward to getting a shot, being poked or prodded, getting cavities filled, or having our teeth scraped clean. And, for children who may have sensory issues and be averse to bright lights and unusual noises, these experiences can be quite frightening.

How can parents make medical and/or dental visits more pleasant for their child with special needs? Below are a few suggestions for parents to consider.

Prior to going to the appointment, practice skills with your child that will make the trip successful. Can they follow simple directions, such as "open your mouth," "say ah," or "look at the light"? Are they able to sit in a chair that reclines? If they do not have these skills, it is important to teach them to your child to help make their visit positive.

When possible, schedule the visit in advance so you, your child, and everyone involved can adequately prepare. Notify the doctor's office that your child has special needs and tell them anything else that will be helpful for them to know. Most offices can be very accommodating by scheduling your child for the first appointment of the day, or the first appointment after lunch, so they will not have to wait a long time to be seen.

Prepare your child by letting them know about the appointment ahead of time, using a calendar or a social story. Social stories are usually written in the first person and give short, positive descriptions about a social or life skill-related situation. They can also include pictures or drawings. For some children, using a social story for doctor or dentist visits can reduce their anxiety by helping them understand what to expect during the visit. You may even want to set up a practice visit or "practice" at home, pretending to go to the appointment and practicing what will happen.

Who will be assisting the child during the appointment? Choose people with whom your child has a good rapport and from whom they will take direction. It is best not to have too many people attend the visit. This can make the environment overwhelming for them and difficult for them to know who and what to attend to. If there is more than one individual present during the visit (other than the medical or dental professionals), select a primary person who will deliver instructions.

If your child has sensory issues, you may want to bring sunglasses they can wear to minimize the glare from bright lights and noise-cancelling headphones that will block out unpleasant or frightening sounds.

Don't forget to bring reinforcers/rewards for your child. Some children may just need to be told that they will get a special treat if they do a good job at the doctor's appointment. Others will need constant reinforcement throughout the entire exam. For this reason, try not to use edible reinforcers, especially for dental appointments. Tablets work well to keep children entertained and happy. Consult with your child's behavior specialist on the best way to provide reinforcement during the visit.

Dentist and doctors' appointments can be challenging for children with ASD and other developmental disabilities. With planning, preparation, and practice, however, the experience can be much easier for children and parents.

Erica Kearney, M.A., LABA, BCBA, is Executive Director of the May Center School for Children with Autism and Developmental Disabilities in Chicopee, Mass. She can be contacted at ekearney@mayinstitute.org.

About May Institute
May Institute is a nonprofit organization that is a national leader in the field of applied behavior analysis and evidence-based interventions, serving autistic individuals and individuals with other developmental disabilities, brain injury, neurobehavioral disorders, and other special needs. Founded nearly 70 years ago, we provide a wide range of exceptional educational and rehabilitative services across the lifespan. May Institute operates five schools for children and adolescents with autism spectrum disorder (ASD) and other developmental disabilities, including one in Chicopee, Mass. For more information, call 800.778.7601 or visit www.mayinstitute.org.

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Preparing a Child with Autism for Doctor or Dentist Appointments

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Categories: ASD and DD, Child-focused By Erica Kearney, M.A, LABA, BCBA Children with autism spectrum disorder (ASD) and other developmental disabilities often have a difficult time during visits to the doctor or the dentist. This is understandable. Most of us do not look forward to getting a shot, being poked or prodded, getting cavities filled, or having our teeth scraped clean.

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Many of us may not like to go to the dentist or the doctor, but we go and for the most part, it is pretty routine. However, for individuals diagnosed with Autism Spectrum Disorder (ASD) an everyday situation like a regular appointment can be a struggle. While the challenges associated with these visits can vary from person to person, as ASD is a spectrum disorder with a wide range of presentations and individual differences, many encounter the same struggles.

Routine Visits Can Be Hard for Individuals with Autism

1. Many individuals with ASD experience sensory sensitivities, meaning they may have heightened or reduced sensitivity to specific sensory inputs. The bright lights, loud noises, unfamiliar smells, and different textures commonly found in dental offices, medical clinics, and hair salons can be overwhelming and distressing for individuals with sensory sensitivities. This can lead to anxiety, discomfort, and difficulty in managing the sensory overload.

2. Those with ASD often find it challenging to adapt to changes in routine or new environments. The dental office, doctor's clinic, or hair salon may be unfamiliar settings with different expectations and procedures. The lack of predictability and routine can cause anxiety and make it difficult to understand and navigate these situations.

3. ASD is characterized by social communication difficulties, which can make it hard to understand and interpret social cues, express their needs and preferences, or engage in small talk. Interacting with dental or medical professionals, who may ask questions, use unfamiliar vocabulary, or expect certain social behaviors, can be stressful and confusing.

4. Some children, teens, and young adults with ASD have difficulties with verbal and nonverbal communication skills. They may struggle to express their pain, discomfort, or preferences verbally, making it challenging for dental professionals, doctors, or hair stylists to understand and provide appropriate care. Limited eye contact, facial expressions, or body language can also affect effective communication and rapport building.

5. Individuals with ASD often experience higher levels of anxiety and fear due to the uncertainty and unpredictability of new situations. They may have difficulty anticipating what will happen during dental procedures, medical examinations, or haircuts, leading to heightened anxiety and resistance.

How Can Parents Help Their Child Overcome These Challenges?

With appropriate preparation and practice, individuals with ASD can develop coping strategies to make these situations more manageable and less stressful. Helpful strategies for parents to try include:

1. Create a Visual - Creating visual schedules or social stories that outline the steps involved in the appointment helps them grasp and anticipate what will happen during the visit, reducing anxiety and providing a sense of structure.

2. Ease In - Gradually exposing a child to the sensory aspects of the experience helps desensitize them and can reduce their anxiety. For example, start by having them sit in a dental chair or hair salon chair without any procedures being done. Then slowly introduce the sound of the tools or the sensation of having their hair touched.

3. Act it Out - Going through the motions of an appointment at home or in a familiar environment helps them remain calm and comfortable. Try taking turns playing the roles of the dentist, doctor, or hairdresser. Through role-playing, you can simulate the experience and practice appropriate behaviors, such as sitting still or opening your mouth for the dentist.

4. Schedule Smart - Begin with scheduling short and less intense appointments. Then, when the child is ready, gradually increase the duration and complexity over time. This incremental approach allows the individual to build confidence and tolerance for the experience as they gain new skills.

5. Communicate Well - Communicating any specific sensory needs or accommodations for the location to be mindful of will help everyone be prepared. For example, some individuals with ASD may benefit from wearing noise-canceling headphones, having a weighted blanket, or using a vibrating tool to desensitize their mouth before dental work.

6. Encourage & Reward - Use positive reinforcement techniques such as praise, tokens, or preferred items and activities to reward the child or teen. This strategy can work before, during, or after the appointment. Rewards can also help create positive associations with these experiences.

Judson Center Autism Connections Helps Build Life Skills

Every child, teen, and young adult with Autism Spectrum Disorder (ASD) is distinct, and strategies that work for one may not be effective for another. At Judson Center 's Autism Connection's Life Skills Lab, our dedicated professionals provide personalized guidance to clients, helping them prepare for routine appointments based on their specific challenges.
Our Life Lab rooms are designed to simulate real-life scenarios and include:

A dental room with a real dental chair, lighting, and tray setup

A medical exam room including a real examination table, eye exam tools, weight scale, and other medical equipment

A barbershop or hair salon room equipped with a barber chair, brushes, combs, and sink

A realistic waiting room so all phases of the appointment can be practiced

We Help Clients Gain Important Skills for Real Life

To serve each individual's unique sensory needs, our highly trained Autism Connections staff utilize these rooms to prepare clients for their appointments. Many parents and caregivers have shared remarkable success stories of their children feeling empowered to confidently participate in these routine appointments.

Learn more about the Autism Connections Life Lab and how we can help prepare individuals with ASD for everyday appointments.
Judson Center's Autism Connections is a preferred provider for diagnostics and early intervention. We have immediate daytime openings available at several locations. We can help prepare for the school year. Autism Connections offers transportation to and from school, and works collaboratively with administrators and teachers to help guide and formulate your child's IEP. Contact us today to learn more about Autism Connections. Or call to discuss the unique needs of your child so we can support them in our Life Skills Lab. Contact Rhia at (248) 837-2031.

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Routine Appointments and Autism - Judson Center

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Routine visits can be hard for individuals with autism. With practice, individuals with ASD can develop strategies to make more manageable. Learn more.

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How to Desensitize Children to Doctors | Increasing Tolerance in Kids with Autism

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How to Desensitize Children to Doctors | Increasing Tolerance in Kids with Autism

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How to Desensitize Children to Doctors | Increasing Tolerance in Kids with Autism

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Systematic Desensitization supports children to gradually become familiar with the clinic or surgery across multiple visits. This is done through small, supported steps that are paced according to the child's needs, with the aim of making health care appointments more comfortable and achievable. There is no fixed number of visits, as each child's journey is different.

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Importance of Desensitization for Autistic Children in Dental Practice

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Importance of Desensitization for Autistic Children in Dental Practice

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Eva Martínez Pérez, Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - original draft, Writing - review & editing, Project administration, Funding acquisition, ¹ Alberto Adanero Velasco, Validation, Data curation, Writing - review & editing, Supervision, 2,* Víctor Gómez Clemente, Validation, Writing - review & editing, Supervision, ³ Mónica Miegimolle Herrero, Methodology, Investigation, ² and Paloma Planells Del Pozo, Conceptualization, Methodology, Data curation, Writing - original draft, Writing - review & editing, Project administration, Funding acquisition ¹

Giuseppe Minervini, Academic Editor and Francisco Alcantud-Marín, Academic Editor

Abstract

Objectives: Dental treatment in special needs patients, including children with autism, can be accomplished by reducing the behaviors that can reduce fear, as it has been demonstrated in other studies. The present study aims to examine the influence of the latency time elapsing between desensitization and the real dental situation on facilitating the access of children with autism to dental treatment. Study design: Nineteen patients with autism, who were aged 3-14 years and attended the Special Education Center in Madrid but were living with their parents at home, were selected for the study. All children in the sample were subjected to a desensitization process before attending the real dental office. Two study groups were established: the latency period between the last desensitization and the real situation was one day for the first group and seven days for the second group. An experimental study was conducted to assess the child's cooperation in the dental chair; the dental examination was divided into several steps and the highest step reached by each child was recorded. Results: There is a statistical difference in the number of steps reached between the children who received the information just before the examination date and the children who experienced a longer latency period between receiving the information and experiencing the examination. Conclusions: We would like to emphasize the importance of providing information in advance when dealing with autistic children; this information should be as close as possible to the real situation. Additionally, we would like to stress the importance of inter-cooperation between parents, educators, and pediatric dentists in order to guarantee adequate oro-dental care for autistic children. Further studies with larger sample sizes and a control group are recommended.

Keywords: autism, behavior management, child, dental, desensitization

1. Introduction

Autism spectrum disorders (ASD) are conditions characterized by impaired autonomy and all kinds of social skills. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [ 1], states that some of the main characteristics of ASD include social communication and deficits, and a lack of interaction, in addition to behaviors that are repetitive. When you compare this edition with the previous edition (DSM-IV-Text Revision [ 2]), the DSM-5 made important changes. When the authors write about the diagnostic area, the language abilities were de-emphasized. Furthermore, some of the subcategories in the diagnostic area were also eliminated, such as childhood disintegrative disorder, Asperger's syndrome, pervasive developmental disorders and Rett syndrome. Furthermore, the diagnostic subcategories, that is, autistic disorders and those not otherwise specified, were abolished. The DSM-5 states different levels of severity in the ASD, that go from requiring support, this one being the lowest, to requiring substantial support, to requiring a lot of substantial support [ 1].

Some studies have addressed the importance of identification as soon as possible for those with ASD, since early treatment is correlated with good outcomes in the long-term when it is intensive. There are many theories about how the patients should be treated and what is the etiology of the syndrome, but there is no consensus yet, and that leaves the families with confusion about how to deal with this illness. It is essential that primary care clinicians have up-to-date information about the science of autism, due to the important role they play in this illness, not only in the early identification but also with the management of the patient [ 3].

The diagnosis criteria used in the last decades for the ASD led to an increase in the prevalence of these disorders [ 4].

The changes made in the DSM-5 classification criteria will surely lead to different groups of children having an ASD diagnosis [ 4, 5].

Documented research about the dental condition of children with autism spectrum disorders is limited. However, given the unique habits, such as movement repetition and difficulties when introduced to new things and experiences, of these children detailed by authors such as Tesini and Fenton [ 6], it is probable that the majority of them require special dental care. Their eating habits and difficulty in learning oral hygiene techniques predispose autistic children to dental complications such as caries and poor oral hygiene [ 6, 7, 8, 9, 10, 11, 12, 13, 14]. It is also important to note that self-injurious habits are part of the behavioral disorders of many autistic children [ 7, 8, 9, 10, 11, 12, 13, 14, 15]. Regarding the face and mouth, we may see auto-extractions, ulcerations, wounds, and tongue, cheek, and lip bites [ 15, 16, 17].

It has also been well documented that children with ASD experience various barriers to optimal dental and oral care [ 18]; many children with autism exhibit fear that is usually because of the difficulty they have in dealing with novel visual and auditory stimuli, which leads them to anxiety. When this happens, parents choose not to take their children with autism for routine examinations because of the children's fear and their behavior in new spaces, to protect them from difficult behavioural situations. When we are talking about oral healthcare, parents prefer other treatments such as conscious sedation or general anesthesia [ 18, 19, 20].

On the other hand, dental professionals caring for patients with an ASD diagnosis will need to give treatments based on approaches that are more family-centered, giving parents support and understanding in their concerns [ 21].

The application of behavioral methods to control dental fear in children is always time consuming, especially when dealing with children with autism. Additionally, there are no procedures that are validated for behavioral treatments in these patients, so there is no consensus in the dental community. However, in children with autism, dental treatments can be accomplished using methods commonly known to reduce phobic behavior in other children, such as systematic desensitization and distraction, as demonstrated by Luscre and Center in their study [ 9].

Different behavioral dental treatment packages have been used to decrease fearful reactions to dental stimuli or increase compliance to dental exams. These procedures include reinforcement, shaping and fading [ 22]; desensitization, video modeling and reinforcement [ 19, 20, 21, 22, 23]; visual pedagogy [ 24, 25]; and desensitization [ 26, 27, 28].

The aim of this study was to determine the influence of the variable "latency time" elapsing between desensitization procedures and the children's exposure to the real clinical examination on the effect of desensitization.

With this aim, the Association for Investigation and Study of Mental Retardation and teachers of the Department of Prophylaxis, Pedodontics and Orthodontics in the Faculty of Dentistry at the Complutense University of Madrid (Spain) participated in this study focusing on dental treatment in autistic children, and this study was made in one academic year. This study was financially supported by the Ministry of Education and Science of the Autonomous Community of Madrid, Spain.

2. Materials and Methods

2.1. Sample

The inclusion criteria were children fulfilling the diagnostic criteria of autism according to the DSM-IV, aged between 3 and 14, attending an education center for children with special needs in Madrid, and whose parents or guardians signed informed consent.

The exclusion criteria were any associated syndromes or disabilities (visual, auditive, or motor).

The sample size was calculated using the number of children that attended the Special Education Center, CEPRI. With all the students between the ages of 3 and 14 from the center, a confidence level of 95% and an error margin of 8%, we had a cohort of 19 patients. All participants met the inclusion criteria and were randomly allocated and divided into two groups using a random number generator.

The recruitment was carried out by the educators of the center over the course of 12 months, and after that, the participants presented at the University. The two groups contained 10 and 9 children, respectively.

2.2. Methods

Information Exchange

First, information was exchanged between the psychologists and pedodontists in the research team by means of lectures and bibliographies. The psychologists gave the pedodontists information about the systematic desensitization they used in the special needs center, and the pedodontists gave information about the clinic, the time required and the methods used during the dental procedures.

The psychologists visited the Department of Dentistry to gather the information that they would pass on to the participating children in advance and to collect any information they might need themselves. They also investigated the physical characteristics of the place where the children were going to be examined, looking for stimuli that could be negative for the participants, such as strong noises and bright lights, in order to avoid them if possible. They additionally took some dental materials for olfactory and taste stimuli, such as topical anesthesia and dental cements used in pediatric dentistry.

Likewise, the dentists on the team visited the educational center that the children attended daily in order to meet them and to help them become familiar with the techniques and protocols. There were several visits during the duration of the project, and there were always at least two dentists at the visit. The aim of visiting the children in the special needs center was for them to become familiar with the presence of the dentist.

2.3. Questionnaire

A questionnaire was made with all the information ( Supplementary File S1). A pilot study was made in order to validate it. It was distributed to the children's families after a presentation to the parents by means of a lecture dealing with the most important aspects of oral health in children and after the parents agreed to participate in the project by means of informed consent. Its aim was to gather information about demographic data, clinical data, habits, previous dental experiences (if applicable) and other data related to the child's behavior in dental offices, among others, in order to assess which aspects of the dental environment could be positive or negative for the successful cooperation of the patient with autism. The data from the parent questionnaires were subsequently analyzed and used during the desensitization of individual children. The questionnaire was made by the dentist with the parents and with one of the special needs center psychologists. This was important because it helped to identify the procedures carried out by the education center in order to facilitate the children's access to dental treatment.

2.4. Examination

Prior to the dental examination, all of the participating children completed a systematic desensitization procedure within the general program of the Special Education Center. Desensitization consisted of a pre-examination to familiarize the child with the dental office, the techniques, the staff and the instruments that would be used during the child's visit.

Representative visual cues of the dental procedure were created. In our study, we used a drawing of a molar as the actual examination key ( Figure 1 ).

Along with the presentation of this pictogram, a plastic dental mirror was shown to the child so it could be related to the activity coming next. Later, information was gradually given to the children prior to the actual visit. Each child was given information at different times, which were selected by the teachers and caregivers at the special needs center who knew the children.

During the desensitization period, photo albums containing photographs with everything to do with the procedure were presented to the children.

After viewing the photo album, video modeling was used. Children watched a video of a girl undergoing a dental examination, which was a simulation of what would occur during the dental visit. The dentist was the same dentist that was going to perform the examination of the patients.

Finally, training was carried out with the children. A dental visit was simulated in a classroom at the center. There was a waiting room, and the office had a desk chair representing the dental chair as well as a light and a little table, to ensure it was close to reality. The children's teachers acted as dentists in this first phase, wearing white coats and gloves and using mirrors and plastic probes.

Each group underwent the same entire sequence twice before going to the real dental office. The latency period between the last desensitization training and the real situation was one day for the first group and seven days for the second group.

On the actual dental examination day, the children were informed of the activity in advance by their teachers using the visual cues and the dental mirror.

Children went to the Department of Dentistry to undergo a dental examination in their designated groups. The same dentists that visited the special needs center were the ones that performed the examinations in the presence of the teachers or parents, as per the child's preference, to reduce anxiety.

The presence of the children's teachers, who had participated in the desensitization process, was suggested for a positive effect on the children´s overall experience.

Several steps were planned within the examination procedure. Thus, every step could be assessed upon completion, even if the examination had not been completed. These steps are shown in Table 1 .

Table 1

Steps Planned in the Examination Protocol

1. Sits in dental chair: seated in dental chair with legs extended but without lying back in the chair.

2. Lies in dental chair: leaning with legs extended.

3. Tolerates direct light on face.

4. Opens mouth.

5. Tolerates physical examination of the face: lets dentist manipulate the exterior of the mouth.

6. Tolerates physical manipulation of the interior of the mouth.

7. Opens mouth in front of a mirror.

8. Tolerates examination of the interior of the mouth with the mirror, keeping the mouth wide open.

It was agreed that a step was to be considered fulfilled despite additional verbal or physical help needed from other sources such as the dentists, the psychologist that worked in the center or the educators. These data were also recorded and analyzed later to assess the impact of help needed on patient cooperation.

The visits to the Department of Dentistry were video recorded by a member of the research team in order to analyze the results obtained in every case.

Two data cards were created to evaluate the steps reached by every child:

Data card recording of the dental experience portrayed in the video.

Data card recording of the achievement of steps in the dental examination.

Two people (one from the education center and another from the Department of Dentistry) watched the video independently. Once the data were recorded, the inter-rater reliability was measured and tested. In order to achieve this, the percent agreement was used for two alternative categories, and the Kappa Index of Agreement was used for dichotomic categories. The reliability results ranged from 0.71 to 1.0 in the Kappa Index (very high reliability) and from 69% to 100% regarding the percentage of total agreement. If there was any disagreement, a third person was brought in to solve the disagreement.

2.5. Statistical Analyses

The data were analyzed using SPSS (Version 17.0) (SPSS Inc., Chicago, IL, USA). Descriptive statistics of the data obtained from the questionnaire were provided for an overview of the findings.

The dependent variable was the number of steps achieved in the examination protocol. The independent variables were characteristics of the sample group, such as the age, and the latency time between desensitization and the dental exam.

The number of patients was low, and we considered that the distribution was not normally distributed, so a non-parametric test was used, the Mann-Whitney and Kolmogorov Smirnov tests, and an ANOVA distribution with an H of Kruskal Wallis test.

A p value of 0.05 was considered statistically significant.

3. Results

3.1. Questionnaire Results

A total of 82% ( n = 15) of the children suffered from hyperactivity disorder, which prevented them from being quiet for any extended period of time (which therefore makes dental visits even more difficult).

More than 50% ( n = 10) of the parents felt that the sound of aspiration or other loud noises near the children had a negative effect. Furthermore, 35% ( n = 7) of the sampled children could not tolerate direct light on their faces.

A total of 94% ( n = 18) of the children liked feeling human contact on their faces. This was advantageous because certain manipulations and contact with the face were implicit in an examination.

Regarding the questions related to the children's previous dental experiences, we found that 83% ( n = 16) had never been to a dental office. In the remaining group, dental treatment that was needed in emergency situations in each of these cases was considered by parents to be a minimally traumatic experience.

A total of 47% ( n = 9) of the children experienced involuntary movements, during which they could potentially injure themselves.

3.2. Examination Protocol Results

Table 2 summarizes the results regarding the completion of steps in the dental examination, including the number and percent of children who achieved each step.

Table 2

Steps of the Dental Examination Protocol
n: 19

Achieved without Help
n (%)

Achieved with Help
n (%)

Total Achieved
n (%)

Not Carried out
n (%)

For the established age groups, no statistically significant relationship was found to be related to the highest step achieved.

The latency time was analyzed in relation to the highest step of the protocol reached.

Figure 2 shows the steps completed by each child related to the time elapsed between the information given in advance and the actual dental examination. There was a remarkable difference between the children who received the information just before the examination date and the children who experienced a longer latency period between receiving the information and experiencing the examination. The mean latency time for the short time delay was 1 day, and the mean time for the long time delay was 6.77 days because not all of the children were given the information 7 days before the examination.

4. Discussion

It has been detailed by certain authors that some stimuli can affect the behavior of autistic children during new experiences, such as noises or smells [ 12, 17, 18, 27, 28]. In our study, we found that noise could be a negative stimulus of the children's behavior, as informed by the parents in the questionnaire.

As shown in Table 2 of the results, most of the children in the sample (with percentages ranging between 68% and 90% of group) completed all steps of the dental examination except the last step (presumably the one causing the greatest anxiety).

Other variables could have carried much more weight for determining the success in achieving more steps of the protocol, such as the support received and the promoting and teaching skills at the education center. We believe these should be part of future research.

The study variable was the latency time between the information provided in advance (completing the desensitization sequence in the Special Education Center) and the real examination.

We have found no references to this factor in other studies in this regard [ 17, 18, 21, 25, 28], but other authors [ 29] studying video modeling have reported that the information should be provided just before the actual situation, stressing the importance of this short time delay.

A report by Bäckman and Pielbro [ 25] and other studies of people with disabilities [ 21, 27, 28] have illustrated the importance of providing the information in advance, although latency periods are not referred to. Moreover, according to the educators at the Special Education Center, due to the characteristics of autistic children, this information must be visual and should be presented by means of a photo album or similar resources. According to the results obtained in our study, the provision of this information must take place as close to the visit as possible and must represent the real situation as accurately as possible.

The presence of some of the educators participating in the desensitization procedure is one of the essential factors in the development of the real situation. Educators are better able to provide verbal support.

Some authors [ 12, 17, 18, 27, 30] agree on the benefits of the presence of parents or educators who have cooperated in previous desensitization procedures.

Bäckman and Pielbro [ 25] also included the participation of parents or teachers to show the dental material to the child and to offer the relevant information in advance.

Other authors [ 12, 17, 27, 30] also agree on the need to use more than one of the established techniques for behavior management in order to achieve the established aims in a real dental situation. The non-pharmacological techniques used by these authors and in our study, such as desensitization or video modeling, are good behavior management tools. Agreeing with authors such as Lewis, we can say that there is no "one size fits all" approach to dental and oral care for children with autism spectrum disorders [ 18].

As a result of our cooperation with a Special Education Center, we developed a procedure for dental treatment within the habitual activity of the center, following the established criteria of their programs for the development and adaptation of the abilities of the center´s pupils. This procedure is based on the systematic desensitization and latency time of our study. This is still under development with new tools such as reality goggles and tablets, which could help the children during the examination steps.

When evaluating the results obtained here, it is necessary to take into account that the children were evaluated after receiving the information in advance, which is essential for proper planning and the regulation of their behavior.

In terms of the strengths and limitations of this research, caution should be taken when considering statistical results because not all children could complete the study in the same way; some of them needed varying degrees of verbal or physical support. As a result of their different limitations, the children could not be homogeneously grouped nor independently studied. This does not reduce the importance of the results from the point of view of the research team; we believe that all the findings derived from this project must be interpreted within the context that they were developed.

We believe, in accordance with the teachers and caregivers of the special needs center and the parents of the children, that new technological advances could help the autistic population with dentist appointments as well as in other areas of their lives. We are also working with other lines of research such as virtual reality.

5. Conclusions

There is no "one size fits all" approach to dental and oral care for children with autism spectrum disorders.

It is important to emphasize the importance of providing information, such as visual cues, in advance when dealing with autistic patients. We found that this information must be as accurate as possible in portraying what will actually happen in the dental office. The shorter latency time provided the best results in our study.

It is also important to develop a simulated clinic. In the present investigation, we observed that the simulation should replicate the real situation as closely as possible.

During clinical procedures, behavior management techniques implemented in dentistry as a reinforcement of previous desensitization techniques should be taken into account.

The presence of parents, educators, and other key people in the autistic child's social environment is desirable.

Although we were satisfied with the results of this study, we agree that more research is needed regarding the dental treatment of autistic children.

Acknowledgments

The authors wish to thank the educators and psychologists of the Special Education Center.

Funding Statement

This research received funding from the Ministerio de Educación y Ciencia de la Comunidad Autónoma de Madrid (number 187/ date: 17 November 1997).

Author Contributions

Conceptualization, E.M.P. and P.P.D.P.; methodology, E.M.P. and P.P.D.P.; software, E.M.P.; validation, E.M.P., P.P.D.P. and A.A.V.; formal analysis, E.M.P., P.P.D.P., V.G.C. and A.A.V.; investigation, E.M.P., P.P.D.P. and A.A.V.; resources, E.M.P., P.P.D.P. and A.A.V.; data curation, E.M.P., P.P.D.P. and A.A.V.; writing-original draft preparation, E.M.P. and P.P.D.P.; writing-review and editing, E.M.P., P.P.D.P., M.M.H. and A.A.V.; visualization, E.M.P., P.P.D.P., A.A.V., E.M.P., P.P.D.P. and A.A.V.; supervision, E.M.P., P.P.D.P., M.M.H. and A.A.V.; project administration, E.M.P. and P.P.D.P.; funding acquisition, P.P.D.P. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Ministerio de Educación y Ciencia de la Comunidad Autónoma de Madrid (number 187/ date: 17 November 1997).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.

Data Availability Statement

Data are available upon reasonable request.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Disclaimer/Publisher's Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

References

23. Marcus A., Wilder D.A. A comparison of peer video modelling and self video modeling to teach textual responses in children with autism. J. Appl. Behav. Anal. 2009;42:335-341. doi: 10.1901/jaba.2009.42-335. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

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