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

You’re listening to another episode of the Turn Autism Around podcast. Today I’m going to be discussing desensitizing trips to the doctor, the dentist, and the barber for kids with autism. And I’m also going to be talking about some adverse procedures such as eye drops, tolerating life vests, and all kinds of things that a lot of kids with autism have difficulty with. So let’s get to that content.

Welcome to the Turn Autism Around podcasts for both parents and professionals in the autism world who want to turn things around, be less stressed and lead happier lives. And now your host, autism mom, behavior analyst, and bestselling author, Dr. Mary Barbera.

Hi, welcome back to another episode of the Turn Autism Around podcast. I’m your host, Dr. Mary Barbera, and it’s great to have you listening. We’ve been at the podcast for several months now and I’m so excited that we’re still going strong. I’ve done a lot of interviews in the past few weeks so I wanted to slip in a solo show to give you some information about how we as parents and professionals in the autism world start to make doctor’s visits, dentist, haircuts, getting your child’s picture taken, wearing smocks at preschool for painting, wearing life vests by pools; tolerating things that the doctor might recommend, like eye drops or nose sprays.

These often can cause major issues in kids with autism and when kids are small, whether they have a diagnosis of autism or not, the general procedures usually which I’m not recommending is usually hold the child down and do the procedure.

But in a lot of kids with autism, it backfires because kids feel like they’re being, you know, attacked and held down and they can often fight back. And as the child gets older, they become stronger and stronger and pretty soon, you know, a four person hold down to get their ears checked is just not even feasible even with four people. And so as both a registered nurse and a behavior analyst, I often see teams really struggle with how to follow through with any kind of medical procedures.

And so I have developed some, some procedures within my online courses that can help people. I’ve, I’ve promoted free information. I do have video blogs on how to get kids to tolerate their haircuts better. I have a video blog about going to the dentist where I show a short video of my son, Lucas and us practicing at home.

So you may want to check out those video blogs. This is a little bit challenging during a podcast about something that is so visual, but I think it’s, it’s such an issue with kids with autism that I, I really wanted to try to cover it in the podcast, even if I have to do follow up videos or points you in the direction of some of my free videos.

Now I… Before we get really into the nitty gritty, I do want to say that even though I’m a behavior analyst and a registered nurse and a mom and a bestselling author, I am using podcasts and video blogs as information purposes only. This is not behavioral advice. This is not medical advice. I am only giving you general information. You really need a onsite behavior analyst who can analyze your child or even a distance consultant who can look at videos and really make a plan and help you, especially if you have an older child, a bigger child that could really cause injury but don’t be too confident if your child is still small enough to hold them because holding children down is never a good idea, because like I said, it’ll just usually backfire with kids with autism and it’ll, you know, if you hold them down for a haircut or you, you hold them down for an ear check, then all of a sudden when you go to get your family picture taken or try to get them to where our best and they don’t want to wear it, all of a sudden it becomes more and more of a struggle.

So whether we’re looking at an ear check at the doctor’s or eye drops or wearing a life vest, we always have to start at the beginning, which is always assessment. I hope you’re like saying it out loud with me, because if you watch really any of my video blogs and listen to any of my podcasts, you’ll know that the first step is always assessment. We have to step back and we have to look at exactly what’s happening. So we need to figure out, okay, what the procedure is that the child is currently not tolerating or maybe they’ve never even been to the dentist so you don’t know how they’re going to tolerate it. Anything that you can prepare, prevent, and plan for, you’re going to be in a lot better shape than stepping back and, you know, going through the procedure and then having it be a mess. And then now we’ve got to try to pair it up.

So we want to get baseline data if we can. Just say you’re a professional and you’re called into talk to the parent whose child has been to the dentist, you know, three times and it’s always been a problem, and they’re getting ready to prepare for the dentist. Okay. So you’re going to have to rely on an interview probably to begin to gather, like, what happened those last three visits, cause you’re not going to have the luxury to view them. They’re most likely not videotaped and you’re just going to have to kind of use that experience to plan. Um, you’d want to interview the person that accompanied the child with this trip… Or maybe they’ve never been to the dentist, but they cause a fuss at the doctor. So you’re going to anticipate that that might carry over, and you’re really going to look at the steps. Write down the steps, like the child, you know, freaks out when they arrive at the doctor’s office or when they’re fine, when they arrive, when they get called back, when they do the weight and the height, everything’s fine until the ear check. So then it’s isolated really to the ear check, or you know, whatever the situation is.

Maybe it’s eye drops and now all of a sudden the child needs eye drops for some reason and it’s a new procedure. The child is resisting and now you have to help the parent try to figure out how to follow the doctor’s order to make that happen. So this involves interviewing, writing down the steps that are involved, coming up with if there are certain steps that are more problematic than others. And then you should set a goal with the parent to enter the room without, you know, any problem behaviors or to tolerate maybe all the other parts of the doctor’s visit except for the ear check or maybe, um, they would just go to the dentist and the dentist would just brush their teeth and count their teeth and then they would be given some kind of reinforcement.

So let’s, let’s think about a sample goal for wearing a life vest. So the goal might be the child will wear a life vest, um, before going in the water at the pool; or that say it’s an eye drop procedure. The goal might be to… the child will tolerate three eye drops in each eye, two times a day without problem behavior. Maybe you’re trying to set a goal for haircuts. Johnny will sit in a seat alone and get his haircut without crying.

Now these seem like they’re really pretty hard, right? So we’re going to have to… and for complex skills, we’re going to have to like eye drops. It’s not just a matter of tolerating an eye drop, like what is that going to look like? How are we going to practice? How are we going to make sure that the variables don’t change too much?

For complex skills we’re gonna need to write down the actual steps of where they’re gonna lay for their eye drops, and how this is gonna take place. So we need to determine where the location is that we’re going to practice trial. So are we going to practice wearing a smock for painting at preschool… are we going to practice that in the therapy room, at school, or at home?

For eye drops, where’s the location we’re going to practice? Okay. The child will lay on a beanbag in the living room for the eye drops. Where are we going to practice haircuts? The child will sit in a chair in the kitchen to practice haircuts. And then after we practice haircuts, then we will begin to move that practice to a child friendly barber.

For simple skills like tolerating wearing a swim best or a smock, we may only need a data sheet to track like duration that the child tolerated and the reinforcement that was given. But like I said, for these more complex tasks, we’re going to have to really write down the steps and work on the child. As I said, I did do a video blog about going to the dentist and I showed a video of my son Lucas, where we practiced… I bought a little dental kit. You can actually buy these like fake, fake little mirror that goes in your mouth and fake instrument to take the plaque off at the dollar store or on Amazon online. So I got this little kit to practice and uh, he sat in the recliner in the living room, and then I was able to say, we’re going to practice going to the dentist, sit in the chair, tilted the chair back, then put a tea towel over him to mimic the bib that would be on him. Then use the mirror and the pick to count his teeth to pair up to somebody in his mouth. And that was an example where we pair that up.

So, but even for some kids, they’re going to need this kind of procedure even to like cut their fingernails or their toenails. And I know I’m guilty of this, so if anybody’s out there listening and thinking, oh my gosh, I do that. You know, when kids are little, to avoid the freak out, you know, I’ve cut Lucas’s fingernails and his toenails, and I know some people even cut kids hair in their sleep. This is just another way to avoid the situation and the child doesn’t get to participate in pairing up adverse  interventions. So I don’t recommend that that you do things to a child when they’re sleeping. I instead recommend that you assess, come up with a plan to systematically desensitize the child to all kinds of adverse events. So in addition to figuring out the location you’re going to practice, we’re also going to need to determine the people that are going to be involved.

And I know I interviewed a former client’s mom, Jenna, recently and I know when I worked at our house years ago with her then two year old son, Cody, he was very adverse to taking a bath. And so that location easy: the bathtub in the main bathroom where that’s the only bathtub they used. But what she was doing that we changed was in order for Jenna’s husband to give Jenna a break… Cody’s father and Cody’s mother were both taking terms and it was just a battle every time they tried to give him a bath. The problem with the father doing it was that I wasn’t able to train the father because he was at work. So Jenna and I decided that in order to have Cody have the best chance of success, we would actually take… have Jenna be the only person to give Cody a bath for a couple of weeks or a couple months until we got the bathtub desensitized because that was, you know, that was a problem. He’s thrashing about. He can bang his head, he could slip and fall. And we didn’t want it to be an all-out struggle.

So determine the location, determine the steps, and determine the person or people involved. If you’re in a school setting and you’re trying to practice any kind of haircuts or doctors or dentists, the less people involved, the better. Because there will be shaping involved, and a lot of it is part science, part art, and part like dancing with somebody. Like you have to kind of feel when you need to prompt or reinforce and while you’ll take data on the prompt level and everything, it’s just a lot easier, the less people that you have to train to be very precise.

So for the child that all of a sudden needed to tolerate eye drops, when I got there, the mom said, you know, the child’s really fussing and it’s really important that he get these eye drops for whatever reason. And so we were able to then identify the beanbag should be put in this location on the floor. The child can watch TV from that vantage point, the mom should kneel on the right side of the beanbag chair. The mom would spread the upper and lower eyelid with her index finger and her thumb, and then the child would look behind him, actually kind of roll his eyes up in his head so that he wouldn’t see the hand or the eye drops… And this particular child had enough language ability, cognitive ability to follow those instructions. And then mom would put three drops as she counts one, two, three. And then the mom would give praise and additional reinforcement and would repeat the process with the other eye and again, give reinforcement. So we went from the child is freaking out with eye drops to a procedure with structure, a procedure that the child could follow.

I know the plenty of adults, including myself, can’t really, don’t really eagerly tolerate eye drops. So we, you know, worked with the individual, and these are all very, you know, very individualized for my client at the time. If I’d have another child that would have to have eye drops, it would probably be a whole different procedure, especially if the child doesn’t understand, like look behind you and roll your eyes so you can’t see. So each procedure needs to be individualized, but it’s so important that we help parents break down skills and help children slowly desensitize to tolerate these community outings, these medical and procedures that are either at the doctor’s office or recommended by doctors.

I do recommend that when we’re trying to do these task analysis, this breakdown of the steps that, I usually use, what we call forward chaining where I’m starting at the beginning and continuing… And I might only do one of the steps at a time. Like I might practice. Okay Tommy, let’s lay in the beanbag chair. Okay. And now you’re going to watch TV and now I’m just going to separate your eyelids, you know, and I’m not doing the rest of the steps. Okay, great. Now I’m going to reinforce, okay, now I’m going to do it, you know, and I’m going to have you practice rolling your eyes up so you can’t see it. Okay. And I’ll do that, those two steps on both eyes. You see what I’m saying? And so reinforce those, step ones that two. Okay, great. We’re going to practice, practice, practice and then we’ll be able to do the medical procedure.

Now obviously with a medical procedure, you don’t want to wait days and days and weeks to desensitize, so you’re going to have to do it as quickly as possible. But what I’m saying is everything is possible. You just need a system to plan and practice in the same location, with the same person or people to get the best results.

For haircuts, and I talk about this in the video blog is you want to break down the steps into, you know, you might want to practice at home in the same setting wearing the cape for instance, spritzing water. Um, one of the things that Lucas used to not really tolerate well was spraying water from a bottle onto his hair. And one of my friends, who’s a hairdresser and also she’s a mom to a son with autism as well. She’s one of my very best autism friends. She told me that kids don’t tolerate the spray water because it’s sitting at room temperature, which is like 72 degrees. Meanwhile, our body temperatures are 98.6 degrees and so that spray is in essence very cold water compared to our body temperature.

So one of the interventions for Lucas when he went to the barbershop was we would actually put warm water, almost hot water in the bottle because by the time we sprayed it would get to roughly room temperature. And then it wasn’t the startle experience of having, cold water sprayed on his head.

So we want to practice all of these procedures and then if we can find a great, you know, family friendly shop that we can even take our little fake scissors and our fake clippers and we can take that stuff to the barbershop. Maybe we don’t even make an appointment. Maybe we’re just practicing the steps before we actually have the barber work on the actual child. So… And for vests or smocks I have found that we want to just increase the time that the child is tolerating that ,while the child’s wearing the swim vest or the smock for painting at Preschool, they are engaging in very reinforcing activities.

They’re not painting necessarily or they are not by the pool, because we’re going to want to practice these away from those actual environments to really get a lot of practice under our belts. Any procedure, whether it’s an ear check at the doctors, the eye drops, the vests going to a pool. We want to do an assessment, we want to have a plan, we want to select a goal, we want to do practice trials. And if you have a behavior analyst or someone that understands the principles of ABA that can help you make a data sheet to take data on it, that would be the best situation.

And then once we get the practice trials going and the child tolerating all the steps, then we want to take that procedure and generalize it to a real setting: to a real dentist, to a real barber, to a real doctor or to the pool.

There is a great book called Further Case Studies Of ABA With People With Autism. Chapter 15 is by Randy Horowitz, an older book. I saw Randy Horowitz present years ago. It was probably 2000 or 2001 on doctors, dentists, and haircuts. And it was a great presentation. So I have adapted some of her advice I learned way back when, and I think because of my nursing background and my ability to help families and share some videos, I’ve been able to develop the procedures that she first gave me a lot of great ideas about. So I would definitely take a look at that book. And for further information you can check out my free online workshops at marybarbera.com/workshop. If you liked listening to this podcast, I would love it if you would go to iTunes and leave me a review and a comment and spread the word because I want to turn autism around for 2 million by 2020, and lots more millions after that.

So I am happy that you are listening and hopefully you have found this information really helpful. So let’s really help our kids, whether they’re your own child or your clients, to tolerate these procedures, to reach their fullest potential, to have a great life. And we want to really help parents and providers also be less stressed. And I think coming up with procedures to help kids tolerate all kinds of potentially adverse situations can really help our stress level reduce as well. So thanks so much for listening and I hope you tune in next week.

Thanks for listening to the Turn Autism Around podcast with Dr. Mary Barbera. For more information, visit marybarbera.com.