Does Autism mean Mental Retardation?

Not all Children with autism are mentally retarded however, it is said that between 75% and 90% of all autistics are mentally retarded. To be diagnosed with mental retardation, one must generally show significant impairment in adaptive living skills and have an IQ under 70 as measured by a standardized IQ test. At the same time, advertisements by certain autism awareness sites proclaim that geniuses such as Albert Einstein, Isaac Newton and Thomas Edison may have had forms of Autism. In order to understand this seeming paradox and to help both parents and dentists keep realistic expectations from an autistic child it is important for us to understand the term "Autistic Spectrum" and the disorders classified under it.

At the same time that Leo Kanner described autism in American children, a German scientist, Dr. Hans Asperger, described a milder form of the disorder that became known as Asperger syndrome. Thus these two disorders were described and are today listed in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (fourth edition, text revision) as two of the five pervasive developmental disorders (PDD), more often referred to today as autism spectrum disorders (ASD). All these disorders are characterized by varying degrees of impairment in communication skills, social interactions, and restricted, repetitive and stereotyped patterns of behavior.  

Disorders such as Aspergers syndrome may result in individuals who, in spite of their social awkwardness, may have an extraordinary intelligence in other fields such as numbers. However the sad truth is that most children diagnosed with childhood autism will have some form of mental impairment. This is even more so in India where the cases with milder forms of autism often go undiagnosed.

Irrespective of their IQ, patients with autism will have some difficulty in communication and therefore it is imperative that both the dentist and parent prepare themselves for a dental visit

See Also

Preparing your Child for a Dental Visit

Preparing to treat an autistic child

For a detailed description of childhood autism you can download the following booklet, put forward by the national institute of mental health.

Click Here

Autism in India - The Challenges of Misdiagnoses

Numerous studies have placed the occurrence of autism at a rate of approximately 1 in 500 people. At India’s current population, this means there are an estimated 1.7 million autistic persons in the country, assuming that there are no significant variations in this rate worldwide, which is a question that has not yet been addressed by epidemiologists outside the West. While the disorder is not rare, the majority of autistic people in India have not been diagnosed and do not receive the services they need. The main reason for this is a lack of awareness and misunderstanding about autism among medical professionals, who may either misdiagnose or under diagnose the condition.

One of the major difficulties faced by parents of children with autism in India is obtaining an accurate diagnosis. A parent may take their child to a paediatrician only to be reassured that their child is just "slow." Unsatisfied, they may visit a psychologist, to be told their child is "mentally subnormal." Convinced that their child does not fit the typical picture of mental retardation, they may visit a psychiatrist, to be told that their child has attention deficit disorder, and must be put on medication to control hyperactivity. After months of sedation and unsatisfactory progress, they may again begin a cycle of searching for the correct name for their child’s problem.

It is therefore very likely that a dentist may find himself/herself treating an Austistic child when the parents are unaware of the condition. It is therefore necessary for the dentist to be able to recognize the symptoms of autism and be aware of the steps he/she may take to render optimal care to autistic individuals. It is similarly important for parents to know the symptoms their child may face, and be mentally prepared for a visit to the dentist.

Large parts of this post have been based on information made available free by the NGO action for autism. Readers can read more at http://www.autism-india.org/afa_autisminindia.html

DCSN does not endorse or take responsibilty for information provided by external sources; we have however verified the information in this post and find it to be accurate to the best of our knowledge.

Preparing to treat an autistic patient

Forewarned is fore-armed. The challenge of managing an autistic patient in the dental office may be greatly reduced by taking the knowledge of the signs exhibited by an autistic child and adapting your treatment plan suitably.

Autistic children like routine

Autistic children are most comfortable in repeating activities they are comfortable with. The dentist can use this knowledge to his/her advantage by:

• Offering parents and children the opportunity to tour your dental office, so that they may ask questions, touch equipment, and get used to the place.
  
• Allow autistic children to bring comfort items, such as a blanket or a favorite toy.
  
• Children with autism need sameness and continuity in their environment. A gradual and slow exposure to the dental office and staff is therefore recommended.
  

No one knows the child like the parent.

Treating the autistic child may be a challenge to you; but the parent knows the habits and tendencies of the child. Spend some time talking to the parent before the procedure - it is time well spent.

The First Visit - Getting started...

• Make the first appointment short and positive.
• Approach the autistic child in a quiet, non-threatening manner. Don’t crowd the child.
• Use a “tell-show-do” approach to providing care. Explain the procedure before it occurs. Show the instruments that you will use. Provide frequent praise for acceptable behavior.
• Invite the child to sit alone in the dental chair to become familiar with the treatment setting.

Use a rational approach

The nature of the disease makes it essential for the dentist to explain each step of the procedure. An autistic individual likes order and can , even in the absence of mental retardation, find abstract expalnations hard to follow.

• Autistics will want to know what’s going to happen next. Explain what you’re doing so it makes sense to them. Explain every treatment before it happens.
• Always tell the autistic child where and why you need to touch them, especially when using dental or medical equipment.
• Talk in direct, short phrases. Talk calmly. Autistics take everything literally – so watch what you say. Avoid words or phrases with double meanings.

Moderate pressure can calm an autistic child

A child may be calmed by moderate firm pressure. The use of a body wrap or a bedsheet to cover the child tightly can greatly enhance the cooperation of the child.Light pressure, such as air from a syringe, however can greatly agitate the child.

Sensory responses of an autistic child may be exaggerated

Autistic children may have an irritability to bright light or some form of hyperaccusis.

• Keep the light out of the child's eyes.
  
• Make sure the child can tolerate the high pitched sound of the airotor; you may be better off using a micromotor handpiece
  

Do we need General Anesthesia or Sedation

Tempting as it may be to directly post an autistic child under general anesthesia DCSN strongly reccomends that the child be given every opportunit y to cooperate on the dental chair. It is also imperitive that the pediatric dentist spots early signs of oral disease and acts swiftly to minimize the operative treatment required by the child. 

• Some children will need sedation or general anesthesia so that dental treatment can be accomplished. Sedation of autistic children who are 8 years and older simply does not work.
  

The following article provides excellent background reading on autism, though its primarily written for the physician, some of you may find it worth reading

Prater CD, Zylstra RG. Autism: A medical primer. American Family Physician 2002; 66: 1667-1674.

Preparing Your Autistic Child for a Visit to the Dentist

A visit to the dentist can be a trying experience for any parent, but add to that the demands of autism and the experience can turn into a nightmare for dentist and parent alike. However most of the problems the autistic child pose to the dentist and parent have a simple etiology: Ignorance. Parents and Dentists alike have to learn to view the world of the dentists office from the child's point of view.

Possible reasons for disliking the experience 

Lack of understanding 
Some people do not understand the purpose of going to see a man or woman in a white coat who looks into their mouth and uses strange equipment, whilst they are expected to lie on a chair with a large light positioned on their face. They may not have understood the importance of having healthy teeth and gums and the consequences of not having regular appointments.

Sensory issues
This is probably one of the main anxiety triggers at the dentist for individuals with an ASD. The obvious areas of difficulty will be tactile (touch) and auditory (noise). Mouths are extremely sensitive places and for a person with an ASD the sensation of a cold instrument entering their mouth could be very painful. In addition, the noise of the drills and cleaning instruments could also be a problem. Sometimes the taste of the mouth wash or the paste being used will also have an adverse impact.

It is also important to check whether there are any factors in relation to the dentist as an individual that might cause distress; for example, their perfume, moustache, or the colour of their clothing. An information sheet on ASD and sensory issues is available through the Autism Helpline. (See resources list below).

Invasion of space
Dentists are one of the few professionals who we permit to enter our personal space. Most people find this uncomfortable but understand that the dentist needs to be so close in order to examine teeth. For individuals with an ASD this close proximity may well be extremely distressing. 

The following strategies are dependent on the person's level of understanding and their individual needs and should be adapted accordingly.

Preparation
As a result of past negative experiences, many carers understandably avoid telling the individual with ASD about their dental visit until the last minute or on the day of the appointment. But even though it may initially cause a behaviour pattern change, it is better in most situations to try and inform the individual as early as possible. This can be difficult if their concept of time is poor. The use of visual supports (for example, a calendar) can help to clarify when an event is occurring.  

If it is the individual's first visit to the dentist you may like to take them to meet the dentist and other staff prior to any treatment. You may also like to show them the equipment which the dentist will use and how it works.

It is also important to prepare the dentist and their team by giving them as much information as possible, so they can make adaptations to the procedure and be aware of the individual's needs.

Try to ensure that the appointment is the first of the day. This reduces the chance of the dentist running late and provides enough time not to feel rushed. It is important to note that because some dentists feel that the presence of an autistic may be embarrassing to other patients they may call in the child as the last patient for the day. This approach on the part of the dentist may not be very advisable as an autistic child in the clinic requires the full energy and attention.

Choose your dentist wisely

If a dentist is uncomforatable working with an autistic child, regardless of his or her qualification, the child will be uncomforatble with the dentist. You can ask the dentist if he/she has ever treatted an autistic child before, or if not whether they understand the difficulties and challenges of working with the child. A simple failure to comprehend the needs of the child can result in the child having to undergo treatment under general anesthesia.

Will the child require Sedation or General Anesthesia?

Due to the nature of the disorder, most severely autistic children will require any prolonged treatment under general anesthesia. However allow the dentist to explore the option of treating the child on the dental chair. Sometimes children may well allow the dentist to perform fillings or the extraction of a single tooth on the dental chair. Any use of preoperative sedation must be done under the supervision of the child's physician or a Pediatric Dentist trained in the field of conscious sedation. We do do not endorse the practice of sedating the child at home and bringing him/her for the appointment as the parent may have the tendency to either overdose or under dose the child, both of which are equally detrimental.