Association for Behavior Analysis International

Noncompliance with healthcare procedures is a widespread problem, especially for individuals with intellectual and developmental disabilities. Noncompliance and avoidant behavior during dental exams (and other healthcare procedures) is problematic because it may a) affect completion and quality of the procedure, b) limit access to necessary healthcare and lead to increased health risks, and/or c) pose risk of injury to the individual. The majority of research in this area has been single-case design studies that describe the use of treatment packages consisting of a variety of components. This symposium consists of three studies involving the use of similar treatment procedures to increase compliance with dental examinations. Two studies are large-N studies of noncompliance by adults with IDD, and one study is an analysis of the degree to which treatment effects from a simulated dental environment generalize and maintain in the actual dental setting.

Individuals with intellectual and developmental disabilities, including autism spectrum disorders, experience significant barriers to medical care, including routine dental exams and procedures (e.g., x-rays). While existing research suggests several strategies for increasing patient compliance with dental exams and procedures, this body of literature is limited and provides minimal guidance for programming for generalization to dental clinics. In this presentation, we will share data from a pilot study in which we collaborated with a local dentist to evaluate the effects of a desensitization procedure with community-based probes for children diagnosed with autism in which results were mixed. We will also share findings from a recent systematic literature review investigating the effectiveness and sustainability of interventions intended to increase dental compliance. Finally, we will present considerations for conducting research related to increasing compliance to medical procedures for individuals with intellectual and developmental disabilities, as well as future directions for this work.

Many adults with intellectual and developmental disabilities (IDD) are noncompliant during routine dental exams. Nonetheless, the majority of research in this area has been conducted with children (Kupzyk & Allen, 2019). In this study, we report the preliminary findings of a large-N study of noncompliance among adults with IDD who had a history of receiving sedation, general anesthesia, or restraint during dental exams. First, we evaluated compliance with a mock dental exam under a baseline condition consisting of several evidence-based procedures, including praise for compliance and frequent noncontingent breaks, in the absence of escape extinction. Participants who did not comply with all steps received increasingly more complex intervention components (e.g., noncontingent access to preferred items [NCR], gradual exposure) until they complied with all steps of the exam. Participants then received an exam by a dentist using the same intervention components. Of the 24 individuals who have participated thus far, 8 (33%) did not require additional intervention components beyond the baseline condition and 5 (20%) required less than three treatment sessions with NCR. These findings suggest that a noteworthy percentage of adults with IDD are unnecessarily exposed to risky procedures during routine dental exams.

Child noncompliance with healthcare routines is a widely reported problem. Recent research varies widely with respect to treatment strategies and inclusion of maintenance and generalizations strategies for increasing compliance during healthcare routines. Harrison, Zonneveld, Bernstein, and Neidert (in preparation) evaluated a reinforcement-based treatment procedure both with and without extinction in an analogue setting to increase child compliance during two healthcare routines: dental examinations and getting a haircut). Six children experienced treatment without extinction. Compliance increased for two children during baseline. Compliance increased for four children following treatment. However, treatment effects (acquisition of compliance) were slow, and the degree of overall generalization to the actual setting varied. Two children experienced treatment with extinction. Acquisition of compliance was drastically faster than those exhibited by children who experienced treatment without extinction, but the degree of overall generalization to the actual setting maintained variable. The current study involves a retrospective, more detailed examination of maintenance and generalization patterns across all participants to identify aspects of the treatment strategies that may lead to more consistent maintenance and generalization effects. Preliminary results suggest that programming for variance of steps presented, variance of order of steps, environmental specific stimuli, and removal of treatment procedures in the analogue setting may be necessary.