Dental Sedation and Autism

     Oral health care for a child with the diagnosis of autism is not much different from the oral health care of other children. However, children with autism often have difficulty in communication skills, so cooperation from your child might be a difficult challenge when visiting the dentist. For parents of children with autism, a visit to the dentist is more than a child opening his or her mouth and getting a reward after. If your child is too difficult to work with and the need for a dental procedure is urgent enough, a dentist may have no choice but to use dental sedation in order to perform his job. 

What is dental sedation? Is it necessary? Is it safe? Sedation is the utilization of medications called "sedatives" to create a state of relaxation. It is usually done to facilitate a medical, or in this case, dental procedure. 

There are three levels of sedation that may be used with pediatric patients that require extensive dental care: 

- Conscious sedation is inducing a minimally depressed level of consciousness that retains the patient's ability to maintain an open airway independently and continuously and respond appropriately to physical stimulation or verbal commands. 

- Deep sedation is a type of sedation in which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes, including the ability to maintain an airway or to respond properly to physical stimulation or verbal commands. 

- General anesthesia is an induced state of unconsciousness. The patient cannot respond to physical or verbal stimulation of any kind and it will be up to the dentist to insure that an airway is maintained. Most people immediately associate sedation with general anesthesia, in which the patient is put to sleep during the whole procedure and awakens afterward in a recovery room. However this is normally the last possible choice for a pediatric dentist. He will recommend a lower level of sedation instead if he can, trying to use whichever form of anesthesia has the lowest risk while being effective. 

To make his decision he will take the child's age, cognitive level, coping and communication skills, physical health, the attitude of the parents toward anesthesia and the urgency of the procedure into consideration. Although the decision regarding which level of sedation to be used on your child must ultimately be made by the dentist, you as the parent should always have a say in the matter. If you are not comfortable with the suggestion of your dentist, make sure that your concerns about it are heard. 

To help you further understand the decision the dentist will be making, here are some guidelines from the American Academy of Pediatrics (AAPD) that the dentist will be using in making his recommendation: (American Academy of Pediatric Dentistry, 2010) The AAPD recommends conscious sedation for: 

- Preschool children who cannot understand or cooperate for definitive treatment 

- Patients requiring dental care who cannot cooperate due to lack of psychological or emotional maturity

- Patients requiring dental treatment who cannot cooperate due to a cognitive, physical or medical disability 

- Patients who require dental care but are fearful and anxious and cannot cooperate for Treatment The AAPD recommends deep sedation or general anesthesia for: 

         * Patients with certain physical, mental or medically compromising conditions 

         * Patients with dental restorative or surgical needs for whom local anesthesia is ineffective

         *The extremely uncooperative, fearful, anxious or physically resistant child or adolescent with substantial dental needs and no expectation that the behavior will improve soon 

         * Patients who have sustained extensive orofacial or dental trauma Patients with dental needs who otherwise would not receive comprehensive dental care Sedation Procedure Dental Sedations are usually done in an outpatient dental clinic that is well-equipped. The whole procedure usually won't take more than 90 minutes for most procedures.

Although some details vary depending on the dentist's practice among other things, in general the process will go like this: 

- Initial assessment of the pediatric dentist and scheduling of the actual procedure. 

- Consent signing by the parents 

- Guidelines are given prior to the procedure - your child will be asked to go on a NPO (nothing per orem or mouth) diet 6-8 hours before the procedure. This is a standard operating procedure for any sedation process. It will aid in the proper ventilation of your child and will avoid any episodes of vomiting after the procedure is done. 

- Sedation medication is introduced via injection, an IV line, rectal line (just like when you give suppositories for fever), orally or through inhalation. 

- Dental procedures are done. Your child may or may not be strapped onto a papoose board. Papoose boards restrain the child's limbs and help in stabilizing your child during the procedure. Oxygen and pulse oximeters should be available and used if the need arises. -Monitoring of the patient until sedative wears off. Safety of Sedation Sedation is an accepted standard of care. 

The 3 levels of sedation are all accepted and supported by the American Academy of Pediatric Dentistry, the American Dental Association, the American Medical Association, and the U.S. Department of Health and Human Services. Pediatrics dentists are also trained and certified to perform sedation as part of their profession. Usually, dentists who specialize in treating pediatric patients are also well equipped to handle children with Autism Spectrum Disorder.

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Autism - Symptoms, Diagnosis and Treatment

     AUTISM Autism starts before a child turns to three years. It is a disorder in the brain development which weakens the social interaction and communication. Autism causes restricted and repetitive behavior. Autism is a hereditary disorder even though the genetics of autism are complex and it is unclear which genes are responsible. Autism is associated with agents which cause birth defects in rare cases. Other possible causes of autism are childhood vaccines which are controversial and the vaccine hypotheses lack convincing scientific evidence. 

According to the experts out of 1000 children 3-6 children will have autism. Male are four times more to have autism than females. Symptoms The occurrence of autism is not known and it affects many parts of the brain. In the first two years of the child's life, parents usually notice the signs of autism. Autism is characterized by three distinctive behaviors. The autistic children have difficulties with social interaction, problems with verbal and non verbal communication, and repetitive behaviors or narrow, obsessive interests. There is a reduced sensitivity of pain, but are more sensitive to sound, touch or other sensory stimulation. These reactions may contribute to the behavioral symptoms such as a resistance to being cuddled or hugged. 

There is no cure for autism but treatment can help. The early behavioral and cognitive interference can help them to develop self-care, social and communication. An infant with autism may be non responsive to people or focus intently on one item by excluding others for a long period of time. With this disorder few children live independently after reaching adulthood and some of them become successful. Some people believe that autism is a condition than a disorder. Autism children have speech problems, they might not look in to the eyes when talk to them. Before they can pay attention they may have to line up their pencils, these children will say the same sentence again and again. To tell that they are happy they flap their arms or they might hurt themselves if they are not. Some people never learn to talk. They lack empathy. The autistic children cannot interpret the thoughts and feelings of others and also cannot understand the tone of voice and facial expressions. 

The autistic people have different symptoms and because this it is known as spectrum disorder. The milder version of this disorder is Asperger syndrome. The disorder lasts throughout a person's life time. Autism shares numerous signs with Rett syndrome and childhood disintegrative disorder. Asperger's syndrome does not have any delay in the language development. Autistic children are at a higher risk for some co-existing conditions such as fragile X syndrome which causes mental retardation, tuberous sclerosis in which the tumors grow on the brain, epileptic seizures, Tourette syndrome, disabilities in learning and attention deficit disorder. 

By the time autistic children reach adulthood about 20 to 30% of children develop epilepsy for the reasons unknown. Also schizophrenic people may show some autistic-like behavior but the symptoms do not appear until the late teens or early adulthood. The Schizophrenic people also have hallucinations and delusions which are not found in autism. Diagnose Based on the IQ autism is sometimes divided in to the low, medium and high functioning autism. The child affected by autism will show less attention to social stimuli, smile and look at others less often and very rarely respond to their own name. The severity and symptoms of autism may go unrecognized mainly in mildly affected children or when it is covered by more weakening handicaps. 

Doctors depend on a group of behaviors for diagnosing autism. These behaviors are: 

(1) Unable to make friends with peers. 

(2) Unable to initiate or to continue a conversation with others. 

(3) Absence of imaginative and social play. 

(4) Unusual, typecast, repetitive use of language. 

(5) Preoccupation with certain subjects or objects. 

(6) Rigid devotion to certain routines or rituals. 

With help of a questionnaire or any other screening instrument doctors assemble information about the child's development and behavior. Some screening depends on the parent observations and some others on a combination of parent and doctor observations. If there is an indication or possibility of autism, the doctors will ask for more comprehensive evaluation. As autism is a complex disorder a combined evaluation is needed with a multidisciplinary team including psychologist, neurologist, psychiatrist, speech therapist and other expert in diagnosing the children with ASDs. 

Girls with autism may be suffering from Rett syndrome, a sex-linked genetic disorder described by social withdrawal, deteriorated language skills and hand wringing. Treatment Autism cannot be cured. But according to the experts the earlier intervention can make them to cope up with the day-to-day life. Structured and skill oriented training sessions to help children develop social and language skills. Counseling for parents and siblings of autistic children can help the families to cope with the challenges of living with an autistic child. To handle symptoms of anxiety, depression or obsessive compulsive disorder doctors often prescribe anti depressant medications. To treat severe behavioral problems anti-psychotic medicines are used. 

With one or more of the anticonvulsant drugs seizures can be treated. To reduce impulsivity and hyperactivity stimulant drugs are some times used effectively. There are several therapies which are controversial and parents should be aware of that before taking in to consideration any of these treatments.

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Foods for Picky Eaters and Children With Sensory Issues

    In preschool, Cole and his classmates were introduced to the story of Green Eggs and Ham by Dr. Seuss. They were excited when their teacher actually cooked up ham and fried eggs with green food coloring. Inspired by the story, all the children took a bite to discover whether they, too, liked green eggs and ham-all, that is, except for Cole. Cole's sensory processing issues made it extra hard for him to tolerate any new food, so while he understood the point of the story, he wasn't going anywhere near that "icky stuff." 

We all know kids need to eat a variety of healthy foods, but picky eaters often need more exposure to a "new" food than other kids do before they will take a bite. For children with sensory processing disorder and/or autism, who experience the world as a confusing and inconsistent place, where unpleasant and disorienting sensations can bombard them at any time, familiarity is very comforting. It may take much time and repetition to get a picky eater with sensory issues to try a new food. To avoid wasting food as you are working on getting your child to try something new, serve him a tiny portion, perhaps even one small bite or spoonful, on his plate. Work toward having him tolerate the unfamiliar food on his plate without fussing. 

You may have to start by serving him the food on a separate plate, then later, serve it on his plate but make sure it's not touching any other foods. The next step is to insist that he touch it with his finger, then pick it up and touch it to his tongue. After that, the goal should be to have him place it in his mouth and chew it. Allow him to spit it out in a napkin if he finds it very distressing and intolerable. In this way, you can slowly but surely expand his food choices. Choose one healthy food to try to work into your picky eater's diet. Make it one that is somewhat similar to a food she already will eat. If she will eat peas, try corn kernels, which are similar in size and texture. 

Often it's the "feel" of the food that matters most to a child with sensory issues. Recipes for toddlers and children that sneak vegetables into sauces may work if there are no lumps or bumps in the sauce, but your child's sense of taste may be so exquisite that she notices something's different about her pizza today. If your picky eater with sensory issues resists mixed textures, which is a common problem, work on introducing simple foods without condiments and that have simple textures. A slice of tomato that has been deseeded, a piece of roast chicken with the skin removed, or a hardboiled egg yolk or egg white separated from the rest of the egg offer simple textures. 

Some parents find some success in getting their child with sensory issues to tolerate two different textures or temperatures by serving a sugary treat such as ice cream with broken cookies mixed into it or hot fudge drizzled over the top. But don't be surprised if her sensory issues cause her to place her need for familiar foods with simple textures over any desire for something sweet! You may actually be better off working on getting her to eat plain celery sticks or cucumbers slices with the seeds and skins removed. What's more, simple, healthy foods are easy to prepare and keep on hand to be introduced again and again. If the child has a favorite junk food, such as French fries or corn chips, introduce healthier versions of these foods and healthier foods that are similar in texture and shape. Steamed red potatoes with the skins removed have a texture similar to that of French fries, for instance, while crunchy foods such as carrots or snap peas give sensory input similar to that of chips. 

Serve raw vegetables and fruits as snacks and appetizers before meals if it is difficult to get her to eat her broccoli rather than just her macaroni and cheese. Encourage your child to find favorite fruits, vegetables, and whole grain foods and serve them to her often. Keep in mind that children who severely limit their food choices, particularly if they self-limit to foods containing gluten (an ingredient in foods derived from wheat and some other grains) and casein (a protein found in milk and milk-based products), may have a food intolerance or celiac disease. In fact, these children often have digestive or skin problems as a result of their food intolerances, and crave the very foods their bodies can't tolerate well. If you suspect this is the case, consult with a nutritionist who is knowledgeable about sensory issues and eating difficulties in children. In extreme cases, a feeding clinic program can help. copyright (c) 2012 Nancy Peske The information contained here is provided as a public service. 

It is for informational and educational purposes only and should not be construed as personal medical advice. Although every effort is made to ensure that this material is accurate and up-to-date, it is provided for the convenience of the user and should not be considered definitive.

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Helping Your Autistic Toddler to Recover

    Silas was our fourth child and from very early on we knew something was different about him. Much to our dismay he did not want to cuddle, he cried constantly, broke things, and at 23 months still could not talk. We had him observed and were not surprised with the diagnosis of autism. We enrolled him in an early childhood intervention program but he was not progressing and was still tantrumming many, many times a day. We decided to look further for some help for him. Here are some of the therapies/treatments that have been successful many times over in recovering autistic children and they have helped Silas wonders! Methyl b12 supplementation - By far the most successful in treating autism. I know it sounds scary but the "methyl" part just means that it has already been processed for their body. 

Typical bodies methylate b12 from vitamins and food, for some reason autistic children are unable to do this process. B12 is necessary in aiding the body in toxin removal. We started with a dissolvable pill and gave it everyday. We now give him a b-12 shot every three days. The shots have been shown to be far superior to the pills. Silas responded quickly. Within ten days he finally mimicked two of my words and he was making eye contact with us. As the days went by, he noticed his brothers and sister and he began to enjoy us in little bits. He is now turning 3 and talks almost non-stop. He laughs when something funny happens and he can now be in a crowd with minimal fear. He is counting down the days until his birthday party. Of course we will have a big one this year since he has been terrified of his party in the past! Liquid Multivitamin with borage and fish oils - I found a liquid multivitamin on-line that included trace minerals and borage oil. It also includes enzymes to aid in digestion. Fish oils and borage oils have also been reported to be in short supply in autistic children. 

They help with language and learning skills. Find a multivitamin that is food derived, not mechanically formed. Get rid of toxins! - Autistic children have been shown to be in toxic overload. For some reason, they are not able to get rid of their toxins at the rate of a typical person. This causes all kinds of behavioral and immune problems. Install a reverse osmosis water filtration system in your home. Chlorine, fluoride, and the other elements present in water are toxic to your child! Replace home cleaning supplies with naturally derived cleaning supplies. If you need a "clean smell", use essential oils. Use natural bath soaps and for detox, add 1 cup of epsom salts to every bath. Read food labels; if they contain words that you cannot pronounce, put the food back on the shelf. Eat fresh vegetables and meats whenever possible, food preservatives are toxins! Melatonin supplementation - A large number of children on the spectrum do not sleep much. Silas happens to be one of these. He stays up late, finally goes to sleep only for a few hours, and is up around two in the morning ready to start the day. 

Melatonin not only helps him to sleep but is required for the brain to produce glutathione (helps rid body of toxins). This is a two-fold benefit for autistic children. I give Silas 6 mg of Melatonin every night. Gluten/Dairy free diet - Because of their sensitive and weakened immune systems, autistic children cannot tolerate gluten and many times cannot tolerate the dairy protein casein. Some children have been reported to start talking only after dairy was removed from their diet. This diet can be very difficult at first, it requires some creativity. As long as you stick with mostly fresh meat, fruits, and vegetables, you will be gluten free. Gluten is found in wheat, barley (malt), and rye and some oats.

There are so many options these days for other types of flour, even ways to make your own. Some examples of substitute flours are sorghum, bean, rice, corn, flax, almond, etc. There are even gluten free sections in most grocery stores and superstores. Even harder for us was the dairy free. We drink and cook with almond milk, coconut milk, rice milk, or soy milk. What Silas misses the most is cheese. The health food stores carry some cheese substitutions and some grocery stores carry soy or vegetable cheese. This diet is very important for Silas's immune system. Gluten and dairy cause inflammation in his digestive system which then triggers an immune response. Silas is then highly susceptible to strep and other viral infections. The immune response can also cause swelling in the brain. The swelling in the brain causes the autistic behaviors. Those are scary words and are the reason we have decided it is worth the inconvenience of the diet! Raising an autistic child has proven to be the most difficult task of my life. It is a long bumpy road and sometimes it seemed there was no reward for our efforts. 

It is stressful controlling everything that enters his body and dealing with his behaviors but he is now making progress that astounds medical doctors. For additional information on recovering autistic children, check out the resources below: TACA - Talk About Curing Autism  AutismOne.

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Step by Step: How to Get Insurance For Autism - California Law SB946

    As of July 1, 2012, California law SB946 requires health insurance plans to cover applied behavior analysis (ABA) for patients who have pervasive developmental disorder or autism. The law also requires insurance companies to maintain an adequate network of ABA providers so that children with autism will have access to this necessary care. Under this new law, either Board Certified Behavior Analysts (BCBAs) or licensed clinicians with appropriate experience are allowed to design and supervise ABA programs. Furthermore, the law allows professionals and paraprofessionals to implement the behavioral treatment plan under the supervision of the BCBA or licensed clinician.

Here is a list of steps you can use to get insurance coverage for your child with autism:

1. Find Out if Your Insurance Plan Must Follow the New Law First, find out if your insurance plan is mandated to follow this new law. Plans that are exempt from following this new law are self-funded plans, out-of-state plans, Healthy Families plans, and Medi-Cal plans. However, some self-funded plans offer ABA treatment for autism as a benefit for their employees. You should check with your human resources representative to find out. Also, if you only have a Healthy Families or Medi-Cal plan, you may contact your local California regional center about funding.

2. Get a Diagnosis In order to receive insurance funded ABA services, your child will need to have a qualifying diagnosis. The law states that patient's with pervasive developmental disorder (PDD) or autism qualify for treatment. If your child does not have a formal diagnosis, you will need to bring your child to a licensed clinician who can conduct an assessment and provide your formal diagnosis in a written report. What is PDD? PDD includes Autistic Disorder, Asperger's Disorder, Rett's Disorder, Childhood Disintegrative Disorder, and PDD-NOS.

3. Get a Prescription for ABA The next step in getting insurance coverage for your child with autism spectrum disorder is to get a prescription for ABA from your child's physician or licensed psychologist. You will likely need to give a copy of your child's diagnostic report your child's physician or licensed psychologist so that he/she is aware that your child qualifies for this medically necessary treatment.

4. Verify Benefits Then, you will need to verify the benefits offered by your child's health insurance plan. This can be done by submitting your child's prescription to your health insurance plan and then contacting their autism team or their general customer service center to find out if your child's plan covers ABA. You can also ask an ABA treatment provider to verify your child's benefits for you, which they can do if you provide them with your child's health information.

5. Select an ABA Provider Once you know your child has ABA benefits then ask your health insurance company for a directory of in-network ABA Providers who can provide the necessary ABA services for your child. You can call and interview the ABA providers listed until you find one that fits your child's needs. Remember, in most cases, ABA services are delivered in your child's home or community so the location of the ABA provider may not be a very important. If your child already has an ABA provider, then you will need to find-out if they are in-network with your child's health insurance plan. You may need to request that your ABA provider join the network if they have not yet done so. In some cases, such as when there is not an in-network provider within 30 miles of your home, then you may be able to use an out-of-network provider.

6. Have Provider Conduct an Assessment & Design the Treatment Plan If you are beginning ABA services for the first time, your ABA provider will need to assess your child in order to design a treatment plan. This assessment may include reviewing past reports, interviewing caregivers, observing your child, and/or testing your child's skills. If your child has an existing ABA provider, they may be able to use current assessment information to design your child's treatment plan. The treatment plan should describe your child's behavioral health impairments and should include measurable goals, evidence-based interventions, and recommendations for service type, number of hours, and parent participation. Your provider may or may not have to get preauthorization to conduct the assessment, depending upon the requirements of your child's plan.

7. Get Preauthorization for Treatment Depending on the policies of your child's health plan, your ABA provider may have to submit a variety of documents to the health insurance company to get pre-authorization for treatment to begin. For example, you may need to give your provider copies of your child's diagnostic report, functional behavior assessment, standardized tests, IEP report, IFSP report, ABA treatment plan, and progress reports from prior ABA treatment to include in the submission. Your ABA provider will submit requested documents to the health plan in order to get treatment authorization.

8. Begin Services! Once your ABA provider receives written pre-authorization from the health insurance plan then treatment may begin. You will likely have a meeting with your child's assigned ABA supervisor to review and consent to the treatment plan and other policies. Once paperwork has been completed, then your child's supervisor will likely bring a treatment plan data collection binder to your home and start training the professional and paraprofessional staff how to accurately implement your child's treatment plan.

We hope this list will help you to make your way efficiently through the process in order to get your child insurance funding for behavioral health treatment. Behavior Frontiers is dedicated to helping families successfully navigate the process of the new California health insurance mandate for autism!

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