1. Going to the dentist
- Tactile sensitivities – there may be aversive responses to the tactile input of the dentist touching the oral area, especially as the touch input tends to be light and unpredictable.
- Auditory sensitivities to the noises of the different equipment used e.g. polisher, drill.
- Vestibular/ movement sensitivities may cause the child/young person to dislike the backward movement of the seat and the reclined position.
- Uncertainty about how long dentist will examine teeth and what other treatments will be carried out; this unpredictability will increase anxiety.
- Lack of understanding about why dental examinations are important.
- May have had a negative/painful experience at dentist in the past.
- Dental appointments are infrequent (ie every six months) so there is no opportunity to become desensitised to the activity.
- Difficulty waiting due to uncertainty of how long he/she will have to wait, especially if already anxious.
- Visual schedule for the activity to show what will happen step by step at the appointment
- Photographs of the waiting area, dental chair, dental equipment etc which can be examined and discussed prior to the appointment in order to prepare the child/young person.
- Social narrative to explain why dental examinations and treatments are required and what will happen at dentist.
- Off We Go
- Developing a desensitisation programme to familiarise the child/young person with visits to the dentist can subsequently reduce anxiety.
- This could involve going to the dentist several times before the appointment without actually having an examination carried out. For example, the child/young person may just go to the reception on the first visit, then the waiting area on the next visit, then sit in the dental chair without any examination but getting used to the environment and looking at the equipment which will be used. This should then reduce anxiety levels when the time comes for the full dental appointment.
Tip to Remember: This desensitisation programme should be discussed with the dentist beforehand and time set aside to allow the child/young person to become familiar with the setting and routine.
- It may be useful if the child/young person has the first appointment of the day to avoid sitting for a length of time in a busy waiting area. Alternatively, the child/young person could be seen at the end of the day or outside normal clinical hours, when the clinic is quiet and the dentist can take more time with the appointment.
- Ensure the child/young person knows how to express discomfort and ask for a break in the examination e.g. raising hand.
- Dentist could agree how long each part of the examination will take and use a visual timer.
- Allow child/young person to listen to iPod (or similar) to relax and block out noises.
- If child/young person dislikes reclining chair, ask if he/she can be examined in an upright position.
- Parent/caregiver could purchase simple dental equipment (e.g. mirror) and use regularly at home to desensitise the individual to the tactile input. This will then help to improve tolerance of the equipment when at the dental appointment.
- National Autistic Society: Going to the dentist
- Going to the Dentist video:
2. Going to the doctor
- Uncertainty about how long he/she will have to wait in the waiting area.
- Unpredictable sensory stimuli in the waiting area e.g. close proximity of others, noise of others talking, patients called for appointment over tannoy system or similar.
- Negative memories of past experiences at the doctor’s e.g. association with feeling unwell or association with unpleasant experiences e.g. having injection.
- Uncertainty about what the doctor will do and what equipment will be used e.g. stethoscope, blood pressure cuff.
- Tactile sensitivity, leading to anxiety if doctor has to do a physical examination or if medical equipment is used e.g. stethoscope, thermometer, blood pressure cuff.
- Auditory processing difficulties and receptive language difficulties will make if difficult for the child/young person to understand all the information discussed with the doctor.
- Expressive language difficulties may make if difficult for the child/young person to explain their illness, pain or concern.
- Uncertainty about how long appointment will last.
- Parents/carers of older children and young people will need to decide if it is appropriate for them to accompany the young person or allow them privacy/independence by attending the appointment alone.
- Older teenagers and young people may need to make decisions about treatment e.g. whether to consent to recommended treatments, medication etc.
- If possible, request the first appointment of the day (or the first appointment after lunch) to avoid a long waiting time.
- If child/young person cannot cope with a busy waiting area, request last appointment of the day when the waiting room will be quieter. Alternatively, wait in the car and ask to be telephoned or messaged when the doctor is ready.
- Bring a favourite distractor for use in the waiting area e.g. iPad, book, puzzle. This will reduce anxiety and help the child/young person with waiting.
- Prepare a visual system to show what will happen at the appointment step by step. If possible, visit the health centre beforehand to take photographs of the waiting area, doctor’s room, medical equipment to be used.
- Prepare a social narrative to explain why child/young person is going to the doctor and what will happen.
- Off We Go
- A visual timer could be used to show the maximum length of time the appointment will last. This will have to be explained to the doctor so he/she knows to end the appointment on time.
- Ask doctor if child/young person can first handle any medical equipment to become familiar with it e.g. stethoscope, thermometer, blood pressure cuff.
- Ensure child/young person brings visual communication system if used. This will help him/her to express pain, discomfort or illness.
- Parent/carer should inform the doctor of any receptive language difficulties and ask for information to be communicated slowly and using minimal verbal language. The doctor could be asked to write down the pertinent points of information.
- If child/young person is to make a decision about any treatment, written information should be provided and time should be given to process the information and make a decision.
- When appropriate, older teenagers and young people should be allowed the option of attending the appointment alone. This respects the right to privacy and autonomy, and is a natural part of developing independence and the transition to adulthood. If there are concerns about the individual’s ability to process and understand the information and make decisions, a parent/caregiver should still attend part or all of the appointment.
- Child/young person may have tactile, taste and/or smell sensitivities causing him/her to react negatively to the medication.
- Oral motor difficulties may mean that the child/young person cannot swallow the medication.
- The individual may refuse the medication as he/she does not understand the benefits.
- The individual may refuse the medication because he/she dislike the side-effects.
- Executive functioning difficulties may cause the individual to forget to take the medication or to take it at the wrong times.
- Ask the GP, paediatrician or pharmacist about the different options for medication e.g. alternatives if the child/young person dislikes the taste or smell of the prescribed medication.
- Ask the GP, paediatrician or pharmacist if the medication is available in liquid form as this tends to be easier to swallow than tablets.
- Consult with a speech and language therapist regarding concerns about swallowing/oral motor difficulties.
- Provide a social narrative for the child/young person regarding the benefits of taking the medication and the possible consequences/risks if medication is not taken. For example, if melatonin is prescribed to aid sleep, explain to the child/young person the benefits of a full night’s sleep e.g. more energy to engage in favourite activities, will help attention in school, improvements in schoolwork, will help overall health and emotional wellbeing.
- Avoid ‘hiding’ medication in food as child/young person is likely to detect this and will affect trust. It also risks putting the individual off food items when diet might already be very restricted.
- Put medication times on a visual schedule so child/young person is prepared.
- Older teenagers and young people should be encouraged to take responsibility for their own medication if appropriate. An alarm could be set on a watch or telephone to remind them to take the medication.
- Child/young person may be sensitive to the textures of different food items, causing refusal and aversions. Some children dislike soft, ‘mushy’ textures, while others dislike dry, crunchy textures.
- Child/young person may be sensitive to the taste of different food items. He/she may only like bland tastes, or only tolerate a small range of tastes, subsequently leading to a restricted diet and affecting nutritional intake.
- Some individuals may have a sensory craving for very strong flavours which can affect nutritional health e.g. too much salt in their diet, putting large amounts of ketchup on every meal.
- Rigid thinking causes some individuals to only eat a limited range of specific food items. They may have associated these items with the only foods they eat, and lack of flexible thinking affects their ability to broaden their diet beyond these items.
- Preference for the familiar and an avoidance of change may limit the diet in young children and persist into older childhood and beyond. For example, the child may have become accustomed to a pureed diet and resist the change to more solid textures and stronger flavours.
- Some individuals with autism like the predictability and routine of always eating the same food items. This may be particularly apparent at times of change or transition, or at times when they feel other parts of their lives lack predictability and routine. Eating the same restricted range of food, however, may be limiting nutritional intake.
- The social demands associated with mealtimes may cause a negative association with eating. The social interaction at the table may increase anxiety cause the individual to refuse to sit to eat a meal.
- The child/young person may not understand why he/she needs to eat beyond the range of favourite food items. The individual may have difficulties in making the link between food and health, and may not understand how nutrition impacts on physical health, weight, attention, sleep, energy and emotional wellbeing.
- Lack of flexible thinking may cause an individual with autism to make sweeping generalisations about food. For example, the individual may have accessed information about pesticides and made assumptions that all fruit and vegetables should be avoided due to the use of these pesticides. Another individual may have read that carbohydrates can cause weight gain and so refuses all food containing carbohydrates. These broad generalisations about food, combined with the rigid thinking in autism, can lead to a restricted diet lacking in essential nutrients.
- If there are concerns regarding a child’s weight and health, consult with GP and dietitian. They can check the child’s weight and blood tests can be carried out to determine nutritional health. Sometimes children who are only eating a very restricted diet can still be physically healthy and no dietary changes may be required. However, if tests show concern with weight and/or health, dietary changes may be required.
- Reduce anxiety around food and eating as an individual is more likely to try new food when relaxed. Do not try to coerce or persuade the child/young person to eat specific food items. Continue to provide the preferred food items but leave other choices sitting on the table, giving the individual the freedom to try them without any pressure imposed.
- Reduce anxiety at mealtimes by controlling social demands. Do not ask the child/young person questions or put pressure on them to engage in interaction. A calmer mealtime experience will develop more positive associations with eating.
- Involve the child/young person in meal planning, shopping and food preparation. This will give the opportunity to discuss and explore balanced nutrition.
- Encourage the child/young person to research nutrition. In school or at home, he/she can be given a list of nutrients to research in order to discover the benefits and what foods contain different nutrients. Access to this information may then encourage the individual to broaden their diet to include more nutrients.
- Identify a motivator for the child/young person and relate this to nutrition. For example, if he/she enjoys sport, discuss which nutrients will help to build muscle. If he/she wants to do well in exams, discuss which foods may help with concentration and memory.
- If introducing new food items, use a desensitisation approach. This involves very gradually introducing a new food, giving the child/young person time to adjust the new taste/texture and develop a tolerance for it. This should not be done at mealtimes as it can increase anxiety. Choose another time of the day instead and place it on the individual’s visual schedule. Initial steps in desensitisation will only involve looking at the food item and then gradually progressing on to touching it and smelling it. The child/young person should only be encouraged to taste it when comfortable to do so. When he/she can tolerate the new food, it can then be integrated into mealtimes.
- Do not try to ‘hide’ more nutritious food into favourite food items (e.g. mixing fruit puree into ice cream or small vegetable pieces on to a pizza). This risks putting the child/young person off that food item, thus further restricting their diet. Always be open and honest about the introduction of new food items, and encourage the child/young person to be involved in these choices.
- Use a visual colour coding system to indicate the nutritional value and/or calorie content of different food items. The examples given below are very general and many individuals with autism will require more specific directions.A dietitian will be able to advise on how to code different food and in what specific quantities they can be eaten for an individual child/young person.The colour coding system can involve putting coloured stickers on different food items, putting foods in different coloured boxes or having a colour coded list on the doors of cupboards and the fridge.
- Example 1:
Green = contains several important nutrients
Amber = contains some important nutrients
Red = contains very little nutrients
- Example 2:
Green = low calorie food so you can eat lots of this food.
Amber = medium calorie food so just eat a little of this food each day.
Red = high calorie food item so eat in small quantities and not every day.
- Example 1:
- A dietitian may also be able to advise on an image of a colour coded plate to visually demonstrate how much of different food items should be eaten in a meal.
There are a range of apps available which could help the individual make informed choices about food and nutrition:
- Many forms of exercise involve joining a sports team or club. This brings a range of social demands which may be overwhelming for some individuals with autism, and subsequently they avoid participating in these sports.
- Delay and deficits in motor skills are often associated with autism. This can then lead to an avoidance of exercise as the individual may find physical exercise too challenging or may lack the confidence to participate in exercise.
- The child/young person may not understand the benefits of exercise and so refuse to participate as they see no purpose in it.
- The child/young person may have only been exposed to a small range of sports/exercise and so may not have found an activity they enjoy yet.
- Many exercise facilities can be overwhelming if the child/young person is sensitive to sensory input. Public swimming pools and leisure centres tend to have high levels of unpredictable auditory and visual input.
- If the individual is easily overwhelmed by social demands and prefers solitary activities, identify types of physical exercise which can be can be carried out alone in parallel with others. Examples may include:
- Walking/ hillwalking/ orienteering
- Using the local gym
- If the individual is overloaded by sensory input, avoid noisy and busy facilities, such as leisure centres and gyms. Exercise in quiet environments will be preferable e.g. walking/running in the local park. Alternatively, he/she could go to the pool, leisure centre or gym at off-peak times e.g. early morning, late evening.
- If using the gym, listening to music through headphones will reduce any unwanted or unpredictable auditory input.
- Avoid competitive sports if the child/young person cannot easily cope with losing. Select non-competitive options instead e.g. attendance at a group exercise class, participation in a walking club, participating in a running or cycling club without involvement in races.
- Some leisure centres and sports clubs will run events (e.g.summer schemes) when children and young people can try a range of different sports. This will introduce the individual to different activities and he/she can then choose which ones to continue.
- Many clubs and centres will have inclusive policies in which staff are trained to facilitate the needs of those with autism and where activities may be tailored to meet specific needs. Further information can be obtained from local leisure centres or from local voluntary organisations.
- Provide a social narrative which explains the benefits of exercise for physical and emotional health.
- Encourage the child/young person to research the health benefits of different activities and then select some activities he/she would like to try.
- Include a time for physical exercise on the individual’s daily/weekly schedule.
- Establish exercise goals for the child/young person as working towards a defined goal may make the activity seem more purposeful, and thus increase motivation.