The dentist has been a LONG and laborious work in progress for 4A. It took us 2 years with a LOT of behavioral support and medicine to get her to walk in there, sit in the chair, open her mouth, and get an exam WITHOUT screaming. Crying=okay. Screaming=unbearable for all involved and makes exam virtually impossible.
We had been doing REALLY well for the past two years. In fact, she would sit in the chair while it moved rather than climbing in after it was positioned, and we accomplished Xrays AND sealant with no social stories and minimal hysteria.
Well, we've hit a bump. Over the summer, 4A overheard a conversation between a dad and a child about permanent teeth...to the tune of "there's nothing they can do to fix permanent teeth if they fall out." Egads! We put a lot of work in on that one, including calling our pediatric dentist, who kindly spoke to 4A, to confirm that there IS something that can be done and to verify that permanent teeth are REALLY hard to lose. We muscled past the anxious hysteria and perseveration and moved into a very long period of constant checking of teeth in the mirror to confirm that they were all still there and frantic feeling of teeth in the morning to confirm that they hadn't fallen out over night. In recent weeks, we seemed to have moved past the issue in its entirety.
Today, we had our regular checkup. 4A was really fine about it last night and this morning. Honest. I didn't feel the need to whip together a social story because she was very nonchalant about the whole thing. No crying, no perseverating, no opposition, nothing. Actually, there was even a bit of glee about missing a few hours of school and having ice cream for lunch after the appointment.
Oh my! Silly momma. First, they've remodeled the office. The waiting room is a different color, larger, and on the other side of the building. The exam room used to have an aquarium theme, but now it's overloaded with darling hot air balloons. The other ones didn't notice. 4A did.
Second, they've got a new hygienist AND a new dentist. The main dentist routinely hires younger dentists to apprentice, I gather, and she and I and her staff have spoken before about 4A's need to see the main dentist. My other ones can and will take anyone they get, but 4A just needs to consistency. Somehow, that message has gotten garbled, so we need to have that chat again.
Okay. So, new decor, new hygienist and dentist, permanent teeth debacle over the summer. It all added up to a regression. To her credit, she cooperated as best she could, only attempting to climb out of the chair twice. The new hygienist was FANTASTIC (as they all are there), and she knew about 4A's autism before we came in. She totally rolled with it, stayed patient and calm, and followed my behavioral lead. We came through it just fine, of course. Anxiety is never allowed to be a reason for avoidance for 4A (or for the rest of them, for that matter).
But, it brought me back, of course, to a time when exams were not so easy.
"Back in the day," I used to handle doc social stories in one of two ways. I'll share them both here in hopes that they help one of you out there in cyberspace.
Social story for doc visit: checklist or sticker method
As I shared in an earlier post, 4A's early years were filled with what felt like constant trips to the pediatric cardiologist, radiologist, behavioral psychologist, pediatrican, developmental ped, and a myriad of others. I remember a particularly terrible trip to the pediatric ER for suspected flu, but I digress.
In those early years before 4A could read, I found that the checklist or sticker method worked best. In a spiral-bound notebook (a sparkly one, if I could find it), I would list a different step that she had to complete with "calm cooperation" on each page. When she finished that step, she could check it off or put a sticker (preferrably sparkly or princess-related) on the page. With this method, I also used an immediate reinforcer in the office and after we left.
So, a trip to the cardiologist once looked like this (save a few more steps).
Here's how you do it.
(1) Call the office, explain the trouble your child usually has at such visits, and ask for an EXTREMELY detailed list of steps that it takes to complete the procedure. They're going to overlook the nitty-gritty and give you the big picture. Keep pestering until you have every single solitary step necessary on your list. They'll probably get annoyed with you. Don't let that bother you. This pales into comparison to how annoyed they'd actually be if you weren't doing this, and all annoyance aside (theirs and yours), this is going to help you and your child immensely. Also let them know about the checklist that you're bringing with you and remind them again when you get there. They're quickly going to realize that playing up the one-step-at-a-time method with your child is going to work better than the calm reassurances that they give to and that work for typical children.
(2) Write one step on a page. You can use pictures or clip art, if you have it. If you can get actual pics of the doc and/or the exam room, all the more better. I drove my ass MILES, more than one time, to snap pics of many an exam room. PTL for technology!
For 4A, the process of slapping that sticker on, scribbling her notes, and flipping the page gave her a huge relief that she was working her way to the end of the experience. I also counted the pages with her and read the steps to her in the waiting room before our visit. It made the expectations more tangible for her, and it allowed me to then countdown for her when we started the procedure. I found that reading it to her the night or morning before only lengthed the perseveration and frazzled my nerves, but you do it how you like.
(3) As you progress through the appointment, read only the next step. That step finishes, put on the sticker, turn the page. Very methodical. Remember how her mind works. Work with it, not against it.
(4) The last two pages of our book always went something like this. Next to last page: 4A earns X prize (a Barbie, a book, whatever. Something she LOVED, something cheap and portable, something that she REALLY wanted to lure her to cooperate). Last page: 4A and Mom will go do X (go to the playground, get ice cream, whatever. Something she enjoyed, something we could do together, something to help us bond and forget what we just went through).
(5) I will address this is a future post, of course, but just a quick word here about reinforcers. Lots of folks will sometimes refer to reinforcers as bribes. Call it what you like, my friend. A child with autism derives absolutely ZERO social benefit from doing a good job and lacks the ability to turn to you for comfort or reassurance. You have to recreate that artificially. A reinforcer allows you to create that artificially for him/her. Still worried about using a reinforcer? You absolutely can and will slowly phase out reinforcers. A good behavioral psychologist will teach you how. Over time, we were able to phase out the immediate reinforcer (Barbie, toy, book) and use just the activity reinforcer. Over even more time, we were able to phase out the activity reinforcer, as well. Over ever more time, we've been able to phase out reinforcers for doctor's visits virtually entirely. You'll get there. Slow and steady wins the race. Worry about TODAY, not tomorrow.
(6) Follow through, both with the appointment and with the book and with the reinforcers and with your system. Praise that ASD child, but please remember that your actions speak louder than your words. For 4A, bailing on an appointment because the hysteria was too much for me or the office staff to handle actually would have been a huge mistake. Because the extinguishment burst that we would have had to deal with on the next attempt would have been MUCH more intense than what we were experiencing at the appointment itself. We went through many appointment in a basket hold. A good behavioral psychologist will help you help your child.
I encourage you to stay calm and carry on. Focus on one page at a time and merely completing the procedure or visit, no matter how hard that is. Do not give in. Do not give up. You CAN do it!
Social story for doc visit: Flip book method
We eventually got to the point where we were able to work through the whole book with only a small reinforcer at the end. This made my life easier on so many levels, not the least of which was a MUCH easier social story to prepare.
For these flipbooks, I printed out a social story (with clip art or board maker images) and put one step in one pane or page of a cheapy dollar store 4x6 plastic photo album.
4A could read it herself (or I could read it to her) and just flip the page to the next step. These worked really well for us, and they were super easy to prepare and transport.
We used this flip book method for picture schedules of errands that we had to make in a given day and over summer vacation for daily schedules, which varied from day to day.
Here is a social story about a pediatrician's visit with shots. I simply cut out each step and one step on a page.
And, a word about bandaids and stickers. For my typical children, those things work wonders. They get a scrape and immediately ask for ice or a bandaid or a hug. They LOVE getting that sticker at the end of a visit. These things are utterly lost on 4A. Dr. Steve once described it to me like this: If 4A gets a scrape, it hurts. If she puts a bandaid on it, it still hurts. If she gets a hug, it still hurts. Because 4A has autism, she derives no comfort (which is a SOCIAL construct) from the typical measures I use to heal bumps, bruises, and little hearts. As such, that reinforcer was necessary to recreate that social feeling of comfort for her artificially.