DISSERTATION – SYNOPSIS
DR. RISHIKA HABIB
POST GRADUATE STUDENT
DEPARTMENT OF PEDODONTICS AND
PREVENTIVE DENTISTRY
A.J. INSTITUTE OF DENTAL SCIENCES,
KUNTIKANA P.O,
BATCH 2013-16
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the Candidate And Address( in block letters ) / DR. RISHIKA HABIB
POST GRADUATE STUDENT,
DEPARTMENT OF PEDODONTICS AND
PREVENTIVE DENTISTRY,
A .J. INSTITUTE OF DENTAL SCIENCES,
KUNTIKANA P.O., NH-17,
MANGALORE.-575004
KARNATAKA.
2. / Name of the institution / A .J .INSTITUTE OF DENTAL SCIENCES, MANGALORE
3. / Course of study and subject / MASTER OF DENTAL SURGERY-PEDODONTICS AND PREVENTIVE DENTISTRY. BRANCH-VIII.
4. / Date of admission to course / 07/06/2013
5. / Title of the topic :
“Comparative evaluation of visual pedagogy with or without auditory stimulus as an aid to augment tooth brushing in children with autism spectrum disorder.”
6. / Brief resume of the intended work :
6.1 Need for the study:
Autism is a lifelong neurodevelopment disorder characterized by a neuropsychological profile1-3, which includes communication problems, proficiency in visual skills, enhanced attention to details (hyper selectivity), anomalous attention and sensory processing patterns, attachment to routines and, finally difficulties in understanding temporal concepts1, 4. The degree of severity may vary from mild to very severe and is hence known an Autism Spectrum Disorder.
Autism was first described by Leo Kanner, a child psychiatrist, in the year 1943. He described the behaviour of 11 children, which he suspected to be an inborn feature that prevented them from forming regular social contacts. Autism is now recognised as an organic disorder characterized by abnormalities in the brain, especially the limbic system and the cerebellum5.
Although known for more than 50 years, Autism was thought to be quite rare2, 6. The prevalence of Autism has been reported to vary from 4-13 children per 10000. Today the accepted prevalence is 1-2 per 1000 for Autism and close to 6 per 1000 for Autism Spectrum Disorder (ASD)3-4, 6. This mental disability is 3-4 times more prevalent in males than females3, 6. The prevalence rate in India as reported by The Times of India in Ahmadabad [titled Autism is not a disease TNN Apr 2, 2013, 02.25am IST] is, 1 child in every 250 and currently over 10 million people are suffering from Autism in India. The Government of India now recognises Autism as a disability.
The main barrier in learning is the child’s communication limitation, difficulty in understanding and following instructions. Over the years, new treatment methods, both medical and psychological, have been developed. Researchers show that behavioural intervention is the most effective therapy. Examples of such behavioural therapies include Applied Behavioural Analysis (ABA) and Treatment and Education of Autistic and related Communication-Handicapped Children (TEACCH). The most important examples for these programmes are visual pedagogy, video modelling and picture exchange communication system1-2, 4.Video modelling typically involves the child observing a videotape of a model engaging in the target behaviour and subsequently imitating7. Picture communication system, a form of augmentative and alternative communication (AAC), is a relatively newer intervention specially designed for children with autism based on the principles of ABA. It uses pictures instead of words to help children communicate8.
On the other hand, occupational and auditory therapies have also shown to be fruitful in modifying the behaviour of autistic children. Auditory therapy involves trying to filter out hearing sensory stimuli experienced by an autistic child in order for him/her to perform daily activities. Music therapy primarily helps autistic children to improve their observable level of functioning and self reported quality of life in various domains such as cognitive functioning, motor skills, emotional and effective development, behaviour and social skills9.
Previous studies have shown that children with Autism have low caries index and poor oral hygiene with high periodontal disease rate6, 10-11. It has also been reported that autistic children lack the manual dexterity to brush their teeth on their own and often need
assistance4, 6, 10-11. And the problem is exaggerated because of their lack of communication ability and interpersonal skills. So training these children to master and to effectively practise the oral hygiene measures, would increase their self confidence, reduce their dependence on care takers and improve their oral health.
Reports show that visual pedagogy and auditory therapy are effective tools for behavioural modification in autistic children and to teach them basic oral hygiene practices1-2, 4, 6-7. This study is conducted to compare the effectiveness of video modelling and picture communication with or without auditory stimulus as an aid to augment tooth brushing.
6.2 Review of literature :
Ø A study compared the effectiveness of video modelling with in vivo modelling for teaching developmental skills to children with autism. A multiple baseline design across five children and within child across the two modelling conditions (video and in vivo) and across tasks was used. Results suggest that video modelling led to faster acquisition of task than in vivo7.
Ø A study was aimed to evaluate the effectiveness of visual pedagogy to teach tooth brushing in 15 autistic children using picture communication. The results showed that there was decrease in the plaque index and children could independently brush their teeth. They concluded that visual pedagogy is a beneficial tool4.
Ø A case study sheds light on the process of picture exchange communication system along with traditional behavioural approaches. The study was conducted on a 7 yr old autistic boy in six phases. Baseline assessment were done using childhood ’
autism rating scale(CARS), vineland social maturity scale (VSMS) and visual analogue scale (VAS). By the end of 32 therapy sessions over 3 months the child had shown approximately 60% improvement in the targeted behaviour as found on the VAS8.
Ø A study was conducted to implement a 3D animation disability-learning tool with music in 8 children, to help in simulating independence in autistic children with objectives of investigating and analyzing the acceptance and the effectiveness of the tool. The results showed that children easily accepted the tool, were comfortable and their independence level increased9.
Ø A study was aimed to evaluate the effectiveness of audio video modeling on behavioral change toward oral health in autistic children. 36 autistic children were divided into 3 groups and taught tooth brushing by 3 different methods: jaw demonstration modeling, pictorial activity schedule modeling and video modeling. The results showed a statistically significant change in the video modeling (p=0.003) and pictorial activity (p=0.025) before and after the program, whereas it showed no statistically significant difference in children with jaw demonstration program (p=0.275)2.
Ø A study by was conducted to evaluate the effectiveness of TEACCH based intervention program to facilitate 10 component oral assessments in 72 children and adults with autism spectrum disorder. The study concluded that the program was effective in facilitating a full dental assessment by increasing compliance in children and adults with ASD with and without intellectual disability1
6.3 Objectives of the study:
1. To evaluate the efficacy of Picture Communication System with or without auditory stimulus to augment tooth brushing to children with autism spectrum disorder.
2. To evaluate the efficacy of Video modelling with or without auditory stimulus to augment tooth brushing to children with autism spectrum disorder.
3. To compare the efficacy of Picture Communication System and Video modelling with and without auditory stimulus to augment tooth brushing to children with autism spectrum disorder.
Method and materials:
7.1 Source of data :
120 study subjects will be included in this study from various institutions for special children in Mangalore city.
Inclusion criteria:
Children diagnosed with autism/ASD aged between 6-12 years.
a. Having fair to poor oral hygiene as assessed using plaque index by Silness and Loe.
b. Understanding visual or simple verbal instructions.
c. Having fine motor skills to brush his/her teeth.
d. Who have not participated in similar intervention previously, and who are not using any intervention presently as an adjunct to tooth brushing.
Exclusion criteria:
a. Children who are on use of antiepileptic drugs and/or steroids.
b. Children with cerebral palsy or any other mental disease.
c. Uncooperative children.
d. Children for whom parental consent is not obtained.
7.2 Methods of collection of data:
Participants will be chosen from four randomly selected special schools. The school authorities, care takers and the parents will be explained about the importance of oral health and the study protocol, and the children with an informed consent and on fulfilling the selection criteria will be randomly selected as study participants. The participants will be divided randomly based on convenience method into 4 groups of 30 children each. The groups will be matched for age and sex.
Group A: Picture communication group.
Group B: Picture communication with auditory stimulus group.
Group C: Video modelling group.
Group D: Video modelling with auditory stimulus group.
7.3 Methodology:
All subjects will be examined for their oral hygiene status using plaque index by Silness and Loe, using a plain mouth mirror and curved probe under natural light at baseline and thereafter at intervals of 1 month throughout the 3 month study. Pre intervention assessment of the participant’s attitude towards maintaining oral hygiene, brushing methods and the duration of brushing will be made using a self administered questionnaire given to the parents/ care takers. Each participant will be given toothbrushes and fluoridated tooth paste. All participants will be given an oral hygiene education programme emphasizing on home oral hygiene as a baseline motivation, and will be repeated at the intervals of one month as a reminder.
The study subjects will then be divided into the following groups.
Group A: In this group, a sequentially arranged series of 12 laminated pictures demonstrating the tooth brushing technique, of size 10 x 10cm will be given to the care takers/parents of each participant to be placed near the mirror in the tooth brushing area.
Group B: In this group, a sequentially arranged series of 12 laminated pictures demonstrating the tooth brushing technique, of size 10 x 10cm will be given to the care takers/parents of each participant to be placed near the mirror in the tooth brushing area will be used along with auditory stimulus, in form of an 3 min audio clip, that will be played daily while the children are brushing.
A 3 min audio clip for the study will be selected by first subjecting a small group of ASD children varying soothing music and the most popular music among the group will be selected for the use in the study.
Group C: In this group, a video of a peer model, filmed while he is demonstrating the brushing technique with audio clip in the language known to the children will be shown in their schools twice a week. The participants will be reminded to pay attention periodically during video modelling and positively reinforced with verbal praise.
Group D: In this group, a video of a peer model, filmed while he is demonstrating the brushing technique with audio clip in the language known to the children will be shown in their schools twice a week along with audio clip played daily during tooth brushing. The audio clip for auditory stimulation used in group D and group B will be the same.
The data obtained will be statistically analysed.
7.5 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes.
7.6 Has ethical clearance been obtained from your institution in case of 7.5?
Yes.
INVESTIGATION DESIGN
LIST OF REFERENCES:
1. L. M. Orellana, S. Martinez-Sanchi, F. J. Silvestre. Training adults and children with an autism spectrum disorder to be compliant with a clinical dental assessment using a TEACCH based approach. J Autism Dev Disord. 2013: 1-10.
2. A. M Sallam, S. B. Y Badr, M. A Rashed. Effectiveness of audiovisual modelling on the behavioural change toward oral and dental care in children with autism. Indian journal of dentistry. 2013:1-7
3. Mohamed A. J. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl. Oral Sci. 2011; 19(3): 212-217.
4. Pilebro C, Backman B. Teaching oral hygiene to children with autism. Inter J Pediatr Dent. 2005; 15: 1-9.
5. Klein U, Nowak A. J. Autistic disorder: a review for the pediatric dentist. Pediatric Dentistry. 1998; 20(5): 312-317.
6. Namal N, Vehit H, Koksal S. Do autistic children have higher levels of caries? A cross sectional study in Turkish children. J Indian Soc Pedod Dent. 2007; 25(2): 97-102
7. Charlop-Christy M, Lee L, Freeman K. A comparison of video modeling with in vivo modeling for teaching children with autism. J Autism Dev Disord. 2000; 30(6): 537-552.
8. Malhotra S, Rajender G, Bhatia M. S, Singh T. B. Effects of picture exchange communication system on communication and behavioral anomalies in autism. Indian J Psychol Med. 2010; 32(2): 141-143
9. Othman A, Kamarudin F. N. Disability learning tool: Brushing-teeth using music for autism. Proceedings of Edulearn11 Conference 2011; July 354-363; Barcelona, Spain.
10. Vajawat M, Deepika P. C. Comparative evaluation of oral hygiene practices and oral health status in autistic and normal individuals. J Int Soc Prevent Communit Dent. 2012; 2(2): 58-63
11. Luppanapornlarp S, Leelataweewud P, Putongkam P, Ketanont S. Periodontal status and orthodontic treatment need of autistic children. World J Orthod. 2010; 11(23): 256-261.