Research Update: Social Stories Improve Toothbrushing Skills
Introduction (What is this study about?):
Toothbrushing is a basic everyday skill that can be difficult for children with autism. One reason for this difficulty may be due to sensory sensitivities. In fact, previous studies have shown that a majority of preschool children with autism are unwilling to put a toothbrush into their mouth and dislike the taste or texture of toothpaste. (Du et al. 2019, Stein et al. 2012). Parents frequently report a significant struggle around this important self-care skill.
Social stories are a tool used in classrooms and at home to help children master social situations or respond appropriately to difficult non-social situations. Social stories are typically a short story that includes at least two components: descriptive statements and directive statements. Descriptive statements explain facts about a situation and how a student may be feeling or thinking. Directive statements tell a student what they can do to respond to the situation more effectively.
Social stories have previously been shown to help students with dental appointments, toothbrushing skills, and increasing appropriate behaviors in a preschool classroom. The purpose of this study was to use a strong experimental design to demonstrate that social stories are an effective intervention for improving toothbrushing skills among children with and without autism.
Method (What did the study authors do?):
Participants were 181 preschool-aged children recruited from Special Child Care Centers in Hong Kong. These centers provide care for preschool-aged children with developmental disabilities and disorders. 87 children were diagnosed with autism and 94 children were diagnosed with down syndrome, cerebral palsy, developmental delay, or other developmental disabilities. These children were separated into different experimental groups to compare the effectiveness of the social story intervention between them.
A social story-assisted toothbrush training was provided to all children by a dental assistant who was unaware of the children’s diagnosis. A toothbrushing procedure with 13 distinct steps was used. The social story was then shown to each child and parent dyad. The child was encouraged to brush their own teeth in front of a mirror after reading the social story. If the child had failed to practice a specific step, which had been illustrated, the dental would prompt the child to complete the task in front of the mirror.
After toothbrush training and social story intervention was completed, feedback was given to the parents on which portions of the mouth the student needs to improve on brushing (e.g., front of teeth vs. back of teeth). Parents were encouraged to read the social stories to their children at least once per day and to continue doing so for at least 6 months.
Data was collected a baseline (prior to the start of the study) and at the 6 month follow-up. Primary outcome of the study was how many toothbrushing steps were following independently. The secondary outcomes were how much time a child spends brushing each section, their overall hygiene status, and their gingival health status.
Results (What did the study find?):
- Regular use (1-7 days per week) of the social stories was reported by 30% of parents at 6 month followup, and irregular use was reported by 43% of parents. The remainder were not used because the children were unwilling to look at the books, they were lost/broken, or parents had no time to show the booklets (30% total).
- After the intervention, children improved from following 4 steps of the 13-step process to 6 steps independently on average. This was a statistically significant result. Overall steps followed (including parental assistance) increased from 7 to 8 on average.
- Results also showed that children increased their overall toothbrushing time from about 98 seconds to 140 seconds.
- Overall, 15% of children in the study were able to complete all steps of the toothbrushing intervention independently at the end.
- Oral hygiene improved significantly among both children with and without autism at 6 months following the intervention. Improval oral status was noted among 82% of the children in the study.
- Results did not differ significantly between children with autism and children with other developmental disabilities.
Limitations:
- Since toothbrushing performance was only observed twice (at the beginning of the study and at the end), students may have been on their “best behavior” when they were being observed. It is not clear how well the improved brushing performance generalized to the home environment. However, their dental hygiene was improved.
- Only 30% of parents reported regular use of the social story intervention. Interestingly, however, regression analysis did not indicate that parents who used the social story more frequently saw better outcomes with toothbrushing skills.
Conclusion (What does this mean?):
The results of this study indicate that social stories could be a beneficial tool to improve toothbrushing skills and dental hygiene among students with a variety of disabilities including autism. Children’s oral hygiene, gingival status, and ability to brush teeth independently was significantly improved a result of the social stories. In this study, children with relatively higher IQ scores benefited more from social stories than those with relatively lower IQs.
Download our free social story for teaching toothbrushing skills in the resources page.
Recommendations and Resources:
Based on this and other research, we recommend that teachers and parents consider using social stories to teach toothbrushing and other life skills. We have developed our own social story based on these research findings that can be printed out and used with your children. It includes visuals for each step of the toothbrushing process and a 14-step data sheet to track progress.
Additional References:
Du, R. Y., Yiu, C. K. Y., & King, N. M. (2019). Oral health behaviours of preschool children with autism spectrum disorders and their barriers to dental care. Journal of Autism and Developmental Disorders, 49( 2), 453– 459.
Stein, L. I., Polido, J. C., & Cermak, S. A. (2013). Oral care and sensory over‐responsivity in children with autism spectrum disorders. Pediatric Dentistry, 35( 3), 230– 235.
