SIGNIFICANCE: Oral care is integral for physical and psychological well-being. Children with autism spectrum disorder (cASD) often experience barriers to oral care compared to their typically developing (TD) peers. One barrier is the uncooperative behavior exhibited by more than half of cASD during dental cleanings. These behaviors may impede or change care, with refusal of care or use of general anesthesia as two possible consequences.

INNOVATION: Previous studies have used dentist-report measures to examine the prevalence of uncooperative behaviors in cASD; however, none have utilized an objective measure of children’s behavior or a physiological measure of stress.

APPROACH: In this study, we investigated behavioral and physiological stress during oral care to test whether (1) cASD, compared to TD children, exhibit significantly greater behavioral and physiological stress during dental cleanings, and (2) physiological stress is correlated with behavioral distress.

RATIONALE: Oral care is essential for overall well-being, but cASD often experience barriers to oral care. One such barrier is uncooperative behavior during dental cleanings, which can impede or change care. Although behavioral displays of stress during oral care have been examined using dentist-report measures, no studies have investigated behavioral stress using an objective tool or measures of physiological stress. Because many cASD have limited expressive language skills, it may be especially difficult to assess stress due to children’s difficulty describing their experience; therefore, utilizing objective tools to measure their physiological experience is an alternative and essential way to obtain this information.

METHOD: A comparison of behavioral and physiological indices of stress was conducted between ASD and TD groups during a dental cleaning. Correlations between physiological and behavioral measures were examined. Participants were 44 children aged 6 to 12 yr (TD, n = 22; ASD, n = 22) receiving dental cleanings at an urban children’s hospital. Dental cleanings were video-recorded and coded using the Children’s Dental Behavior Rating Scale; stress behaviors were also measured by traditional dentist-report tools. Physiological stress was measured using electrodermal activity (EDA)—a noninvasive way to measure sympathetic nervous system activation; EDA increases in stressful or painful situations. Comparisons between groups were performed using analysis of covariance (ANCOVA) models.

RESULTS: Overt behavioral distress, as measured by both dentist-report measures and coded videos, confirmed that cASD exhibited greater uncooperative behavior during dental care compared to TD children (all ps ≤ .001); cASD also exhibited significantly higher EDA compared to their TD peers (p = .001). In the ASD group, EDA measures were significantly and positively correlated with dentist-report and researcher-coded measures of overt distress behavior (rs = .43 to .62; all ps ≤ .05), indicating that as physiological stress increased, so did overt uncooperative behaviors. No such correlations were found in the TD group.

CONCLUSION: This study supports prior research; cASD exhibit greater uncooperative behavior during dental cleanings compared to TD children. Physiological stress was also greater in cASD, and physiological stress was positively correlated with behavioral distress in the ASD group. Novel strategies may be required to decrease behavioral/physiological stress during oral care in cASD.