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May 6, 2024
As a licensed and nationally certified school psychologist and board-certified behavior analyst, Reeva Morton, PhD, BCBA-D, NCSP has her feet in two places at once: the University of Florida’s (UF) College of Medicine and the College of Dentistry.
“With projects in the College of Dentistry, I’m a behavioral consultant, which I love because I'm able to tie all my hats together with the goal to support children with special needs, whether it be a dentist, parent, or teacher,” Morton says. “I’m able to support them by using a collaborative team approach. I provide the caretakers with information on making the oral health experience a little easier for everyone, especially for those who may need some extra support.”
She is now able to merge those two worlds even further as an advisor on a $125,000 grant to the UF College of Dentistry provided by CareQuest Institute. With that funding, the college uses mobile dentistry equipment to provide oral health care to adults with intellectual and developmental disabilities at the Arc of Alachua County, an organization that supports adults with special health care needs.
Providing this oral health care was UF’s answer to a problem that developed in 2022 when the state government stopped funding outpatient dental services at the Tacachale Developmental Disability Center, which provided residential care and outpatient dental services for adults with developmental disabilities. This left hundreds of adults with disabilities and their caregivers driving more than two hours away from Alachua County just to get a dental cleaning.
“[The grant’s] even more important because with the Arc, a lot of the patients are what we would call ‘of age,’” Morton says, “so they’re over 18. They’re legally adults. Adults in general likely do not have an opportunity to receive oral health care [through Medicaid], and for an adult who has special needs, the chances are even smaller because they also cannot find a provider who will see them. So, with this grant, we're able to tackle both areas of need.”
Morton took a few minutes out of one of her busy days to share more about why the integration of behavioral and oral health care is critical to help people with developmental differences.
What kind of special care do people with intellectual and developmental disabilities need at the dentist?
It varies for each person. Some individuals with developmental differences have sensory needs, for example.
There are things they may avoid, but there are also things they seek. A dentist shining a bright light in their face when they're laying back in the chair may be super uncomfortable, and some individuals may not have a way to communicate those sensory aversions or be able to tolerate the distress. Or they may really like the light, so turning the light off may make them upset and never move out of the chair. Some individuals may focus on certain things because they really like those visual stimuli. So, putting on glasses may not be something that an individual with a developmental difference is able to do as easily as someone who does not have those sensory needs. Or it could be the taste or the texture of something. If someone does not like the texture of the bib or the taste of the fluoride, they may just rip it off or spit it out and then never visit the dentist again because they associate the dentist with this sensory aversion.
Are there differences in communication style?
For some individuals with developmental differences, communication may be nonverbal. That could be in the form of eye contact or pointing, or very short two-word phrases, or it may be using a device to communicate. Others can communicate verbally but are not able to say how they specifically feel or what they need to feel comfortable at the dentist.
What was the moment you realized oral health and behavioral health were connected?
Before I came to UF, I was working in a private practice, and there was a family that I had seen for years, and their little girl was diagnosed with autism. The family told me the girl, who was younger than 5 at the time, had never been to the dentist before. I knew that all children should have an opportunity to go to the dentist, but I also knew the barriers that many families with developmental differences experience. She would put everything in her mouth. She also didn’t like wearing certain textures of clothes, would scream when she was upset, and she had a lot of what some clinicians would call “challenging behaviors.”
But I’m the type of clinician who says, “Shoot for the stars.” So, that day, I searched on Google to find dentists in the area who see individuals with special needs, and I found one. I was excited but also curious to see how my little girl would be treated, so I volunteered to go with her, and the dental office was awesome.
About every month we’d go to that dentist just to practice walking through the door, waiting for our turn, and sitting in the chair. She had to get used to the lights and someone covered in a mask. Now she’s able to open her mouth, lie back if we hold her, and the dentist can count her teeth.
This experience taught me that I could collaborate with dentists on using behavioral strategies with a patient during a dental visit, and, in turn, the dentist could teach me things the patient and I could practice in between visits. We came up with innovative solutions to serve the little girl, and from that experience I realized that neither one of us in either expertise was able to meet her needs individually. We had to collaborate and work as a team. To this day I still refer families to that dentist.
As an advisor for the CareQuest Institute grant-funded initiative, how do you educate dentists on providing and accessing oral health care for people with developmental differences?
As a board-certified behavior analyst, I’m able to understand some of the strategies that we're taught in the field of behavior analysis. I also have a background in psychology, so I’m also trained in human development, school- and community-based systems, neurodiversity, many types of consultation models, and effective treatment approaches. I combine both of my backgrounds and use behavioral consultation to approach this collaboration. Specific techniques I have used include tell, show, do; task analyses; first/then statements; positive reinforcement; visual contingencies; sensory breaks; social stories; and the importance of environmental changes. I’m able to show dentists how to incorporate those practices in their everyday setting while they're providing care.
How about caregivers?
I can also provide caregivers and parents with support. That’s where my school psychology background comes in, because I can make sure the caregiver feels safe to bring their loved one in for oral health care visits and help break any barriers they may experience. I let parents know that even though their loved one may have Down syndrome, or autism, or cerebral palsy, or any other need, this does not mean that their oral health is not a priority. Oral health is just as important as mental or physical health. I usually can sense when others are apprehensive, so I can support the parent or the caregiver with psychoeducation and reassurance. Sometimes, they just want someone in their corner.
What is your hope for the future of this work?
Right now, through the grant, we're providing oral health care with a mobile unit. We don't have to have people come to the UF campus; we're able to meet them in their community. But that mobile clinic is at the Arc of Alachua County and mainly focused on adults.
Ideally, I would want to spread the interdisciplinary concept and include children in the community. Children and special needs have always been my focus. I completed my doctoral program in rural Mississippi and then interned in rural Nebraska. My family is in Mississippi, and I know so many people there who could benefit from a mobile clinic.
It would also be nice to eventually serve people in rural areas and train dentists there on how to use these skills. We know there are people who live two to three hours away who definitely aren't going to the dentist, and they may not even be able to go to the Arc. It would be really inspiring to reach those rural communities and maybe other states, or larger cities, would be able to model this outreach clinic. Some of those rural community members also have developmental differences.
All in all, it is important for clinicians to continue to shed light on the concept of intersectionality and how that looks for each family. A verbal Black boy with autism who is wheelchair bound and does not have transportation is likely going to have a different experience than a nonverbal Asian girl with a rare genetic disorder, even though they both need oral health care. So, my idea for the future is making sure that the needs of all children are met, and oral health providers feel equipped to service them.