Skip to main content
NCBI home page
Journal of Oral Biology and Craniofacial Research logoLink to Journal of Oral Biology and Craniofacial Research
. 2025 Sep 3;15(6):1440–1447. doi: 10.1016/j.jobcr.2025.08.022

Comparative evaluation of the effect of Snoezelen Distraction Technique on children with Autism and healthy children during dental treatment

Sanjna K Sreenivasan 1, Nikita Lolayekar 1, Kavita Rai 1, Aishani Baksi 1, Kripa Dutta 1, Manju R 1,⁎
PMCID: PMC12445563  PMID: 40979253

Abstract

Aim

To compare the effect of Snoezelen distraction technique (SDT) on children with Autism disorder and healthy uncooperative children during dental treatment.

Method

ology: 17 children diagnosed with Autism (Group 1) and 17 uncooperative healthy children (Group 2) requiring dental treatment were considered for the study. The study comprised of two appointments during which physiological and behavioural parameters were recorded. First appointment, dental treatment was done without any distraction and the second appointment with Snoezelen distraction technique (SDT).

Results

In Group 1, there was a statistically significant decrease in mean pulse rate (p < 0.01), mean respiratory rate (p < 0.05) and decrease in the negative behaviour frequencies (p < 0.01) from first to second appointment. In Group 2, there was a statistically significant decrease in the mean pulse rate, respiratory rate values (p < 0.01) and decrease in the negative behaviour (p < 0.05) frequencies from first to second appointment. On comparative evaluation, there was a statistically significant difference seen for the values between the groups (p < 0.05) for the change in respiratory rate with higher values in Group 1. In Appointment 2 there was a statistically significant difference seen in the frequencies between the groups for behaviour (p < 0.01) with a higher frequency for negative behaviour in Group 2 and definitively positive in Group 1.

Conclusion

In children with Autism and healthy uncooperative children there was a significant change in both physiological and behavioural parameters on using SDT. The changes in these parameters were statistically higher in children with Autism.

Keywords: Autistic disorder, Behaviour, Snoezelen room, Multisensory environment

1. Introduction

The American psychiatrist, Leo Kanner first described Autism disorder in 1943. He believed that these children with autism possessed an inborn feature which prevented their regular social contacts.1

The most recent study conducted by Center for Disease Control and Prevention in 2016 suggests that 1 in 54 children worldwide meet the criteria for Autism Spectrum Disorder (ASD).2

The Diagnostic and Statistical Manual (DSM-5) published by the American Psychiatric Association defines ASD as the onset prior to two years of age and the presence of deficits or unusual behaviours within two domains: social communication and restricted, repetitive behaviours along with a severity level for each.3

“The criteria for the diagnosis of ASD involves a triad which includes.

  • -

    Qualitative impairment in social interaction

  • -

    Qualitative impairment in communication

  • -

    Restricted, repetitive and stereotyped patterns of behaviour, interests and activities”4

Temper tantrums, hyperactivity, short attention span, anxiety, anger, obsessive routines, unusual interests and a tendency for aggressive and self-injurious behaviours are the usually observed behavioural features in these patients. Kanne and Mazurek found that 56 % of individuals with ASD directed aggression toward caregivers and 32 % directed aggression toward noncaregivers.5

Self injurious behaviours may range from self-pinching to self-biting or head banging, whereas flapping of arms and walking on toes are automatic stereotyped patterns of behaviour observed in these individuals.6

Sensory processing difficulties such as auditory, visual and tactile sensory processing, integration of multiple sensory stimuli and processing, are also affected.7 A distinctive occurrence in these individuals is echolalia. Even a minor deviation from a daily routine can either trigger or even increase it.8 These behavioural characteristics also vary widely from person to person and the clinical management has to be customised to each patients’ needs rather than adopting a one size fits all approach. These above mentioned features may collectively make providing oral health care to these children with ASD a challenging task.

Thus the management of these patients can include various techniques of behaviour management which may be pharmacological or non-pharmacological. Some of the preferred behaviour guidance techniques are communication, tell-show- do, restraints, desensitization, distractions etc. Alteration of the environment to a calm one, utilization of simpler commands and visual aids for communication as well as tell show do, providing deep pressure or touch using weighted vests, providing audio and visual distractions, sensory alterations to decrease taste perceptions of dental materials, use of social stories to desensitize the dental environment are some modifications to these general behaviour guidance techniques that have proven beneficial in individuals with Autism. 9,10Another management strategy incorporated the applied behaviour analysis strategy that focused on analysis and modification of human behaviour9,10

Snoezelen therapy is one of the multisensory distraction strategies that can be adopted in the management of these patients. The concept was developed by Hulsegge and Verheul in Holland, and since then it has gained popularity in various fields and spread to other countries.11 The sensory stimulation from this therapy invokes environmental manipulation to effect internal change in the child, in order to decrease the maladaptive behaviours.12

“Snoezelen”, presently a commercially registered trade name is a combination of the terms “sniff” and “dose”.13 It is derived from the Dutch words “snuffelen” and “doezelen.” However, here “sniff” or “snuffelen” is to be considered in the sense as “to sniff out,” i.e., to find something out by exploring a situation or event. It is an environment that delivers controlled sensory stimulation while placing minimal cognitive demands on the individual.14

Even though Snoezelen has no fixed prerequisites it normally includes some standardised equipments as sources of stimulation which may include lava lamps, coloured lights, aromatherapy, fibre-optic cables, bubble tubes, mirror balls, and music etc.15 With this the individual is introduced to an array of instruments and materials fabricated to create visual, tactile, auditory, gustatory, and olfactory experiences as well as an overall feeling of relaxation and restoration.16, 17, 18, 19

Snoezelen can reduce physiological arousal, agitation, anxiety and also induce relaxation.19,20,21 Multisensory therapy has seen to reduce the incidence and duration of stereotypic self-stimulating behaviours in children with intellectual disabilities.22,23

Snoezelen therapy has been studied on different populations by various authors. In subjects with developmental disabilities it has been found that the impact from Snoezelen therapy was in the form of relaxation and promotion of positive emotions.24 Whereas in subjects with intellectual disabilities, Snoezelen therapy provided an effective setting for decreasing self-stimulating behaviours.22 Various studies have also provided evidence of reduction of these maladaptive behaviours of individuals with mental retardation in a Snoezelen room.25,26 Withers PS et al. reported that on employing Snoezelen therapy the most striking effects were leisure, relaxation, improved rapport, and reduction of negative behaviours.27

Majority of research on Snoezelen focuses on adult participants, only minimal research has been done on multisensory therapy for children.13According to researchers additional qualitative research is essential in providing an accurate understanding of how clients experience Snoezelen. Limited studies to no studies are available on the use of Snoezelen for dental management. Therefore this study aims to bridge this gap in research and comparatively evaluate the effect of Snoezelen distraction technique on behaviour of children with Autism to that of healthy uncooperative children during dental treatment using both physiological and behavioural measures.

There has been a marked increase in the use of sensory stimulation to meet the complex needs of people with learning disabilities.28 However, most of the studies adopted an applied behavioural analysis approach, while only a smaller number used physiological measures.14 Hence, the objectives of this study were to assess the behaviour of children with Autism Spectrum Disorder and healthy uncooperative children, during dental treatment, by recording pulse, respiratory rate and behavioural changes; with and without using Snoezelen distraction technique and to comparatively evaluate the changes in behaviour between the two groups on using Snoezelen distraction technique.

Dental environments can be fear provoking and as a defense mechanism there are notable physiological changes in the body. These responses can be correlated to an increased activity of the autonomic nervous system.29 The result of this increased activity can be in the form of alterations in the activity of cardiovascular system seen as increase in blood pressure and pulse rate, increased sweating and electrical conductivity, increase in muscle tone and alterations in respiration.30 Various studies have shown the changes in cardiovascular system noted in the form of blood pressure and pulse rate that can be clear indicators of anxiety.31 Psychologists claim that when an individual is experiencing heart pounding, these maybe be reflected by changes in the pulse rate.32

Respiration is regulated by the combined actions of brainstem, limbic system and the cortical structure of the brain. However a part of this limbic system known as amygdala plays a major role in the processing of negative emotions, thus any change in respiration in response to any form of fear or anxiety is controlled by the brain center. Therefore respiratory rate has been established to be indicative of changes in the anxiety levels.29 Pulse rate and respiratory rate were chosen as two physiological measures that can be measured as indicators of anxiety in this study as they could be easily measured without majorly affecting the patient's cooperation. And the behavioural parameter was assessed using the Frankl's behaviour rating scale on both appointments.24

2. Materials and methods

The Group 1 consisted of 17 Children (10 males and 7 females) in the age group of 3–15 years, diagnosed with Autism Spectrum Disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria given by American Psychiatric Association, who visited the Department of Pediatric and Preventive Dentistry, seeking dental care.

The Group 2 consisted of 17 (9 males and 8 females) in the age group of 3–15 years healthy uncooperative children who visited the Department of Pediatric and Preventive Dentistry, seeking dental care.

The sample size was estimated at 80 % power and type I error to be 5 %.

Inclusion Criteria:

Children diagnosed with Autism disorder.

Exclusion Criteria.

  • -

    Children with any other medically compromising conditions.

  • -

    Without consent provided by parent/caregiver.

  • -

    Previous exposure to dental environment

2.1. GROUP 1 (children with autism disorder)

Our institute is affiliated to a Special care unit which involves multiple departments such as Department Of Pediatrics, Ophtalmology, Otolaryngology, Neurology, Audiology and Speech, Physiotherapy Pediatric Dentistry for the care of children with special health care needs. Therefore the diagnosis is made by the Department of Pediatrics following which the child is referred to our department for oral health concerns.

The severity and verbal ability of the individuals were not taken into consideration.

2.2. GROUP 2 (healthy uncooperative children)

Inclusion Criteria.

  • -

    Uncooperative behaviour (categorised under Frankl's behaviour rating 1 and 2)33

  • -

    Healthy children

Exclusion Criteria.

  • -

    Medically compromised children

  • -

    Children with visual impairment

  • -

    Cooperative behaviour (Frankl's behaviour rating scale 3 and 4)33

  • -

    Children with previous exposure to dental environment

Ethical clearance was obtained from the Institutional Ethical Committee. Informed written consent and assent was obtained from every parent/guardian.

The study comprised of two appointments:

Appointment 1 (A1) → dental treatment was done without using any distraction technique for both the groups.

Appointment 2 (A2) → dental treatment was done using Snoezelen Distraction Technique for both the groups.

The dental treatment included introduction to dental setup followed by clinical examination and oral prophylaxis.

A “Snoezelen Cart” was used, which included multicoloured bubble tube (Medilab Bubble tube 100 × 32 cms- Fig. 1) and customised Snoezelen jars (Fig. 2). The Snoezelen jar was customized after a literature survey of various Snoezelen techniques used for multisensory approach. The Snoezelen jars were customized with the aim of having a distraction that can be held by the patients themselves during the dental treatment. The jars had attractive colours and constant movement of tiny objects within with the intention of providing adequate sensory stimulation.

Fig. 1.

Fig. 1

Open in a new tab

Snoezelen Muticoloured bubble tube.

Fig. 2.

Fig. 2

Open in a new tab

Customised snoezelen jar.

Dental treatment being done using Snoezelen Distraction technique is depicted in Fig. 3.

Fig. 3.

Fig. 3

Open in a new tab

Dental treatment with Snoezelen Distraction.

2.3. Physiological parameters

The pulse rate (beats/minute) was recorded by means of a pulse oximeter (SN: 17234206113; OXEE CHECKTM) and the respiratory rate (breaths/minute) was visually observed during the procedures listed under both the appointments.

2.4. Observational parameters

Frankl's Behaviour Rating Scale33 was recorded during the procedures listed under both the appointments.

The Frankl's Behaviour Rating Scale includes the following markings.

  • 1.

    Definitely negative - refusal of treatment, crying forcefully, fearful, or any other overt evidence of extreme negativism

  • 2.

    Negative - reluctant to accept treatment, uncooperative, some evidence of negative attitude but not pronounced

  • 3.

    Positive - acceptance of treatment; at times curious, willingness to comply with the dentist, at times with reservation but patient follows the dentist's directions cooperatively

  • 4.

    Definitely positive - good rapport with the dentist, interested in the dental procedures, and laughing and enjoying the situation.33

The difference in pulse, respiratory values and behaviour between the two treatments with a one month interval was recorded. The values obtained were tabulated, compared and statistically analysed.

2.5. Statistical analysis

All data was entered into a computer by giving a coding system and proofed for entry errors. Data obtained was compiled on a MS Office Excel Sheet (v 2019, Microsoft Redmond Campus, Redmond, Washington, United States).

Data was subjected to statistical analysis using Statistical package for social sciences (SPSS v 26.0, IBM).

Descriptive statistics like frequencies and percentage for categorical data, Mean & SD for numerical data has been depicted.

Normality of numerical data was checked using Shapiro-Wilk test & was found that the data did not follow a normal curve; hence non-parametric tests have been used for comparisons.

Inter group comparison (2 groups) was done using Mann Whitney U test.

Intra group comparison was done using Wilcoxon Signed rank test (up to 2 observations)

For all the statistical tests, p < 0.05 was considered to be statistically significant, keeping α error at 5 % and β error at 20 %, thus giving a power to the study as 80 %.

Image 1

Open in a new tab

STUDY DESIGN FLOWCHART

3. Results

3.1. Physiological parameters

Pulse rate and respiratory rate values of Group 1 (children with Autism) and Group 2 (healthy uncooperative children) was recorded during dental treatment on both the appointments Appointment 1- (A1) did not employ any distraction technique whereas Appointment 2 (A2) employed Snoezelen Distraction Technique. The values are given in Table 1.

Table 1.

Comparison of pulse rate and respiratory rate in Group 1 and Group 2, without (A1) and with (A2) Snoezelen Distraction Technique during dental treatment.

Groups Mean Standard Deviation Standard Error Mean (±) Mean difference SD of difference Median Z value p value of Wilcoxon Signed Ranks Test
Group 1 PR at A1 76.94 6.600 1.601 2.588 2.785 79 −2.8300 0.005∗∗
PR at A2 74.35 6.652 1.613 75
RR at A1 20.71 1.532 .371 2.000 3.279 20 −2.0420 0.041∗
RR at A2 18.71 3.754 .911 18
Group 2 PR at A1 88.71 7.983 1.936 2.118 2.759 90 −2.767 0.006∗∗
PR at A2 86.59 8.740 2.120 89
RR at A1 18.18 1.629 .395 1.412 1.460 19 −2.948 0.003∗∗
RR at A2 16.76 1.200 .291 17
Open in a new tab

PR- Pulse rate, RR- Respiratory rate, A1-Appointment 1, A2 -Appointment 2, SD- Standard deviation.

From Table 1, Table 2, the following inferences can be made.

  • 1.

    The pulse rate and respiratory rate, without (A1) and with (A2) Snoezelen Distraction Technique during dental treatment was recorded and then analysed by Wilcoxon Signed Ranks Test.

Table 2.

Comparison of changes in pulse rate and respiratory rate between Group 1 and Group 2, without (A1) and with (A2) Snoezelen Distraction Technique during dental treatment.

Group Mean Std. Deviation Std. Error Mean(±) Median Mann- Whitney U value Z value p value of Mann-Whitney U Test
PR at A1 1 76.94 6.600 1.601 79 38.500 −3.657 0.000∗∗
2 88.71 7.983 1.936 90
PR at A2 1 74.35 6.652 1.613 75 35.000 −3.775 0.000∗∗
2 86.59 8.740 2.120 89
Change in PR 1 2.82 2.531 .614 3 123.500 −0.738 0.460#
2 2.24 2.658 .645 1
RR at A1 1 20.71 1.532 .371 20 36.000 −3.810 0.000∗∗
2 18.18 1.629 .395 19
RR at A2 1 18.71 3.754 .911 18 94.500 −1.744 0.081#
2 16.76 1.200 .291 17
Change in RR 1 3.06 2.249 .546 4 86.000 −2.067 0.039∗
2 1.53 1.328 .322 2
Open in a new tab

PR- Pulse rate, RR- Respiratory rate, A1-Appointment 1, A2 -Appointment 2.

3.2. Group 1

  • -

    Statistically highly significant difference were seen for the values between the two appointments (p = 0.005) for pulse rate with higher values at Appointment 1.

  • -

    Statistically significant difference were seen for the values between the two appointments (p = 0.041) for respiratory rate with higher values at Appointment 1.

3.3. Group 2

Statistically highly significant differences were seen for the values between the two appointments for pulse rate (p = 0.006) and (p = 0.003) respiratory rate with higher values at Appointment 1.

  • 2.
    On the intergroup analysis of changes in pulse rate and respiratory rate values done by Mann- Whitney U Test showed:
    • -
      Difference in pulse rate (beats/min) was noted observed to be higher in Group 1 but the difference is statistically non-significant for the values between the groups (p = 0.46) as shown in Table 2.
    • -
      Statistically significant difference were seen for the values between the groups (p = 0.039) for the difference in Respiratory rate (breaths/min) with higher values in Group 1 as shown in Table 2.

4. Behavioural parameters

Frankl's behaviour rating scale of Group 1 (children with Autism) and Group 2 (healthy uncooperative children) was recorded during dental treatment on both the appointments Appointment 1- (A1) did not employ any distraction technique whereas Appointment 2 (A2) employed Snoezelen Distraction Technique. The values are given in Table 3.

Table 3.

Comparison of behaviour rating frequencies, during dental treatment between Group 1 and Group 2 using Frankl's behaviour rating score at Appointment 1 and Appointment 2.

Group
1 2 Total
A1 1N 5 12 17
1P 8 0 8
2N 4 5 9
Total 17 17 34
A2 1N 1 9 10
1P 8 6 14
2N 3 2 5
2P 5 0 5
Total 17 17 34
Open in a new tab

A1- Appointment 1, A2- Appointment 2, 2N-Definitely Negative behaviour,1N- Negative behaviour,2P- Definitely Positive behaviour, 1P – Positive behaviour.

4.1. Group 1

The analysis done by Chi- Square Test showed a statistically highly significant difference for the frequencies between the two appointments (p = 0.001) where 11 subjects out of the total 17 who showed a positive behavioural change in Group 1. There was a significant decrease in negative behaviour frequencies by the second appointment (A2) on employing Snoezelen Distraction Technique during dental treatment in Group 1 subjects.

4.2. Group 2

The analysis done by Chi- Square Test showed a statistically significant difference seen for the frequencies between the two appointments (p = 0.025) with a positive change in the behaviour of 9 patients in Group 2. There was a significant decrease in negative behaviour frequencies by the second appointment (A2) on employing Snoezelen Distraction Technique in Group 2 subjects.

4.3. Intergroup

The analysis done by Chi square tests showed that there was a statistically highly significant change in behaviour frequencies at both the appointments 1 (p = 0.04) and 2 (p = 0.008) with a higher frequency for negative behaviour rating in Group 2 when compared to Group 1.

These changes in behaviour frequencies at A1 and A2 for both the groups are depicted in Graph I, Graph II.

Graph I.

Graph I

Open in a new tab

Comparison of behaviour rating frequencies between Group 1 and Group 2 using Frankl's behaviour rating score at A1.

A1- Appointment 1, A2- Appointment 2, 2N-Definitely Negative behaviour,1N- Negative behaviour,2P- Definitely Positive behaviour, 1P – Positive behaviour.

Graph II.

Graph II

Open in a new tab

Comparison of behaviour rating frequencies between Group1 and Group 2 using Frankl's behaviour rating score at A2.

A1- Appointment 1, A2- Appointment 2, 2N-Definitely Negative behaviour,1N- Negative behaviour,2P- Definitely Positive behaviour, 1P – Positive behaviour.

5. Discussion

Snoezelen, or multi-sensory environments (MSEs), support autistic children by offering a calming and controlled space with a variety of sensory stimuli. These environments help regulate atypical sensory processing, allowing children to explore and respond to visual, auditory, tactile, and other sensory inputs at their own pace.21 This tailored stimulation aids in emotional regulation by reducing anxiety and stress, fostering a sense of relaxation and safety. The playful and non-directive setting encourages engagement, communication, and even social interaction, particularly when the child feels emotionally secure. Children are empowered to make choices, boosting their sense of control and independence. Interaction with sensory equipment also promotes cognitive development, confidence, and learning through exploration.10,11,14

In our study the first appointment (A1) dental treatment was done without using Snoezelen Distraction Technique and the second appointment (A2) dental treatment was done using Snoezelen Distraction Technique. The time interval between both the appointments was established as one month as a washout period to promote children's cooperation.34

In Group 1 there was a statistically significant decrease in both physiological parameters i. e pulse rate and respiratory rate and behavioural rating scores i. e a decrease in the negative behaviour (Frankl's behaviour) frequencies from A1 to A2. The drop in pulse rate and respiratory from an average of 76.9 beats/minute(A1) to 74.3 beats/minute (A2) and 20.7 breaths/minute (A1) to 18.7 breaths/minute (A2) respectively along with the behavioural changes are highly suggestive of decrease in anxiety in A2 on using Snoezelen Distraction Technique in children with Autism. These findings are in accordance with a pilot study by Cermak et al. assessing the feasibility of sensory adapted dental environments for children with Autism where it was concluded that it is a viable option for limiting the negative behaviours initiated by stress in these children.35

In Group 2 there was a statistically significant decrease in both physiological parameters i. e pulse rate and respiratory rate and behavioural rating scores i. e a decrease in the negative behaviour (Frankl's behaviour) frequencies from A1 to A2. The drop in pulse rate and respiratory from an average of 88.7 beats/minute(A1) to 86.5 beats/minute (A2) and 18.18 breaths/minute (A1) to 16.16 breaths/minute (A2) respectively along with the behavioural changes can be very indicative of decrease in anxiety in A2 on using Snoezelen Distraction Technique in healthy uncooperative children. These findings were similar to those demonstrated by Shapiro et al. in healthy subjects, through behavioural and psychophysiological measures that the patients were in an improved state of relaxation while in a Snoezelen environment in comparison to that of a conventional dental environment.21

On comparative evaluation of the changes from A1 to A2 between both the groups; there was greater decline in mean pulse rate in Group 1 (2.82 beats/minute) when compared to Group 2 (2.24 beats/minute) even though the difference was statistically non-significant. A statistically significant greater drop in mean respiratory rate in Group 1 (3.06 breaths/minute) when compared to Group 2 (1.53 breaths/minute) was seen.

The behavioural parameter changes assessed through Frankl's Behaviour rating showed that in A2 there was a statistically significant difference seen for the behaviour frequencies between the groups. In A2 a higher frequency was recorded for negative behaviour in Group 2 and definitively positive in Group 1 suggesting that there was a greater positive change in behaviour in Group 1 when compared to Group 2. Thus it is evident that although there was a decrease in physiological parameters and positive change in behavioural parameters (i.e a more favourable behaviour pattern) noted in both the groups, these changes were more significant in Group 1 when compared to Group 2. These findings may suggest that the calming effect of Snoezelen Distraction in children with Autism was more evident in comparison to healthy uncooperative children. This necessarily meant a reduction in restricted repetitive movements, echolalia, hyperactivity and aggressive behaviours in these subjects.

An additional observation made was one subject with Autism who did not comply for recording of the physiological parameters and was excluded from the data sample. On introduction to the Snoezelen Distraction Technique the patient exhibited extreme aggression and ran away from the sensory stimuli. This is similar to the findings by Koller D et al., in 2018 who showed that the individual responses to this distraction may vary considerably.13

This is because the subjects with ASD are known to have sensory processing disorders and a subtype of sensory processing disorder is sensory modulation disorder.36 They can display a range of sensory symptoms ranging from sensory over-responsivity, Sensory Under-responsivity and Sensory Seeking/Craving. Individuals with Sensory Over-responsivity often display negative responses to touch, sound or bright lights. Behaviorally they avoid certain sensory experiences or have extreme emotional reactions to typically non-aversive sensory stimuli as seen in this particular patient.37

On the other hand, individuals with sensory under-responsivity ignore or do not notice typical sensory stimuli.38 They appear passive, uninterested in the environment which is hypothesized to be caused by the inability of the sensory information to reach their threshold for awareness. Lastly, individuals with Sensory Seeking/Craving, often appear reckless and dangerous in their attempts to fulfill their sensory needs.36,37

Few drawbacks of employing Snoezelen Distraction Technique would be the expenditure involved in the process and the requirement of an established infrastructure, trained personnel as well as judicious patient selection for the use of this technique. Individual responses to the therapy may vary and some subjects would find the distraction therapy to be claustrophobic.39 For maximising the effect of Snoezelen therapy it may need to be used in combination with pharmacological therapy for improving the behaviours of the target populations. An attributing factor in the change in behaviour may be the developing sense of comfort to the dental space and clinician in both the group.

Besides the above mentioned drawbacks of Snoezelen Distraction Techniques the study had a few limitations. The study included a small sample size. The sample included did not differentiate the individuals in the study group on the basis of severity of Autism, verbal ability, hyposensitivity and hypersensitivity. The first appointment may not have been the child's first dental visit, which can also cause alteration in behaviour. The etiology behind negative behaviour in healthy children in the control group can be attributed to various reasons that haven't been explored. In addition, only minimal treatment strategies have been taken into consideration, which do not involve any invasive technique that might induce pain. Thus future studies with appropriate modifications to the above shall be useful in throwing further light on the effect of Snoezelen on these individuals.

6. Conclusion

In children with Autism there was a significant change in both physiologic (pulse rate, respiratory rate) and behaviour parameters (rating scores) on employing Snoezelen Distraction Technique.

In healthy uncooperative children there was a significant change in both physiologic (pulse rate, respiratory rate) and behaviour parameters (rating scores) on employing Snoezelen Distraction Technique. Therefore Snoezelen Distraction Technique can be recommended as an effective method of distraction during dental treatment in both the groups.

On comparative evaluation of the changes in physiological and behavioural parameters between both the groups, it can be concluded that the changes in these parameters (respiratory rate and Frankl's behaviour rating) were statistically significant and observably favourable in children with Autism.

Parent's/Guardian's consent

Written informed consent was obtained from the parents of the participating children.

Ethical clearance statement

Ethical clearance has been granted by the Institutional Ethics Committee with certificate no: ABSM/EC 60/2019 dated 14/10/2019.

Source of funding

This original research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

Authors have nothing to report.

Contributor Information

Sanjna K. Sreenivasan, Email: sanjna695@gmail.com.

Nikita Lolayekar, Email: drnikitashanbhag@gmail.com.

Kavita Rai, Email: kavhegde@gmail.com.

Aishani Baksi, Email: aishanibaksi23@gmail.com.

Kripa Dutta, Email: drkripadutta21@gmail.com.

Manju R, Email: drmanjur@nitte.edu.in.

References

  • 1.Kanner L. Autistic disturbances of affective contact. Nervous child. 1943 Apr;2(3):217–250. [PubMed] [Google Scholar]
  • 2.Maenner M.J., Shaw K.A., Baio J. Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2016. MMWR Surveillance Summaries. 2020 Mar 27;69(4):1. doi: 10.15585/mmwr.ss6904a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.American Psychiatric Association . fifth ed. American Psychiatric Association; Washington, DC: 2013. Diagnostic and Statistical Manual of Mental Disorders; pp. 88–90. [Google Scholar]
  • 4.Rellini E., Tortolani D., Trillo S., Carbone S., Montecchi F. Childhood autism rating scale (CARS) and autism behavior checklist (ABC) correspondence and conflicts with DSM-IV criteria in diagnosis of autism. J Autism Dev Disord. 2004 Dec 1;34(6):703–708. doi: 10.1007/s10803-004-5290-2. [DOI] [PubMed] [Google Scholar]
  • 5.Kanne S.M., Mazurek M.O. Aggression in children and adolescents with ASD: prevalence and risk factors. J Autism Dev Disord. 2011;41(7):926–937. doi: 10.1007/s10803-010-1118-4. [DOI] [PubMed] [Google Scholar]
  • 6.Akhila T., Ditto Sharmin D. Dental management and behavioural modifications of children with autism spectrum disorders (ASD) EC Dental Science. 2015;1:33–55. [Google Scholar]
  • 7.Marco E.J., Hinkley L.B., Hill S.S., Nagarajan S.S. Sensory processing in autism: a review of neurophysiologic findings. Pediatr Res. 2011 May;69(8):48–54. doi: 10.1203/PDR.0b013e3182130c54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Golysheva M.D. A review on echolalia in childhood autism. Adv Soc Sci Educ Human Res. 2019 Jul;333:200–204. [Google Scholar]
  • 9.Udhya J., Varadharaja M.M., Parthiban J. Autism disorder (AD): an updated review for paediatric dentists. J Clin Diagn Res. 2014 Feb;8(2):275. doi: 10.7860/JCDR/2014/7938.4080. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Chandrashekhar S., Bommangoudar J.S. Management of autistic patients in dental office: a clinical update. Int J Clin Pediatr Dent. 2018 May;11(3):219. doi: 10.5005/jp-journals-10005-1515. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Hulsegge J., Verheul A. Rompa; 1987. Snoezelen, Another World: A Practical Book of Sensory Experience Environments for the Mentally Handicapped. [Google Scholar]
  • 12.King B.H. Self-injury by people with mental retardation: a compulsive behavior hypothesis. Am J Ment Retard. 1993 Jul 1;98(1):93–112. (Ed. ital.). [PubMed] [Google Scholar]
  • 13.Koller D., McPherson A.C., Lockwood I., Blain-Moraes S., Nolan J. The impact of Snoezelen in pediatric complex continuing care: a pilot study. J Pediatr Rehabil Med. 2018 Jan 1;11(1):31–41. doi: 10.3233/PRM-150373. [DOI] [PubMed] [Google Scholar]
  • 14.Hogg J., Cavet J., Lambe L., Smeddle M. The use of ‘Snoezelen’as multisensory stimulation with people with intellectual disabilities: a review of the research. Res Dev Disabil. 2001 Sep 1;22(5):353–372. doi: 10.1016/s0891-4222(01)00077-4. [DOI] [PubMed] [Google Scholar]
  • 15.Minner D., Hoffstetter P., Casey L., Jones D. Snoezelen activity: the good shepherd Nursing home experience. J Nurs Care Qual. 2004;19(4):343–348. doi: 10.1097/00001786-200410000-00010. [DOI] [PubMed] [Google Scholar]
  • 16.Ball J., Haight B. Creating a multisensory environment for dementia: the goals of a Snoezelen room. J Gerontol Nurs. 2005;31(10):4–10. doi: 10.3928/0098-9134-20051001-04. [DOI] [PubMed] [Google Scholar]
  • 17.Collier L., Truman J. Exploring the multi-sensory environment as a leisure resource for people with complex neurological disabilities. NeuroRehabilitation. 2008;23:361–367. [PubMed] [Google Scholar]
  • 18.Cox H., Burns I., Savage S. Multisensory environments for leisure. J Gerontol Nurs. 2004;30(2):37–45. doi: 10.3928/0098-9134-20040201-08. [DOI] [PubMed] [Google Scholar]
  • 19.Hotz G., Castelblanco A., Lara I., Weiss A., Duncan R., Kuluz J. Snoezelen: a controlled multi-sensory stimulation therapy for children recovering from severe brain injury. Brain Inj. 2006;20(8):879–888. doi: 10.1080/02699050600832635. [DOI] [PubMed] [Google Scholar]
  • 20.Houghton S., Douglas G., Brigg J., et al. An empirical evaluation of an interactive multisensory environment for children with disability. J Intellect Dev Disabil. 1998;23(4):267–278. [Google Scholar]
  • 21.Shapiro M., Melmed R.N., Sgan-Cohen H.D., Eli I., Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children's dental anxiety. Eur J Oral Sci. 2007;115(6):479–483. doi: 10.1111/j.1600-0722.2007.00490.x. [DOI] [PubMed] [Google Scholar]
  • 22.Shapiro M., Parush S., Green M., Roth D. The efficacy of the “Snoezelen” in the management of children with mental retardation who exhibit maladaptive behaviours. Int J Dev Disabil. 1997;43(85):140–155. [Google Scholar]
  • 23.Tunson J., Candler C. Behavioural states of children with severe disabilities in the multisensory environment. Phys Occup Ther Pediatr. 2010;30(2):101–110. doi: 10.3109/01942630903546651. [DOI] [PubMed] [Google Scholar]
  • 24.Novakovic N., Milovancevic M.P., Dejanovic S.D., Aleksic B. Effects of Snoezelen—multisensory environment on CARS scale in adolescents and adults with autism spectrum disorder. Res Dev Disabil. 2019 Jun 1;89:51–58. doi: 10.1016/j.ridd.2019.03.007. [DOI] [PubMed] [Google Scholar]
  • 25.Chan S., Thompson D., Chau J., Tam W., Chiu I., Lo S. The effects of multisensory therapy on behaviour of adult clients with developmental disabilities – a systematic review. Int J Nurs Stud. 2010;47(1):108–112. doi: 10.1016/j.ijnurstu.2009.08.004. [DOI] [PubMed] [Google Scholar]
  • 26.De Bunsen A. A study in the implication of the Snoezelen resources at Limington House School. Sensations and disability: sensory environments for leisure, Snoezelen, education and therapy. Rompa. 1994:138–162. [Google Scholar]
  • 27.Withers P.S., Ensum I. Successful treatment of severe self injury incorporating the use of DRO, a snoezelen room and Orientation Cues: a Case report. Br J Learn Disabil. 1995 Dec;23(4):164–167. [Google Scholar]
  • 28.Centers for Disease Control and Prevention Key findings from the ADDM network: a snapshot of autism spectrum disorder. Community Report on Autism. 2016 [Google Scholar]
  • 29.Susilo C.W., Fauziah E. 11th International Dentistry Scientific Meeting. Atlantis Press; 2018 May. Respiratory rate as a physiological response to dental anxiety; pp. 45–51. [Google Scholar]
  • 30.Méndez F.X., Macià D. Un enfoque para el cambio en psicología clínica y de la salud. Pirámide; Madrid: 1994. Evaluación de los problemas de ansiedad. En: Fernández-Ballesteros R. Evaluación conductual hoy. [Google Scholar]
  • 31.Jimeno F.G., Bielsa S.Y., Fernández C.C., Rodríguez A.L., Bellido M.M. Objective and subjective measures for assessing anxiety in paediatric dental patients. Eur J Paediatr Dent. 2011 Dec;12(4):239–244. [PubMed] [Google Scholar]
  • 32.Alrshah S.A.M., El Kalla I.H., Abdellatif A.M. Live modelling and reinforcement vs tell show do technique for behavior management of children in the first dental visit. Mansoura J Dent. 2014;1(3):72–77. [Google Scholar]
  • 33.Frankl S.N. Should the parent remain with the child in the dental operatory? J Dent Child. 1962;29:150–163. [Google Scholar]
  • 34.Bagattoni S., D'Alessandro G., Sadotti A., Alkhamis N., Piana G. Effects of audiovisual distraction in children with special healthcare needs during dental restorations: a randomized crossover clinical trial. Int J Paediatr Dent. 2018 Jan;28(1):111–120. doi: 10.1111/ipd.12304. [DOI] [PubMed] [Google Scholar]
  • 35.Cermak S.A., Duker L.I., Williams M.E., Dawson M.E., Lane C.J., Polido J.C. Sensory adapted dental environments to enhance oral care for children with autism spectrum disorders: a randomized controlled pilot study. J Autism Dev Disord. 2015 Sep;45(9):2876–2888. doi: 10.1007/s10803-015-2450-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Schoen S.A., Miller L.J., Brett-Green B.A., Nielsen D.M. Physiological and behavioral differences in sensory processing: a comparison of children with autism spectrum disorder and sensory modulation disorder. Front Integr Neurosci. 2009 Nov 3;3:29. doi: 10.3389/neuro.07.029.2009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Miller L.J., Coll J.R., Schoen S.A. A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. Am J Occup Ther. 2007;61:228–238. doi: 10.5014/ajot.61.2.228. [DOI] [PubMed] [Google Scholar]
  • 38.Bar-Shalita T., Goldstand S., Hahn-Markowitz J., Parush S. Typical children's responsivity patterns of the tactile and vestibular systems. Am J Occup Ther. 2005;59:148–156. doi: 10.5014/ajot.59.2.148. [DOI] [PubMed] [Google Scholar]
  • 39.Merrick J., Cahana C., Lotan M., Kandel I., Carmeli E. Snoezelen or controlled multisensory stimulation. Treatment aspects from Israel Sci World J. 2004;May11(4):307–314. doi: 10.1100/tsw.2004.30. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of Oral Biology and Craniofacial Research are provided here courtesy of Elsevier

RESOURCES