1 Introduction

Autism spectrum disorder (ASD) usually manifests in children before 3 years of age, affecting three main areas: (a) social interaction, (b) communication and language, (c) symbolic or imaginative play. The severity of symptoms varies significantly from individual to individual, so it is very important to deliver a personalized training intervention tuned to the child’s needs, preferences, pace and abilities. Accessible training is delivered through trials and games based on Augmentative and Alternative Communication (AAC), an assistive technology allowing people with autism to take advantage of their visual channel, usually the most effective of the senses [23]. In fact, hearing and touch are often altered, so unfamiliar voices and noises (such as that of dental tools), touch sensations in the mouth and unknown social contexts are challenging situations that must be gradually introduced to the subject to avoid provoking anxiety, stress and pain. Communication and comprehension are the basis for enabling child interaction. In addition, rewards and motivations are fundamental for modeling adequate behaviors and encouraging collaboration. The peculiarity of the syndrome (each person with autism is different and has specific special needs) suggests adopting a personalized holistic intervention involving behavior, skills and social abilities. The use of visual stimuli (familiar images and objects) as well as the massive use of reinforcement are motivating elements.

Oral hygiene is very important for everyone, since prevention reduces the need for invasive interventions in the mouth. Indeed, for a child with autism, accepting the unknown sound-visual stimulations typical of a dental care setting is very difficult task: the sounds of suction or dental drills can be intolerable, as can be the bright light above the dentist’s chair. The main obstacle is the previously unknown context, which produces anxiety and unexpected behaviors in nearly all people with autism, often forcing dentists to administer anesthesia in order to complete dental work.

In recent years, ICT has been used to teach people with autism how to adapt to new contexts and cope with distressing social situations [13, 17]. However, to the best of our knowledge, using ICT to familiarize these children with dental care procedures and environments in a personalized way is still a largely unexplored topic.

In this paper, we describe an exploratory study to evaluate the potential of ICT to facilitate dental care of children with autism by lowering anxiety and avoiding sedation. Previous studies have reported successful experiences, suggesting that digital resources and ICT tools could facilitate dental care for children with autism [4, 15]. Starting from this, we investigated how to take advantage of the every child’s interest in gaming and multimedia content, to design an assistive educational methodology enhanced by ICT, to facilitate the dental care of children with autism. The flexible and dynamically programmable technology is able to adapt to the specific needs and preferences of each child. Moreover, we collected the user requirements for an assistive application able to help dentists and parents/caregivers organize and deliver personalized ICT activities to each child. In the rest of this paper, we use the term “caregivers” to indicate anyone (including parents and other family members) who cares for a patient with autism.

To better identify the most usable and useful digital resources and ICT tools for children and dentists, we applied a participatory design approach [26] with a multidisciplinary team (researchers, developers, dentists, a psychologist and parents). Furthermore, in order to better refine the user requirements, investigate and prove their acceptability in a real dental setting, also collecting feedback from final users, we performed a 3-month exploratory qualitative study with ten children with autism observed under natural conditions during their first dental care cycle. Children performed personalized pleasant ICT activities, such as multimedia games, to lighten the tension and familiarize themselves with the dentist’s environment and oral procedures. Furthermore, during dental visits they used a tablet to take photos and videos of the dental setting and procedures. The multimedia content was recorded on a server and made available to the children together with other interactive ICT tools (games, interactive pdf files, didactic videos, etc.) to be (re)viewed at home. The results appear to confirm the potential of technology for reducing anxiety and increasing the children’s wellbeing and safety, while making the procedure more pleasant and encouraging oral hygiene as part of their daily routine.

The contributions of this paper are (1) a general methodology using ICT to simplify dental care for children with autism, (2) results of a 3-month exploratory qualitative study involving ten children and their caregivers; and (3) the user requirements for the design of a customizable web application to facilitate ADS children’s dental care according to the proposed methodology.

The paper is organized into five sections. Section 2 introduces related work and Sect. 3 introduces the study design, detailing our methodology and what procedures were identified and followed during the 3-month observational study carried out with ten children with autism undergoing dental care in the clinical environment. Section 4 discusses the results of our study, highlighting lessons learnt and introducing the requirements for supporting software as well as some general guidelines for designing software tools to support children with autism in a dental setting environment. Section 5 concludes and discusses some future work.

2 Related Works

2.1 Autism Challenges in Dental Care

The dental health of children with ASD has been investigated in several recent medical studies. The behavior of patients with ASD makes the delivery of oral hygiene and dental treatment a serious problem [27]. The link between the patient’s sensory sensitivity, related to the autism spectrum, and their refusal of the dentist’s interventions appears clear, considering the specific setting where the dentist receives patients [5, 6]. Thus, since the 1990s physical restraints and chemical sedation have been commonly implemented in dental sessions to control disruptive behaviors caused by the reaction to a stressful situation [12]. In addition, recent studies acknowledge the child’s difficulty approaching dental visits and performing daily oral care as the most significant factor in their poor oral health [9, 15, 16]. A recent study showed that due to poor oral care, children with autism exhibited a higher prevalence of caries (tooth decay), poor oral hygiene and extensive unmet needs for dental treatment than did a non-autistic healthy control group [16]. Analogously, the predisposition of ASD subjects toward oral issues was studied by Cagetti, who observed that the increased number of dentistry issues is not connected to a peculiar predisposition of ASD subjects (a sample of 35 children between 6 and 16 years of age). The higher rate of pathologies can be related to a lack of prevention in oral care, which usually is not appropriately delivered to meet their special needs [6]. Unfortunately, the professional training offered by most university programs does not include dealing with ASD children, so it is necessary to teach dental professionals how to treat them correctly [14, 29]. ASD children need to be supported and guided during her/his visit by an interdisciplinary plan of action that takes into account his/her specific needs to promote better dental health [15]. Therefore, to increase the probability of successful dental treatment of ASD patients, the dentist should have an in-depth interdisciplinary understanding of the autism syndrome as well as of behavioral principles for therapeutic intervention.

Difficulties dealing with the dental care of ASD children are documented in literature but are also experienced every day by many dentists who are unprepared to deal with these patients. Anxiety, lack of collaboration, stereotypes and disruptive behaviors can scare dentists, who often bypass these difficulties by delivering patients to the hospital to undergo the procedure under chemical sedation. In this setting, a simple dental disease will nearly always become a serious health problem. Families too are painfully tried by their child’s suffering. Therefore, ASD children have few chances to learn how to perform and maintain good oral hygiene autonomously. Barry [4] examined the issues encountered by children with ASD accessing dental care, using a questionnaire completed by 112 parents. This research provided insight into potential barriers to dental care for children with ASD from the perspective of their parents, and suggestions to help to overcome some of them. Some of the strategies proposed involved photos and social stories, which are a subset of the ICT activities attempted in our study.

2.2 ICT in Dental Care for People with Autism

The use of ICT to facilitate dental care delivered to patients with ASD is a relatively unexplored field. Medical research clearly supports the need to apply behavioral approaches to model ASD people’s actions appropriate for the context, especially under stressful conditions, [18, 25, 30]. Several studies underline the positive effect of daily use of ICT on people with ASD, in both learning contexts and social situations, such as a dental visit [8, 10, 20, 22, 29]. The effectiveness of ICT in teaching different skills has been studied by many authors. Several studies have proved the advantages of using video modeling techniques [8, 11, 30], augmented reality [7], and software to facilitate communication (such as Picture Exchange Communication Systems) [13] and develop social skills [3]. All these studies report that people with ASD like the innovative educational approach introduced by ICT. Using technology, they could avoid typical issues involved in human interaction, such as impatience, feelings of inadequacy, unpredictability of people’s behavior, and poor recognition of emotions, irony, and figurative language.

The literature mainly reports the use of video materials to create favorable conditions for obtaining the cooperation of children with ASD in a dental visit. For instance, a sequence of images showing how to perform tooth brushing was proposed to fourteen children for a period of 18 months, demonstrating the potential of this tool for improving the oral hygiene of people with ASD [23]. Visual scheduling has also been very useful for making the child understand and accept sequences of activities [17, 24]. Conyers et al. carried out desensitization using video modeling to encourage collaboration in persons with mental retardation, observing the best results with in vivo desensitization [9]. However, this cognitive impairment differs greatly from autistic syndrome, for which video modeling has proved to be very successful in different educational and social contexts [3, 8, 30].

A study closer to ours is the work of Isong et al. [15] in which the authors tested two types of electronic screen media – a Google glass (sun-glass-style video eyewear) and a DVD reader – showing that their use helped reduce fear and uncooperative behaviors in children with ASD undergoing dental visits. They performed a randomized study to verify whether visual materials could facilitate the dental operation. Results showed that the anxiety decreased in children when they were approached by the dentist with visual tools. Although the goal of this study is similar to ours, there are some important differences. Isong et al. used tools and content not strictly related to the specific context. We believe personalization may increase the intervention’s usability and efficacy so we use videos and pictures made during the child’s own dental sessions; in our approach the child is an active actor in content creation. Isong et al. only used video content, while we used various kinds of multimedia content (images, audio, interactive games, etc.) that most likely can better meet different users’ needs. Finally, Isong et al. tested the effectiveness of some ICT tools for anxiety reduction but did not indicate a way to reproduce its approach. Barry [4] describes a potential strategy mediated by photographs of the dental clinic and staff, social stories made by picture cards and an Apple application as a means of distraction, in order to enhance communication with the patients. In this study, the ICT tools were not personalized and the children were passive users not involved in content creation.

Summarizing, only a few studies have attempted to explore the full potential of ICT to teach useful skills for improving ASD people’s dental care. Positive results have been achieved using video modeling, helping patients reduce their anxiety, but to the best of the authors’ knowledge, other tools such as cognitive games or the active involvement of children in content creation have not yet been investigated.

3 Study Design

3.1 User Recruitment

Users were recruited from among young patients with autism seeking access to dental care at a public hospital in Pisa (Clinica Odontoiatrica Universitaria). The no-profit association Autismo Pisa Onlus (part of Autism Europe), facilitated the identification of a group of ten children in need of dental care or interested in a preventive course of dental treatment. We recruited them as our user group. Only one child fell within the category of high-functioning autism while nine were low-functioning; three of them were non-verbal and non-receptive, three non-verbal but receptive, and three were both verbal and receptive. The only recruitment criterion was age, accepting children 6-12 years old in the study because this age range covers the permanent dentition process.

We describe the protocol followed in Sect. 3.2 and give a detailed characterization of the user sample in Sect. 3.3.

3.2 Protocol

The protocol of the study was defined in collaboration with two dental professionals and one neuro-psychiatric expert enrolled in the project. Procedures and rules of protocol included: (i) identification of all the figures to involve and their role in the study (Sect. 3.2.1); (ii) the number and frequency of the visits for each user (Sect. 3.2.2 and 3.2.3); (iii) the amount, type, and collection of data needed to characterize the users (see Sect. 3.3); (iv) activities to perform with the children during dental sessions (see Sect. 3.4); (v) definition of the materials to be used during the study (see Sect. 3.2.4).

3.2.1 Planning Actors and Roles

The multidisciplinary team enrolled in this study comprised clinical professionals (dentists and neuropsychiatrist) and ICT researchers. Parents played a crucial role, especially in assisting and supervising recommended activities at home. The team member roles were specified: two dentists performed the activities in the clinical room in collaboration with a hygienist and a researcher; one of them supervised the overall procedures and interacted mainly with parents especially during data collection, the other dentist (the operative dentist) was directly involved with medical procedures with children, assisted by the hygienist if necessary. Activities regarding technical and research aspects such as preparing tools (hardware and software), management and collection of digital resources, included in materials (see Sect. 3.2), and collection of observational data regarding children’s behavior, were carried out by an ICT researcher on the team. Children were naturally brought to interact mostly with the operative dentist, the hygienist and the ICT researcher. The presence of all these three figures was guaranteed in each session.

3.2.2 Planning Visits with Users

First Visit:

The first meeting helped the dentist to get to know each child (and his/her parents) and to test their reactions to simple requests such as to sit down on the dental chair or to open his/her mouth. During the visit, a questionnaire was administered to the caregivers in order to collect data related to the child’s oral condition, dental hygiene habits, child’s autism condition, the presence of any sensory disturbances and the usage of technological devices such as tablets, smartphones and video cameras.

Other Appointments:

Aseries of weekly appointments (each lasting around 45 min) for each patient over a period of 3 months was scheduled. All the appointments took place in the same clinical room, in order to avoid confusion and ease familiarization. During these appointments, thanks to the parents’ cooperation, we offered a kit of digital tools to the child to help him/her become familiar with the dentist and the clinical environment, before carrying out the medical intervention. The dentist (helped by the ICT researcher) personalized the kit’s components in all the intervention phases depending on the child’s needs. At the end of each appointment, a set of tools for the kit was selected to be used at home to introduce the activities scheduled for the next appointment.

3.2.3 Planning Activities

The children’s training was structured to include three different types of activities, as detailed in Fig. 1.

Fig. 1.
figure 1

Proposed activities

Full size image

3.2.4 Defining Materials to Use

Materials used during the study included hardware and software tools, together with common objects that are part of the clinical setting. Two tablets were used by the children, usually as a camera, in order to create a personal multimedia archive of resources constantly updated with materials from the dental sessions. Tablets were selected since they are familiar to most of the children and are a source of great interest regardless of the context. A kit of software resources was provided to the children starting from his/her second appointment. The kit included customizable digital games and multimedia materials narrating in a simple way what is present (such as dentist mirror, probe, toothbrush, gloves and sunglasses) and what happens in a dental clinic. Specifically:

  • Cognitive learning games (memories, puzzles, sequences and matching exercises) to familiarize the patient with dental procedures and environment in an amusing way. The use of games for educating people with cognitive needs has been widely investigated in literature. In children with autism, games are used to stimulate learning through imitation (since subjects with autism usually lack this skill [1, 2, 30] and to capture user attention and collaboration for performing specific tasks, taking advantage of AAC (Augmentative Alternative Communication).

  • Interactive PDFs (pdf files equipped with sound effects): particularly useful for narrating procedures and/or dental objects. This allows associating positive elements with a stressful event and can help reduce resistance to the change.

  • Audio, video and photos indexed by visit date, to keep track of the important phases of the visit. The child can navigate their resources and show them to caregivers.

  • Videos reproducing all actions from the arrival at the clinic to the child sitting in the dentist’s chair. The videos are essential for activating the imitation of a targeted behavior functional to the context. Seeing familiar people performing target actions can help the child’s imitation process [21]. Crucial attention is devoted to technical details such as freeze frame, zoom, audio-visual aids, and graphics that transform the footage into a powerful educational tool.

The resources are partly created using the tablet’s camera (photos and videos) and partly (games, interactive PDFs and video-modeling sequences) specifically prepared by ICT researchers on the team.

3.3 User Group Characterization

Data collected via the questionnaire administered to the caregivers during the first visit allowed us to characterize the user group, as shown in Tables 1 and 2.

Table 1. Demographic information and autism condition
Full size table
Table 2. Clinical information and dental habits
Full size table

Regarding children’s familiarity with the use of electronic devices (smartphone and tablets), data collected highlighted that all of them have some experience. The most common use of the tablet included watching YouTube videos, using the camera, searching elements in the archive of photos and video. Some of the users, (specifically U2 and U8) also used the tablet during other autism intervention programs external to the dental care context, U1 used the tablet with his/her parents at home for entertainment and educational activities. In the latter cases, children were also familiar with digital games such as puzzles and sequences. U3 and U4 manifested compulsivity in the use of tablet. In U3, that fact made it impossible to propose the approach described herein; instead, with U4, the work was possible after overcoming some initial difficulties.

3.4 Sessions with Users

Sessions with children were structured to include activities that relate to the current visit and activities to prepare for next visit. Each activity was planned and performed taking into account a specific subdivision of goals in distal outcomes and proximal outcomes. The latter in turn was divided into elementary units. The distal outcome is the process of familiarization of the medical environment and the dental procedures and it was pursued during all the study. This familiarization process was then applied to a list of medical activities represented by proximal outcomes.

For instance, if the proximal outcome is oral hygiene, the child has to be prepared for this activity and in parallel he/she has to work toward familiarization with the general environment: (i) go to the dentist; (ii) access the clinic; (iii) wait for his/her turn; (iv) sitting in the dentist chair; (v) open their mouth; (vi) halt the dentist; (vii) ask for help. If this familiarization process fails somewhere, the proximal activity cannot be performed or needs to be proposed in a lighter form; for instance, it would be a great result even to clean only one tooth.

Given this subdivision, depending on the objectives to achieve, as illustrated in Sect. 3.2, the proposed activities were the same for all the children but adapted to the circumstances and to the children’s needs. For instance, for the proximal outcome requiring the patient to “open your mouth” the dentist planned to achieve the goal in two steps, in order to allow the child to rehearse in the clinic with practice activities (first time) and at home with video-modeling sessions (second time). If one child was more receptive than others were and he/she was able to perform the task quickly, the two-step procedure was equally respected but in a different form, trying to allow the child to generalize the task. Likewise, if the child manifested some disturbance regarding one of the phases’ procedures, the task was re-modulated.

We proposed to the patients a general schema including medical and ICT activities at the clinic and at home. Obviously, the medical activity is the main goal for each patient; the activities with ICT tools are only an aid toward reaching this goal. During the first visit, the dentist tries to ascertain the child’s oral situation and he/she uses the tablet to record photos, videos and selfies aided by the child. The ICT activity is mainly carried out by the dentist and serves to collect resources for future visits. On this occasion, the child learns preliminary strategies to familiarize themselves with the environment, acting there (if he/she wants) in first person. Moreover, he/she becomes familiar with the tablet as a part of the clinical setting. In that sense, the pleasure offered by the tablet’s use acts as reinforcement for the child, helping mitigate the aversion to the medical environment. From the second appointment onward, the order of activities is as follows:

  1. 1.

    ICT activity at home: learning games, review of photos and video modeling sessions with materials collected in the previous visit, to prepare for the next visit.

  2. 2.

    Medical activity at clinic: different for each child depending on his/her need.

  3. 3.

    ICT activity at clinic: depending on the success of 2. Medical activity:

    1. a.

      If the medical task failed: 20 min of activity using the tablet performed away from the dentist’s chair in a dedicated room including activities to familiarize themselves with the failed medical task and familiarization activity in general

    2. b.

      If the medical task is successful: 20 min of activity using the tablet performed away from the dentist’s chair in a dedicated room including review of activities already mastered and positive rewards for activities well completed.

Each activity respected the general approach used in behavioral intervention with subjects with autism [19]: short and diversified activities are performed quickly in order to avoid problem behaviors and reduce self-stimulations in children. Moreover, each “theoretical” activity should have a correspondent in practice. For instance, a desensitization task of noisy sounds using digital games is followed by a direct experience (touching it) with the medical devices that produces those sounds. This practice is already efficiently used in children’s dentistry to control the source of disturbance in order to reduce the pain but in this case the novelty is the combination of these good practices with ICT tools.

Regarding appropriateness of tools during the dental session, the following summarizes the main observations:

  • Familiarization with objects: a matching program using images (photos) of dental setting objects was proposed with efficacy.

  • Familiarization with procedures: digital games such as “sorting sequence” of the intervention were usually considered the default best tool since they provide an effective way to learn the sequence of steps of the procedure. For example: “the child has a toothache, (s)he goes to the dentist, then the pain goes away”.

  • Child “control” over his/her environment to relax him/her: a suitable activity was the collection of digital photos and videos: (i) take photos and videos of everything that might be of interest in the dental environment and of procedures, to create the child’s digital toolbox; (ii) reassure the child during an intervention using the camera’s selfie mode (some children became more cooperative knowing what the dentist was doing inside their mouth).

Regarding what specific tool could be the best choice for homework assisted by parents, we observed that:

  • Customized video-modeling resources and photos or videos reproducing memories of the dental visit in the clinic are useful for learning procedures. In this case, customization mainly relates to photograms with the child’s caregivers and the child himself, as actors.

  • Logical sequences about dental procedures and interactive digital stories had introduced main concepts that helped develop the child’s conditioning process to facilitate the procedures.

  • Most of the parents helped their children do their homework, especially in tasks requiring imitation of the procedure of the mouth inspection. The simulation of the visits in a familiar context, repeated many times, in most cases was decisive in overcoming the dentist’s otherwise common difficulties completing the child’s mouth evaluation

4 Results and Discussion

4.1 Children’s Responses

Children performed didactic activities, using the tablet attentively and collaboratively. Its use facilitated the initial contact with the dentist and the other figures who were present during sessions, capturing their interest and reducing any pain resulting from the unknown environment and dentist’s intervention procedures. Nearly all the children used the tablet carefully and followed the rules. Younger children unfamiliar with the tablet needed to be physically guided initially, but they quickly learned how to use it.

Regardless of disability, no technological aid can be valid for all. In our study, two children used the tablet in a compulsive way. Specifically, with one child, U3 (6 years old, non-verbal) that fact impeded the training. Stereotypies are a frequent symptom in autism so we must contemplate this scenario, managing the compulsion before the intervention, or abandon this approach to identify the more suitable strategies.

Most of all, the other children greatly appreciated the opportunity to take and collect photos and videos of their visits. Some of them wanted to see themselves during the dental intervention (using the camera in selfie-mode) to better understand what was happening. In some cases, the tablet camera had a very positive distraction effect, especially during invasive dental procedures. At home, all the children wanted to explore their personal archive and share it with parents. Photos and videos are also a great resource for the parents and the dentist, allowing customization of stories and games.

After two visits, one child (U9) abandoned the study for family reasons. Of the remaining eight children (not considering U9 and U3), most of them began to perceive the tablet as a part of the clinical environment: (i) they expected to see the assistant taking photos during the dental operation (in some cases no photos meant no visit); (ii) they were motivated to play with the tablet, considering it a reward (iii) at home, they asked to see all the material collected during the visits again.

For three children (U5, U7, U10) the time scheduled for the intervention protocol was not enough to implement and verify all the familiarization steps, planned to achieve the previously mentioned distal outcomes. This is mainly because caregivers were not steadily present in the weekly visits, affecting the results. Participants in the whole (3-month) experimental phase (four children) respecting scheduled appointments changed their attitude radically; they started with a total rejection of the intervention, refusing even to sit in the dentist’s chair, but at the end of the intervention accepted a dental hygiene procedure collaboratively and without a sedative.

One child also accepted sealing molars, revealing high confidence in the environment and the people who took care of him during the experimental period. Those children, for whom systematic frequency had sustained the intervention, even when the dentist’s requests increased, such as for invasive procedures, showed an increased willingness to accept them, reflecting a successful desensitization process and decreased level of anxiety. Those children started to learn how to ask for help or pause, and how to wait to complete the activity even if they wished to escape.

The educational activities performed during the visits as well as at home motivate children to tolerate the fear and pain associated with the unfamiliar, noisy, multi-stimulating clinical environment that without personalized training is quite stressful (often children accepted sitting in the chair after having a relaxing time using the tablet). Positive results achieved in this exploratory study seems to confirm the potential of ICT technology in a dental care context with subjects with autism, already suggested by previous studies. However, the approach, in the form described here, has some limits affecting its replicability: (i) It required considerable time and effort, and the children needed to be constantly guided and monitored during the proposed activities; (ii) Each visit produced a great deal of digital material, growing exponentially visit-by-visit. It seems unrealistic to propose a similar setting every time a child needs a dental intervention. However, it seems possible that proceeding in the familiarization process with dental procedures, the child will require less and less support; (iii) During the observational phase in the real context, children did not use the tablet completely on their own; an adult (dentist, parents, assistant, etc.) constantly monitored each activity since the use of the Internet connection lacked system protection for the child; (iv) As confirmed in literature [19], we observed that caregiver and family involvement was a crucial key to the success of an intervention, guaranteeing continuity of intervention at home/clinic. Moreover, it also seems to influence correct or incorrect usage of technology.

From this exploratory study, it is clear that following this approach requires effectively managing a large volume of data, games and personalized material. Thus, there is a clear need for an accessible digital platform able to effectively support dentists and patients during the process. In the following sections, we turn our observation to global software requirements for a Web application supporting dentists and patients and to a few guidelines that could drive the next phase of our project and benefit other researchers working in this field.

4.2 Software Requirements

Platform Requirements

Functional and non-functional requirements of the ICT platform have three main objectives: (i) Providing children with ASD and their caregivers with an accessible and usable digital resource toolkit to familiarize them with dental tools and settings, and deliver a structured dental hygiene educational course; (ii) Facilitating patient management and make easier for the dentist personalizing patients profiles and assigning preparatory activities, according their personal and medical profile; (iii) Improving the organization and management of resources for ease of use by professionals, patients and caregivers.

Global requirements incorporate the Web Content Accessibility Guidelines (WCAG 2.0): the platform should promote inclusion and satisfy usability principles: easy to learn, easy to remember (control elements), and satisfying to use [28].

Domain-related requirements involving technical aspects aimed at optimizing the platform in flexibility, scalability and performance. Selecting a Web platform offers some advantages: multi-device availability, ease of deployment and update, rapid and efficient data exchange, multimedia dimension, privacy and security treated carefully, so health information should be stored in a remote database (anonymized data, and secured transfer sessions).

User requirements could be instantiated differently depending on the user’s role (dentist or patient) as illustrated in the next sections.

User Requirements: The Dentist’s Nees

User requirements emerged from the direct observation of the dentist’s work during the 3 months of the study, and from participatory design sessions:

  • Environmental: this requirement is crucial for the interface’s design. Our main constraints were to simplify interaction, ensure robustness and minimize errors while engaging children with ASD. The dentist needs to easily manage everyday activities and gain more time to win the patients’ cooperation.

  • Usability and User Experience: (i) Efficiency – goals need to be easily and rapidly accomplished, minimizing possible user errors; (ii) Intuitiveness – UIs must be easy to learn and navigate; buttons, headings, and help/error messages should be simple and easy to understand (iii) Natural interaction – with clear UIs and recognizable elements and functions; the interaction should not require much cognitive effort and should satisfy the user.

  • Functional: The activities identified during the study have to be reproduced in the system (collecting user data, organizing current and future visits, preparing and showing games and materials, personalizing the intervention, etc.).

Above all, functional requirements demand appropriate UI design and a suitable navigation flow of UIs. We identified three main activities carried out by the dentist that need attention:

  1. (a)

    To record and manage the child’s information, i.e., personal details, neuropsychiatric diagnosis and dental care diagnoses.

  2. (b)

    To manage materials related to personal visits as well as other resources to share among patients. Manage, in this context means: (i) collect and redistribute primary resources (photos, video, audio files and other documents); (ii) use these primary resources to generate other resources, especially personalized learning games.

  3. (c)

    To schedule the next visit and prepare tasks and materials for the child, selecting them from the available resources (public repository or the child’s personal repository)

Interaction mechanisms and time are decisive aspects in this special context; UI visual elements should be preferred to textual elements, and the (inter)actions to accomplish a task have to be minimized, exploiting natural paradigms (e.g., exploiting drag-and-drop). Globally, the proposed approach should be efficient and not time-consuming.

User Requirements: The Child’s Needs

Careful design is required for the user experience of children with ASD since each individual has his/her own peculiarities. Observational data coming from contextual task analysis during sessions with users (see Sect. 3.4) showed how our young participants used a tablet and performed proposed tasks. Children should access a personal section in the platform offering:

  • Extremely simplified UIs (minimal), with only a few elements clearly linked to the available activities, to avoid anxiety and confusion during user interaction

  • Accessible stimuli: soft colors, sounds only where necessary

  • An errorless system: no possibility of error in performing the activities that lead to unexpected system behavior

  • Timely feedback from the system to reinforce or discourage certain behavior

  • A safe environment for the child: (i) inability to quit the application and move to the Web; (ii) screen control, available on the mobile platform to avoid zoom-in/out, scroll, etc., which might trigger problem behaviors in ASD children.

The platform should facilitate the child when performing activities of the intervention protocol. We propose a main interface organized in three sections, reproducing activities that have been observed to be effective in a real context.

Play:

This section would promote the child’s acceptance of dental procedures by allowing access to interactive learning games and video-modeling created by the dentist.

Explore:

In this section the child can access all materials collected or selected by the dentist: explore photos and interactive pdf files, and play videos or audio. Menus should be minimal and visually oriented so that the child can move among different types of resources correctly oriented in the platform structure.

Remember:

This section should be a sort of a digital Personal Visual DiaryFootnote 1 where the child is invited to remember and “refresh” previous dental visits. At the same time, it offers a memorandum on what (s)he will do during the next visit. The child should move between past and future experiences using clear and accessible elements linked to the history of past experiences, or to a preview of future appointments. In this case, an interactive calendar page would be the best choice to give the child a description of what he/she will do and provides a collection of materials and tools (pre-selected by the dentist) for facilitating the familiarization process with new situations.

4.3 General Guidelines

The experience of participatory design was extremely valuable and help us to better understand the needs and preferences of people with autism. We have summarized a few guidelines to help researchers offer a pleasant and accessible experience for this target. Since every individual is different, some guidelines might not be suitable for everyone and must be adapted to a specific subject. Probing the target subject on the first visit as well as previously collecting information and preferences with their parents can help to correctly evaluate the child’s needs and preferences. In the following, the guidelines are listed and marked as software design (s) or behavioral principles (b):

Familiarization with the Context

  • Show pictures of dental setting (s)

  • Show pictures and videos of dental tools and procedures (s)

  • Introduce the subject slowly, with one or more sessions solely for familiarization with environment and dental tools (b)

Personalization

  • Incorporate pictures/videos showing the child’s previous activities (s)

  • Enable the addition of familiar preferred images (s)

  • Enable customization of preferred games (sequence, matching, puzzle, …) (s)

Awareness of Next Action

  • Offer visual scheduling, to make children aware of and ready for the visit time (s)

  • Incorporate video showing next activities (s)

Time Adaptation

  • During the visit offer a visual tool for Request to Pause (provide a plasticized card to require a pause) (b)

  • The same functions might be activated using technology, for example with one click of a wireless mouse activating an audio alert for the dentist (s)

Control of Current Actions

  • Offer a mirror to see what dentist is doing in the child’s mouth (b).

5 Conclusion

Children with autism find it very hard to accept dental treatment due to the unfamiliar people and context with new sounds, lights and tactile stimulation; this provokes high levels of anxiety and stress that can degenerate into inadequate behaviors. Unfortunately, many dentists are still unprepared to deal with these special needs patients, and often chemical sedation is administered even for simple interventions, with a potential negative impact on children’s health.

This research investigates whether technology can make dental care more efficient, effective and pleasant for children with autism. To address this challenge, a multidisciplinary team composed of professionals and researchers worked together for 3 months. Since co-design is hard to carry out with people with autism, an observational protocol was applied to gain information in an operative environment, probing the use of digital resources as an emotional balancer. Specifically, a clinical protocol also using digital resources was tested with ten children with autism who had a weekly dental visit for 3 months, in order to implement desensitization and anxiety control in a real dental care setting using a kit of digital resources as assistive technology.

Results seem to confirm the feasibility of the proposed approach and the positive role of technology support. Eight out of ten children responded to this approach positively, overcoming their initial diffidence, modeling their behavior and becoming increasingly collaborative, visit-by-visit. Almost all caregivers manifested satisfaction with the approach due to their active involvement. Furthermore, caregivers strongly committed to the protocol and respecting the weekly schedule felt the child-parent relationship was reinforced, and five children successfully completed the dental protocol in the time scheduled. In contrast, three children who missed half or more of the scheduled sessions due to caregiver issues were also unable to complete the familiarization protocol. This result confirmed the importance, already highlighted in literature, of active parent involvement in the care of children with autism [19].

Results obtained from this exploratory study enabled the definition of user requirements for the collaborative design of a Web platform for easy creation, management and fruition of digital resources for children with autism and dentists in a more accessible structured framework. Furthermore, to exploit the valuable insights collected, we have formulated some general guidelines for designing accessible multimodal tools for reducing anxiety during dental care sessions that could be useful cues for other researchers and developers approaching this research field.

Future work will apply participative design and early prototyping to create the platform. This digital environment will be rigorously experimented with testing protocols and the software tool (with a control group) in order to evaluate both its efficacy and efficiency. Lastly, additional effort will be devoted to raising awareness of local healthcare and educational organizations regarding the need to create dental care protocols for patients with special needs, using ICT technology as a valid support for the medical intervention.