Teaching Toothbrushing Skills to Children with Autism Spectrum Disorder: The Use of Visual Cues and Video Modeling

ABSTRACT

Objective:  To compare the use of visual cues and video modeling as tools for developing toothbrushing skills in children with Autism Spectrum Disorders (ASD).

Material and Methods:  Descriptive and exploratory study, with a quantitative approach. Nine children with ASD aged between six and nine years old, diagnosed with ASD level 1 (mild), and their parents, were randomly divided into Group 1 (visual cues) and Group 2 (video modeling). Parents were asked to send four video recordings of their child brushing their own teeth, one per week (one baseline, three brushing with the instruments).

Results:  Despite improvements in the frequency of tooth-brushing behaviors, there was no statistical difference in behavior frequency across videos for both groups (p>0.05). Spontaneous parental intervention was more frequent in the visual cues group, suggesting that this method may require greater caregiver involvement for effective implementation.

Conclusion:  The methods employed improved tooth-brushing skills, especially for the group that used video modeling. The increased parental mediation in the visual cues group highlights the importance of caregiver involvement.

Keywords:
Autism Spectrum Disorder; Toothbrushing; Education; Dental; Oral Hygiene.

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by a group of conditions that typically manifest themselves from early childhood. It includes persistent deficits in communication and social interaction across multiple contexts, and the presence of restricted and repetitive patterns of behavior, interests, or activities, including hyperor hypo-reactivity to sensory stimuli or an unusual interest in sensory aspects of the environment [¹]. It is estimated that in the United States, one in 31 children is identified with ASD [²]. In Brazil, recent data from the Demographic Census revealed that approximately 2.4 million people have ASD, which is equivalent to 1.2% of the Brazilian population [³].

Learning new skills can be challenging for children with ASD, especially when it comes to personal hygiene habits. Similarly, regular oral hygiene can be difficult for these children and their parents [⁴,⁵], which is related to the difficulties that children with ASD face during interpersonal contact [⁶] and hyperreactivity to sensory stimuli [⁷]. As a result, people with ASD exhibit a higher prevalence of periodontal problems [⁸], caries, poor oral hygiene, and extensive unmet dental treatment needs when compared to neurotypical children [⁹,¹⁰].

Although research on psychological approaches to people with ASD in the dental environment is scarce, the most referenced techniques for improving these habits are: "tell-show-do", positive reinforcement, avoiding punishment, modeling techniques, elimination of stressful sensory stimuli, use of clear and objective commands and orders, use of voice control, establishment of a routine of care and short sessions, which can be used alone or in combination [¹¹]. Accordingly, it is clear that among the interventions used to teach new behaviors to people with ASD, applied behavior analysis has been among the most widely used [¹²].

The use of behavioral approaches can be an alternative to improve toothbrushing behavior, especially when combined with visual aids, as children with ASD process visual information better than auditory information. Examples include visual cues and clear, objective images of sequences of actions to be performed, which can assist people's independence [¹³]. Doichinova et al. [⁶] implemented a training program using visual cues and reported improvements in children with ASD's oral hygiene.

This strategy, despite using static images, is similar to behavior-based modeling techniques. Commonly used to enrich the behavioral repertoire of children with ASD, modeling consists of demonstrating one or more behaviors performed by a model that must be reproduced by those who see it. Initially, live modeling was more commonly used, where the demonstration would take place in person, side by side with the learner. However, advances in information technology have enabled the development and dissemination of variations in the modeling procedure using video. Visual cues and editing features help highlight relevant elements in performing the task [¹²].

Several published studies focused on the acquisition and improvement of toothbrushing behavior have concluded that video modeling is beneficial and promotes increased frequency, acceptance, and ability to brush teeth in children with ASD [¹⁴-¹⁷]. For example, a recent study in dentistry sought to combine TEACCH and ABA techniques to develop software that facilitates dental care for individuals with Autism Spectrum Disorder (ASD). The proposal incorporates visual and repetitive stimuli and effective strategies for teaching children with ASD, thereby improving interaction with professionals and patient autonomy in oral hygiene [¹⁸].

Among recent literature reviews, there is consensus on the effectiveness of using visual cues and video modeling [¹⁹,²⁰], but it remains unclear which is more effective for families' routines. In the use of visual cues, the improvements described by Doichinova et al. [⁶] encountered difficulties, including the potential for boredom with static images and the challenge of management by parents. The instructions offered by the researchers involved the entire family context and the children's caregivers, who needed to apply behavior analysis techniques and know how to reinforce each behavior. The instructions' complexity makes it more difficult to apply visual cues. On the other hand, video modeling stood out for its greater practicality and positive results in forming this habit, facilitating the learning process and children's cooperation [²⁰].

It is worth noting that, although essential, parental involvement in the learning process can overload the family system. According to Doichinova et al. [⁶], it is necessary to encourage independence in performing activities, while providing supervision to ensure the quality of execution. Consequently, daily independence initially requires direct monitoring, which is difficult for both specialists and families.

Despite these difficulties in providing regular preventive care, brushing teeth at home is the best way to reduce the risk of caries and oral problems in this population, as it is the best scenario for building a routine of independence [²¹]. Given the above, the main objective of this study is to compare the use of visual cues and video modeling as resources for developing toothbrushing skills in children with Autism Spectrum Disorder. To this end, visual cues and video modeling developed specifically for this research were used. Parents, guardians, and caregivers were responsible for making the tool available to children, ensuring its usability, and recording toothbrushing sessions for analysis of the results. In this way, the routine is decentralized from parental assistance, and the hypothesis that videomodeling fosters greater independence in application can be tested, clearly elucidating the impact of each tool on the oral hygiene process.

Material and Methods

Study Design and Ethical Clearance.

This research was descriptive, exploratory, and applied in nature. This research was approved by the Ethics Committee of UNIVALI, opinion number 4.663.416, dated April 22, 2021.

Context and Participants

Data collection took place between May 2021 and October 2021, during the COVID-19 pandemic, with families and children treated at the Specialized Rehabilitation Center (CER II) in southern Brazil. This outpatient care service provides diagnosis, assessment, guidance, early stimulation, and specialized rehabilitation and functional and psychosocial habilitation, aiming to promote autonomy and independence for people with disabilities. The center did not have any educational approaches related to oral health at the time of the research. Due to the pandemic, in-person appointments were limited in capacity and followed established safety protocols. In total, sixteen children and their parents were approached and invited to participate. Of these, only one child did not consent to TALE, while the other fifteen children and their parents consented to TALE and signed the informed consent form to participate in the research. Of the fifteen who agreed to participate, four did not send all the requested videos, and two did not meet the inclusion criterion of presenting level 1 ASD, as their WASI scores were below the cutoff (70). Thus, six participants were excluded, leaving nine in the sample.

The participants were nine children with ASD aged between six and ten years old, diagnosed with Autism Spectrum Disorder, support level 1, and their parents. The inclusion criteria for children with ASD in this study were: diagnosis of Autism Spectrum Disorder (Level 1); being a user of CER II; and being between six and ten years of age. The exclusion criteria were: having an intellectual disability; having a physical or sensory disability, such as deafness or blindness, that prevented them from following instructions; and already using visual cues and/or video modeling to brush their teeth. The inclusion criteria for parents were: being over 18 years of age; having two electronic devices at home that would allow the application of the instrument and simultaneous audio and video recording of the task; and having internet access. The exclusion criteria were: having a mental or communication disorder that would prevent them from answering the questionnaires.

Instruments

Validated instruments were used to characterize participants and collect measurements, while the other materials were used for intervention or observation purposes. The instruments used for data collection were: Wechsler Abbreviated Intelligence Scale (WASI); sociodemographic questionnaire; questionnaire on the child's clinical conditions and health routine, whose questions were adapted from the Autism Continuum [²²]; visual cues, created by the authors of this research, containing the steps of tooth brushing (Figure 1); a video modeling video, also created by the researchers, with details of toothbrushing with simple and direct guidelines based on the figures in the visual cues; videos recorded by the principal investigator (the first containing general information about oral care and problems, the second providing guidance on how the videos should be recorded at home, the third on how to use visual cues, and the fourth on how to use video modeling) that were presented to the parents by the researchers and also sent via WhatsApp; observation sheet on toothbrushing behavior with visual cues/video modeling.

Figure 1
Example of the first steps of tooth brushing from visual cues.

The Cues resources and the Video Modeling video were developed by the researchers, following the principles of Task Analysis proposed by Applied Behavior Analysis, which consists of dividing a larger skill, in this case brushing teeth, into smaller pieces that comprise smaller skills, such as putting toothpaste on the brush, brushing the right side of the teeth, the front, the left side, and so on, teaching in a step-by-step format, allowing the child to better learn the new skills being presented to them [¹¹].

Procedures for Data Collection

A list of children who met the inclusion criteria was requested from the service's registration system. A pilot test was conducted before data collection with two participants, one for each instrument (visual cue and video modeling), to evaluate the collection and analysis instruments and correct any flaws before their final implementation. After completion of the pilot test, these participants were included in the sample, as the instruments were deemed adequate for this investigation.

First Stage

Initially, training was conducted with the scientific initiation fellows on the data collection instruments. Next, family members at CER II were invited to participate in the research. Upon acceptance of the invitation, the Free and Informed Consent Form (FICF) was made available and signed by the parents. The researchers then invited the children and explained the objectives of the research for the Free and Informed Consent Form (TALE). To record their consent, two figures were presented, one representing agreement and the other representing disagreement, and the choice was documented on video. Children who consented to the TALE were given the Wechsler Abbreviated Scale of Intelligence (WASI), a brief intelligence assessment tool (taking approximately 50 minutes to complete) applicable to children aged six to elderly people aged 89 years old. Through the WASI, it is possible to obtain information on Total, Performance, and Verbal IQs from four subtests (Vocabulary, Blocks, Similarities, and Matrix Reasoning) [²³]. To parents who consented to the TCLE, the researchers presented a video with guidelines in a private room at CER II. They then administered individual questionnaires on clinical conditions and health routines, as well as a sociodemographic questionnaire. They also requested a video recorded by the parents of the child brushing their teeth that day, which should be sent within three days of the requested date for the participant to take part in the next stage of the research. Instructed by the researchers, the parents watched and received a video on how to record audio and video using their smartphone in the child's natural environment, for brushing their teeth, for example, in the bathroom of their home. At the end of this stage, a kit containing a children's toothbrush with a small head and soft bristles and mint-flavored toothpaste was made available. Use of the kit was not mandatory; it was offered only when the child did not have these items at home.

Second Stage

One week after the first stage, the parents who had submitted the brushing videos were approached again by the researchers on the day of their appointment at CER II. On that occasion, a new video was presented with guidelines for using the designated intervention resource-visual cues or video modeling. Participants were assigned alternately, randomly composing Group 1 (visual cues) and Group 2 (video modeling) (Figure 2). Parents received only the video for the group to which they were assigned, along with a brief explanation of how the respective resource worked. It is important to note that parents did not receive training or detailed instructions, limiting themselves only to delivering the resource and filming the child brushing their teeth. In Group 1, five children and their parents received Visual Cues for Modeling Tooth Brushing Behavior, represented by illustrative figures showing the steps of brushing, printed and laminated. In Group 2, four children and their parents received the file and link to access the YouTube video modeling via WhatsApp^®, which contains an animation of the visual cues and audio demonstrating the steps of tooth brushing. Parents were then asked to apply the instruments daily when brushing their children's teeth at home, to record one of the brushing moments of the day using the visual cues or video modeling on their smartphones, and to send it to the researchers within three days of receiving the researchers' guidance.

Figure 2
Flowchart of procedures for allocating participants to groups.

Third Stage

In the third week of data collection, the researchers contacted the parents via WhatsApp^®, requesting a video of the day's brushing for Groups 1 and 2, to be sent within 3 days.

Fourth Stage

In the fourth week, the researchers asked parents via WhatsApp^® to send a video of their child's brushing within 3 days.

Data Analysis Procedures

Initially, the information collected through the sociodemographic questionnaire and the questionnaire on the child's clinical conditions and health routine was organized and analyzed in a spreadsheet in a descriptive manner, aiming to identify the participants' profile in relation to the fundamental points of this research.

In a second stage, the parents' video recordings were analyzed according to the categories of the observation form for toothbrushing behavior and the frequencies of the items in this instrument were counted for each video. The data obtained were transcribed into a document, and the frequencies were recorded in an Excel spreadsheet.

The brushing steps were evaluated in the four videos using an observation form based on a task analysis, consisting of 17 sequential steps of toothbrushing behavior. These steps included: 1) applying toothpaste to the toothbrush; 2) brushing the buccal surfaces of the anterior teeth; 3) brushing the buccal surfaces of the posterior teeth on the left and 4) right sides; 5) brushing the occlusal surfaces of the upper right teeth, 6) upper left teeth, 7) lower right teeth, 8) lower left teeth; 9) brushing the palatal surfaces of the upper teeth and 10) the lingual surfaces of the lower teeth; 11) brushing the tongue; 12) spitting out the toothpaste; 13) putting water in the mouth; 14) rinsing the mouth with water; 15) spitting out the water; 16) drying the perioral region; and 17) putting the toothbrush away. Each step was considered completed when performed by the child and observed in the videos sent by the parents, allowing the quantification of behaviors throughout the study.

To validate the completion of the observation form, the three researchers (two scientific initiation project fellows and the master's student) filled out the forms independently, without exchanging them. An agreement between researchers was considered to exist when two or more observed the expected behavior. Thus, an agreement index was obtained for each of the four videos of a single participant, using the following formula: ∑A/ ∑(A+D) x 100. To obtain the individual index for each participant, the average agreement index across videos was calculated. Based on the judges' analysis, an overall average agreement index of 87.58% was obtained for all participants, calculated as the average of each participant's individual average divided by the number of participants. In general, a research instrument that obtains 80% agreement is considered satisfactory [²⁴].

Parental intervention during tooth brushing was evaluated by analyzing videos sent by the guardians and recording the presence or absence of caregiver interventions. These interventions were categorized as verbal guidance, physical assistance, positive reinforcement, negative reinforcement, positive punishment, or negative punishment. It should be noted that this is an observational assessment, as the researchers did not request or guide any intervention; the intervention occurred spontaneously during brushing.

The categories of analysis, based on the occurrence and frequency of behaviors, were: a) Stages of toothbrushing behavior: in this procedure, frequency was considered according to the number of correct steps completed in each item of the toothbrushing task analysis; b) Intervention by the caregiver: each parental intervention was counted according to its manifestation in each video. Given this, descriptive statistical analyses and inferential statistics were performed using nonparametric tests due to the ordinal nature of the variables and the small sample size (n=9), which do not meet the assumptions of normality, limiting the statistical power and generalization of the results, but were considered sufficient for an initial exploratory comparison of these interventions. The Friedman test was used to assess intragroup differences, and the Mann-Whitney test was used to analyze the differences between Groups 1 and 2 [²⁵].

Results

The results reveal that of the nine participants who completed the study, seven were male and two were female (P1, P7), aged between six and nine years old, and enrolled in regular school. Regarding the children's total Intelligence Quotient (IQ), which refers to the overall level of intelligence functioning, five participants had average performance (P2, P3, P6, P7, P8), two had below-average performance (P5 and P9), and two had borderline performance (P1, P4). Regarding tooth brushing, the parents answered a questionnaire and reported that all children brush their teeth and all perform this task alone, except for P1. Only two children enjoy this moment of the routine (P1 and P7). Regarding tooth brushing frequency, participants P5 and P8 brush only once a day, while the others brush 2-3 times a day.

Table 1
Participant profile.

Participant	Group	Age (Years	Gender	IQ
P1	Video modeling	6	Female	79
P2	Visual Cues	9	Male	101
P3	Video Modeling	8	Male	95
P4	Visual Cues	9	Male	73
P5	Video modeling	7	Male	84
P6	Visual Cues	6	Male	96
P7	Visual Cues	6	Female	96
P8	Video Modeling	8	Male	95
P9	Visual Cues	9	Male	85

Figure 3 shows the frequency of behaviors observed in the videos for Group 1 (PV) and Group 2 (VM). Regarding the results obtained with participants in Group 1 who used visual cues, an average of 13 (SD = 0.33) steps out of the 17 steps of toothbrushing behavior were performed by participants in video 01 (initial), after one week, these behaviors increased to 15 (SD = 0.25) in video 02, followed by 14.6 (SD = 0.30) in the third week in video 03 and 14.8 (SD = 0.23) steps completed in video 04. The Friedman test was used (X²= 1.86, p=0.60), and there was no significant difference in the emission of behaviors throughout the videos of Group 1 (PV).

Figure 3
Frequency of behaviors observed in the videos for Group 1 (PV) and Group 2 (VM).

Regarding the results obtained with Group 2, which used video modeling, it was noted that the participants completed an average of 9.75 (SD = 0.31) steps in the first video 01 (initial), increasing to 13 (SD = 0.25) in the second video after one week, 14.75 (SD = 0.21) behaviors performed in video 03, corresponding to the third week, and finally, 14.75 (SD = 0.17) in video 04. To analyze the data obtained with Group 2, the Friedman test was performed, and the results revealed (X²= 4.72, p=0.19) (p>0.05). Thus, it cannot be concluded that the use of video modeling leads to statistically significant differences in the number of behaviors emitted over the weeks. To compare Group 1 to Group 2, the Mann-Whitney test was used, obtaining U= 4.5 and p=0.31. Although the statistical test did not reveal a significant difference between the groups (p>0.05), the data suggest a possible trend: Group 1 (video modeling) showed greater improvement than Group 2 (visual cues). The small sample size limits the ability to detect statistically significant differences, and these trends should be investigated in larger studies.

The videos were analyzed for the interventions of caregivers on the toothbrushing behavior of children with ASD using the resources provided by the researchers, which were classified into verbal guidance, physical assistance, reinforcement, and punishment. As illustrated in Figure 4, the records of caregiver interventions showed that in Group 1, there were an average of 1.6 interventions per participant for videos 01, 1.4 for videos 02, 1.8 for videos 03, and 2 for videos 04. Meanwhile, for Group 2 of video modeling, the average number of interventions per participant in each recorded video decreased, with a total of 1.5 interventions for the initial videos, 0.75 for videos 02 and 03, and 0.5 interventions for videos 04. Statistical analysis was performed using the Mann-Whitney test, and a value of p=0.04 (p>0.05) was obtained. Therefore, it can be stated that the interventions of the guardians differ between the groups, being greater for the group that used visual cues. This result indicates that this type of resource requires greater mediation by parents than when compared to video modeling. It should be noted that the interventions made by caregivers occurred independently of the influence of guidelines provided by the researchers; parents acted spontaneously as they deemed necessary.

Figure 4
Occurrence of parental interventions during the videos of Group 1 (PV) and Group 2 (VM).

Regarding the types of intervention (verbal guidance, physical assistance, reinforcement, and punishment), the most common for both groups was verbal guidance (f=27). For example, during the recording of video 1, while P1's mother watched and recorded the child brushing her teeth, she gave guidance on the steps to be performed: "turn on the tap", "turn it off", "go ahead, brush", "the other side", "smile", "okay, now rinse your mouth". The second most common intervention was positive reinforcement (f=12), for example: at the end of video 01, when the boy spits out the water correctly, P6's mother uses praise as a form of social reinforcement: "That's it!", "Very good!". Physical assistance was the third most common intervention used by parents (f=6), as exemplified in video 01 of P1 when the mother puts toothpaste on the child's toothbrush and, after the child brushes his teeth his own way, redoes the brushing, completing the movements that had not been performed. Punishment was rare, occurring only once for P1 (video modeling) and for P4 (visual cues). This behavior can be exemplified in video 01 of P1 when the mother needs to get the girl's attention a few times: "A., stop", "A., don't move".

Discussion

Among the main findings of this research, it is noteworthy that all participants, after receiving the instruments, were able to look at the resource and try to imitate the movements represented by them. Some even tried to position their hands and head according to the drawing. Professionals who intend to recommend these tools should observe whether the child already has the ability to sustain and maintain eye contact with objects, since in order to have imitation skills, it is necessary to at least sustain eye contact, which is a prerequisite for the emission of behavior [¹¹]. The sample in this study did not have these difficulties because it was limited to the level 1 support audience, whose IQs were within the average range. Smutkeeree et al. [²⁶] conducted a comparative study of tooth brushing with the aid of visual cues among participants with level 1 and level 2 ASD and reported slower learning with visual cues for level 2; however, they considered the instrument effective for both levels. Esposito et al. [²⁷] found that the low IQ of children with ASD has a negative association with the ability to brush their teeth.

Given the importance of toothbrushing behavior for oral health, visual cues and video modeling were evaluated for the development of toothbrushing skills in children with ASD. However, there were no statistical differences within groups in toothbrushing behavior over the four weeks of the study for both groups, and there was insufficient evidence to say that the average number of behaviors differed between groups. Despite the absence of intraand intergroup statistical evidence, the average number of brushing steps completed by participants in both groups increased throughout the videos, especially for Group 2, which used video modeling for tooth brushing. Sallam et al. [¹⁷] reached a similar conclusion in their study, suggesting that visual cues and video modeling are useful tools for improving the oral hygiene of children with ASD and that video modeling would bring better and faster results. However, in the present study, the limitation of statistical power must be considered as an explanatory factor for this inference about the advantage of video modeling.

During the observation of the four videos, an improvement in the quality of the movements performed in each of the 17 steps can be seen. However, the quality of the videos sent by the parents did not allow the visualization of several steps in several videos, thus reducing the number of positive behaviors emitted, not necessarily because they were unable to perform them, but because they were not recorded. The literature does not provide conclusive evidence to date on the effectiveness of tools such as visual cues and video modeling in improving oral hygiene skills. However, the articles produced show a significant trend in the results, suggesting that these tools help improve these habits [¹⁷,²⁷].

Parental intervention was another criterion observed that may have influenced the results obtained between the two groups, being greater for Group 1, which used visual cues. It should be taken into account that the video modeling tool provides more information that may have allowed parents to give their children more autonomy, without the need for so many parental interventions, such as verbal guidance and positive reinforcement, as it presents the steps of brushing that should be performed in the form of animation and with verbal guidance, while visual cues only present the main behaviors involved in brushing, without the intermediation of a narrator or demonstrative movements [¹¹], thus providing an opportunity to increase verbal guidance and positive reinforcement interventions for Group 1.

Given this, parental behavior must be taken into account, as it can be a determining factor in the successful use of the proposed instruments, especially for visual cues that require further explanation when first used [²⁸]. It is worth noting that behaviors are also learned as a function of environmental consequences, which can increase or reduce the occurrence of certain behaviors, mainly through reinforcement strategies [²⁹]. Among the interventions that parents made during the recordings, the most frequent were verbal guidance, followed by positive reinforcement, physical help, and punishment. It should be noted that the behavioral difficulties typical of ASD can affect the way parents interact with their children and that, often, the demands involved in daily tooth brushing can increase parental stress, which has been identified as a factor that directly interferes with the quality of the relationship between parents and children with atypical development, especially for mothers, who are generally responsible for the care of the child [³⁰].

Conclusion

Visual Cues and Video Modeling contributed to the gradual improvement of children's brushing skills, although no statistically significant differences were observed between the groups, mainly due to limitations in the number of participants that impacted the explanatory power of the statistical analyses. Although the data suggest a trend toward greater autonomy in the group that used video modeling, the use of Visual Cues required greater parental intervention. Limitations in the remote collection context, especially the quality and framing of the videos, restricted the full evaluation of the brushing steps. Future studies with larger samples and direct observation in more controlled contexts are needed to clarify the relative effectiveness of these instruments and their impact on different levels of ASD support.

• Financial Support
  Scientific Initiation Research Grant from the UNIEDU Program of the Government of the State of Santa Catarina (Edital 01/2021).

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor: Catarina Ribeiro Barros de Alencar

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  12 Sept 2025
• Reviewed
  19 Dec 2025
• Accepted
  05 Jan 2026