Watching Hockey to Increase Compliance with Wearing a Dental Retainer

Elizabeth Anderson, M.S., BCBA / Dr. BRidget Shore, Ph.D., BCBA-D


Transitioning from braces to a retainer is a necessary step to straighten teeth, but it may be difficult to gain compliance particularly with children with autism. Previous research has demonstrated efficacy in using NCR to decrease desensitization to necessary health and medical procedures. The purpose of this study was to increase a young girl with autism’s compliance with wearing a retainer using continuous reinforcement and reinforcement fading. Watching hockey was used as the reinforcer, and duration of retainer wear and IOA was measured. Results demonstrated that using continuous reinforcement and fading out reinforcement increased compliance with retainer wear.


Wearing a retainer after the removal of braces is necessary in order to maintain straight teeth. Transitioning from braces to a retainer can be difficult for the user and result in refusal or inability to maintain wear. Several studies have examined using desensitization such as demand fading (Conyers & Miltenberger, 2004) and noncontingent reinforcement (Richling et al., 2011, Deleon et al., 2008) to facilitate compliance through distraction. It was determined that reinforcement of compliance led to increase in cooperation (Hagopian & Thompson, 1999). Specifically, Conyers & Miltenberger (2004) evaluated in vivo desensitization and video modeling to increase compliance to dental procedures. In this study, it was found that desensitization was more effective in increasing compliance to dental procedures than video modeling. The demand fading and differential reinforcement principles that were included in the desensitization procedure allowed participants to contact reinforcement initially for lesser demands and then access differential reinforcement for tolerating additional parts of the procedure. In addition, Richling et al. (2011) investigated using noncontingent reinforcement to increase compliance with wearing prosthetics, and then fading back to fixed time (FT) attention only. Results demonstrated that NCR was effective in gaining compliance to wearing prostheses; furthermore, participants continued to wear their prosthetics when only given FT attention. Moreover, Hagopian & Thompson (1999) researched reinforcing compliance to respiratory treatments and discovered that praise and preferred items contingent on compliance to treatments was effective for the participant. Additionally, reinforcement was faded back in this study and the participant continued to comply to respiratory treatments. Consequently, this study assessed increasing a young girl with autism’s compliance with wearing a retainer using continuous reinforcement and reinforcement fading.


The participant in the study was a 13-year-old-girl with Tuberous Sclerosis and Autism. All sessions were conducted after school in the home. Data collection included duration of retainer wear, defined as the participant fully wearing the retainer in the mouth. A timer was started as soon as the participant put in the retainer and it was paused during instances of partial or full removal of the retainer. The timer was restarted when the retainer was back correctly in the mouth and total duration of wear was marked for each session. Interobserver agreement on duration of retainer wear was collected during 20% of sessions and demonstrated 100% agreement. The procedures included a free operant stimulus preference assessment, an indirect functional assessment, the implementation of continuous reinforcement, and the fading out of reinforcement. The preference assessment identified watching hockey as the participant’s most preferred activity. An indirect functional assessment based on interview with parents identified attention and escape as hypothesized functions for retainer removal. For implementation, a video was played continuously while retainer was fully on her teeth and stopped when the child removed the retainer. Planned ignoring was implemented during all attempts or actual removal of the retainer throughout the study to address identified attention function. The duration criteria  initially set was 5 minutes, based on baseline data exhibiting that the participant refused to keep in the retainer for more than a few seconds. Mastery of this initial goal was met quickly so the duration was increased to the total session duration (3 hours), and continuous reinforcement was faded out as other session goals were faded in.

Results and Discussion

Results demonstrated that using continuous reinforcement and fading out reinforcement increased compliance with retainer wearing. Generalization to parents was not fully achieved and is ongoing to increase duration of retainer wearing outside of sessions. It should be noted that although retainer wear with parents still isn’t as consistent as retainer wear with the therapist, that the overall duration of retainer wear has drastically improved in the home in the absence of the therapist. Some limitations to this study include difficulty generalizing compliance with parents, and that the increase in wearing the retainer was not clinically significant to dentists’ recommendations (i.e., all waking hours and when sleeping). However, there was a time constraint as sessions were only conducted in the home between after school and before bedtime. Future studies could look at extending retainer wear to more significant time periods and generalizing to other settings outside of the home.