Introduction

It was a sunny afternoon in mid-July, my day off. The children ran ahead as I brought up the rear, laden with carrier bags and PE kits, all of us excited at the prospect of the long summer holidays ahead. Once drinks had been poured and greedily guzzled, I tipped out the bags onto the kitchen table: an avalanche of brightly coloured exercise books. As the pages of one fell open, two words in my son's looping pencilled script caught my eye: 'rights' and 'wants' (Fig. 1). Intrigued, I read on.

Fig. 1
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Children and young people are able to learn about their rights from an early age. An encouraging teacher overlooked that this example of a completed classroom activity for six- and seven-year-olds has an error: to have information is also a right! (Image is a reconstruction informed by the original)

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Just two months previously, I had for the first time cited children's rights, needs and wants as the rationale for action in the opening chapter of a 2006 guidance document on safeguarding children in dentistry.1,2 Children's rights was new knowledge for many of us at the time - me included - yet my seven-year-old had learned almost as much about that term in primary school as I had gleaned from all my training as a paediatric dentist.

Over the years that followed, I frequently heard children's rights asserted as the basis for protecting children from maltreatment, and we as a dental profession rose to the challenge and increasingly played our part.3,4 As time went on, children's rights also found more frequent mention in the medical and dental literature as a driver to ensure we listen to the voice of children and young people, particularly when designing healthcare services and in conducting research.5,6,7 The latter was not only in relation to protecting them against exploitation but equally important was upholding their right to participate in research and have new discoveries made specifically for them. Co-design and co-production entered the vocabulary when devising healthcare policy. More recently, dental colleagues now argue convincingly that children's rights provide a mandate to strive for equity of access to oral health and health care, while also acknowledging that we are as yet some way off achieving that.8,9

But is there more to it than that? The literature on children's rights in health care tends to focus otherwise on extreme individual cases, such as when children refuse life-saving treatment or seek treatment without parental knowledge and where there is parent-child conflict in life-changing decision-making.10 I remain curious to know if we are missing something else. I want to understand, in relation to the bulk of my clinical work as a paediatric dentist, what a 'rights-based approach' should mean for my day-to-day interactions with my child patients. This article is an exploration of that question.

The United Nations Convention on the Rights of the Child

It was in 1989 that children's rights were laid out in the United Nations Convention on the Rights of the Child (UNCRC).1 It is the most widely ratified human rights treaty in the world, having been ratified by the UK in 1991 and by all other United Nations (UN) member states, except the USA. It is comprised of 54 statements, known as articles.1,11

Overarching principles

The Convention has four overarching general principles:

  • Non-discrimination (Article 2)

  • Best interests of the child (Article 3)

  • Right to life, survival and development (Article 6)

  • Right to be heard (Article 12).

In addition, dignity, participation, transparency and accountability are essential themes. The four overarching principles support the interpretation of all other articles and play a fundamental role in achieving the rights in the Convention for all children. All children under 18 have all these rights. We should let that sink in; all the rights are for all children, worldwide.

Interdependence and indivisibility

Of note, all children's rights are linked and no one right is more important than the others, rather they should be taken as a whole. They are both interdependent and indivisible: they depend on each other and cannot be divided into different parts. For example, the right to play is no lesser a right than the right to safe water to drink. The following quote explains this concept from a young person's perspective:

  • 'Rights are like pancakes - each right is important but when you layer them up they make something strong which protects all children and young people'.12

Practical outworking

If we are seeking to support children's rights in dentistry, perhaps we could look for pointers in the work of the UK Committee for the United Nations Children's Fund (UNICEF UK). UNICEF was established by the UN to support children's rights, translating the UNCRC into practical action. In its own words, it 'works to build a better world for every child, every day, everywhere'. In the UK, where more than four million children live in poverty,13 it works in hospitals, schools and communities, focusing special effort on reaching the most vulnerable and excluded children (Table 1).14 To translate upholding children's rights into practical action in dentistry, the parallel would include extending a child rights-based approach to our own day-to-day practice.

Table 1 The work of UNICEF in the UK to translate children's rights into practical action14
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Towards a child rights-based approach for clinical dentistry

In our relationship with young people, they are the 'rights holders' and we, as the service providers, are the 'duty bearers.' At its core, our duty as dental professionals is to ensure all children and young people can receive the highest attainable standard of oral health care. Beyond that, we have a duty to plan or modify the environment in our practices to welcome children, to change the way we talk and interact with children, young people and their families, and to seek their views, without discrimination and always ensuring their dignity. As I explore some examples of key rights relevant to clinical dentistry, I acknowledge that each should not be viewed in isolation, rather their interdependence and indivisibility means we constantly need to integrate and balance them.

Article 24: the best health care possible

We must strive to provide the best available oral health care, with continuous improvement as new evidence emerges. It is our duty to keep up-to-date and adapt our practice. This aspiration is second nature to most of us and there are a multitude of examples to choose from, of which I will pick just one.

For me, it has to be the Hall technique for preformed-metal crowns for managing caries in primary molars: in my mind, without a doubt, the most impactful innovation in my working lifetime as a paediatric dentist.15 In the past, a conventional pre-formed metal crown - the gold standard of primary dentition restorations - was a procedure usually restricted to the realm of the paediatric specialist. It required local analgesia and high-speed rotary tooth preparation, together with a high level of coping skills from the child and behaviour management skills from the clinician. In its place, the Hall technique, a simple, highly acceptable, child-friendly approach, opened the opportunity for long-lasting restorations to children who would have otherwise had to settle for less. For children with disabilities, who have a right to extra help and special care (Article 23) yet often receive a disproportionate number of extractions rather than restorations,16 the advantages include a better chance of a high-quality restoration, of keeping their teeth for longer, receiving care from their own dentist or therapist closer to home and avoiding a general anaesthetic referral.17,18 This is a big step in restoring primary molars and, when taken with all other scientific progress in paediatric dentistry,19 a giant leap towards Article 24.

Article 17: information they can understand

We must strive to provide information for children that they can understand, especially information for their health and wellbeing. That only happens when we make it our deliberate intent to do so and seek the input of children themselves.

In the dental surgery, this means communicating in child-friendly language. The same applies to written information, now considered an important part of the consent process. There are many excellent examples of communication tools and information resources, often now developed in partnership with children. Young people can describe new procedures to their peers, facilitated by video sharing and social media platforms as a route for health information direct to the smartphone in their coat pocket.20,21 Furthermore, language interpreters must be available when needed and matched by provision of translated written materials.

Again, children with additional needs are easily disadvantaged unless we take active steps to uphold their rights by providing extra help and special care. For those with autism, learning disabilities and other communication difficulties, visual schedules and symbol communication tools are often helpful to describe what is going to happen, whether at a routine dental appointment or on a more complex general anaesthetic journey.22,23,24

Article 12: giving their opinion and adults taking it seriously

We must strive to make opportunities for children and young people to give their opinion and must encourage adults to take it seriously. We have already mentioned the importance of the child's voice influencing health service policy, planning and research. Equally, on a smaller scale, we can give children a say in how we design and organise our own dental practices, or community and hospital clinics.

Furthermore, for the first time, I have recently found myself bringing discussion of children's rights directly into treatment decisions in my surgery. On one occasion, it seemed a parent was trying to coerce their child into an orthodontic referral they did not want. I found myself speaking of a child's right to a voice and to be taken seriously. As the three of us (child, parent and dentist) collectively shifted our focus, it paved the way to a much more constructive discussion.

When we listen to children's voices, we should use not only our ears but also our eyes to observe their behaviour. If true that 'all behaviour is communication',25 a so-called 'uncooperative' child is simply a child giving their opinion and asking for adults to take it seriously. One of the few papers in the literature to directly address children's rights in the dental surgery describes a study in New Zealand. Experienced children's dental practitioners were filmed treating children aged five to nine.10 The films were analysed by a non-dental professional with reference to children's rights. Worryingly, the researchers concluded: 'our findings show that [...] there were numerous examples of children's rights violations'. I hope my own interactions with children would withstand such scrutiny. I fear sometimes they may not. Yet it is essential that we are open to having our existing practice challenged and to collaborate with other disciplines to look for a better way. Fortunately, new rights-based standards offer just that, guiding us to an alternative way to manage children's behaviour when they are having health care procedures and describing what good practice can look like.26

An innovative technique, a raft of better information resources, and a listening ear and watchful eye for the child's voice - I have described just three examples that illustrate how we, the duty bearers, can balance and uphold children's interdependent and indivisible rights in our dental surgeries. I have limited my discussion here to our contributions as individual clinicians. I acknowledge that, to do this at all, we are reliant on all children having access to oral health care, something that at the present time seems more uncertain than ever.27,28 But, that aside, perhaps children's rights is not the unchartered territory distantly removed from clinical dentistry that I thought it might be, but rather a fairly familiar local landscape not previously viewed from this particular perspective. And maybe, all these years after that summery end-of-term walk home, I've been somewhat closer to understanding the scope of what a child rights-based approach means for my day-to-day practice than I had originally thought.

A further challenge

However, a further challenge remains. Article 42 of the UNCRC states that adults should know about children's rights and should help children learn about them. In fact, it words it more strongly: 'parties undertake to make the principles and provisions of the Convention widely known, by appropriate and active means'.

Therefore, to help raise awareness of children's rights, the British Society of Paediatric Dentistry (BSPD), the British Dental Association (BDA), the National Society for the Prevention of Cruelty to Children (NSPCC) and UNICEF UK have joined forces to produce a fact sheet for dental professionals (Fig. 2). Please consider displaying it as a poster in your staff room or email it to your team. Talk about it with your colleagues and consider if your day-to-day clinical practice needs to change in any way. You could even display the fact sheet in your waiting room and talk about children's rights with your young patients and their parents because, importantly, they need to know this too (Article 42).

Fig. 2
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Image of the 'Rights from the Start' children's rights fact sheet for dental teams from the BSPD, supported by the BDA, NSPCC and UNICEF UK Child Friendly Cities and Communities programme. Cartoon by Harry Venning, www.harryvenning.co.uk. Available to download from www.bspd.co.uk/Rights-from-the-Start

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