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Child vs. adult patient

One of the major differences between children and adults in the dental setting is that adults choose to attend but children are simply taken there and have no choice in the matter. For the young child, this can be a worrying experience. They are asked suddenly to cope with strange people in an unfamiliar environment. The other major difference is, of course, that in most instances you are not dealing with a 1:1 situation as happens with your adult patients. Instead you have to manage a three or four-way interaction with the parent and dental nurse involved.

Credit: © iStockphoto/Thinkstock

So why do children behave as they do in the dental setting? Some children seem to embrace their first dental visit as an opportunity to socialise and play yet others are to be found sobbing in the waiting room clinging to their mother.

Although we as dental professionals can do very little (if anything) to influence what happens before they reach our door, there are some tools which can help ease the path for the child and make that first visit less traumatic for all concerned.

Some of the factors which shape the child's behaviour at that first encounter include personality and temperament, communication skills, maternal anxiety, previous medical history and family factors. Although we cannot influence these, knowing about them can help dental staff feel more prepared so that the approach taken can be more tailored to the individual child.

There are a number of non-pharmacological behaviour management techniques that aim to help prevent and/or manage behaviour management problems for children. Some methods focus on improving the communication process whilst others are intended to reduce anxiety. Although many techniques are described in the paediatric dentistry literature, these techniques are often used in combination.

Be prepared

The Pre-Appointment Questionnaire

One of the most useful techniques for managing the child's behaviour can be used even before the parent and child enter the building. You will be relieved to hear that this doesn't involve a home visit!

The use of a Pre-Appointment Questionnaire (PAQ) is widespread amongst paediatric dentists and of immense value when seeing a child for the first time. Although the medical history form tells you about the child's physical health, it doesn't really tell you about what makes that child in front of you tick.

What is a PAQ and how is it used?

Sending out a PAQ has proved successful in a number of areas:

  1. 1

    We all recognise the anxious mother who (inadvertently) transmits her anxiety to her child. This is especially true for the very young child where they are able to 'pick up on' their mother's emotional state. Such a letter/questionnaire to new child patients informs the parent about what will actually happen at the visit. The parent can then give advice on preparing the child and it can help to reduce parental anxiety. Surprisingly, many parents have unrealistic fears about what the child will have to go through at that initial visit. These fears are often based on their own personal experiences and are sometimes coloured by time and their own personal anxieties. So you can ask the mother (usually) if they are nervous themselves. The evidence suggests that maternal anxiety is reduced simply by sending such a PAQ out before the visit.

  2. 2

    By explaining what will happen at that first visit the PAQs help to address the 'fear of the unknown' which can be extremely worrying for some children. This is especially true if the child has in fact had dental treatment before and perhaps it didn't go very well for them.

  3. 3

    The PAQ can explain that you will try to introduce the child to dental care in a supportive way and emphasise the importance of prevention in maintaining oral health as opposed to more 'restorative' approach. A surprising number of parents still expect dentists to carry out what are sometimes quite demanding and extensive procedures at that first visit. Some parents may not appreciate that dental care for children doesn't merely involve 'getting the job done as quickly as possible'. Although this is an element of oral care for children, true behaviour management should also instil a positive dental attitude to facilitate ongoing prevention and improved dental health in the future. In other words – the child should be happy to come back to see you! This is only achieved by establishing good communication and trust – so very important for the young child.

  4. 4

    You can find out what the child likes and dislikes. It is a starting point in establishing a dialogue and interaction with the child.

  5. 5

    You can personalise your PAQ and perhaps make it your USP (unique selling point)!

Of course there is much more to behaviour management for children than just a PAQ, but it is a starting point. It helps the whole team identify those children who may take that extra time to settle in the dental environment and a more measured approach.

There are excellent professional guidelines for non-pharmacological behaviour management for children available via the British Society of Paediatric Dentistry website.1 This document lists the various techniques which can be employed to help gain cooperation and trust with the child.

Adapt your communication

It is well known that communication is made up of the following:

  • 7% of our communication is related to the meaning of the words we use

  • 38% is related to the volume, tone and rhythm of our voices

  • 55% is related to our body language.

When it comes to interacting with a small child it is not surprising that their reaction to what is said is more to do with how it is said to them rather than the actual content.

Any language used should naturally always be age appropriate (childrenese) as should the non-verbal communication component which should act such as to reinforce rather than contradict what is being said.

Such communication includes having a child-friendly environment in the waiting area and a happy, smiling team who are positive and genuinely 'up-beat'.

This may come as a surprise to some of you but the available research suggests that using reassurance to manage a child's behaviour doesn't actually work very well!

In other words, reassurance doesn't really reassure. The act of verbally reassuring without doubt makes the dental staff feel better; however, it doesn't actually reduce anxiety in children.

What works?

Empathy

Strong evidence and personal experience have shown that the use of empathy is very effective in reducing anxiety in children. In other words - questioning for feeling.

Simple phrases such as 'Is that okay?' or 'Does that feel a bit funny?' ... are remarkably effective in reducing distress in children. This is an important part of the rapport building which is so essential to the successful management of the child patient.

Combining an empathic approach with gentle pats and squeezes has been found to minimise distress for young children undergoing operative treatment. These non-verbal cues and signs are used to give positive encouragement and enhance other management techniques.

Other techniques

What other techniques are there? The techniques unsurprisingly haven't really changed substantially over the past 30 years; these include Tell-Show-Do, behaviour shaping, positive reinforcement and desensitisation – to name but a few.

So is behaviour management for children an art or a science? Of course the answer has to be that it's a bit of both. If it were not so, then all we would have to do is read the books and instantly all children would become star patients and behaviour management problems would cease to exist.

Knowledge of child development (physical, psychological, emotional and social) is essential as is the awareness of the various behavioural techniques available. However, the art of behaviour management concerns elements which are less tangible.

My favourite quotation in the field of behaviour management sums this point up and is from G. H. Kreinces in 1975: 'In human relations the agents of help are never solely the techniques, but the person employing them. Without compassion and authenticity, techniques fail.'

Wendy Bellis is presenting at the BDA course 'A team approach to managing the young patient' on Friday 29 November 2013. For further information visit www.bda.org/training, call the booking hotline on 020 7563 4590 or events@bda.org.