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Strive-the Student View Making Every Pediatric Appointment Child's Play "No, Mom! Anything but the dentist!" One can imagine a child, fear-stricken, holding onto their car seat for dear life as their guardian attempts to drag them to their dentist appointment on time. Those of us who compare an oral health care appointment to a day at the spa might find such behavior upsetting, but dental anxiety is very common. Oral health care professionals and dental hygiene students encounter it frequently, whether in person or in the classroom. When it comes to treating children especially, many factors, fear included, help determine their actions and attitudes towards the oral health care professional. Dental anxiety is a feeling of fear or extreme discomfort towards oral health care treatment or personnel. A number of things can cause it. If a patient has previously had a bad experience with dentistry, they might associate the dentist with that isolated traumatizing experience. Even if a patient has simply heard "horror stories" from others, without a negative personal experience, they could experience dental anxiety.1-3 With children, you may notice anxiety due to a previous traumatizing experience or due to their parents' own dental anxiety. If a parent expresses fear of the dentist, the child is very likely to be subject to that same fear. Fear and anxiety can drastically affect the child's level of compliance.(1) Fear and anxiety can affect a child's behavior in the office, but they are not the only factors. Some children may misbehave for a variety of reasons. Parental behavior is one of the strongest factors that determine why a child may act the way they do. If the child is "spoiled" or overindulged by their guardian, it could definitely affect their attitude towards an oral health care professional. Parental overindulgence can lead to a child being inconsiderate, selfish, stubborn, tyrannical and likely to defy anyone trying to get them to obey even the simplest of directions. If a parent is more authoritarian and rigid in their parenting style, you can expect the child to also come off as being rigid, possibly aggressive. These are only two examples of how parenting determines child behavior. If ever you cannot understand why a child is acting the way they are, it is usually related, directly or indirectly, to their relationship with their parents and their parents' attitude toward the situation.(2) When a child's behavior prevents a professional from properly or comfortably providing them with appropriate care, behavior management skills are required. One approach is to manage the parent first. Whether the parent should be present in the operatory with their child is ultimately up to the parent, but the oral health care professional can offer expert guidance. For example, children under the age of three would most likely benefit from having their parent present in the operatory, simply because they are so young. For older children, the presence of their parent might create a barrier between the patient and the professional because the professional would have to divide their attention between the child and the parent. And though the parent's presence allows you quick access to informed consent, it may also delay procedures if the parent misunderstands any part of the appointment and requires an explanation. Another important management skill is effective communication. If an oral health care professional can communicate with the child verbally or nonverbally, the child's compliance and comfort can be attained. Using age-appropriate language and short directive statements, and incorporating subjects of interest to the child are important. Not only should you be talking to the child and verbally emphasizing positive behavior, but you should also be listening to the child. Pay attention to their words and actions and respond accordingly. Nonverbal communication such as warm smiles, reassuring touch, and slow, smooth movements can also set a child at ease.(3) Voice control is also very important. You may raise your voice slightly when wanting to be sterner, or quiet your voice to the point where the child must stop any protesting to be able to hear you. If you are treating a child who continues to misbehave despite your use of behavior management, operant conditioning techniques may be used.(3) A few special techniques that can and should be used with pediatric patients to avoid tantrums and other forms of rebellion follow. Positive reinforcement--If the child does something desirable, praise them immediately. Rewarding good behavior teaches them to associate good behavior with pleasing results. Extinction--If the child does something undesirable, the oral health care professional may try to ignore the negative behavior. Usually a child who misbehaves is seeking attention. If no one gives them the attention they seek, eventually, the negative behavior will cease. Tell-Show-Do--Many of us use this extremely effective technique and some of us might not even know it. You include the child in their oral health care procedure. Using language that the child can understand, explain everything you are doing before, while and after you do it. Always be truthful to the patient and stick to your word. Show the patient what is going on, let them feel the prophy cup, and have them listen to the suction. Remember to let the child know what you're doing before and during the procedure. Nicknames and "fun words" for instruments or procedures can also be helpful (e.g., referring to the suction as "Mr. Slurpy"). This gains the child's trust and interest in you and the procedure. Distraction--Distract the child from the procedure. Simply talking about something totally unrelated to the treatment and interesting to the patient can work. "I love your purple shoes! Is purple your favorite color?" Aside from simple conversation, a television or radio can provide distraction. Modeling--Allow the child to observe a cooperative patient. If a child sees that their sibling or a peer is behaving in the chair, they will be apt to copy that behavior. Proper use of these techniques can make the appointment more tolerable and pleasant for you as well as your patient, both for the present appointment and for future visits. Even after you employ behavior management and operant conditioning principles, your patient may still be uncooperative or fearful. Rather than forcing an uncontrollable child through treatment, it is recommended that the appointment be terminated and rescheduled following consultation with the parents. It is your responsibility as an oral health care professional to assess the patient's medical and social history and observe their behavior and attitude toward their parents and toward you as you introduce yourself and prepare them for their appointment. After a few minutes, you should be able to decide what management techniques, if any, may need to be used. Formulate a plan and implement it if the patient misbehaves. If your plan doesn't work, try another technique. Sometimes you just can't win with a child; don't let it get you down. If you remember to be confident, dedicated, flexible, and relaxed, you and the child will make it through any kind of appointment. And if all works out the way it should, you can mold that child into yet another compliant and agreeable oral health care patient/client.
Kelly-Marie Thi Barr is a second-year dental hygiene student at The Ohio State College of Dentistry where she is a resident advisor, scholars ambassador and academic chair of the Delta Omega Kappa Pre-Health Sorority.
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By Kelly-Marie T. Barr
