Chapter 1
Introductory Remarks
More than a century has elapsed since a dentist, writing in one of the professional journals of the day, voiced concern about the behavior of children in his practice (Raymond 1875). It was his opinion that “getting into the good graces of children is almost half the work to be accomplished.” This observation opened the gates to a flood of comments on a subject which hitherto had been unrecognized in the dental literature.
Much attention has been focused on shaping children’s behavior in the dental environment. Although some dentists have reacted intuitively to the needs of their child patients, others have been more systematic. They have tried to identify children’s behavior patterns and to find the best means of coping with them. Practitioners have adopted and adapted the techniques of their dental colleagues. The better methods have been passed from one generation of practitioners to the next. These procedures have stood the test of time. The cumulative effect of this knowledge and experience has been the gradual development of an area known as behavior management.
When planning the second edition of this book, the change in nomenclature was an initial stumbling block. Forty years ago the foremost national specialty organization in the world, the American Academy of Pedodontics, now known as the American Academy of Pediatric Dentistry (AAPD), used the term behavior management. The AAPD now prefers the term behavior guidance rather than behavior management. Checking with other organizations around the world, many of which were non-existent 40 years ago, we found that behavior management was the global term of choice. Therefore, at the risk of political incorrectness, the term behavior management will be used in this book.
The study of behavior management has undergone changes. Early writing on the subject was essentially subjective and anecdotal. Interest matured in the 1970s . The result has been a more scientific approach to behavior management.
The descriptive terms “subjective” and “anecdotal” might be interpreted as a criticism. This was not the intention. Earlier writers on the subject of behavior management were pioneers. They attempted to list the causes of uncooperativeness. They classified behavior patterns. They made accurate observations. They established guidelines for behavior management, some of which are incorporated into the foundation of contemporary practice.
Professional recognition that the behavior of the child patient is the most influential factor affecting treatment outcomes significantly heightened interest in behavior management. As a consequence, dentists began to confer on the subject the same respect and objectivity that they have accorded other areas of science in dentistry (Teuscher 1973). Collaborations with psychologists and psychiatrists have broadened the theoretical bases of behavior management. The current systematic approach has been referred to as behavioral science research in pediatric dentistry. The maturing interest has resulted in a healthy questioning of our earlier subjective considerations. Investigators have explored various hypotheses, new and old, in an attempt to further enhance our relationships with children.
As one would expect, the practice of behavior management has been a dynamic one. Differing treatment techniques have been recommended and debated by pediatric dentists. The choice and acceptability of technique is directly dependent on the societal norms of specific cultures. As a result, today’s practitioners have a wide selection of methods which can be used for managing children’s behavior.
Aims and Scope of the Second Edition
This book has two main purposes: (l) to introduce current information basic to the understanding of children’s behavior and (2) to describe and discuss many of the techniques and methods, new and old, used for promoting the cooperative behavior of children.
Despite the numerous clinical approaches, the increased research output by behavioral scientists and the growing awareness of the importance of this area, no longer is there one up-to-date source which the dentist or dental student could turn to for a comprehensive coverage of the subject. Books dealing with behavior management have come and gone. That is one reason for reviving this book with a second edition. It is intended to integrate current pertinent information from research with current clinical practices.
Another aim has been to balance the practitioner’s need for some basic knowledge of child psychology with the requirement of practical clinical instruction. Dental teachers and clinicians have expressed the need for such a book provided that it is relevant to dental practice. Little psychological background on the part of the reader is therefore presumed, but an attempt is made to build a foundation on which a practicing dentist can develop an understanding of the dynamics of children’s behavior in the dental environment.
The volume begins by describing in some depth psychological, social and emotional development of children. What is normal behavior for a three-year-old may be unacceptable for a child of five. There are margins of normality which those treating children should understand.
When the first edition of this book was written, maternal anxiety was significantly related to children’s cooperative behavior and the primary focus of a chapter. But there are many types of families nowadays—single parent families, same sex families, blended families—to name a few, and they too will be discussed. While the nuclear family is still predominant in society, understanding family environments and how they influence child behaviors is much more complex than in the past. Therefore, much more emphasis has been placed on the study of families of dental patients and an entire chapter is devoted to this subject.
As the reader progresses through the book, a spectrum of techniques for managing the behavior of children is offered. The approach is characterized by eclecticism. It includes clinical management of children using many non-pharmacologic and pharmacologic methods.
The non-pharmacologic techniques generally are those which have been time-tested over generations. They still form the basis of behavior management. However, there has been an increase in the use of sedation and it is obvious that many new pharmacologic methods need to be highlighted. Sedation usage has led to numerous changes in dental practice: new sedation agents along with optimum drug dosages and new drug combinations, guidelines for patient monitoring, and emergency measures are only some of these changes.
An entire chapter is devoted to the management of children with disabilities. Most writings on this topic have been technique-oriented. The present chapter takes a broader approach. A disabled child creates special problems in a family and alters the dynamics of that family. Since the trend today is to maintain the special patient in the community, rather than in an institution, it is apparent that a greater knowledge and understanding of the management of these patients is required. Additionally, much more is known today about communicating with these children than was known when the first edition of this book was created. Some of these communication methods will be addressed in this chapter.
In the last two chapters the book covers practical considerations in the office, discussing a myriad of strategies. The dentist plans and has ultimate responsibility for these strategies, while the office personnel carries them out. There is abundant evidence that successful behavior management is facilitated by a well-run office, the employment of personnel well-trained in relating to children, and the design and appearance of the dental office. The final chapter is devoted to the office environment. Having an office that appeals to children makes management much easier. An appealing office might be considered a starting point in behavior management.
By now it should be apparent that this book has been organized to present an overview of an extremely broad field, rather than an investigation of a few topics. It was designed for all members of the dental health team who deal with children. These team members combine their efforts in the management of children’s behaviors. Each makes their own unique contribution as a dental professional. Consequently, certain aspects of this book will be more appealing, or more germane, to one or the other of the team members. It is the sum total of the children’s experiences in the dental environment which ultimately determines their cooperative behaviors. All team members have a stake in determining the nature of those experiences: each of the team members should have a mastery of their own profession and an understanding of the roles of office associates.
This book also has a major difference when compared to the original book. To elucidate some of the key points in the writings, cases are presented. The cases provide examples that make the book more clinically relevant. Some of these cases are from the book Managing Children’s Behavior in the Dental Office by Wright, Starkey and Gardner (1983).
The Pediatric Dentistry Treatment Triangle
The concept of the pediatric dentistry treatment triangle (Figure 1-1), to some extent, has provided the framework for this entire volume. It is not possible to view any single corner of this triangle in isolation. The child is at the apex of the triangle and is the focus of attention of both the family and the dental team.
The two lines of communication emanating from the dentist’s corner emphasize a major difference between children’s dentistry and adult dentistry. These lines show that treating children is at least a 1:2 relationship (i.e., dentist:child and parent). Adult dentistry tends to be a 1:1 situation (i.e., dentist:patient). It is extremely important for all dental personnel to communicate in both directions.
The arrows at the end of the lines indicate that communication is reciprocal. They also signify that the dental treatment of the child patient is a dynamic relationship between the corners of the triangle—the child, the family, and the dentist. The importance of this unifying concept will become evident as techniques are described in subsequent chapters.
Note the difference in Figure 1-1 between the triangular illustrations in 1975 and 2013. In 2013, societal expectations have greatly impacted the practice of pediatric dentistry. The pediatric triangle does not represent an isolated environment, but rather exists within and is influenced by the surrounding society, hence the addition of the circle.
Perhaps the greatest societal impact on pediatric dentistry was the law of informed consent. Informing the parent about the nature, risk, and benefits of the technique to be used and any professionally recognized or evidence-based alternative is essential to obtaining informed consent. The impact upon professionals became more widespread in the 1980s. Pediatric dentists became aware that it was far more difficult to obtain legal consent from a parent on behalf of a child than it was to have consent when dealing with an adult on a dentist-patient (1:1) relationship.
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