Child development, relationships and behaviour management
Richard P Widmer, Daniel W McNeil, Cheryl B McNeil and Linda Hayes-Cameron
Promoting positive behaviour among children, adolescents and their caregivers in the dental surgery
This section is a practical guide for specific modes of interacting in the dental environment which can help produce positive and adherent behaviours in child and adolescent patients, as well as their parents and other caregivers (e.g. grandparents). These guidelines are based on principles and research findings from behavioural dentistry, as well as behavioural, developmental, child and paediatric psychology.
It is probably true for most of us that the meaning of our lives is centred on our personal relationships. These are the source of our sense of personal identity; they are the source of our emotional security or insecurity that might define us; they are the source of our greatest joys, of our deepest comforts but, of course, they are also the source of our most bitter disappointments. However, without personal relationships life for most of us would be meaningless. We might dream of escape to the proverbial ‘Desert Island’ but we wouldn’t want to stay there for more than an hour or two or possibly a week, because we would soon realize that the lifeblood of our lives is in our relationships. That is where we get all the rich material for coping with life (Hugh MacKay, ABC radio 26 March 2010). So at home and at work, we need to nurture our relationships constantly. In dentistry, this is particularly relevant, as we are working intimately, not only with those we are caring for, but also with their carers and indeed the entire Dental Team. We spend a great deal of our waking hours ‘at work’, which we want to enjoy as much as possible and so our relationships become crucial and can be used to positively affect the behaviour of the child in the dental environment.
Much has been written about management of problem behaviour among children receiving oral healthcare, with a focus on the use of various techniques. This guide, however, emphasizes specific, simple methods that can be used with children and adolescents to enhance their comfort and cooperation. The general idea is to use finesse instead of trying to achieve absolute behavioural control. Since a sense of lack of control is one of the major components of anxiety and fear (along with a lack of predictability), using methods that are encouraging rather than demanding can go a long way in promoting comfort in the dental environment.
Dentists, dental hygienists and dental therapists are integral members of the healthcare team for children and adolescents and must have an awareness of practical methods of behaviour management that are based on knowledge of psychological principles and stages of growth and development. The adage that ‘children are not small adults’ promotes the idea of special knowledge and behaviours that are important in caring for younger dental patients. Oral health professionals must have a knowledge base in child and adolescent medicine, as well as in social, emotional and cultural factors affecting the health and behaviour of this age group.
It is imperative that dental appointments in infancy, childhood and adolescence are positive, as research clearly shows that early experiences have strong effects on whether dental advice and treatment is sought in adulthood. Having a rapport with the parents/caregivers (e.g. grandparents) is essential, as they typically are the most influential people in the child’s life.
Child behaviour and development
Working with children is, of course, different from working with adults, therefore, it is essential to be familiar with age-appropriate skills and functioning, and development. Infants, children and adolescents are undergoing progressive changes in cognitive, receptive and expressive language, fine and gross motor ability, and social/emotional development. Each child is unique and may develop at varying rates relative to their same-aged peers, For example, one child may present with strong motor skills but less well-developed language, while this may be the opposite for another same-age peer.
Developmental milestones and issues
There are two essential needs that remain constant from birth to adulthood: the desire to feel important and having an emotional connection with others. Oral health professionals who are aware of their patient’s age-appropriate development and needs can use that information to develop a rapport with the child and have appropriate expectations of the behaviour of that particular child in the dental setting.
General developmental milestones and child behaviour
Age 3–4 months
Age 6–8 months
• By 6–8 months, infants are discovering new ways to share and express their curiosity, joy, frustration and fear within their world. Babies can shift their attention while keeping in mind the object on which they were focusing. They can look at a ‘teddy bear’ and be delighted by it, then turn to look at the parents to share those feelings.
• The infant learns to ‘social reference’, where he/she shows interest in an object or person and then turns to the parents for emotional feedback. The infant is able to read the parent’s/caregiver’s facial expression, tone of voice and words, to understand the concept of a particular danger or safety.
It is generally accepted that teething has the potential to cause local irritation, however, there is no accepted evidence connecting the systemic symptoms, such as diarrhoea, flushed cheeks and fever, to teething. It is important to seek medical advice if an infant has persistent febrile illness.
Age 9–12 months
• By 9 months, two-way conversations about feelings are now possible. Infants become aware of the possibility of others sharing their thoughts and feelings. Understanding and labelling the infant’s feelings and experiences can help with relationship building, acceptance and trust.
• Object constancy or permanence is developing in which infants begin to realize that objects and people still exist even when out of sight (e.g. repeatedly throwing the spoon off the high chair and it magically reappearing).
Children’s behaviour is a function of their learning and development, and so it is reasonable to expect that their behaviour in the dental environment will also vary.
• The child has limited ability to understand dental procedures. Nonetheless, with a sensitivity to the child’s normal emotional development and play expectations, even without cooperation, an oral examination and some treatment can often be accomplished without sedation.
Age 1–3 years (Toddler years – egocentric)
• Infants begin to develop a sense of self and explore their autonomy. They may become non-compliant for the first time, as they practise asserting themselves, trying to establish themselves as independent and avoiding situations that make them feel out of control and with a limited sense of self.
• Sharing and cooperative play is meaningless at this stage, as the ‘toddler rules of ownership’ outweigh all concepts, such as: If I see it it’s mine. If it’s yours and I want it, it’s mine. If it’s mine, it’s mine and mine only!
• Preferences for ‘boy’ and ‘girl’ objects is common at this age: many toddler boys show interest in cars, trains, the colour blue and other boys, while many toddler girls show interest in dolls, fairy dresses, the colour pink and other young girls, for example. Play remains solitary, however, and is ‘parallel play’ to their peers.
• The ability to communicate varies according to the level of vocabulary development, which is expected to be limited. Thus, the difficulty in communication puts the child in a ‘pre-cooperative’ stage.
Age 3 years
• In times of stress, they will turn to a parent and not accept a stranger’s explanation. Typically, these children feel more secure if a parent is allowed to remain with them until they have become familiar with the dental professionals. Then a positive approach can be adopted.
Age 4–5 (early childhood years)
• By this age, children are exploring new environments and relationships in their world. They prefer one-on-one friendships, as more than one is difficult to manage. Once at school, however, they have to learn to sit quietly in groups and pay attention. Further development of social skills and regulation of emotions is occurring while mixing with their peers.
• These children listen with interest and respond well to verbal directions. They have lively minds and may be great talkers who are prone to exaggeration. In addition, they will participate well in small social groups.
• 4-year-old children are extremely creative, as fantasy and imaginary play allows them to work through confounding problems, emotions and the stressors of daily life. Therefore, pretend play can open the door to a young child’s thoughts and worries and provide the dentist with valuable information. Showing great interest, listening and reflecting back to the child what they just said or taking on the role of another toy in conversation with them, will encourage them to explore further.
• Promotion of autonomy and the development of self-esteem by allowing decision-making and choices in their treatment, and encouraging them to take responsibility for tasks such as manoeuvring the dental chair, is important.
• Children at this age usually have no fear of leaving their parents for a dental appointment because they have no fear of new experiences. They take pride in their possessions, and comments about clothing can be effectively used to establish communication and develop a rapport. By this age, children usually have relinquished comfort objects such as thumbs and ‘security blankets’.
Age 6–8 years
• For some children, this transition may cause considerable anxiety with outbursts of screaming, temper tantrums and even striking parents. Furthermore, some will exhibit marked increase in fear responses.
• This age may be an ideal time to help the child and parent/caregiver move from the parent/caregiver being in the surgery to the child being able to go back alone from the waiting room to the surgery.
• The increased tendency toward fearfulness prompts special care in working with children at this age, accepting that new fear(s) may develop, even if the child has been a prior patient who earlier was comfortable in the dental setting.