CHAPTER 3 Nonpharmacologic Management of Children’s Behaviors

The foundation of practicing dentistry for children is the ability to guide them through their dental experiences. In the short term, this ability is a prerequisite to providing for their immediate dental needs. More long-lasting beneficial effects also can result when the seeds for future dental health are planted early in life. The process of leading a child through a dental appointment had for many years been termed “behavior management.” In 2003, the American Academy of Pediatric Dentistry (AAPD) sponsored a national symposium on behavior management that focused on clinical techniques as well as the changing environment and trends of contemporary pediatric dental practices. Following this conference, the AAPD introduced the term “behavior guidance” in its clinical guidelines to emphasize that the goals are not to “deal with” a child’s behavior but rather to enhance communication and partner with the child and parent to promote a positive attitude and good oral health.

A professional goal is to promote positive dental attitudes and improve the dental health of society. Logically, children are keys to the future.

A major difference between the treatment of children and the treatment of adults is the relationship. Treating adults generally involves a one-to-one relationship, that is, a dentist-patient relationship. Treating a child, however, usually relies on a one-to-two relationship among dentist, pediatric patient, and parents or guardians. Fig. 3-1, which illustrates this relationship, is known as the pediatric dentistry treatment triangle. Recently, society has been centered in the triangle. Management methods acceptable to society and the litigiousness of society have been factorsin fluencing treatment modalities. Note that the child is at the apex of the triangle and is the focus of attention of both the family and the dental team. Although mothers’ attitudes have been shown to significantly affect their children’s behaviors in the dental office, the roles of families have been changing, and the entire family environment must be considered. Because changes are constantly occurring within each personality, one must remember that there is an ever-changing, dynamic relationship among the corners of the triangle—the child, the family, and the dental team. The arrows placed on the lines of communication also remind us that communication is reciprocal.

Figure 3-1 The pediatric treatment triangle illustrates basic relationships in pediatric dentistry.

The importance of this unifying concept will become evident as behavior guidance techniques are described. However, this concept also serves as the basis of organization for this chapter, whose goal is to discuss the nonpharmacologic approaches to managing children’s behavior in dentistry.

PEDIATRIC DENTAL PATIENTS

Child development involves the study of all areas of human development from conception through young adulthood. It involves more than physical growth, which often implies only an increase in size. Development implies a sequential unfolding that may involve changes in size, shape, function, structure, or skill.

Over the years, numerous child development theories have evolved. Summarizing them, Alpern stated that the most important general principle concerning development is that human development is not unitary.¹ He contended that there were several relatively important aspects of child development and that no single aspect could be used to assess development. He cautioned about relating to children through a single developmental label and suggested that a basic appreciation of child development knowledge could be helpful to the dentist.

Early child development study linked changes to specific chronologic ages. The initial work gathered age norms for physiologic developmental tasks. Eventually personality description principles also evolved. One of the pioneering and most notable groups, headed by Arnold Gesell, was at Yale University. Typical personality characteristics related to specific chronologic ages that have relevance to dentistry are listed in Box 3-1. These can help when developing behavioral guidance strategies. For example, if the dentist knows the limitation of a 2-year-old’s vocabulary, it becomes apparent that communication must occur through the sense of touch and voice modulation rather than through the spoken word. Recognizing also the close symbiotic relationship with parents, dentists generally try to keep the parent-child pair intact.

Based on the work of Dr. A. Gesell.⁵

TWO YEARS

Geared to gross motor skills, such as running and jumping

Likes to see and touch

Very attached to parent

Plays alone; rarely shares

Has limited vocabulary; shows early sentence formation

Becoming interested in self-help skills

THREE YEARS

Less egocentric; likes to please

Has very active imagination; likes stories

Remains closely attached to parent

FOUR YEARS

Tries to impose powers

Participates in small social groups

Reaches out—expansive period

Shows many independent self-help skills

Knows “thank you” and “please”

FIVE YEARS

Undergoes a period of consolidation; deliberate

Takes pride in possessions

Relinquishes comfort objects, such as a blanket or thumb

Plays cooperatively with peers

Relating personality characteristics to chronologic ages has led to some interesting labeling. For example, a noncompliant 2-year-old often is referred to as in the stage of the “terrible twos.” Dentists sometimes refer to such children as being in the precooperative stage. Unfortunately, this has led in some instances to using the age of the child, rather than the child’s ability, as a reason for noncompliance.

The broad area of physical development involves changes that occur in children’s size, strength, motor coordination, functioning of body systems, and so forth. Thus the child’s total physical growth and efficiency from the moment of conception until adulthood is termed physical development. Because a child’s physical development is relatively independent of other major areas of development, subareas of physical development have to be relatively independent. A child’s coordination cannot be judged by physical size, nor is physical strength related to dental development.

Relating physical changes to specific chronologic ages led to the establishment of developmental milestones that became a means of assessing individual children. Classic developmental milestones are listed in Table 3-1. From these milestones, ranging from infancy through early childhood, two pieces of information are derived: (1) the average age at which a child acquires particular skills and (2) the normal range of ages at which a skill is acquired. A general principle is that, the earlier a skill emerges, the narrower is the range. On the other hand, developmental tasks tend to occur with wider ranges of normality as age increases. For the dentist, this holds practical importance. For example, consider the task of teaching children how to floss their teeth. Because the ability to floss occurs later in life (9 to 12 years of age), there is a wide performance range. Knowing the general developmental principle reminds the clinician to consider the ability or readiness of the individual to perform a given task.

Table 3-1 Average Age and Age Range of Selected Physical Developmental Milestones

Developmental Task	Average Age	Normal Age Range
Focuses on light	2 wk	1 to 4 wk
Lies on stomach, lifts chin	3 wk	1 to 10 wk
Birth weight doubles	6 mo	5 to 7 mo
Rolls from back to stomach	7 mo	5½ to 11 mo
Sits alone	7 mo	6 to 11 mo
Stands with support	10 mo	7½ to 14 mo
Stands alone	13½ mo	9 to 18 mo
Walks alone	14 mo	10 to 20 mo
Bowel control attained	18 mo	1 to 2½ yr
First menstruates	12 yr, 9 mo	10 to 17 yr

Another area that has received great attention from psychologists is the socialization of children. As with physical development, age-specific skills have been derived for social development; these take into account both interpersonal relationships and independent functioning skills. Some of the key personality characteristics are identified in Box 3-1.

An important process for dentists is the child’s growth toward independent functioning. For their survival, infants are dependent on others to clothe, feed, and nurture them. As children grow and their ability to care for themselves improves, they gain social independence. Recognizing that the change from functional dependency to functional autonomy is a normal process in social development can assist the dentist. Many young children want to brush their own teeth, but lack digital dexterity. Parents, on the other hand, understand the lack of digital skills and often insist on attending to their children’s oral health care. Appreciating that this tug-of-war is a normal part of social maturation allows the dentist to intercede and make appropriate conciliatory recommendations.

Intellectual development is probably the area most comprehensively studied, beginning in the early 1900s with the work of Alfred Binet.² The method that he employed quantified mental abilities in relation to chronologic age. It led to the concept of the IQ (intelligence quotient), which was measured by tasks examining memory, spatial relationships, reasoning, and a variety of other primary mental skills. By determining the average age required to pass each task, he derived age norms. This enabled an examiner to determine a child’s mental age based on performance. For health care providers, viewing children in terms of their mental ages can be a helpful approach.

The IQ formula used by Binet follows:

Thus a child who performs tasks accomplished by a 10-year-old and who has the chronologic age of 8 years has an IQ of 125 (10/8 × 100 = 125). Quantification of intelligence has led to various classification guides. Since the time of Binet, more than 300 tests have been devised to measure intellectual development. The best known and best standardized of these tests are the Wechsler intelligence scales. These are individualized as opposed to group tests, and separate forms of the test are available for preschoolers (Wechsler Preschool and Primary Scale of Intelligence, or WPPSI), children (Wechsler Intelligence Scale for Children-Revised, or WISC-R), and adults (Wechsler Adult Intelligence Scale, or WAIS).

Currently, IQ is obtained by assessment with one or more standardized, individually administered intelligence tests such as the Wechsler Intelligence Scales for Children or the Revised, Stanford–Binet. Those judged to be of normal intelligence may span categories ranging from very superior or genius to dull or borderline deficiency. Significantly subaverage intellectual functioning is defined as an IQ of about 70 or less (approximately two standard deviations below the mean). However, retardation or intellectual disability (a term now recommended by the American Association on Intellectual and Developmental Disabilities) would not be diagnosed in an individual with an IQ of less than 70 without significant limitations in adaptive function in at least two domains. These might include communication, self-care, social/interpersonal skills, and adaptation to home living, use of community resources, functional academic skills, and as an adult, work/leisure skills and safety. A measure of adaptive functioning is obtained from a developmental and medical history and one or more reliable collateral sources (e.g., caregiver, educator). Scales have been designed to quantify adaptive functioning, such as the Vineland Adaptive Behaviour Scales, whose measures provide a composite score reflective of subscores in several adaptive skill domains.

It is those individuals with intelligence deficiency that concern the dentist because they may require special behavior guidance. Four degrees of severity of mental retardation are specified according to the level of intellectual impairment (and with the proviso of a deficit in adaptive functioning).³ They are listed in Table 3-2.

Table 3-2 Degrees of Severity of Mental Retardation

Mild mental retardation	IQ level 50-55 to approximately 70
Moderate retardation	IQ level 35-40 to 50-55
Severe mental retardation	IQ level 20-25 to 35-40
Profound mental retardation	IQ level 20 or 25

From American Psychiatric Association, DSM-IV.³

The environment is such a crucial factor in the development of a human being that it can be discussed as an independent factor only on the theoretic level. The fact that each child appears to have a characteristic temperament from his or her earliest age has been suggested by Sigmund Freud and by Gesell and Ilg.^4,⁵ In recent years, however, some psychiatrists and psychologists have emphasized the influence of the child’s early environment when discussing the origin of human personality. Whether personality is developed by “nature” (genetic influence) or “nurture” (environmental influence) is an age-old, unresolved question. However, if these two influences are in harmony, healthy development of the child can be expected; if they are dissonant, behavioral problems are almost sure to ensue.

VARIABLES INFLUENCING CHILDREN’S DENTAL BEHAVIORS

The responses of children to the dental environment are diverse and complex. Children present for treatment with differences in age, maturity, temperament, experience, family background, culture, and oral health status. Klingberg and Broberg,⁶ in a review of literature from 1982 to 2006, reported dental fear/anxiety and dental behavior management problems were relatively common for pediatric dental patients, each affecting 9% of children and adolescents. Girls exhibited more dental anxiety and dental behavior management problems than did boys. Dental fear/anxiety was more closely associated with temperamental traits such as shyness, inhibition, and negative emotionality, whereas behavioral problems were connected with activity and impulsivity.

Most dentists readily recognize children with dental behavior management problems, whereas dental fear and anxiety may be more subtle. Fear is best understood in context of personal, environmental, and situational influences. It can be a normal reaction for young children, especially in unfamiliar situations where they lack control or perceive the potential for pain. As children age, with increasing ability to anticipate, understand, and control impulses, fears may be expected to decline. But if fear or anxiety is disproportionate to the situation, an unpleasant experience is likely and the child may become uncooperative, displaying disruptive behavior.

Dental fear/anxiety is not synonymous with dental behavior management problems. In a study of more than 3200 Swedish children, Klingberg and Berggren ⁷ found that 27% of patients with dental behavior management problems showed dental fear and anxiety, whereas 61% of those with fear/anxiety reacted with behavioral problems. The key to successful outcomes (ie, compliance, relief of anxiety, completion of quality care, development of trusting relationship) is appropriately assessing the child and family to prepare them to actively participate in a positive manner in the child’s oral health care. Dentistry has had some difficulty identifying the stimuli that lead to misbehavior in the dental office, although several variables in children’s backgrounds have been related to it.

Parental Anxiety

With few exceptions, investigations indicate a significant correlation between maternal anxiety and a child’s cooperative behavior at the first dental visit. High anxiety on the part of parents tends to affect their children’s behavior negatively. Although the scientific data reveal that children of all ages can be affected by their mothers’ anxieties, the effect is greatest with those younger than 4 years of age. This might be anticipated because of the child-parent symbiosis that begins in infancy and gradually diminishes.

Medical Experiences

The importance of medical experiences, a highly complex variable, has been debated over the years. There is general agreement, however, that children who view medical experiences positively are more likely to be cooperative with the dentist. The emotional quality of past visits rather than the number of visits is significant.

Pain during previous medical visits is another consideration in a child’s medical experiences. The pain may have been moderate or intense, real or imaginary. Nonetheless, parental beliefs about past medical pain also are significantly correlated with their children’s cooperative behavior in the dental environment. Study also has shown that previous surgical experiences adversely influence behavior at the first dental visit, but this was not the case in subsequent visits.

Awareness of Dental Problem

Some children may approach their dentist knowing that they have a dental problem. The problem may be as serious as a chronic dental abscess or as simple as extrinsic staining of the dentition. However, there is a tendency toward negative behavior at the first dental visit when the child believes that a dental problem exists. Their concern about having caries also may lead to missed appointments. Such considerations provide the dentist greater motivation for educating the parents about the value of establishing a dental home early, before any dental problems develop.

General Behavior Problems

Klingberg and Broberg ⁶ found some support for a relationship between general behavioral problems and dental behavior management problems. Children who have difficulty focusing attention and or adjusting activities to their general environment have increased problems complying with behavioral expectations in the dental environment. General fears can be important etiologic factors in development of dental fears. Some children, however, have behavioral problems only in the dental environment; this may be due to previous negative experiences with dental care.