Chapter 4

Influence of the Family

Barbara Sheller

Introduction

The family is critical to a child’s nurturing and development. A child’s sense of self-worth develops from being cared for, loved, and valued. Along with meeting basic physical needs, families provide children with emotional support, socialization, coping methods, and other life skills. The purpose of this chapter is to review aspects of the relationship between children and their families, which may influence their ability to cooperate for dental treatment. Some parent and family factors which may be manipulated by the dental team are identified, and sample strategies are outlined to identify and shape key family factors to enhance child coping and cooperation. To provide the greatest value for the clinician, there is a summary of important learning concepts at the end of each section, translating theory and research into the clinical dental practice with children. Dentistry does not stand alone in its interest in promoting child coping and cooperation skills, or in its recognition that parents and family can affect a child’s responses during a dental appointment. Thus, this chapter includes selected research from pediatric medicine, developmental psychology, and neuroscience to supplement the dental evidence base.

Families influence children’s oral health of in daily life through eating behaviors and oral hygiene practices. Parents decide when their children should see a dentist, choose the office or clinic and dentist, arrange the visit, and often accompany their children to the appointments. Before stepping into the dental office, parents are invested in the quality of their child’s dental experience.

Family Structure

A family is a network of interconnected relationships. Over the last several decades, social and cultural changes have expanded the concept of what comprises a family. Dental practices worldwide serve a multicultural population with a wide range of family structures. Family diversity includes, but is not limited to, parental status (married, divorced, separated, single, step, biological, adoptive, foster), along with differing racial, ethnic, linguistic, spiritual, religious, sexual, social, and inter-generational aspects. Parent age can vary widely—maternal age may extend from pre-teen into late middle age due to the availability of advanced fertility treatments and surrogacy, and there is no clear upper limit for paternal age. Family size and composition may range from a small and straightforward family of one parent and one child to a large and complex multi-generational, multi-parent, multi-child family with varying relationships among the children and to the parents. Important variations within these diverse family structures are parenting style, parenting behaviors and practices, communication style, roles of family members, use of time within the family, commitment to individual family members, type and quality of childcare, connection to the community, economic and social resources, and methods of responding to challenges of life (American Academy of Pediatrics Task Force on the Family 2003).

A child’s well-being is closely linked to physical, emotional, and social health; social circumstances; and behavior of their parents. Children do best when raised by two caring, cooperative parents with adequate social and financial resources providing a secure, supportive, and nurturing environment. The family stress model proposed by Conger et al. (2000) recognizes that parents become emotionally depleted by financial hardships, health problems, marital discord, fatigue, employment difficulties, lack of social support, and other traumatic life events. Parental emotional distress can lead to family conflict, instability, and disrupted, poor-quality parenting.

In general, stressful events which occur early and/or result in long-lasting disruptions in a child’s care and nurturing lead to worse outcomes for children. However, no particular family structure makes poor outcomes for children inevitable (American Academy of Pediatrics 2003). Family risk factors such as a single parent household, a parent’s ill health, or financial hardship adversely impact parents’ attitudes and behaviors and reduce their ability to positively socialize, support, and guide their children during dental treatment. Family characteristics of 230 children and adolescents ages eight to nineteen years of age who were referred to pediatric dentistry specialists for behavior management problems were compared to 248 controls without behavior management issues. Striking differences in life and family situations were found between the groups. The uncooperative children more often lived in families with low socioeconomic status, had parents who were not living together, reported fewer leisure-time activities, performed poorly in social interactions, had personal professional support, and had received interventions by social agencies. The “burdensome life and family situation” was suggested as a factor explaining some of the patients’ non-cooperation (Gustafsson et al. 2007).

Application in Dental Practice

The dentist has no control over a child’s family situation, but knowledge of family circumstances contributes to optimal clinical decision-making. A constructive partnership between the dentist and the parent and/or key caregiver lays the foundation for a positive and satisfying child–dentist relationship over the child’s lifetime.

The dentist should know who is most involved in the care and nourishment of the child, as well as the primary caretaker’s oral health perspective and preferred style of interaction. Other information to consider includes: identity of family members living in the home, custody arrangements, child care setting and primary caregivers, family disruptions such as marital strain or divorce, severe illness of a family member, moving, refugee status, military deployment, social support, parent employment status, and financial security.

Understanding this information will guide the dentist’s communication with parents and/or other key family members whose understanding and “buy in” is essential for promoting a child’s positive attitude about healthy diet, oral hygiene behaviors, and cooperation for dental treatment. For families experiencing difficult circumstances (e.g., divorce, unemployment, moving to a new city, or death of a family member), the dentist can express appreciation for the effort that has been made to bring the child to the appointment, and should understand that recommendations for changes in diet or oral hygiene may not be actualized until the family situation improves.

Attachment

The bonding of an infant with a parent or other caregiver is one of the key developmental tasks of infancy (see attachment theory in Chapter Two). Infants become bonded, or attached, to caregivers with whom they have significant amounts of interaction. They develop a hierarchy of preferred attachment figures, having a most-preferred caregiver, a next most-preferred, etc. Infants have limitations in their capacity for attachments, and serious attachment disturbances have been reported among children raised in settings with large numbers of caregivers. Children who are institutionalized or maltreated may have no definite attachments to anyone (Zeanah and Fox 2004). Preferred attachments can develop at any time after infants reach a cognitive age of seven to nine months if the new caregivers have substantial involvement with the child. Young children adopted out of foster care or institutions form attachments to their new caregivers, but in some cases the quality of the attachment is compromised (O’Connor et al. 2000).

Researchers observing securely attached and insecurely attached children have found that those with secure attachments are more likely to engage with their environment in an active manner. Theoretically, successfully attached infants have learned to trust the outside world as a welcoming place and to trust adults. A secure parent-child attachment appears to prepare a child to be receptive to and cooperative with parental socialization influences (Kochanska 1995). Conversely, infants whose emotional needs have not been consistently or adequately met come to view the world as unpredictable and learn that adults are not to be relied upon. For poorly attached children, discipline is experienced as rejection and disapproval, and they overreact to the negative feelings caused by routine childhood rules and restraints. They are at risk for chronic anxiety or distrust, less able to cope with challenging or adverse life experiences, and are more likely to exhibit behaviors that result in adverse experiences (Bowlby 1982). Understandably, children with insecure attachments are more likely than securely attached children to feel threatened by new or stressful situations (McKernon et al. 2001).

Most research on attachment has focused on the child’s bond to the mother. Recent investigations indicate the importance of the father-to-child bond. “Double-insecure” (insecure attachment to both parents) six to eight year old children had high levels of behavior problems at school as rated by teachers and by the children themselves. A secure attachment with one parent offsets risk for poor behavior, but having a secure attachment with two parents did not confer additional benefit to the child (Kochanska and Kim 2013).

Application in clinical dental practice

The dentist should assess the child patient’s social history regarding risk factors for disrupted attachment, such as: extended hospitalization during infancy or toddlerhood, early life in an orphanage with multiple caregivers, history of foster care—particularly with multiple foster home placements, adoption after infancy, history of physical abuse or neglect, or a parent with substance addiction or mental health issues. In the dental setting, a child disadvantaged by an insecure attachment may show extreme fear and reluctance (retreat from an unsafe and unpredictable world) or be defiant and uncooperative (battle against an unsafe and unpredictable world). Either response should elicit the compassion, patience, and understanding of the dentist and dental team. Time, consistency, and patience must be invested when working with an insecurely attached child, using positive and incremental efforts to form a relationship and earn the child’s trust. A long-term perspective should be paramount when the dentist meets a child with a severe attachment disorder. An insecure attachment does not make poor psychosocial outcomes inevitable for a given child or adolescent; it is more useful to think of attachment quality as a risk factor or protective factor in a child’s life experience. The advantage and psychological protection resulting from a secure attachment enhances a child’s ability to listen, relate, and respond to the dentist, and then to cooperate during dental treatment. The young child will do best if introduced to the dental environment and dental team in the presence of their preferred attachment figure.

Genetic Contribution to Child and Parent Interactions

The answer to the question “Does behavior result from nature or nurture?” is now understood to be “both.” Genes and interactions between genetic potentials and the environment (epigenetics) are both determinants of behavior. The structure and function of the developing brain is strongly influenced by social interactions in infancy and early childhood. While most existing research on socialization was completed with observational and behavioral methods, the discipline of social and cognitive neuroscience now has tools to study neural pathways within the brain. As this chapter is written in 2013, a working hypothesis is that recurrent, active, and long-term engagement in behavioral sequences (cultural tasks) shape and modify brain pathways. Connectivity and functions of different areas of the brain change as a result of experience in general, and particularly by repeated participation in specific cultural practices (Kitayma and Park 2010).

Mapping of the human genome has made it possible to study mechanisms of gene and environment interactions. These techniques are now being applied to the study of parenting and child behavior. For example, it has been found that children with certain serotonin transporter gene haplotypes show greater reactivity to both supportive and unsupportive parenting styles and practices (Sulik et al. 2012). The serotonin transporter gene variation could offer the child either an advantage in socialization if the parent messages are clear and constructive (high quality), or a disadvantage in socialization if the parent’s socialization messages are unclear (low quality).

Further clarification of the contributions of genetics and epigenetics to understanding child development and human behavior is expected as refined scientific tools become more available and opportunities for this type of research explode. It is expected that mechanisms of interaction between all aspects of a child’s family life and the developing brain will be clarified. For example, children genetically at risk for behavioral problems due to their serotonin transporter gene haplotype demonstrated low levels of self-control when they also formed insecure attachments to their mothers during infancy. This finding suggests that secure attachment in infancy may protect children who are genetically vulnerable to behavioral problems with self-control (Kochanksa et al. 2009).

Application in Clinical Dental Practice

Scientific knowledge of genetics, behavior, and the bi-directional influence of genetics on human behavior and human behavior on genetic expression is increasing rapidly. Today’s partial picture of genetic influence on parent and child behavior will become clearer through research. In the near future, patient genetics may be more relevant to dental practice than is currently appreciated, and increased knowledge in this area is likely to influence some diagnostic and treatment decisions.

Family Influences on Child Behavior

The family serves as the child’s connection to the world and has a critical role in preparing a child for life outside of the home. Socialization, the process by which an individual learns and accepts the established ways of a particular social group or society, may be viewed as the “nurture of nature,” whereby the family transmits cultural values, expectations, and behavioral standards to the child. The family is considered the major arena for social growth. Although socialization and re-socialization can occur throughout life, childhood is viewed as a uniquely malleable period when social skills, personality attributes, and values are established. Examples of socialization include learning to share toys, obey adult requests, and behave politely (Maccoby 1991). Socialization also can determine a child’s response to dental treatment. It can influence behavior standards, attitude toward adult authority, how much discomfort justifies complaint, and how to express distress.

Parenting Styles

A viewpoint or philosophy toward the child is reflected by the parenting style. It creates the emotional climate and context in which parents’ socialization behaviors occur. Parenting style classifications consider the balance between 1) parental warmth and affection, and 2) parental behavioral controls. The first version of a widely used parenting style typology was proposed by Baumrind in 1973. The degree of parent responsiveness (affection and attentive responsiveness to the child’s needs) was considered with the level of parental control (demandingness for developmentally appropriate, pro-social, responsible behaviors) to classify an individual’s parenting style as Authoritative, Authoritarian, or Permissive. Maccoby and Martin (1983) modified Baumrind’s groupings, renaming “Permissive” as “Indulgent” and adding “Neglectful.” Most research examining parenting styles and child behavior cited in this chapter employs the typology of Baumrind, as well as Maccoby and Martin. The four parenting styles and a brief description of their characteristics are: Authoritative (high responsiveness + high behavior control), Authoritarian (low responsiveness + high behavior control), Permissive (high responsiveness + low behavior control), and Neglectful (low responsiveness + low behavior control).

Parents with an Authoritative parenting style set up a collaborative home environment that is democratic, flexible, and supportive of the child, with guidelines aimed at enabling the child to become self-regulating. These parents may be warm and involved, yet still firm and consistent in establishing limits. Rules are not simply set in place, but are supported through age-appropriate rationales.

Authoritarian parents clearly take charge, may be more autocratic, rigid, and use punishment as needed to enforce a high degree of structure, expecting obedience from the child. Parents shape and control their children in accordance with a set of standards and rules. The rules are not to be discussed or arrived at by argument and interaction. On the contrary, rules are imposed upon the child as mandatory, and the child or adolescent is not consulted. Authoritarian parents discourage verbal give-and-take between parent and child.

Authoritarian and Authoritative parents share their high expectations for the child’s self-control.

Parents with a Permissive parenting style indulge the child’s wishes and agenda, placing the child in the power position with an appeasing, nondirective, lenient approach without clear rules or guidelines. They are considered more responsive than demanding. The Permissive parenting style has more negative than positive effects on the social outcome and is associated with aggressive, impulsive children lacking independence and a sense of responsibility.

Neglectful parents are less involved in their child’s lives than parents within any of the other three categories. The passive, emotionally removed, lax, or indifferent attitude exhibited by neglectful parents leaves the child to negotiate the world without structure, assistance, rules, or guidelines. Indifferent parents tend to be cold and uninterested in the needs of their children and adolescents, reflecting a desire to keep them at a distance. They try to minimize time and interaction with their children. This type of parent is characterized as uninvolved, meaning that they have a low degree of commitment to their role as a parent. There is a risk of a child or adolescent being neglected by this type of parent. Both Permissive and Neglectful parents have low expectations for the child’s self-control.

Parenting Practices

Parenting style is expressed through behaviors or “parenting practices.” Parenting practices are mechanisms through which parents directly help their child attain socially valued outcomes such as development of a conscience, cooperation, compliance with societal rules, and academic success. Parenting practices include both specific goal-directed behaviors (time-out, physical punishments, shaming) and non-goal-directed behaviors (gestures, tone of voice, emotional expression) (Darling and Steinberg 1993). Children become accustomed to their own parent’s practices and behaviors and develop the ability to read their parent’s internal state. A typically developing child can accurately and rapidly perceive if her parent is pleased or displeased, comfortable or anxious, or calm or distressed by interpreting the parent’s tone of voice and body language.

Cultural Influence on Parenting Style

Culture has a pervasive influence on family life, including the way in which parents socialize their children. Parenting styles and practices hold psychological and cultural meanings and vary between cultures. For example, parental harshness (hostile behavior and/or physical punishment) carries a message of care and concern within a culture valuing strict behavior controls and high expectations for children’s behavior. However, in a less strict culture holding lower expectations for children’s behavior, it carries a message of unsympathetic criticism (Ho et al. 2008). It was initially suggested that Authoritative parenting likely would result in good psychosocial outcomes for children from all ethnic and cultural groups. Some studies, however, have found better outcomes associated with the Authoritarian parenting style, depending on family context and culture (Deater-Deckard et al. 1996; Ho et al. 2008). No investigation in any culture has reported consistent positive social outcomes for children of any age with the Permissive or Neglectful parenting styles; this may be due to lack of rules and limits upon the child’s conduct, which communicate which child behaviors are desired and expected and which actions are unacceptable.

The prevalence of parenting style types varies by culture. Sociologists and educators have noted an increase in the Permissive parenting type in many countries, including the United States (Long 2004). In traditional parenting models (Authoritarian, Authoritative), the adult determines, communicates, clarifies, and enforces rules for the child. In families with the Permissive parenting style, children question adult authority and a “the child should feel good” ethos permeates family life and parent decisions. Permissive parents are generally well-intentioned, want to be nice, and would like their children to be happy doing what they want to do. In some cases, the Permissive parent attempts to become a friend to their child, abrogating the traditional parental role of socialization.

The term “helicopter parent” is employed in the popular lexicon to describe a parent who is attentive, hovering, and available to rescue their child from the consequences of any poor decisions or actions (Cline and Fay 1990). Today’s ever-present cell phones have made it inexpensive and simple for parents to stay connected to their child, even when physically separated. It is theorized that the extension of the usual time period of parent-child close connection may prolong the child and young adult’s dependence upon parent and family resources.

The disparate cultural views of proper parenting style and practice between Western-European and Eastern-Asian cultures was illustrated for the public consciousness by Chua in the book Battle Hymn of the Tiger Mother (2011), which recounts the strict methods she used to promote the academic success of and mastery of musical instruments by her daughters. Chua’s behavioral controls over her children, such as limiting access to the bathroom, requiring many daily hours of homework and musical instrument practice, forbidding television viewing, and emotional tactics of ridicule and shame, engendered extensive commentary supporting and criticizing this parenting style. Those embracing the predominantly Western philosophy that children are fragile and require protection and nourishment of their self-esteem called Chua’s strict methods cruel and abusive. In contrast, those with a predominantly Eastern viewpoint assume that the child has inner strength and the parent’s job is to override the child’s preferences because “to enjoy anything you have to be good at it, to be good at it you have to work, and children on their own never wish to work” (Chua 2011).

Interactions between culture, parenting and child behavior are complex and challenging to thoroughly describe and study. Existing research is primarily cross-sectional with varying methodologies, focuses nearly exclusively on mothers, and heavily relies on subjective data such as parent reports on behavior practices, rather than on observation of parents’ behavior (Paulussen-Hoogeboom et al. 2007). Parenting behaviors appropriate at a developmental stage and in a specific social context will predictably differ depending on a child’s developmental stage. A simple example is crossing a street with traffic: parents carry or hold the hand of a young child (high behavioral control) but do not need to hold the hand of a school-age child who has mastered the social task of safely crossing the street (low behavioral control).

There is no single “best” parenting style universal to all children. It is believed that a child’s internal state of fear, arousal, and anxiety is integral to their receptiveness to social learning; the best child outcomes appear to result when a parent’s style is in harmony with the child’s temperament. For example, gentle, low-power discipline has been found to create the optimal anxiety arousal for social learning for temperamentally fearful children. Negative, punitive, and other types of power-assertive parenting have been found to be detrimental for temperamentally fearful children with a low anxiety threshold. In contrast, for relatively fearless children, gentle parental discipline does not capture the child’s attention. For low-fear children, high parental pressure results in child anger and disregard for parent messages. Preliminary evidence suggests that reciprocal positive parent–child interactions are more effective in achieving social learning for children with low-fear temperaments (Kochanska et al. 2007).

Application in Dental Practice

Dentists should be aware of the parent’s style of interacting with their child. To an experienced clinician, the parenting style may be obvious after a short observation of the parent and child. The less seasoned dentist may wish to include questions in the social history to indicate the parent’s philosophy and style. Sample questions are presented in Table 4-1.

Children raised by Authoritative or Authoritarian parents who expect and demand appropriate, responsible behavior will understand that the dentist and staff members establish the rules and will guide them through a dental visit. These children have been socialized to follow the lead of adults. The dentist can expect that most Authoritative or Authoritarian parents will endorse and support the rules, structure, and behavior guidance that the dentist presents to the child.

Children raised by Permissive parents have been conditioned to view adults in a more egalitarian manner. They may expect the dentist and staff to offer them the same degree of choices and control that they are accustomed to in their home environment. Since a dental appointment is not a situation where the child should or can lead, the he may become unsettled, disappointed, or frustrated with a role of diminished power, and react negatively. Permissive parents may take offense at firm, clear structure provided for their child by the dentist and dental staff and advocate for their child’s preferences to be accommodated. Recent research illustrating implications of parenting style on child cooperation during dental treatment is presented later in this chapter in the section “Parent influence on child cooperation in dental settings.”

Table 4-1. Parenting Style Questions.

A majority of answers in the left column indicates a parenting style with high behavioral controls. A majority of answers in the right column indicates a parenting style with low behavioral controls.

Coping Socialization

The term “coping socialization” is defined as the parental and familial factors that may affect children’s coping. (Kliewer et al. 1996). Attaining maturity and acquiring social competence occurs as a child grows from toddlerhood through childhood, adolescence, and into adulthood. A typically developing toddler is easily frustrated, emotionally labile, and lacks the ability to shift her attention away from sources of stress and toward positive stimuli or thoughts; a socially competent adolescent has developed internal resources and strategies to meet the demands of life outside the home. In the child development, psychology, and medical literature, the term “coping” is used to describe the thoughts and behaviors that an individual uses to manage and respond to environmental or internal stresses and demands. An individual who is cooperative with dental treatment is exhibiting “coping behaviors.” Coping behaviors allow a child to handle the demands of dental treatment and accept care.

Emotional Expression Within the Family

The family is most commonly the initial place for children to experience and learn to cope with negative emotions. The emotional climate of the family results, in part, from the way that parents express their own emotional feelings. Emotional expression is both verbal and nonverbal, and has been classified by Valiente et al. (2004) as positive (e.g. praising and demonstrating admiration), negative dominant (e.g., expressing anger and displaying threatening emotions) or negative submissive (e.g., sulking and/or crying). Multiple investigations have found that children of emotionally positive parents are happier, more socially competent, and have lower rates of behavior problems than those of parents with low expressions of positive emotions and/or high levels of negative emotional expression. Parental expression of anger, whether or not it is directed toward the child, is associated with: decreased amounts and quality of child play and exploration; child avoidance of the parent; increased periods of the child’s negative emotions (e.g., sadness, fear, anger); and deterioration of child behavior (Teti and Cole 2011).

Children are strongly influenced by their parents’ methods of emotional expression (Thompson 1994). The type and intensity of parent emotional expression provides a model for a child to imitate. Constructive, upbeat expressivity and support from the parents have been found to relate positively to children’s constructive coping with daily stress. Mothers with negative dominant expressions have children with lower levels of constructive coping. Witnessing or being the target of hostile negative emotions is stressful at any age, and children have limited life experience and capacity to withstand, process, and cope with such stress. Evidence that children’s constructive coping is positively related to parental supportive strategies is mounting. It is possible that parents who express emotion in positive ways are more likely to insist that children manage and control their emotions in socially appropriate ways in stressful situations and/or teach them constructive ways of coping (Valiente et al. 2004).

Parental responses to their children’s emotions influence and teach children strategies for self-regulation. Effective parent responses have been found to be problem- and emotion-focused and express encouragement. Unhelpful parent behaviors include minimizing, punitive, and distressed responses to their children’s emotions. High levels of family chaos have been found to be associated with lower levels of effective parent responses (Valiente et al. 2007).

The terms “emotional contagion” and “emotional attunement” describe the observation that a person’s emotions are highly influenced by the emotions expressed by those around them, and there is a tendency for individuals in proximity to emotionally converge. Emotions are shared in multiple ways, subtly and overtly, verbally and non-verbally. Research using functional magnetic resonance imaging has found that observing another individual’s emotions and facial expressions activates regions of the brain which 1) experience similar emotions and 2) produce facial muscle activation and mimicry (Morrison et al. 2004). A simple example is that when someone smiles at us, we reflexively smile back. Due to the negative bias of the human brain to detect potential threats, it is easier to become upset and distressed by someone else’s negative emotional expression than it is to become happy and relaxed by someone else’s joy and contentment. Emotional contagion theory explains how ambient mood states of both parties influence parent-child interactions. A child in a positive mood is more likely to comply with a mother’s requests (Lay et al. 1989). A mother who is angry, even for reasons unrelated to her child, is more likely to believe that interactions with her child will be unpleasant and require a stern approach (Dix 1991).

Child Influence on the Parent

Children are not passive recipients of adult influence. The parent-child relationship is reciprocal, with each influencing the other’s thoughts, feelings, and behavior. Parents and children develop a long history of interaction; each acquires a set of expectations concerning the other’s behavior and establishes a method of interpreting the other’s reactions. The relationship is unique in the asymmetry of knowledge, power, control, and physical strength, and the balance of power in the relationship changes as the child develops. Disruptive behavior in a toddler holds less consequence, risk to the child, and threat to the parent than disruptive behavior in a teenager. Parenting affects children’s behavior most strongly during early childhood (Slagt et al. 2012) while problematic adolescent behavior strongly affects parenting (Reitz et al. 2006). Parental sense of competence is defined as a parent’s opinion of her ability to positively influence the behavior and development of her child (Coleman and Karraker 1998).

Social relations theory views children as active agents in their interactions with parents and assumes that disagreements, conflicts and changes occur frequently. It is developmentally normal for children to resist some of the socialization demands of their parents (Goh and Kuczynski 2009). A parent’s philosophy of parenting (style) and behaviors (parenting practices) will determine the degree of parent accommodation and submission to the natural resistance of the child. It has been observed that a child’s status and power is higher in single-child homes. China introduced its One-Child Policy in 1979, resulting in a generation of children and young adults without siblings or cousins. Most of these solitary children are the focus of interest for six adults: two parents and four grandparents (Goh and Kuczynski 2009). Chinese parents and teachers have used the term xiao huangdi, meaning “little emperor,” to describe pampered and entitled children who have inflated views of their own status and importance. Both teachers and employers have observed that many One-Child-Policy babies never learned how to cope with disappointment and frustration in ways that would best prepare them for life outside the home (Cameron et al. 2013).

Application in Clinical Dental Practice

The dentist and staff should continually monitor the ambient emotional tone in the office and quickly intervene in cases of negative emotional expression by parents. A parent who verbally or nonverbally expresses the stress of a bad day is not emotionally available to help his child and may unintentionally sabotage that child’s dental appointment. If the dentist or staff member’s sincere and respectful attempt to redirect the parent to the intended positive purpose of the dental appointment is unsuccessful, the parent should be offered the opportunity to reschedule at a time when they are more in control.

Sibling Influences

Throughout life, the sibling relationship may be cooperative, ambivalent, or antagonistic. The child grows and develops within a dynamic and variable family context across time. Multiple studies have confirmed that families differentially distribute such resources as parental time, attention, money, nurturance, and love among the children in a family. Parents tend to concentrate reso/>

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