Understanding and managing the fearful and anxious child
The foundation of practicing dentistry for children and adolescents is the ability to guide them through the completion of any dental procedure successfully and to create and promote a positive attitude toward dentistry, with emphasis on the prevention of dental disease.
Dentists and dental health practitioners have a challenging task when providing care to young patients given the wide variability of factors that take place in the dental setting, factors that will have some bearing on the way dental care is delivered to the pediatric patients.
Dental treatment for children involves a complex relationship between the dentist, the child and the parent. Unlike providing care for adults, treating children includes the participation of one or both parents; as a result, the ultimate decision regarding on how a child will be treated dentally must be done collaboratively by the parent and the dentist.
Once the caretaker is informed and has decided to carry on with the dental treatment suggested by the clinician an informed consent must be obtained.1
Informed consent is the legal process that protects the patient’s right not to be treated in any way without the parents’ permission.
The parents must be informed beforehand on the potential manner that the child’s behavior will be handled by the staff and the dentist; caretakers must provide verbal and written authorization before any type of behavior management technique is used with their children. The practitioner must make sure that the parents have a clear understanding of the specific technique to be utilized during the dental treatment.
In other words, an informed consent implies that the parents are aware of the type of treatment, consequences, and alternatives pertaining to the treatment and the risks involved.
The same process of obtaining informed consent applies to the clinician who treat adolescents; occasionally, these older children will present unaccompanied by a parent for dental care, and the dentist and the office staff will be under the assumption that it is appropriate to deliver any dental treatment because the patient agrees. Many times, the parent will not be in agreement with the treatment, and the dentist will be facing a difficult dilemma. It is advised that only noninvasive and limited procedures be performed in these circumstances.
The multiple variables that may influence the manner that dental treatment is granted to the pediatric patients may include one or a combination of two or more factors. For instance, individual personality of parent or child, socioeconomic factors, type of dental procedure, clinician and parent relationship, a history of an unpleasant dental experience by parent or the child, language barriers, diverse ethnic and cultural backgrounds, and many more.
The successful emotionally uneventful completion of dental treatment in pediatric patients is an important part of any practice dedicated to treat children.
Furthermore, pediatric patients who are anxious and fearful may become uncooperative and difficult to treat dentally; therefore, it is imperative for the clinician to have the necessary tools to select the appropriate approach in these unique clinical scenarios.
In order to offer and complete dental treatment in anxious and fearful children, dentists are trained to use and implement a variety of management techniques to deal and resolve these difficult behaviors.
The American Academy of Pediatric Dentistry (AAPD) sponsored two consensus conferences on behavior management over the past two decades, and after an extensive review of literature, it was concluded that numerous clinical studies exist about behavior management, and that multiple surveys and opinions have been written on the subject of behavior management techniques in the field of pediatric dentistry. Most of these documents are opinion based, and there is minimal evidence derived from clinical studies on techniques used to control undesirable behaviors.
Many questions remain regarding the efficiency and effectiveness of clinical protocols associated with behavior management.2
A recent survey of the American Board of Pediatric Dentistry Diplomates on parenting and its effects on practice indicated that children’s behaviors have changes for the worse over the last 10 years. Children cry more and demonstrate more disruptive behaviors while being treated.3 Parents, on the other hand, have become more permissive and overprotective.
The old adage “the doctor knows best” is not longer true; absolute trust is no longer part of the dentist–parent relationship. A parent expects that a pediatric dentist can administer local anesthesia to crying, difficult-to-manage child only because she/he is a “pediatric dentist.”
In today’s litigious society, the ability to recruit, justify, and perform scientifically sound clinical studies is more limited. In addition, these potential studies are highly regimented and regulated by institutional review boards, and frequently present significant barriers to the efficiency of performing these studies. Parenting and child-rearing skills and other societal forces are changing and possibly interfering with the enlistment of children into clinical studies has been mentioned.3
In a study done by Eaton, 55 parents were examined in their attitude toward current behavior management techniques used in pediatric dentistry, and it was found that a modified hierarchy of acceptability is emerging in behavior management techniques, and that the aggressive physical management techniques appear to be less favorably accepted; however, the pharmacological techniques are increasing in acceptance over time.4
Today’s dentists enjoy many advantages compared with their predecessors. The dental settings are designed to be children friendly. Contemporary materials, advances in technology and staff, who are trained to serve children, supplement the ambiance. Yet the mission of a pediatric dentist remains the same as it was a generation ago: to perform quality dental procedures on children and adolescents whose behavior may range from cooperative to aggressive, to defiant and anxious or fearful.5
The general public has become suspicious of science and science-based professions while demanding all the benefits of scientific discovery. This Western culture demonstrates diminished respect for and is less trustful of professionals. The multimedia exposure influences the general public, and people question professionals’ intelligence, ethicsand safety of care.6
Today’s parents reflect the changes in society. The traditional parent role included setting boundaries, maintaining discipline, and teaching respect for others have become obsolete. These parenting styles have affected adversely the behavior of children and adolescents in the dental office.2
Some of the behavior managements techniques used and taught in dental schools are now perceived negatively by parents.7
Many parents now attempt to dictate the treatment approach; however, the vast majority of these parents lack the scientific background to understand what dentists do. Many of the parents will demand for their child to be sedated or to be placed under general anesthesia for procedures that clearly can be managed without anything else than with the appropriate of behavior management technique.
In recent years, we have seen a significant increase of the interest in “better” parenting. One possible explanation might come from the more and more complex issues in raising children in today’s society. Certain child-rearing issues faced in the 1950s or 1960s have been replaced with more difficult to deal with factors such as drug use, suicide, violence and teen pregnancy.5
According to a survey done by Casamassimo of board-certified pediatric dentists, they believe that parenting styles have changed during their professional lifetime, and that parents today are less likely to set boundaries on their children’s behavior. The survey also showed that parents are more likely to accept their children’s disrespect and are more overprotective. These perceptions are difficult to confirm; however, we can examine some of these changes in parenting styles from looking at trends in society and how these trends impact parenting styles.3,8
Members of families are influenced by other members within the same family, and children’s behavior will be impacted by a variety of factors within the same family, community, and the changing society.
Parenting styles are influenced by popular advice from friends, grandparents, and the media. Parents are looking for advice on how to respond to specific behaviors on the Internet without following any scientific background.
Another important factor that impacts children’s behavior in today’s society is that parents are spending less time with their children and more time working to provide for their basic needs. Women are now part of the workforce, and more and more women are the main breadwinners in the family, and at the same time they are expected to be mothers, wives, and housekeepers.
Another difference in today’s families is that men are now increasingly involved in household chores and find themselves caring for their children and sharing housekeeping responsibilities more as well.
Another factor that impacts the families nowadays is that we are under an increasing financial stress. When both parents work and share the financial responsibilities of the family, parents will be exposed to routine stressors, such as dealing with a sick child at home and missing a day’s work pay, rush hour traffic, school issues, deadlines to meet, etc.
Among other factors that definitely will change our style as clinicians is that our society is multicultural and is presently composed of many different ethnicities with their own particular parenting styles. By 2050, it is projected that 50% of the population will be composed by groups that now we consider minorities.9 In respect to certain behavior management techniques, what might be acceptable for some ethnic backgrounds might not be for others, hence it is the dentist’s responsibility to assure that parents are well informed on how their children will be managed during the dental appointments.
In 2004, the American Academy of Pediatric Dentistry conducted a “Behavior Management Conference” addressing specific issues and seeking input from attendees regarding current behavior techniques used in their practices. The purpose of the conferences was to discuss the appropriateness and effectiveness of current behavior management techniques, the scientific support for those techniques, and the role of the pediatric dentist in managing the difficult child.10
The assembled panel of this conference consisted of pediatric dentists, an attorney, child psychologists, parents, and a specialist in early childhood education and a pediatrician.
The recommended actions from the participants included a need for improvement in communicative methods with parents and other family members. It is important to mention that behavior management “begins” with the parent’s initial call to the office. The common saying on first impression applies here. Methods of communication with parents that are simple, succinct, and compassionate will likely lead to better dental experiences for the parent, the child, and the pediatric dentist.
Also, it was noted that it is necessary to seek further discussion and information on the impact that changing attitudes towards behavior management may have on the accessibility of treatment.10
Regarding patient care, it is important to note that not every dental appointment can be a positive experience for every child, and that is not possible that the dentist can instill a positive attitude in every child either. Some behavior management techniques, particularly the “tell-show-do” technique are the tools most likely to enable the dentist to lead the child to a positive dental attitude.10
Parents and patients should be treated with respect, and at the same time we as clinicians will expect to be treated in the same manner. The pediatric dentist should attempt to determine the parents’ expectations for every visit, and, when necessary, help them establish realistic expectations. Parents should be involved in treatment decision to certain extent and with the clinician’s guidance.
In reality, no pediatric dentist uses a “pure” technique; behavior management comes with experience, and children have their own individual personalities and will respond differently to the different behavior techniques.10
The term “difficult” child refers to a noncompliant child. Children who are uncooperative usually are because of specific behavioral issues, such as ADD or a psychological, mental, or a systemic disorder, or because of anxiety and fear due to a wide variety of factors.
The pediatric dentist’s responsibility lies primarily with the second group, children who are anxious or fearful.
The definition of a “difficult” child may also include children whose parents often have a difficult interaction with the dentist.
Some instances of difficult parents might be parents who are overprotective, anxious themselves and transmit their fears and anxieties to their children, parents who do not comply with the basic d/>