A child’s age and cognitive development are helpful in predicting the likelihood of disruptive behaviors associated with dental procedures. As a general rule of which there are exceptions, children who are 3 years of age or less may be expected to have a short attention span, be fearful of strangers, or lack sufficient cognitive and language skills, all of which can contribute to unfavorable reactions in the dental setting. Often, the primary coping responses of these toddlers are crying, expectations of immediate parental protective intervention, and avoidance behaviors. As the child approaches school age, the fear of strangers may subside, language and communication skills become more effective, and subtle socialization gains including better emotional control often become apparent. Once children are of school age, changes in cognition are notable. This developmentally cognitive and emotional growth often translates into fewer incidences of disruptive behaviors. Again, exceptions to this expected developmental change can and do occur.

From a sedation perspective, one can anticipate that toddlers will likely require deeper levels of sedation creating less opportunity for effective behavioral guidance in obtaining successful procedural outcomes. But as the child’s age and cognitive/emotional states mature, the depth of sedation targeted may generally ebb more toward a need for only minimal to moderate depths of sedation along with a heavier emphasis on behavioral guidance.

There are many factors associated with disruptive, uncooperative behaviors exhibited in the dental setting by children, but anxiety and fear likely top the list. The prevalence of anxiety and fear of children in the dental setting has been estimated as ranging from 6 to 20 % [9, 12]. That’s probably an underestimate.

In one review, fear and anxiety reportedly were more prevalent in the youngest of children decreasing with age, are associated with gender, and temperamental traits were notable. Temperamental characteristics of shyness, negative emotionality, poor adaptability, and high activity and intensity were consistent with anxiety and fear. Anxiety and fear are often thought to be the predominant states underlying many of these expressions of behavior. However, as pointed out by others, dental fear does not necessarily equate to the primary cause of disruptive behaviors, and such uncooperative behaviors do not necessarily imply that dental fear is the culprit [12].

Anxiety and fear cause a complex range of emotional behaviors. Recent neurobiological evidence has evolved aiding in the understanding of these states. Apparently, fear-elicited response patterns in the human are mediated primarily and initially in the limbic system of the CNS and, more specifically, in the area of the amygdala of the midbrain [13–15]. This system is genetically geared to rapidly assess impending danger and, within microseconds, initiate and orchestrate a pattern of motor, emotional, and autonomic responses designed specifically to protect the organism. Furthermore, the system seems particularly sensitive to and organized in such a way as to memorize and categorize each threatening situation in an attempt to prepare the organism for future encounters. Toxic stress likely plays an influencing factor on this system.

Behavioral inhibition has been described as a temperamental trait of young children who tend to withdraw from novel or unfamiliar stimuli [16–18]. Inhibited behaviors, such as avoidance of novelty, represent a coping mechanism by which the fearful reaction is decreased. Over time, coping with fear through avoidance is thought to reinforce the associated physiological responses and behaviors leading to continued behavioral inhibition and social wariness: a positive reinforcement cycle. Interestingly, it has been hypothesized that temperament types may be associated with different response sets within the limbic system.

Evidence of change manifested as generational differences in parental management styles is associated with disruptive behaviors of children in the dental setting. Pediatric dentists are reporting that today’s children are less cooperative, cry more, and are more disruptive in response to normal guidance techniques than children of a decade or more ago [19]. In order to address these changes, evidence is slowly accumulating suggesting a movement toward greater use of pharmacological management of children than has been done in the past.

Temperament describes a child’s overt responses as a basic and daily expression pattern to solitary and social situations. Temperament is believed to have a fairly strong genetic component and is somewhat stable over different situations and developmental phases of an individual’s life. Some children may appear shy, withdrawn, irritable, and moody, whereas others may be friendly, approachable, euphoric, and pleasant during initial interactions with other children or adults.

There is fairly consistent and widespread evidence that temperament affects how children tend to respond in dental as well as other settings [20–22]. In fact, a child’s temperament may aid in predicting, to a certain degree, how the child may respond while under the influence of therapeutic doses of sedatives and during perioperative periods surrounding general anesthetics [23–26]. Some authors have concluded that shy, withdrawn children do not behave as well compared to peers who are less shy and withdrawn [27].

Attachment is another psychological concept wherein the presence and strength of emotional bonds to caregivers affect a child’s response in different contextual situations. Evidence suggests that attachment may have implications for one’s health and behaviors. Relationships between attachment and temperament have been reported, but the strength of these associations is not well understood. The interactions between the two concepts appear complex [28–30]. Attachment per se has not been studied in pediatric dentistry as of this writing.

The patient’s age and corresponding cognitive development are important considerations for anticipating different expressions of behaviors in children during dental procedures [31]. Generally speaking and in terms of broad classifications of patient age, the young preschoolers seem to have a higher likelihood of displaying disruptive and uncooperative behaviors [32]. Disruption and uncooperative behaviors usually wane as children age; however, traumatic episodes or series of such episodes may increase the expression of these behaviors. Some school-aged children and adolescents may actually regress and display an unwillingness to participate in dental procedures.

Another important factor of consideration associated with aging and cognitive development of youngsters, albeit not documented in any systematic fashion in dentistry, is language acquisition and its understanding and use [33]. Its importance, as a bridging mechanism for communication between the patient and provider, cannot be overstated and forms the basis of the popular technique of tell-show-do. Sedation of infants and toddlers, who may lack sufficient language skills to understand procedural interventions, is a well accepted and frequent adjunct for many types of medical procedures, thus recognizing the immature state of coping mechanisms characteristic of these very young children.

As children age and their personality begins to congeal, individualized traits and styles of interaction with others become more observable and predictable even into adulthood. Some individuals will have general as well as specific types of traits associated with potential anxiety or fear-provoking situations. The interaction of general and specific qualities in children is complex and not always intuitive. Evidence does suggest that procedural-evoked anxiety can be favorably modified through appropriate interventions. Thus, the astute clinician should make efforts to gain information from parents and guardians in anticipating patient anxieties and fears that may become manifest during dental procedures. Furthermore, the clinician should have a repertoire of interventions whose implementation may lessen these emotionally charged states.

Children’s experiences with the medical field begin very early in life. Even infants learn quickly and express anguish during routine visits to the physician in anticipation of inoculations. Depending on the general health and incidences of traumatic episodes children may endure, those experiences may be well tolerated or induce a lifelong stigma possibly leading to unwanted avoidance behaviors of medical and dental needs. Family member’s support or hurtful exacerbation (e.g., teasing) of anticipated experiences of planned procedures also may impact the outcome and contribute to the processes of internalizing coping skills of the child. For example, parental or sibling comments such as “next comes the painful shot” sometimes have deleterious effects even if not consciously intended. It is even possible that some degree of discussion about the “shot” has already occurred at home. Either way, these remarks heighten the child’s sense of anticipatory dread of the procedure which at the time of occurrence may immediately overflow into an outburst of disruptive and uncooperative behavior.

Parents are usually a beneficial source of knowledge about their children and how they may respond during procedures and interactions with professionals. Generally, parents know the child’s behaviors, limits, adaptive skills, and emotional responses quite well. They are an obvious benefit to the professional who takes the time to understand the parent’s perspective; acts in a caring professional manner when explaining expectations, techniques, procedural processes, and possible outcomes; and gains parental confidence in managing their child’s situation. Parental knowledge of the child’s medical and social history and insights regarding their child’s typical responses in a host of settings is invaluable.