Case• 14. A difficult child
A mother brings her nervous 4-year-old daughter for treatment. How will you approach examining her and defining a treatment plan?
|The child and mother in your surgery.
Your nurse shows the child and mother into the surgery. The child is clinging tightly to her mother and will not look at you or acknowledge you.
The child has no complaint but her mother has noticed holes in her back teeth.
History of complaint
The mother first noticed the holes 6 months ago and there has never been any toothache.
The child has never had a dental examination or treatment before. She was taken to another dentist but became hysterical in the waiting room and refused to go in. She is only in your surgery because she has been bribed with a chocolate bar.
The child is fit and well.
▪ This is not looking hopeful. What must you do before you can attempt to examine the child?
You need to encourage child to feel safe and engender feelings of trust. To do this you must establish a rapport with the child. Without some form of rapport little progress is possible.
▪ The child appears frightened. What fears would you expect in a 4 year old in a dental setting?
A typical 4 year old is usually scared of:
• the unknown
• new environments
• new people
• being separated from their mother.
▪ What further questions would you ask and why?
Does the child attend a nursery or playgroup full-time or part-time? If so for how long have they attended? A child attending nursery will be used to dealing with people outside their home and should have greater coping skills, be more socially developed and used to being separated from the mother. They should also understand the concept of rules that have to be followed. You can be more confident of successfully managing the behaviour of such a child.
How does the mother feel about going to the dentist? Maternal anxiety is a strong influence on the young child’s reaction to dentistry. If the mother is nervous at this appointment the child will already have sensed this. Indeed if the mother is severely anxious it may be better for the father or grandparent to accompany the child. A mother who is herself very nervous may not be able to support you later on if things get difficult.
How is the child’s behaviour at home? This will have to be asked very tactfully as parents usually insist that their children behave well. Try asking whether she sleeps well – perhaps the child goes to bed when she wants and also gets her own way in most other things. Find out whether the parents routinely use bribes to gain the child’s cooperation. You need to find out whether the child is over indulged (‘spoilt’) or whether the parents are used to setting limits for their child’s behaviour. Limit setting is considered good parenting practice. If the child is used to having limits set to her behaviour, she will be much easier to direct in the dental setting. If she is an only child, the parents may be inexperienced in good parenting.
Is the child genuinely nervous or just playing up? Your strategies for managing fear, shyness and naughtiness would be different. However, this is difficult to assess without observing the child’s behaviour. You may not be able to make an immediate decision and, of course, it is quite possible that all factors are contributing.
You discover that the patient is an only child. She has just started part-time nursery but is having problems settling down after her mother leaves the room. The child is generally good at home and, like most children, she likes to have her own way. However, she responds well to direction and is not allowed to have her own way all the time. Her mother attends the dentist but is rather nervous of treatment. From this you can see that in addition to allaying the anxiety of both child and mother, you will also have to teach the child what behaviour is expected and appropriate at the dentist.
▪ What can the average 4-year-old child be expected to do? How does this knowledge help?
Some of the developmental milestones for a 4-year-old child are shown below.
• Usually separates well from mother
• Names four primary colours
• Can state own age and address
• Listens intently to stories
• Understands turn-taking
• Starts to understand concept of obeying rules
• Washes and dries own hands
• Understands yesterday, today and tomorrow, simple past and future
• Blows nose reliably
Talking about these abilities with the mother allows you to develop a rapport with her and may alert you to any educational difficulties that the child may have. Not all parents are completely forthcoming about their child’s development. If the child has learning difficulties your approach will be slower and more considered.
You discover that the child appears to have reached the normal developmental milestones for her age.
▪ Now that you have a better appreciation of the background, how will you develop a rapport with the child?
Make eye contact. You may catch the child’s attention while talking over the previous points with the parent and already be interacting with her in some way or other. If not you must now direct all your attention to the child. Start with a compliment about the child’s clothes, toys, hair or a similar topic and catch her eye. You may need to say gently ‘look at me’.
Talk to the child in appropriate language. You must be able to converse at the level of a 4 year old and this takes knowledge and practice. Always use the child’s first name, child friendly language and avoid potentially fear-promoting words. This is often called ‘childrenese’ and examples are referring to your vacuum as a hoover and the operating light as sunshine. Ask open questions that cannot be answered with a simple yes or no to promote responses. Knowledge of some current children’s television characters is always useful and will provide plenty of topics of conversation.