Behavior Management by Dr. James Nickman

by Dr. James Nickman

Treating children can be one of the most challenging yet rewarding parts of your clinical practice. Imagine an apprehensive child presenting to your office for the first time, nervous about new surroundings and the unknown. The parents stand chairside and support their child with affirmative and loving terms, while your team greets her with a friendly smile and escorts her back to the exam area.

After some discussion with the parents, the patient is taken through the examination using child-friendly terms. Radiographs are needed, and even though there are a few tears, your team gently reassures the child and the images are captured. When all is completed, the child gets out of the chair and gives you a confident smile and fist bump. Then reality hits and you realize that the task is just beginning.

As you review the radiographs, you note that there is interproximal decay in the patient’s posterior teeth that was not clinically visible. Your mind starts to assemble a treatment plan based on the clinical findings. The options start to roll regarding which treatment would be ideal, whether it’s something you feel comfortable treating, and whether you think you’ll be able to walk the child through treatment. The plan comes together and you discuss it with the child’s caregivers. Based on the response, you begin to wonder what you’ve overlooked, and it hits you—the parent!

The parental obstacle
Parents, parental expectations and parenting styles have a tremendous impact on the success of your treatment and execution. Parenting has changed tremendously over the past several decades. From the 1960s to the 1970s, parents usually accepted and respected professionals and generally consented to treatment recommendations based on the practitioner’s experience. Today, it’s not uncommon for parents to question each phase of the dental experience. The new “expert” in the room includes what can be found on the internet and in parents groups or blogs.

Expectations have also shifted over time. In the past, parents realistically expected that you would provide dental treatment in a compassionate manner and that there may be some discomfort involved in the process. Now, there are some that expect that every visit to the dental office will be an experience with entertaining, pain-free treatment. While that is a goal, it’s a tough mark to obtain daily. Regarding parental presence in the operatory, the expectation today is that the parent or guardian will remain with the patient through all phases of treatment.

With the increasing cultural diversity in the United States, another potential variable is the expectations of the parents who are recent immigrants and their dental experiences before immigration. Acceptance of treatment and behavior management techniques will vary widely depending on culture and their dental knowledge. Complicating that is the potential interaction of communicating with a parent and child through an interpreter. The challenge is delivering care in a culturally appropriate manner.

Parenting styles have also changed, from parents being the managers of their children and behavior to, in some cases, children being on essentially equal footing with their parents. With this shift in style, the expectation is that the dentist will assume the role of “co-parent,” requiring that the practitioner balance the need to guide the child during treatment while respecting parental wishes and desires. Multigenerational families can also complicate treatment in that the guardian or primary caregiver may have differing behavioral expectations from the child’s parent. Blended families or divorced households present a similar challenge.

Another factor to consider is parent behavior. Children’s perceptions of a challenge such as dental treatment are strongly influenced by their parents’ reaction to situations. Anxiety is a major challenge for both adults and children. During a child’s restorative appointment, parents can have anxiety based on their personal experiences or the experiences of others. Children quickly pick up on their parents’ anxiety and the mood in the room can switch quickly.

Parents can also influence the dentist’s ability to effectively communicate with their child. Treating a child is a guided journey with the dentist constantly communicating each phase of treatment. The experience begins when a child first enters the office and continues until the appointment has been completed.

When communicating, you need to inform, set expectations and prepare the child for the next task. The level of communication is geared to the age or developmental status of the child. For younger children, child-friendly terms are commonly used to explain sensations and noises that the child is likely to experience (e.g., “sleepy juice,” “Mr. Bumpy”). Positive forms of parental support include providing positive reinforcement at appropriate times and comforting the child during difficult moments.

Parental behaviors that can negatively influence dentist/child communication are the use of negative terms (e.g., “shot,” “hurt”), negative behavioral reinforcement, and repetitive or contradictory information. Given a choice, the child is more likely to listen to a parent than the dentist.

Finding the perfect balance
The successful treatment can be guided by several suggestions to enlist the parent as an engaged partner in the child’s oral health care:

Fully explain the possible options. As part of a valid informed consent process, the dentist should discuss all realistic options available for treatment. In addition to the treatment needed, it’s necessary to discuss parent desires and expectations regarding behavior management and possible treatment settings. Risks and benefits of each behavior management technique should also be covered.

The conversation is very straightforward for a well-behaved older child; for precooperative or uncooperative infants or toddlers, it will likely be more complicated. In the case of a young infant with extensive treatment needs, it may make sense to use an advanced behavior management technique, such as treatment with sedation or general anesthesia.

A parent may prefer to treat the infant in the office rather than administer general anesthesia in a hospital or ambulatory surgery center, because of the potential risks versus benefits. The goal is to reach a best solution utilizing the provider’s experience and respecting the parents’ wishes.

Establish ground rules and expectations of the child, parent and provider. Before providing any restorative treatment, it’s important to discuss and explore the expectations of all involved and establish ground rules for the method that the treatment is provided. The initial or recare examination can provide a perfect setting to assess the child’s behavior and parental interaction in a noninvasive setting.

In the case of a parent who is likely to interfere with doctor–child communication, it will be helpful to discuss that the parent may need to be a silent partner in his child’s care. For a child who may behave better in the presence of one parent than another, it may be helpful to have the “cooperative” parent or family member be present with the child. The potentially “uncooperative” parent or family member can attend the appointment but should remain out of the child’s sight.

In the case of a child potentially requiring advanced behavior management techniques, establishing a system of go/no-go during treatment would be helpful. For example, with a marginally cooperative child and a parent who desires in-office treatment, establishing that the dentist will stop and check in with parents at strategic points (e.g., after local anesthesia) will help the dentist avoid exceeding parent comfort level. If the check-in reveals that the parent is not comfortable with the progress of treatment, alternatives can be discussed for continuation of care in an alternative setting.

Realize that you may not be able to help everyone. Unfortunately, there will be families that do not have realistic expectations for their child or desire treatment that may not meet the standard of care. If after a thorough discussion of options a consensus is not possible, referring for a second opinion may be the best option for you and your patient. In the best case, it may be helpful for the family to hear the same reinforcing message from a neutral party. Alternatively, they may find someone who better meets their needs and expectations. Either way, the child’s needs and best interests are being advanced.

Working with children can be a fun and rewarding experience. You have an opportunity to make an impact in the overall growth and development of a young individual and shape their dental experiences for a lifetime.