Behavior Behavior Management in Management in

Pediatric DentistryPediatric Dentistry

Behavior Behavior Management in Management in

Pediatric DentistryPediatric Dentistry

Dr. Suzan MillerDr. Suzan Miller

TOPICS• Treatment for Children• Basic Behavior

Management– Tell-show-do– Suggestion and guidance– Voice control– Locus of control– Distraction– Modeling– Positive reinforcement

• Crash Course in Child Development

• The Injection• Managing Parents

Pedophobia• We hear a lot about children who are

afraid of the dentist, but what about dentists who are afraid of children?– Adult not in control– Child’s behavior may be difficult to predict– Guilt/shame/distress if child upset– Parent’s reactions

Treating Children Effectively

Control - Learn how to work WITH children – basic management techniques work better than authoritarian control

Predicting behavior - Learn more about child development, family interactions and cultural differences – experience is often the best teacher

Guilt – Think like a parent! Doing what is best for the child (providing care) is more important than being a buddy, and children generally recognize this.

Parents – Make the parents your allies. They are there because they want the best for their child.

What You Can’t Change• The 99.99% of a child’s behavior learned

before arrival in your office• Parental styles of child rearing and

discipline affecting behavior• Previous experience with medical

procedures• Child’s environment – family, neighborhood• Religious and cultural background

What You Can Do• Be prepared and work efficiently – disorganization

destroys patient and parent confidence

• Be approachable – make the parent and child feel liked and accepted

• Accept apprehension as real and natural• Speak to child at eye level• Talk to child about subjects that interest him/her (school,

pets, hobbies, toys)

• Be honest and reliable– explain first and do what you say you would

• Initially approach child without instruments

• Be caring – put yourself in the child or parent’s place, do your best to help

Avoiding Behavior ProblemsTake note of:

• Previous behavior• Child’s demeanor• Body language• Parent’s expectations• Medical history• Dental pain or

problems

Basic Management Techniques • Tell-Show-Do• Suggestion and guidance• Locus of Control• Voice Control• Distraction • Modeling• Positive Reinforcement

Tell-Show-Do• This is the most important

technique, effective with ALL age groups– Tell what you are going to

do– Demonstrate in a non-

threatening way– Engage child in

demonstration– Do it!– Praise cooperation

Suggestion and Guidance

• Children are highly suggestible. • Using “child-friendly” language will alter

the child’s perception of new experiences• Bad Examples:

• This won’t hurt• Let me put this clamp on your tooth

• Good Examples:• Mr. Slurpy feels funny!• My silly toothbrush will tickle your teeth!

Pediatric Dental Terminology

• Explorer - Tooth Counter• Rubber Dam - Raincoat• Clamp - Tooth ring• High Speed - Whistle• Slow speed - Motorcycle• Suction - Mr. Slurpy• Anesthetic - Sleepy juice

Voice Control• Be in charge!• Be clear in your expectations

tell child what you want them to do, not what they should not do

• Set limits• Make important requests firmly• Praise cooperation

Locus of Control• Children feel less

helpless when given limited control– Example: use hand

signal to slow down or for short break

• Be careful to give acceptable options

• Let child hold a hand mirror

Distraction• Don’t hide what you’re

doing, but don’t focus on it.

• Examples– Talking – successful

pediatric dentists often talk throughout the visit…

– Counting, spelling– Games– External (i.e. ipod, radio,

TV, small computer games)

Modeling• Let child watch older

sibling or other child• Select procedure and

model carefully – avoid injections and restorations

• Avoid using adults as models unless the procedure is simple

Positive Reinforcement• Reward cooperative

behavior with praise, small prizes or “points”

• Do not bribe! Make it a game

• Make suggestions for improved behavior

Using Reinforcement Effectively

• Reward should be immediate and specific – not for overall ‘good’ behavior

• Use points or “bunny tails” – this can be presented as a game and helps avoid prize overload

• Avoid reinforcing negative behavior (i.e. excessive bathroom visits)

• Verbally praise child in front of parent• Punishing or shaming child will result in

poor cooperation or avoidance

Crash Course in Child Crash Course in Child DevelopmentDevelopment

Crash Course in Child Crash Course in Child DevelopmentDevelopment

Age 1-3 Precooperative”

• Very attached to parents

• Communication variable and largely non-verbal

• Crying and resistance is common

• Precooperative rather than uncooperative

Age 1 – 3 “Precooperative”

• Be calm and reassuring, your tone and manner are as important as your words

• Primary communication with parent

• Parent usually remains with child

• “Knee to knee” exam

Age 3 – 5 “Preschool”• Highly imaginative and

suggestible• Gaining some

independence from parents

• Basic communication skills• Low manual dexterity• Poor concept of time

Age 3-5 “Preschool”• Use familiar and safe words• Suggest positive feelings• Use tell-show-do• Use praise and positive

reinforcement• Modeling often effective• Keep appointments very

short

Age 5-8 “School Age”• Imaginative! Pretend play

common• Rational thought still

developing• Hard time sitting still• Cooperative but independent• Proud of accomplishments• Peer relationships gain

importance

Age 5- 8 “School Age”• Listen!• Respect their feelings• Ask about their interests

and activities• Engage cooperation• Positive reinforcement and

‘games’ very effective• Short appointments, breaks

as needed

Age 8 – Puberty “Preteens”

• Beginning to deal with abstract concepts

• Good motor skills• Inferiority feelings

common• May act grownup, but

lack good judgment• Social relationships

and sports important

Age 8 – Puberty “Preteens”

• Compliment appearance and accomplishments

• Emphasize present rather than future

• Give limited control – they still need adult direction – but they may not like to admit it!

Adolescence• Profound physical,

emotional and social changes

• Developing independence

• May challenge authority• Peer relationships most

important• Not future oriented

Adolescence• Be honest and direct• Relate as an adult health

professional• Focus on present and

social concerns – appearance is very important

• Give limited control

The Injection• “The Needle”

– Many children fear ‘shots’– Parents and others often make it worse

• “Be good or the dentist will give you a needle!”

• New practitioners are often as fearful as their patients!

– If you are nervous, your patients will be, too• Avoiding anesthesia may cause pain and may result

in an incomplete or inadequately done procedure

Needle Phobia Nobody likes actually likes “shots”. Nobody. Anxious or fearful children may try to delay

or avoid the injection with many questions Examples

Are you going to give me a shot? Will it hurt? Can I see the needle?

Your answer should be casual and avoid frightening words

Be empathetic, but firm It will be over soon It will make the tooth/the filling feel better

Anesthesia Technique• Begin with a simple

explanation of what you’ll be doing

• A calm and casual attitude are essential

• Don’t stop talking! Give reassurance and direction.

• Waving the syringe in front the patient’s eyes invites management problems…

• Assistant should pass the syringe under the line of vision.

• Thumb palpates the landmarks, and helps steady the child’s head• Shaking or vibrating the cheek helps mask

the feeling of injection• Some children move their heads – stay

lose and move with them• The child may flinch or cry out as you

begin. DO NOT STOP, as it will be harder to regain the child’s cooperation. Talk calmly and keep going.

• A slow steady injection is most comfortable and causes less postoperative soreness

• Most children find constant, soft talking soothing

• If you are counting to ten – make sure you end at ten (no cheating)

Post-op Be sure to let patient

know that their cheek will wake up soon

Children often bite or chew an anesthetized cheek, make sure you give adequate post-op instructions to the patient AND the parent

Managing Parents• Parents bring their own

personalities, anxieties, fears, attitudes and experience

• Parents often react emotionally rather than rationally when their children are concerned

• In an increasingly multicultural society, sensitive listening will help avoid many problems and misunderstandings

Managing Parents• You must address the reason

the parent and child are here – or they will not be back

• Speak face to face with parent and child

• Give clear and complete information in everyday language

• Respect their opinions and priorities – even when you don’t agree

• Avoid placing guilt and seek parental cooperation

Parents in the Operatory?• Advantages

– Parent education– Some children do better

with parent– Avoids legal issues

• Medical problems• Using restraint

• Disadvantages– May transfer fears– Interference

Parents in the Operatory?• In general, operator’s preference• Recommended when

– Child under 4– Initial appointment– During oral hygiene/prevention instructions– Emergency or trauma– Foreign language speaking patients– Some handicapped and medically compromised

patients

Remember, Kids may look like this to you,

but

This is how you look to them!