We have one or two patients in our pediatric dental practice who do not tolerate dental care well. They are younger than 5 and scream loudly, flail about sometimes knocking over treatment trays, and basically cause a ruckus, even though their parent is present. As you can imagine, this upsets our other patients as well as staff. What strategies do you suggest for dealing with these types of patients?
Anxiety, in the proper amount, is viewed as a positive and necessary emotion and serves to alert us to danger. Most children probably associate a dental appointment with some danger and will display variable degrees of anxiety. The behavior guidance techniques that appear most useful focus on the dental professional and auxiliaries helping children learn to cooperate during dental treatment even though they are experiencing a significant amount of anxiety. In addition, and of equal importance, the dental professional should help children learn to be willing to return for further dental care. Learning is a relatively permanent change in behavior resulting from experience. Some amount of learning probably occurs as a result of every experience. To a great extent we all are that which we learn to be. There are, of course, certain instinctive and inherent behaviors that influence our responses. Included in this area for the very young child may be the fear of separation from the mothering person, falling, loud sounds, and life-preserving behaviors such as sucking. Much of the behavior a child exhibits in the dental office is the result of learning experiences in his or her past. The child associates these experiences with pleasant events and, subsequently, is willing to enter into new relationships. On the other hand, refusal of the child to separate from his mother suggests that the child may have had few positive experiences with others, or the experiences have been unpleasant in his or her view. Children tend to behave in a manner that has been the most satisfying to them in the past. Children who get their desires met by displaying an undesirable behavior are likely to use this behavior in the dental office. For example, if a child is usually given a cookie for having a tantrum, he learns to use that behavior as a means of manipulating his environment. On the other hand, if the child is not rewarded for tantrum behavior, he or she will abandon that approach and try methods that prove more useful.
Children Age 1 to 2
Children in this age group tend to have rather basic fears. An overriding fear is one of separation from the parent/caregiver and the related fear of strangers. Children younger than 3 have had relatively few experiences and have not learned to adapt to unfamiliar situations. In general, children in this age group are too young to be expected to cooperate in dental treatment. For this reason, the parent should be with and perhaps hold the very young child during the initial examination. Sedation and physical restraint are frequently required to provide dental treatment for this age group.
Children Age 3 to 5
Children in this age group are in the process of separating from their parents. They have a need to learn to manage their life without the direct control of parents. This time of development is one in which the child is developing autonomy and learning to initiate new experiences and relationships. During children’s growth toward autonomy and initiative, they are also learning to impose certain restraints on their behavior. They no longer want their every move directed by others, but, at the same time, they are learning that they are responsible for their actions and that there are consequences to their actions. This is the age when most children begin to be able to actively participate and cooperate in dental treatment. Because of the psychological growth stages just described, children in the 3 to 5 age group have two primary and somewhat conflicting needs. On the one hand, children need to be allowed to develop autonomy, while at the same time they need control and structure in their environment. A lack of either of these needs can be disturbing to a child. If children feel that they are being overwhelmed by circumstances and have no power or autonomy in the situation, they may become very anxious. For this reason, it becomes important for the dental professional to communicate to children that they have an active role in the treatment experience. The child’s role is to actively help by sitting still, keeping hands out of the way, and opening wide. The dental professional can show regard for the child’s need for autonomy and initiative by allowing the child as many options as possible. For example, if it really makes little difference which treatment is performed during a particular appointment, the dental professional might help meet the needs of the child by asking where should treatment begin. Merely listening to the child and inquiring about interests helps the child to further develop autonomy. The child’s need for structure and control is easily combined with treatment in the dental office. The nature of dental treatment provides a great deal of structure for the child. Usually two people are working closely with the child telling him what to do and allowing him very few choices in behavior. The highly structured dental treatment experience is helpful for many children who have not learned to impose restraints on their behavior. It often occurs that a child is considered to be “poorly behaved” in a loosely structured environment, but when the same child is placed in a very structured and closely supervised situation, behavior improves dramatically. In the dental treatment experience, which has been described as highly structured, certain children may be made less anxious and consequently, more cooperative, merely by providing a very structured environment during dental treatment. As a part of growth in the 3 to 5 age group, children explore the limits of acceptable behavior. It is essential that children understand clearly the boundaries of acceptable behavior that exist for a variety of situations. They are much more comfortable and likely to be less anxious if they are aware of behavioral limits that are firmly and consistently held. It is when the caretakers of the children are inconsistent in their setting of limits that children may develop behavior problems. Children age 3 to 5 often tend to be anxious regarding tangible, concrete objects. They may fear unfamiliar objects that can be seen, heard, felt, smelled, or tasted. They may have all sorts of fantasies about the dental instruments they see in the office. While many children undergo dental treatment without crying at all, crying should be regarded as a normal response under a variety of circumstances. Children cry for a variety of reasons and the nature of their crying can help interpret the factors associated with crying. The dental treatment team needs to respond to the crying in a manner that takes into account the reasons for a child’s crying. A significant aspect of effective behavior guidance is the art of determining the reason for particular behavior and selecting an appropriate response.