Management of the crying child during dental treatment

Resident: Hencler
Date: 09/11/2009

Article title: Management of the crying child during dental management
Author(s): Zadick, DMD, MPH; Peretz, DMD
Journal: Journal of Dentistry for Children
Pg:55-58 Year: Jan-Feb 2000

Major topic: Behavior Management
Type of Article: Observational/Questionnaire

Main Purpose:
To present parents’ attitudes toward their child’s crying in the dental environment and suggest a classification of crying children and discuss management implications.

Overview of method of research:
104 parents accompanied their children for dental treatment. Each child had 1 operative appointment following an initial exam. Parents were present during treatment. Parents were asked to fill out a questionnaire. Operator was asked to document assessment of child’s behavior and tendency to cry.

Findings:
No significant association between socio-demographic variables of the parents and dependent variables. Parents attributed a tendency to cry to their children much more frequently than the clinician. When the child cried, with no evidence of pain, most parents preferred the treatment to stop, calm the child and resume. Most parents felt they had to assist the operator in calming the child. Parents’ inclination to help a crying child was greater when the child was male. Using Frankl’s scale, operators assessed tendency to cry and found categories 1 and 2 children (uncooperative) were more associated with high tendency to cry.

Key points in the article discussion:
Parents much more frequently than operators classified their children with higher tendency to cry most likely because there children have used crying to manipulate them. This behavior may be exhibited in the dental environment in one form or another. In trying to sabotage the appointment a child may cry bitterly and without behavior management, treatment would seem cruel to the child, unsatisfactory to the parent, and exhausting to the clinician. This may imply that management of the crying child should involve the child and the parent. The child often lacks the ability to respond effectively to an adult authority and display avoidance behavior in the form of crying. For these children stopping the treatment may serve as a reinforcement to continue crying. The new classification focuses on the ‘crying child’ and not ‘the nature of the cry’ as appears in Elsbach’s classification.
1. The child who communicated by crying
a. Fearful
b. Resentful
c. Released (tension released)
2. The ‘crying type’
3. The manipulative child
When the diagnosis classifies the child as communicating a message, a soft, calming approach is preferred. The ‘crying type’ and manipulative child should both be managed with “matter of fact” approach. It is important to carry on with treatment so the child will not think that crying will affect treatment outcome. Instead of trying to stop the crying, let it be known that crying is allowed and will not help the child’s purpose in stopping the treatment.

Summary of conclusions:
The effective Pediatric dentist should have a wide variety of behavior management techniques in order to direct negative behavior and facilitate a more cooperative patient. Effective behavior guidance will result in more successful treatment outcomes. It is of utmost importance that the parents be informed of these techniques and consent to them before treatment begins.

Assessment of article:
Good article, not great. Bottom line is that every clinician will practice many behavior management techniques that will vary from child to child. What works for some clinicians will not work for others. I thought the questionnaire results were kind of interesting but not particularly surprising. The new classification may be helpful when deciding what behavior management approach to take with a particular crying child.

The Changing Nature of Parenting in America

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: Kris Hendricks Date: September 11, 2009

Article title: The Changing Nature of Parenting in America

Author(s): Nicholas Long, PHD

Journal: Pediatric Dentistry

Volume (number): 26:2

Month, Year: 2004

Major topic: Parenting Styles

Minor topic(s):Behavior Management

Type of Article: Professional Opinion

Main Purpose To discuss how changes in parenting styles affect the practice of pediatric dentistry.

Overview of method of research: Mostly professional opinion with some references to the scientific literature.

Findings: Most board certified pediatric dentists feel that parenting has taken a turn for the worse. They also feel that children display worse behavior now than they did in the past and that this has negatively affecte the practice of pediatric dentistry. Many blame these behavioral changes on changes in parenting, but it is important to realize that parenting takes place within the context of society and that societal changes play a significant role in child outcomes, perhaps even more significant than parenting.

Key points/Summary : Americans are almost as fixated with child rearing as we are with sex. The problems facing children today are much more severe than those facing children in the "Leave it to Beaver" era. Drugs, suicide, violence and teen pregnancy are just a few of the problems that children are facing these days. The media suggests that these problems are the result of poor parenting.

A recent survey of diplomats of the AAPD (sounds like a bunch of cranky old men) found that parents today are much less willing to allow their kids to suffer pain at the hand of the dentist. Traditional behavior management techniques like hand over mouth are no longer acceptable. 43% of them say this has decreased satisfaction in the practice of pediatric dentistry.

There is still some debate as to how much parenting matters in the outcome of children. But most researchers believe it to be important. Society, however, has a very significant influence on children. It is especially important for us to be careful in our judgement of parenting and also not to apply Anglo-American parenting values on other cultures.

Assessment of article: This was an interesting read. The survey of the AAPD diplomats sounds like they're really missing the good old days. I was particularly impressed by the suggestion that we should not apply "our" concept of good parenting on other cultures and act judgmentally. Most of our patients come from a very different culture than myself and I'm easily tempted to judge them by my values.

The Childs Voice: Understanding the Contexts of Children and Families Today

Resident’s Name: Brian Schmid DMD Date: 9/11/09
Article title: The Childs Voice: Understanding the Contexts of Children and Families Today
Author(s): Dennis Harper PhD, Donna D’Alessandro MD
Journal: Pediatric Dentistry
Month, Year: 2004
Major topic: Social context of the modern family
Type of Article: Review
Findings: There have been many changes in societal outlook over the last 15 years, all of which may contribute to increased stress both in parents and children. This may lead to decreased compliance in children today, something with which we will have to deal acutely. According to modern medical professionals, discipline has been on the drop and ambivalence on the rise when it comes to modern parenting techniques, the majority of providers think that the change in parenting practice has been negative. Less assertive behavior management techniques have also become more popular due to the changes in parental attitudes.
Accountability has been passed on to mental or physical problems the child may have, as opposed to implementing strict disciplinary guideline in the home. The amount of children being treated for an attention disorder or other psychosocial issue has more than doubled. It is also thought that the tidal wave of information from the media and the internet can make parents less likely to make a definitive choice due to the high chance of performing the “wrong” kind of rearing practice. Parental expectations and contexts can influence how they impart the priority of oral hygiene and how they interpret and employ the dentists advice.
Childhood fears can greatly influence a childs behavior and compliance. It should be determined whether poor behavior is due to fear and anxiety versus general non compliance. Four to 8 year olds fear is generally due to imagined problems while 9+ s more concrete and based on previous experiences. Todays families are very different from in the past: married, two parent homes comprise only 26% of American families and 8% have a working father and stay at home mother. Fifty percent of children live in single parent homes, 85% of which are single mothers. Gay/lesbian homes comprise 8-10% of American homes. Currently, 60% of mothers with<1 y.o. children work full time outside the home.
Language and cultural issues have also become apparent in the recent decades, with a significant portion of the US population with limited or no English proficiency. Asking the right questions and learning more about the home-life of your patients will facilitate communication and improve the child’s experience, as well as your own. Using a relaxed voice, acknowledging interests the child may have and talking to children at the appropriate developmental level are other important ways to communicate. Also, giving the children ample opportunity to make decisions regarding their experience will give them a sense of control which can allay their fears. Be honest and forthright both with patients and parents.
Behavior management techniques are similar to in the past, with the decreased use of HOME being the most significant change. Also, the use of pharmacologic treatments has risen dramatically. Distraction and TSD are still considered the most effective first line of defense.
Key points/Summary: Honest communication and prudent use of behavior management techniques is essential to modern pediatric dentistry but we must be wary of changes in societal and cultural expectations in order to maximize our efficiency and be able to handle any child who comes into our operatory.
Assessment of article: A very good article, but does sometimes stray into the “Kids these days!” territory.