Ethical issues in managing the noncompliant child

Resident: Murphy
Date: 09/18/2009
Article title: Ethical issues in managing the noncompliant child
Author(s): Griffin, Ann. Lawrence Schneiderman
Journal: Pediatric Dentistry 14, #3 1992
Major topic: How to manage the child who doesn’t want to consent to treatment
Type of Article: Clinical Case Review

Main Purpose: To discuss the ethical dilemma involved with why we should or should not treat a child who needs treatment, but will no consent to treatment

Overview of method of research: Descriptions of procedures were provided to 120 parents by one of 4 methods: 1) Video 1 of technique during live appointment with an accompanying explanation before video is viewed, 2) video 2 of technique without explanation, 3) written presentation, and 4) oral presentation.

Findings: One of the first things we all learn in dental school is that you don’t do anything without an informed consent, no exceptions. A proper consent should include a description of recommended techniques, benefits of the procedure, alternative tx options, and risks for not doing any treatment. This article discusses the dilemma of having a child who needs emergency dental treatment, but is noncompliant. Patient autonomy is a fundamental right of all patients. Because a child may not be able to understand the consequences of their choices, parents sometimes need to override their refusal. While children may refuse the necessary treatment due to fear, parents may refuse treatment of their child due to monetary reasons or insurance reasons. All of these pressures can compliment treatment and cloud what our primary focus should be; providing the best care for the child.
This article reviews five areas of consideration 1.tx indications, 2. patient autonomy, 3. benefits vs. risks of tx and no tx, 4. parents wishes, and 5. allocations of reasons($$$$).

Is the treatment needed right now?
When a patient cannot be persuaded to agree to treatment, we must decide on how pressing the dental needs are. If treatment is delayed could the patient be harmed? The article reviewed the case of a 3 yo girl with small occlusal caries on two lower teeth. After much coaxing, the child would not allow the dentist to perform any tx. While the dentist may feel it necessary to try to complete some type of treatment, because the needs are not pressing, it is best to postpone the tx, and try another day.

When should we disregard Patient’s right to refusal?
As stated previously, each case, and each child is different. The term “consent” is reserved for individuals with the full capacity to make independent decisions. By the age of 14 or 15, most adolescents have the decision making ability of an average adult. Depending on the child’s maturity and their dental needs, it may not be our right to force them to consent to tx, whether or not we agree with their decision.

Weighing Benefits and Risks of management techniques:
If the decision has been made to proceed to tx without consent of the child, the proper management techniques benefits and risks must be considered. Behavior management (or as we say now, guidance) is an art, and each practitioner has a variety of techniques that could be used to calm the child. The main goal is to provide the best tx possible while not physically or emotionally harming the child.

Parental approval:
When a patient is not old enough to make an informed decision, their parent can give consent for them as a proxy. A legal guardian can also act as a proxy. With that said, parents do not always act in the best interest of their children. When this happens, healthcare providers may be better equipped to decide for a child rather than self interested, incompetent, or uninformed parents. If the parents refuse the proposed tx, the professional should due their due diligence to attempt to educate and overcome the ungrounded fears or misapprehensions.

Allocating resources:
Sometimes the best treatment for a child is to be seen under GA. While this is what’s best for them, it may not feasible due to lack of money or insurance companies denying treatment. Dental problems are considered less serious than other procedures requiring GA. Therefore, third party companies often limit their coverage. This limitation on available options isn’t in the best interest of the patients, and compromises care. It’s up to us to advocate for these kinds of patients.

Summary of conclusions: As professionals, it is up to us to use our best judgment and weigh all of the variables in a given case when deciding what is best for a child. If a child has a large abscess and is in pain, all efforts should be made to get that tooth taken out. If the child has a small occusal, pushing treatment isn’t indicated. Basically think everything through, communicate effectively with parents and patients, give the child the best tx possible for today, and for their future dental visits.

Assessment of article: Good article, results not surprising. More common sense than anything.

Teenager's reality

Resident’s Name:  Joanne Lewis                                                            Date: September 18, 2009

Article title:  The teenager’s reality

Author(s):  David Elkind PhD

Journal:  Pediatric Dentistry

Volume (number):  9(4)

Month, Year:  December 1987

Major topic:  Psychology of teenagers

Type of Article:  Professional opinion

Main Purpose:  To review some of the realities constructed by adolescents as an aid to understanding their behavior.

Discussion:  Adolescence is a time of expanded logic and understanding (called the “second age of reason”) that is associated with an increased ability to conceptualize time and space as well as the outlook of others.  Teenagers are able to think about the thinking of others, but they routinely mistake what others are thinking about with what they are thinking about; the teenager has trouble taking the mental position of another person when it is different from his/her own.  Teenagers assume that everyone else is thinking about what they are thinking about, which is themselves.  This viewpoint allows teenagers to construct an “imaginary audience”, by whom they are constantly being observed, admired, or criticized.  This construct can have positive consequences – it can prevent people from behaving badly even when no one else is around, or serve as a motivator for personal success – and it can have negative consequences, as it makes teenagers particularly susceptible to peer pressure.  Teenagers also begin to develop the “personal fable”, which convinces them that bad things (drunk driving accident, unwanted pregnancy, etc.) can happen to other people, but not to them.  Teenagers are convinced that their experience is unique and couldn’t possibly be understood by anyone else (“you don’t know what it’s like to be in love!”).  Both the imaginary audience and the personal fable stay with us in an adapted (more moderate) form the rest of our lives and help us to deal with the challenges and risks of daily living. 

Key points/Summary:  The teenager’s actions are not guided by education or lack of it, but rather by their imaginary audience (peer pressure) and personal fable (belief of invincibility).  This sheds some light on why teenagers often make bad decisions and disregard known consequences.  It does no good to fully accept or deny these assumptions; rather, put them to the test.  For example, “Look, I don’t think most people will notice or care that you are wearing braces, but I could be wrong and you could be right.  Why don’t you wear them for a few days, and if people really do notice, then we can talk about which is worse, some temporary unpleasantness or a lifetime of crooked teeth?”

Assessment of article:  Interesting theories to put the reader in the mindset of a risk-taking, self-obsessed teenager.  Applying these theories may help the practitioner to motivate patients and increase compliance.

Parents in the Operatory

Department of Pediatric Dentistry

Lutheran Medical Center

Kris Hendricks Date: 9-18-09

Article title: Parents in the Operatory

Author(s): Margaret A. Certo, DDS; Joseph E. Bernat, DDS, MS

Journal: NYSDJ

Volume (number):

Month, Year: Feb, 1995

Major topic: Presence of parents in the operatory during dental treatment

Minor topic(s: Changes in approach through time.

Type of Article: Professional paper.

Main Purpose:

To review the history of parental presence in the dental operatory, address changing opinions from early dentistry to present and lastly, make suggestions for guidelines to include parents in the operatory.

Overview of method of research:

Review of literature combined with professional opinion.

Findings:

Today, parents want to be with their children in the operatory and it is probably an inevitable that pediatric dentists will have to allow parents to be present during treatment. To make their presence a positive aspect of the treatment 7 recommendations are given (which can be reviewed in the paper).

Key points/Summary

In the past, parental presence was considered to have a negative effect on children’s behavior for dental treatment. Throughout the past hundred years, most studies have shown that there is little difference in children's’ behavior in the presence or absence of parents. Studies have argued both sides of the argument and make valid points on to both effects: on one hand, parental anxiety has been shown to negatively affect their children’s behavior at the dentist. However, it has also been shown that parental presence can have a calming affect on the patient.

The big deal is that today’s parents want to be with their children during treatment. Most parents feel strongly that they should be present during treatment. It is unlikely, moving into the future that parents can be excluded from the operatories.

Assessment of article:

I agree with the authors that parents should be allowed to be present during treatment of their children. However, I do not agree with this at St. Joes. Due to our set up, It is very crowded and uncomfortable to have parents present. It is also annoying to have nosey parents poking their heads into the treatment areas. What this article hardly addresses is the problem with siblings being allowed back. Just yesterday I had a bloody screaming mess on my hands only to look up and see some other kid standing at the foot of the chair watching. But, I don’t blame any parent for now wanting to leave other kids in our waiting room, and I can see why they don’t want to stay there themselves.

The use of imagery suggestions during administration of local anesthetic in pediatric patients.

Resident: Adam J. Bottrill
Date: 18SEP09 Region: Providence
Article title: The use of imagery suggestions during administration of local anesthetic in pediatric patients.
Author(s): Peretz B., Bimstein E.
Journal: Journal of Dentistry for Children
Volume #; Number; Page #s: July-August pp: 263-267
Year: 2000
Major topic: Behavior management
Minor topic(s): Hypnotism
Type of Article: Experimental study.

Main Purpose: To evaluate the effect of suggestion in a group of children before and during the receiving of a local anesthesia injection. Also, efforts were made to correlate these reactions with social and dental treatment variables.
Overview of method of research: Controlled study of effect of behavior management technique.
Findings: Not telling

Key points in the article discussion:

A. General: It is generally agreed upon that the most stressful time of a dental visit, for both patient and dentist is the administration of anesthesia (to a child).
1. “suggestion” is the main component in hypnosis
2. Found that the pulse rates of hypnotized children decreased and observed levels of crying were less intense.
3. Hypnosis is found, in general, to be more effective on younger children. It has been suggested though, that it not be used on those younger than 7 y.o.
4. Suceptability to suggestion:
a. females more than males
b. younger more than older
c. children of lenient parents more than children of strict parents.

B. Materials and Methods:
1. 80 children, age 3-16
2. All required anesthesia administration
3. Treated by one of two dentists:
4. Pre-data collected:
a. general behavior (relaxed, tense, highly tensed)
b. previous behavior (cooperative, uncooperative but allowing tx, uncooperative and didn’t allow tx)
c. mode of previous behavior management (non-pharmacological, nitrous, premed with nitrous, GA)
d. previous traumatic medical or dental treatment.
5. Behavior measured at current appt using previous measurements
6. Younger children told tooth was “going to sleep”, older children told the tooth would be “anesthetized”.
7. Before administration, all children was asked to think of their favorite pleasant image. Those who could not think of one were asked their favorite game/pet etc…
8. Throughout injection procedure, operator provided comments reinforcing the pleasant image.
9. Data collected:
a. whether they used the same image throughout, facial expressions, eye movement, body tonus.
10. Chi-square used for variable comparison, t-test used for boys vs. girls.

C. Results:
1. Mean ages: 5.3 boys, 7.2 girls
2. Nearly a third of the patients had previous dental/medical traumatic experiences.
3. 60% maxillary
4. 53% demonstrated facial pleasure, 31% indifferent, 16% dislike
5. 81% were “relaxed”
6. No gender difference found WRT eye movement, facial expression or body tonus.
7. Most children were able to maintain the images throughout procedure and most kept their eyes closed.
8. Those treated with nitrous or oral sedation were more able to maintain images.

D. Discussion:
1. Most children could conjure up images.
2. Boys (pets) were different than girls (nature) at what type of image they selected.
3. Present study agreed with previous studies that suggested younger patients are more susceptible to suggestion.
4. The request to “fantasize is a relaxation tool. The child is allowed to go into a light “trance.”
5. Good rapport is essential to this process.
6. Though many dentists use the power of suggestion intuitively, the findings of this study should encourage the routine and deliberate use of this technique.

E. Conclusions:
1. Visualization suggestions may be effective in children from the age of three.
2. The utilization of the child’s imagination is a baluable behavior management adjuvant during dental treatment.
3. Nitrous oxide enhances the children’s capacity to accept and retain images..

Assessment of article: Don’t we all sort of do this already? Seemed like a first year pedo resident project, but better organized. Shenanigans?

Comparing four methods to inform parents about child behavior

Resident: J. Hencler
Date: 09/18/2009

Article title: Comparing four methods to inform parents about child behavior management: how to inform for consent

Author(s): Allen, PhD; Hodges, DDS; Knudsen, MS
Journal: Pediatric Dentistry 17:3 1995
Major topic: Informed consent delivery methods
Type of Article: Comparative Survey

Main Purpose:
Compare 4 methods for informing parents to gain their consent for eight behavior management techniques: Tell-show-do (TSD), Nitrous oxide (NO), Passive restraint (PR), Voice Control (VC), Hand-over-mouth (HOM), Oral premedication (OP), Active/physical restraint (AR), and General anesthesia (GA). This study was designed to determine how best to inform the parent, which procedures parents feel should require informed consent prior to use, which behavior management techniques parents are willing to consent to, and variables that may influence parental willingness to consent.

Overview of method of research:
Descriptions of procedures were provided to 120 parents by one of 4 methods: 1) Video 1 of technique during live appointment with an accompanying explanation before video is viewed, 2) video 2 of technique without explanation, 3) written presentation, and 4) oral presentation.

Findings:
Written method produced fewer parents who felt informed (61%). The oral method resulted in 97% of the parents feeling well informed while video 1 produced 80% and video 2 produced 89% of parents feeling well informed. The oral method produced the highest consent rates (80%). Parents were willing to consent significantly more to VC, AR, and NO than to PR or HOM. Parents reported that they felt info about each technique was relevant to their decisions to consent and more than 75% of all parents believed informed consent should always be obtained for the most invasion techniques including NO, PR, HOM, OP, and GA. 60% felt strongly that they should be informed about each technique, even TSD.

Key points in the article discussion:
The oral method of delivering info to parents about child behavior management techniques was the best method of ensuring the average parent felt well informed and was likely to consent. Videotapes are time-saving but data suggests may not provide adequate info. Written method may be a poor alternative for gaining consent because it was significantly worse than any other method as a means of informing patients. The fact that both the written and oral methods contained the same info suggests a problem in the transfer of that info (reading or comprehension). Techniques such as HOM and PR were much likely to receive consent from parents. Age, anxiety and socio-economic status were not reliable predictors of consent for behavior management techniques.

Summary of conclusions:
The results of this study suggest an inter-personal (oral) delivery of info to parents about each technique is most likely to result in parents who feel well informed and who are likely to provide written consent. Handing parents a written form to read independently and sign, or having them watch videos showing techniques do not appear to be adequate to ensure that parents are well informed and likely to consent.

Assessment of article:
Good article, results not surprising. I would think that explaining techniques to parents would result in them being more informed resulting in written consent.