Child behavior in a pediatric dental practice associated with types of visits, age, and socioeconomic factors

Dan Boboia

Article Review 9/18/09

Title: Child behavior in a pediatric dental practice associated with types of visits, age, and socioeconomic factors

Author: Brill W

The Journal of Pediatric Dentistry: Vol 25, 2000

Major Topic: Patient behavior patterns in a private pediatric dental office

Type of Article: Prospective Study

Purpose:

To describe child patient behavior patterns seen in a private pediatric dental office

Methods:

976 visits made by 539 patients during a period of 3 months. Patients grouped in the following way: newborn to 60 months of age, 61-96 months, 97-144 months, and 145 months and greater. Behavior was scored using the Sarnat scale during 5 types of visits: new patients exams, periodic recare, restorative dentistry, orthodontic adjustment, and quick check observation.

Findings:

New patients 0-5 referred by general dentists had patterns of behavior that were the same as new patients in general. No fee for service patients above the age of five were referred with Sarnet scores 345. 33% of Medicaid patients received scores of 345. For restorative 345 was 75% for ages 0-5 and decreased to 4% for ages above 12.

Summary:

There is a relationship between patient behavior and the age of the patient, type of procedure, source of patient referral, method of payment, and familiarity with the office. The younger the child and the more threatening the procedure, the more prevelant the negative behavior. Patients who are fee-for-for service are more likely to have more positive behavior then Medicaid patients.

Assessment:

Most of the points the article brings up would seem fairly obvious to most providers.

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.

The Papoose Board and mothers' attitudes following its use

Resident: Roberts
Date: 9/18/09
Article title: The Papoose Board and Mothers Attitudes Following its Use
Journal: Pediatric Dentistry:
Volume 13 number 5; pages 284-287
Year: 1991
Introduction:
Sedation, tell – show – do, voice control, and positive reinforcement are techniques employed by pediatric dentist in order to obtain cooperation by their patients. In some circumstances these techniques do not work sufficiently. When dentistry is imperative and these techniques are unsuccessful, sometimes physical restraint must be used in order to get the job done. Studies conducted in the early 1980’s report that upto 86% of pediatric dentist used papoose boards as a behavior management technique in their office. Upto 53% of pediatric dentist in past surveys have reported preferring this technique to sedation methods. In a study performed by Fields in 1984, this technique was determined to be the least favorable method to obtain cooperation of patients by their parents.
In this article a study was conducted in a Midwest city, in a suburban pediatric dental practice where subjects could be drawn from Caucasian, Asian-american, African –american and families of all socioeconomic status. The goal was to reevaluate patient and parent acceptance using the papoose board as a method of behavior management in the dental office.
Techniques:
First appointment consisted of an initial exam without the PB in order to develop a tentative treatment plan. Second appointment consisted of an Indian game to entice the child into the papoose board and an astronaut game that allowed the child to be fitted for nitrous oxide comfortably. The mother was allowed to stay in the room during the appointment holding her child’s one hand that was not securely fastened within the PB. All other aspects of the appointment remained consistent with routine operative care.
Survey and results:
Seventy four children were treated while securely fastened to a PB. Their mothers were issued surveys at the end of the appointment which could be mailed back anonymously. Of the original 74 only 59 were mailed back.
Take home message:
66% of mothers indicated that using a PB was stressful for their child
96% of mothers said the PB was necessary in order for the dentist to do his job
90% realized that immobilizing their children protected them from harming themselves
70% felt that their children were comfortable despite the stress of the appointment
60% did not rate their children as being more afraid of the dentist after being papoosed
68% did not report negative effects after the treatment
86% would be willing to have their next child treated with the PB

Conclusion: Implementing the PB as a behavior management technique is an effective method of dealing with difficult patients. Unlike previous studies, this study found that parent acceptance of the method was favorable. The conclusion was that proper presentation to the parent and child must be performed prior to and during treatment. Allowing the mothers to participate in the treatment by holding their childs hand seemed to have a positive effect on their perspective of this treatment and its outcome. It was recommended that pediatric dentist keep the PB as part of their armamentarium in dealing with patient behavior in the office.

Assesment: good article - makes sense

Temperament and Child Dental Fear

Resident: Roberts
Title: Temperament and Child Dental Fear
Author: Klingberg et al
Journal: Pediatric Dentistry
Volume# 20:4 pages: 237-243
Year: 1998
Key pts and findings:
In this study 124 children ages 5-7 and 10-12 years of age participated. Three test were administered to measure four aspects of tempermant, which are: negative emotionality(characterized by crying, shrinking back, hiding, fear, anger and temper tantrums), shyness( the tendency to be slow to warm up to others in social situations), sociability( described as preferring the presence of others to being alone) and activity( defined as tempo and vigor in this article). Together, these aspects assessed can help to determine if a child is at risk of developing dental fear. Preliminary surveys were done before exams were performed in the dental chair to determine the characteristics of each child. The results concluded that shyness along with negative emotionality can lead to development of dental fear in children. Most shy children do not present with behavior management problems, and most children with behavior management problems are not shy. However, dental fear should not be confused with dental behavior management problems. Shyness thus has been associated with dental fear but not behavior management problems. Dental or medical treatment of shy children should therefore include 1) plenty of time to allow the child to get acquainted with the situation. 2) A proper introduction to all steps in treatment. 3) sufficient medications and techniques for minimizing pain and discomfort during procedure.

Assessment: The article was steep in to numbers and statistics. I thought the take home message was good though.

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.

Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective.

Resident: Adam J. Bottrill
Date: 11SEP09 Region: Providence
Article title: Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective.
Author(s): Kuhn, Brett
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 16 pp: 13-17
Year: 1994
Major topic: Behavior management
Minor topic(s): Technology
Type of Article: Discussion

Main Purpose: Discuss issues relevant to incorporating new behavior management technology into the dental school curriculum and disseminating it to practicing dentists.
Overview of method of research: Discussion
Findings: More research needed.

Key points in the article discussion:
A. General: Behavior management is as fundamental to the successful treatment of children as are hand piece skills and knowledge of dental materials.
1. Disruptive behavior leads to increased delivery time, risk of injury to the child.
2. AAPD’s 10 endorsed behavior management methods in 1991:
a. voice control
b. TSD
c. positive reinforcement
d. distraction
e. nonverbal communication
f. hand-over-mouth
g. phsycal restraint
h. conscious sedation
i. nitrous oxide
j. GA
3. A lot has changed over the years WRT appropriate behavior management practices.
a. traditional behavioral techniques don’t always work
b. changes in community standards have resulted in objection to HOM, restraints and pharmacological intervention.
c. changes in legal and ethical standards have made some dentists hesitant to use some techniques.
4. The result is a lot more dentists currently open to new, non-invasive behavioral management techniques.
5. The answer may lie in a collaborative effort between dentists and behavioral psychologists.
6. The 3 discussed techniques were chosen based on initial research efficacy with pediatric patients.
a. non-intrusive
b. non-cumbersome
c. conceptually fit well along-side current techniques
B. Contingent Distraction:
1. Diverting a child’s attention and engaging them in alternative activities like watching TV, playing video games or listening to audio tapes (music or stories).
2. Making this distracter’s availability contingent upon cooperative behavior. Immediate termination of distracter at first sign of uncooperative behavior.
3. Initial studies reveal that this may be an effective, yet practical means of reducing problem behavior.
C. Live Modeling:
1. Permitting children to observe other children adaptively undergoing dental treatment is an effective way of preparing them to accept treatment and demonstrate what’s expected of them.
2. Decreases in disruptive behavior can also be produced by simply having a child observed by peers (peer pressure).
3. One other option is to show I video of a cooperative patient.
4. This wil need to be analyzed across a wide range of patient-types… cooperative to uncooperative.
D. Contingent Escape:
1. Instilling a sense of trust and control is important.
2. In the past, the “raised hand” technique could give the child this sense of control.
3. Often, disruptive behavior results in halting of the procedure… which reinforces the behavior.
4. In this procedure, brief periods of “escape” from the ingoing dental treatment are provided contingent upon good behavior. Disruptive behavior delays escape from the treatment.
5. I can actually see this form of contingent reward as a problem… especially if the child simply won’t allow the procedure to proceed.
6. Preliminary studies show great success with this procedure when implemented early and consistently in the treatment.
7. Further research needed to figure out how to train dental students on this method.
E. Conclusions:
1. Collaboration between dental and behavioral scientists has been encouraged by the AAPD and viable alternatives have begun to be developed.
2. More research is needed on all fronts to more firmly establish treatment parameters, curriculum changes etc…
3. It is important to note that these techniques serve to SUPPLIMENT, not replace existing behavioral management techniques.

Assessment of article: Seemed more like loose opinions rather than science. But I’ll let it slide because the topic interests me. "Need more IIIIIINPUT" (Johnny Five style)

Effective Communication

Resident’s Name:  Joanne Lewis                                                            Date: September 11, 2009

Article title:  Engaging Children’s Cooperation in the Dental Environment through Effective Communication

Author(s):  David A. Nash, DMD, MS, EdD

Journal:  Pediatric Dentistry

Volume (number):  28(5)

Year:  2006

Major topic:  Communication techniques

Type of Article:  review

Main Purpose:  To review and discuss 3 communication skills that can aid the pediatric dentist in gaining the cooperation of children.

Discussion:  Establishing a trusting relationship with a pediatric patient is a prerequisite for gaining the child’s cooperation in providing dental care.  This article reviews 3 communication skills that are useful in developing such a relationship; these skills are reflective listening, self-disclosing assertiveness, and descriptive praise.

Reflective listening (or active listening) – a mirroring of the emotional communication of another.  Should demonstrate congruence (genuineness/honesty with child), empathy, and respect.  Many times pediatric dentists (and staff) try to talk children out of their feelings, or deny their feelings.  Example:  child – “I’m scared” dentist – “There is nothing to be scared of!”  Better to reply with  “I understand.  Sometimes new things are scary.  Sometimes I am afraid to try new things.”  All feeling should be permitted, but certain actions are limited; what children are feeling should not be translated into unacceptable behaviors.

Self-disclosing assertiveness – after empathetically acknowledging feelings through active listening, the clinician must motivate children to behave appropriately.  Often, expressions that are described as “roadblocks to communication” are used in an effort to gain cooperation.  These roadblocks include blaming, name calling, threats, commands(?), warnings, comparisons, sarcasm.  Self-disclosing statements (I-statements) permit pediatric dentists to confront uncooperative behavior without resorting to roadblock statements.  Examples:  “I see that your hands are not in your lap”, “I cannot see the teeth when the mouth is closed”, “Ouch!  That hurts me – I do not like to be bitten.”  I-messages cannot be argued with – they are the practitioner’s experience.  I-messages also place the responsibility on the child for modifying behavior.

Descriptive praise – positive feedback is a powerful way to reinforce correct behavior; the praise should deal only with the child’s efforts and accomplishments, not with his character or personality.  Praise using broad evaluative terms such as “great” and “wonderful” places the pediatric dentist in the role of a judge.  It is much more effective to praise a specific action, such as “You sat so still and kept your mouth open wide while I put your tooth to sleep.”  The child is left to judge the quality of his or her behavior.

Key points/Summary:  These communication skills are not natural or intuitive and must be practiced.  However, keep in mind that without compassion and authenticity, techniques fail.

Assessment of article:  Good reminder of communication pointers that we have all heard at one time or another.

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.

Dentist’s reassuring touch: effects on children’s behavior 9/11/09

Resident: Murphy
Date: 9/11/09
Article title: Dentist’s reassuring touch: effects on children’s behavior
Author(s): Greenbaum, Paul. Mark Lumley, et al.
Journal: Pediatric Dentistry 1993, Vol. 15, #1, pg 20-24
Major topic: How a dentist’s touch can affect a child before and during treatment
Type of Article: Clinical Behavioral Study

Findings:
When seeing any type of doctor, some sort of anxiety experienced by most children, especially when making a trip to the “dreaded” dentist. This anxiety, or actual fear is a definite obstacle to adequate care, resulting in patient management problems and possible avoidance of necessary treatment. Many different types of behavior guidance strategies have been published and used by pediatric dentists all over the world. On strategy not mentioned is the use of reassuring touch, which may be an easy way to reduce fear and stress in the anxious child.
Numerous studies have proven that a doctor’s touch can improve patients reactions to treatment. Patients who were touched before and/or during treatment reported feeling more comfortable with their doctors and nurses, and having less pain and anxiety (up to this study, none were done in the dental setting, and none were done on preschool children).
In this study, 38 children were treated by two dentists a male and a female. For the purpose of the study, a reassuring touch was considered a gentle patting or rubbing on the shoulder or upper arm. Children were also separated by age, splitting up children younger than 7 and older than 7. Half of the children seen by each dentist were treat with reassuring touch and words, and the other half with only reassuring words. The children’s anxiety and fear was observed and calculated before, during, and after treatment using the Dental Fear Scale(DFS) and the Self Assessment Manikin(SAM). The DFS represents a more stable, trait like index, where SAM situational fluctuations. Also, the Behavior Profile Rating Scale BPRS was used to measure fear related behavior i.e. fidgeting, squirming, and constant closing of the mouth.
The dentist were instructed that with the touch group, they should pat the upper arm or shoulder for 10 seconds at two separate times during the appointment while giving reassuring comments.

Conclusions:
Essentially, the children who were treated with reassuring touch and words showed less fearful behavior, and reported the experience as being better than the no touch group (see chart in article for review/breakdown). However, this was only the case for the children in the >7 group. The younger children in the touch group still showed fidgeting, mouth closing, etc. This could simply be age appropriate behavior. Studies show that fidgeting and other repetitive behaviors increase a person’s psychological anxiety, and therefore increase stress. Basically they’re saying fidgeting is a manifestation of fear.
While the findings in the study are encouraging, there are many things to keep in mind. There are numerous factors that cold have affected how each child reacted to their respective treatment. These factors include how the child reacted to each dentist, past dental experience of the child, what kind of procedure was being performed, other types of behavior guidance that was used, etc.

Assessment of article:
Overall I thought it was good article. My major problem with the study was that while they tried to keep everything uniform, there were still so many variables that could have affected the children’s reactions. As we all know, some times you just can’t connect with a child while someone else can. The main thing I tool away was that a gentle touch of the shoulder, or pat on the arm can’t hurt.

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.