Non-pharmacological behavior management of children: a review of the evidence

Introduction

General and paediatric dentists are expected to be able to diagnose and treat children in the dental clinic effectively and efficiently (AAPD, 2015). One of the main pitfalls a dentist might fall into in treating children is lacking behavioral management skills (AAPD, 2015). As McElroy (1895) said “although the operative dentistry may be perfect, the appointment is a failure if the child departs in tears”.

In this paper we are going to mention and discuss the non-pharmacological behavioral management skills and methods that can be used effectively to manage child patients and patients with dental anxiety.

Behavioral modification

Behavior modification in the dental setting is defined as the effort to modify human behavior and emotional state in a beneficial manner according to the laws of modern learning theory with a positive dental attitude influence (Wright, 1975); (Eysenck, 1964).

Goals of behavior management

According to the American Academy of Pediatric Dentistry guidelines in 2015 the goals for an effective behavior management include (AAPD, 2015):

• Establish communication with the child.
• Develop trust of the patient.
• Identify fears, anxiety and alleviating pain.
• Promote and encourage good dental attitude.
• Deliver high quality treatment for the child.

Classification of child’s behavior

The first step to establish behavior management is identifying the patient behavior classification (Sharma & Tyagi, 2011). This is done by observing the child’s psychological and physical responses in the dental setting and identifying environmental factors that affect the patient’s behavior (Sharma & Tyagi, 2011).

Many classifications were established in the past century including Wilson’s classification, Lampshire’s classification and Wright’s classification (Campbell et al., 2008). However, the most used and reliable one in the clinical practice was developed by Frankl, named Frankl’s behavioral rating scale (Klingberg, 2007).

Please refer to Figure 1.

Children who present in the dental clinic differ from adult patients in the context of involving the parent in the processing of emotions and behavior (Long, 2014). Therefore, developing the trust of the parent and cooperation during the dental visit can drastically affect the outcome behavior of the child (Long, 2014). Natural coping mechanisms of the child at a young age can be magnificent specially in developing strategies in fearful and anxiety inducing situations (Zhou et al., 2011).

This set of skills can help the patient create a space for behavior management while providing dental care (Roberts et al., 2010). Although fear and anxiety were mentioned side by side in the literature. However, the difference lay in that fear is a response to a specific known trigger whereas anxiety is the fear of the unknown (Yon et al., 2020).

A child’s behavior in the dental clinic is influenced by multiple aspects which are child, family or dentist related (Jain et al., 2016).

Below we will discuss each factor and how to manipulate this knowledge in our practice to enhance the behavior management of the child.

Child factors

This involve first and foremost the child’s development; to assess the development of the child one must know the chronological age and cognitive age of the child (AAPD, 2015).

These two factors affect the behavior management of the child drastically as the cognitive ability helps in determining the understanding and processing capacity for the emotional state of the child (Morton, 1997).

Every child has unique understanding and character development journey, this involves the understanding and interpretations of their environment and surroundings (Roberts et al., 2010). That’s why communication and words used in communication must meet the child’s expectations (AAPD, 2015).

Cognitive development

The cognitive development of children was discussed by Piaget’s theory (So, 1964). This theory classifies the cognitive development in 4 stages (So, 1964). Although these stages are not identified in real life situations as they were proposed (Welbury et al., 2012). The 4 stages include first stage which is from birth to 18 months, it is called the “Sensorimotor” stage (So, 1964). Where the child learns through their senses, reflexes and by manipulating materials (So, 1964).

Secondly from 18 months to 6 years, this stage is called “Preoperational”, child comprehend life by ideas based on their perceptions and can only focus at one thing at a time (So, 1964).

Thirdly, 6 years-12 years, termed “Concrete operational”, the behavior is based on reasoning and logic starts to develop (So, 1964). However, thinking is limited to objects and familiar events (So, 1964). Lastly, 12 years and older, also known as the “Formal operations” stage, the thought process is developed in a way where one can think conceptually and hypothetically by developing their own perspectives and views (So, 1964).

Past medical and dental history

It is always essential to obtain the child’s past medical history as this can be a detrimental factor which affects the child’s development (AAPD, 2015). Thus, affecting the child’s cognitive skills and behavior (AAPD, 2015). In certain cases, the communication and pathway for treatment of the child with a history of medical illness necessitates alteration in the behavior management techniques used by the dentist (Campbell et al., 2008).

Most children presenting for care at the dental clinic are already in pain and treatment require local anesthesia or extraction (Campbell et al., 2008). Hence, the attitude of the child toward future dental treatment is affected and rather becomes linked to an unpleasant experience (AAPD, 2015). That’s why it is important to initiate dental visits early for young children to develop a dentist-child relationship before any dental pain (AAPD, 2015).

Family factors

Family impact on the child behavior is seen as a reflective image of the parents (Burstein et al., 2010). Rather it is seen when one encounter an anxious parent (Burstein et al., 2010). The parent shape the expectations and attitude for the child which in this case increase the anxiety of the child (Burstein et al., 2010). Furthermore, the position of the child in the family in terms of sibling’s order is also known to affect the child’s behavior (Herrera et al., 2003).

For instance, the first child is shown to be responsible and compliant (Herrera et al., 2003). However, middle child is more aggressive and daring (Herrera et al., 2003). On the other hand, last child is more emotional and spoiled (Herrera et al., 2003).

Dentist factors

These factors depend on the communication skills of the dentist in the clinic (AAPD, 2015).

The dentist and dental team play an integral part in creating a positive experience for the child (AAPD, 2015). In addition, the dentist must display empathy, be affirmative and have confidence in the way they speak to the child (Welbury et al., 2012). Dentist must not forget to maintain the same communication with the parent as mentioned before it can reflect on the child’s behavior (Welbury et al., 2012).

Since the child develops different intellectual, physical, social and mental development (AAPD, 2015). It is vital that the dentist master a wide selection of behavior guidance and management techniques to be able to accommodate the diversity presented by children from different backgrounds (Feigal, 2001). That’s why this comprehensive approach must be practiced by general and paediatric dentists to be flexible and easy to implement. This practice will finally create trust between the dentist-patient and alleviate anxiety (AAPD, 2015).

Behavior management techniques

In this section we are going to discuss the behavioral guidance technique recommended by the American Academy of Pediatric Dentistry (AAPD, 2015).

Communicative guidance

It is a set of communication tools that can be used with a cooperative and apprehensive child (Nash, 2006). This tool can involve an active and reflective listening approach, which can be initiated at the beginning of the appointment (AAPD, 2015). In addition, asking general questions can help better understand and develop rapport with the patient (Nash, 2006).

Self-disclosing assertiveness techniques is also used in examples like, “Now you will open your mouth so that I can see your teeth” or “I need you to sit still to take a photograph of your teeth” in instances when we take an x-ray (Nutter, 2009). This way the child is told how to be cooperative (AAPD, 2015); (Nutter, 2009). In communicative guidance one must consider the cognitive development of the Adult when choosing exact communicative approaches (Nash, 2006).

Positive pre-visit imagery

This approach is used prior to the dental treatment; it is initiated by stimulating the reward system using a set of imagery visuals (AAPD, 2015). It is conducted with a set of images and diagrams to describe and show dentistry treatment as a positive outcome (Fox et al., 2006). In addition, it will allow the child and parent to be able to ask questions related to the treatment (Fox et al., 2006). This way the child can be motivated and excited for the outcomes of the treatment (AAPD, 2015).

Tell-show-do

This technique is broken down into 3 steps as the name of the technique suggests and involves verbal and non-verbal communication (AAPD, 2015). First “Tell”, this involves explanation of the procedure in an understandable language to the level of the child cognitive development (AAPD, 2015). Secondly, “Show” with auditory, visual and tactile stimulus what was explained (Feigal, 2001). Lastly, “Do” without deviating from what was explained for the child the procedure takes place (Feigal, 2001).

Undergoing this technique shapes the child’s reaction through desensitization and well-explained anticipations (AAPD, 2015).

Ask-tell-ask

This technique is used to evaluate and understand the patient’s anxiety level (AAPD, 2015). It is initiated first with “ask”, this involves asking the child about their concerns, expected outcomes and feelings toward treatment (Goleman, 2014). Then explaining “tell” the procedure thoroughly and in a non-threatening language, keeping the cognitive development level in consideration (Goleman, 2014). Lastly, “ask” inquiring if the child comprehends and understands the impending treatment (Goleman, 2014).

Voice control

Voice control stands for alteration in the voice tone to reflect assertiveness in the language used with the child (Mier et al., 2019). This sudden and affirmative commands are given to the patient to attain their attention and allow cooperation (Mier et al., 2019).

Objective of this technique is to avoid negative behavior and enhance compliance (AAPD, 2015).

Positive reinforcement and descriptive praise

In this technique the child is praised for their compliance using social reinforcement (AAPD, 2015).

The positive attitudes and actions of the child are identified and rewarded; this encourages the child to further comply with the treatment knowing that there is a reward for their actions (Mier et al., 2019). The most effective positive reinforcement form is the social reinforcers (Nash, 2006). Including but not limited to, facial expressions, positive voice tone and appropriate physical demonstration of admiration (AAPD, 2015).

Descriptive praise includes identifying the action of the child in cases like “you did a great job opening your mouth while I was washing your teeth”, rather than saying a general statement such as “good job” (AAPD, 2015).

Other modalities of reinforcement can be materialistic including stickers and toys (Mier et al., 2019).

Distraction

Distraction is used in pediatric dentistry to direct the child’s attention away from the stressful situation (Mier et al., 2019).

This is done by giving short breaks, directing the patient away from what is perceived as an unpleasant procedure (Nash, 2006). It also provides a window to where the dentist can consider a more advanced behavior guidance technique (Pinkham, 1993).

Memory restructuring

This technique is used to recreate negative memories to a reconstructive positive one (Pickrell et al., 2007). Memory restructuring has shown to be an effective behavior management approach when it involves four main components: (1) Sense of accomplishment (2) Solid examples to stimulate sensory system (3) Positive reinforcement through verbal cues (4) Visual reminders (AAPD, 2015); (Pickrell et al., 2007). A visual reminder can involve taking a photograph of the patient during the dental procedure, showing a positive attitude (Pickrell et al., 2007). Sense of accomplishment is when the patient is asked to recall the treatment and describe it to the parent (Pickrell et al., 2007).

Parental presence/absence

Manipulating the presence or absence of the parent during the dental treatment can drastically affect the compliance of the child (AAPD, 2015). The presence of the parent or family member can act as a positive influence, where the child can feel empowered by the encouragement of the parent (Kotsanos et al., 2005). This was shown to reduce the fear and anxiety (AAPD, 2015). Parent exclusion from the dental clinic can act as a negative reinforcement which can be effective (Pinkham, 1991). However, one must consider the protective instinct of the parent and the need of the parent to stay present during the procedure (AAPD, 2015).

The AAPD (2015) defines special needs children as children with “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment”. With these patients, more commonly the use of general anesthesia is done as the last resort after attempting to use behavioral guidance and protective stabilization (AAPD, 2015).

In special need children with intellectual disability protective stabilization can be feasible to undergo a simple procedure (AAPD, 2015).

Aversive techniques

These techniques include stabilization and Hand over mouth (HOME).

Stabilization

Protective stabilization suggests a variety of techniques either done by the parent or using active devices or both (AAPD, 2015). It can be done by the parent through “knee to knee” stabilization which will hold the patient to allow examination or fluoride application (AAPD, 2015).

It can also be done through utilization of devices such as a mouth prop and kiddie wrap.

It is recommended that this approach is feasible when the patient is extremely uncooperative or mentally challenged and in case of emergency where sedation or general anesthesia is not available (AAPD, 2015). Additionally, consent form must be signed by the parent/caregiver prior to any aversive technique is applied (Connick et al., 2000).

Hand over mouth technique

Hand over mouth technique, although was shown to be successful when utilized appropriately. It is not recommended anymore by the American Academy of Paediatric Dentistry guidelines (AAPD, 2008). A recent survey suggests that advanced behavioral management techniques such as voice control, positive reinforcement and tell-show-do is endorsed and encouraged (Oueis et al., 2010).

Conclusion

Multiple techniques are suggested with different approaches but rather the same objectives, these objectives are to reduce the anxiety and fear and facilitate a positive dental attitude. These objectives are achievable when the pediatric dentist utilizes the most appropriate technique or combination of techniques tailored for the child’s unique personality.