Behaviour management
Behaviour management - Helping the child to adapt to a dental environment
The aim of Behaviour Management (BM) is to promote a positive attitude to dental care and facilitate ongoing prevention and care. A variety of techniques may be useful to the dental team working with children and families to promote oral health.45 While they are described individually, they are often used in combination, and all rely on good communication. For example, a clinician may find that relaxation, coupled with behaviour shaping and giving control, empathy and praise, will help the majority of children in a dental setting. The expectation is that the successful practitioner will use appropriate behaviour management with all patients.
While BM techniques may be effective for some children and appropriate for some clinicians, the evidence base for their effectiveness is limited. However, the following techniques may help children adapt to a dental environment and enable a stress-free experience for the child and dental team. Although they are often described in the context of providing restorative management, they may be equally valuable when trying to examine a child for the first time or to introduce a child to any new situation.
The techniques summarised below are described in more detail in the British Society of Paediatric Dentistry Non-pharmacological behaviour management guideline. Some of these techniques are components of cognitive behavioural therapy, for which there is low certainty evidence of effectiveness in helping children to cope with dental anxiety.51 All these techniques can be used with children who can communicate but the child’s ability to understand the language used must also be considered.
Consider the use of one or a combination of the following behaviour management strategies to facilitate provision of both preventive care and treatment.
If a child continues to demonstrate significant anxiety despite the dental team using these techniques, consider referral to a specialist.
- If referring to a specialist, include in your referral letter details of treatments that have been attempted and how successful each was found to be (see Referral for a referral checklist).
Communication with children can be more complex than the one-to-one communication that exists with most adult patients. The child, clinician, parent/carer and dental nurse may all be involved. Each member of the team, including the parent/carer, needs to understand their role to create an effective treatment alliance and communicate in a consistent manner to support the child. The dental team needs to ensure that parents/carers know how to support their child without disrupting the appointment. This might entail discussing how to prepare the child for a visit and negotiating ground rules on how to behave and communicate in the surgery. For very anxious parents/carers who cannot mask their own fears it may be beneficial to discuss whether another adult familiar to the child should attend visits. The ability to communicate as a dental team and to include the family in this process is critical to deliver effective care (see Gaining rapport).
We communicate continuously and need to be aware of the messages we are sending consciously and unconsciously to children and families. Communication consists of:
- non-verbal communication – which conveys emotion and attitude
- words – which convey information
- tone – which conveys emotion and attitude
Non-verbal communication occurs continuously and may reinforce or contradict verbal signals. It includes facial expressions, eye contact, gestures, body movements, posture and touch. A happy smiling dental team from reception to the clinical staff needs to be sending the same positive message. A child-friendly environment is also important as some posters aimed at adults might scare a child.
If the three components of communication are not working in harmony the messages we send can be confusing. Young children may not understand the words that we use but will recognise tone. They will also pick up on the body language that the dental team and any accompanying adult exhibits. A relaxed posture, smile and gentle tone convey empathy even if the words cannot be understood. Used well, communication is a powerful way to support a child.
People often complain about the feeling of loss of control in dental appointments. Making the child’s role in saying ‘stop’ and ‘go’ explicit is a very simple way of enhancing feelings of control. This technique should be used every time for all children. It gives the child a degree of control over the clinician’s behaviour by giving them a way to interrupt an examination or active treatment. Saying to a child “Let me know if you want me to stop” is not adequate to give them control. Giving control means making sure the child understands that they decide whether the clinician continues or not by rehearsing a signal to stop, such as raising their hand.
If the child gives the signal, then stop the examination or treatment immediately. If you do not stop treatment, the child may develop mistrust phobia which can be very difficult to resolve.
The technique is useful for children of school age and older; younger children may not understand the concept of them having control.
This technique is widely used to introduce a child to a new situation.
Explain what you are going to do (Tell), and then show them (Show), before actually performing the action (Do).
The “Tell” phase should use age-appropriate language that avoids technical and emotive terms.
Example
Using "tell, show, do" to acclimatise an apprehensive 5-year-old child to accept treatment that involves use of a high speed handpiece for the first time will involve the following:
- Gain rapport (see Gaining rapport).
- Give control (see Enhancing control above).
- Tell the child what you would like to do, and show them the handpiece.
- Show them the high-volume aspirator and ask them if it would be all right to try it.
- If they agree, ask the nurse to put the aspirator tip into the child’s mouth, switch it on, then off and then remove it.
- Tell the child they have done well and check that it was OK.
- Tell the child you are going to put the handpiece in their mouth using language appropriate to the child’s age and understanding, switch it on, count to four (see Structured time below) then remove it. You will not touch their tooth and they can practise staying big and wide while you wash their tooth.
- Ask them to open their mouth, then proceed as above. If the child manages this, praise them, and tell them you would now like to touch the tooth for the count of four.
- Continue using this technique for each new action.
Although this approach can appear laboured, after a child has accepted the procedure, it is usually not necessary to work through all the stages at subsequent visits. The approach can be adapted for a child with anxiety using an enhanced approach termed Systematic Desensitisation.
Dental visits can be confusing to children who need assistance to learn how to behave in the surgery. Behaviour shaping consists of a defined series of steps towards ideal behaviour. This is most easily achieved by positive reinforcement of desired behaviour, increasing the probability of that behaviour being repeated, while ignoring undesirable behaviours to avoid drawing attention to them.
Scenario
The child keeps closing their mouth during placement of a fissure sealant.
Approach
Highlight the desired behaviour and praise the child when it occurs, thus reinforcing it. For example:
“Can you open your mouth big and wide like a lion for me? That’s great, that makes my job really easy!”
This approach requires practice, as it is very easy to become frustrated, stop smiling and say something like:
“Can you try and stop closing your mouth?”
This reinforces the undesired behaviour and, instead of praising the child, might sound cross.
The most powerful reinforcers are social stimuli, such as facial expression, positive voice modulation, verbal praise, and approval by parent/carer in the form of a hug. Anything that the child finds pleasant or gratifying or is a visible sign of ‘good’ behaviour can act as a positive reinforcer, for example, stickers or badges at the end of a successful appointment. However, it must be clear to the child what action is being rewarded. A child-centred, empathic response giving specific praise, for example, “I would like you to choose a sticker for sitting nice and still while I counted your teeth” has been shown to be more effective than a general comment such as “Choose a sticker for being a good girl.” As with Tell, Show, Do, the use of age-specific language is important.
Children can tolerate what they may find a potentially upsetting procedure (such as counting their teeth for the first time or use of a slow handpiece) if they know it will only continue for a finite period of time. “Just a little bit more” for a child could mean anything from a second or two, to eternity. Instead, break down time into units the child can understand.
Example
“I’ll buzz your tooth while I count to three, then stop. Is that OK? Good, 1…..2…..3. Well done! And again, 1….2….3" etc.
Note that young children (less than 5 years old) may not understand the concept of numbers above four, despite being able to recite them.
This technique aims to shift the patient’s attention from the dental setting to some other situation or from a potentially unpleasant procedure to some other action.
Cartoons have been shown to reduce disruptive behaviours in children when combined with reinforcement; the children knew the cartoon would be switched off if they did not behave.
Audio distraction, although proven effective for adults, has been shown to have variable success in children.
Short term distracters such as diverting attention by pulling the lip as a local anaesthetic is given or having patients raise their legs to stop them gagging during radiography or while taking impressions may also be useful.
Verbal distraction, for example the clinician who talks while undertaking an examination, polishing teeth or applying topical paste and administering local anaesthetic, can also be effective.
Telling a child to relax will not help them to relax but showing them how to breathe deeply using their diaphragm can.
- Ask the child to place a hand on their tummy.
- Ask them to breathe in slowly and deeply, making the air “fill their tummy”.
- Watch to see if their tummy rises; if so, praise them, and ask them to release their breath slowly, telling them that as they breathe slowly out they will become more relaxed.
- Ask them to do this three times, any time they feel tense and worried.
This technique is useful for children of school age and older.
Systematic Desensitisation can be a very powerful technique for helping a child with anxieties regarding local anaesthesia, radiography or any other aspect of dental care that they struggle to cope with. It involves teaching the child how to relax because it is not physiologically possible to be both anxious and relaxed at the same time. In its simplest form, the procedure is broken down into stages, and the child is taught to relax at each stage before moving on to the next with positive reinforcement.
A common application in dentistry is systematic needle desensitisation which is used to manage needle phobia. Only an outline is given here. For further details refer to the British Society of Paediatric Dentistry Non-pharmacological behaviour management guideline.
Discuss with the child how to recognise the signs of stress and anxiety that they may be experiencing (e.g. hyperventilation, tension).
Teach the child how to manage their anxiety, principally with breathing (see Relaxation above) but also using progressive muscle relaxation and other techniques such as guided imagery.
Teach the child how to describe their level of anxiety, using a scale from 1 to 10 (where 1 is completely relaxed and 10 is the most anxious they have ever been).
Break the procedure down into stages and describe all the stages to the child.
Give control, then try the first stage, asking the child at the end of it to describe their anxiety level. If rated above 5, ask them to spend a minute going through their relaxation regime, and try again, only proceeding to the next stage when the child has reduced their anxiety to a manageable level and the child has given their permission to proceed.
- Giving local anaesthesia could, for example, be broken down into holding the syringe by the side of the chair, placing it in the child’s mouth but with the cap on, then holding the syringe in the child’s mouth with the cap off, and so on.