MANAGING THE PATIENT, PRACTICE, AND PARENT I “The Behavior of Children in the Dental Environment”

CLASSIFYING BEHAVIOR Cooperative Lacking Cooperative Ability Potentially Cooperative –Uncontrolled Behavior –Defiant Behavior –Timid Behavior –Tense-Cooperative Behavior –Whining Behavior

Cooperative Cooperative children are reasonably relaxed. Minimal apprehensions Following instructions Permit dentist to function effectively and efficiently % of children seen in the dental office will be cooperative.

Lacking Cooperative Ability Very young children with whom communication cannot be established due to lack of developed communication skills. Typically children under 2 ½ to 3 years of age. Also includes “special needs” children of any age.

Potentially Cooperative Behavior Use of the term ‘potentially’ is a euphemism! Classification for children who are a “behavior problem.” Have the ability to be cooperative, but are not. Require the dentist’s skills to develop cooperative behavior.

Uncontrolled Behavior Typically seen in young child between ages 3-6. Can manifest kicking, flailing and fighting behavior. Once children socialized by kindergarten and elementary school, typically become cooperative. Suggestive of a state of acute anxiety or fear. (We will differentiate between the two later.) Requires great patience from the dentist. Also requires assuring that the child does not harm self or other.

Defiant Typically associated with school aged children. More characterized of boys. “I don’t want to.” I won’t.” “I don’t have to.” Sometimes passive resistance. Requires strong assertive response from dentist.

Timid Behavior Milder form of negativism. Characteristic of pre-school child Hide behind mother Typically anxious child. Require patience; empathy; and frequent instructions.

Tense Cooperative Behavior Borderline between cooperative and uncooperative. Extremely tense, but attempting to cooperate. Emotions controlled, but obvious they are emotionally stressed. Accept dentistry, but express dislike for not consistent with experience.

CRYING TYPES Compensatory cry Fearful cry Obstinate cry Painful cry

Compensatory Cry Whining Droning on accompanied by few if any tears.

Fearful Cry Sobbing Rasping Tears Result of fear, either objective or subjective—as we will discuss.

Obstinate Cry Siren like pitch. Crying to be attempt to avoid cooperating Physical flailing and fighting. Associated with “uncontrolled behavior” reaction. Firm, assertive behavior required by dentist.

Painful Cry Moaning Associated Grimacing Authentic manifestation of a problem. Lack of profound anesthesia typically the issue.

FEAR AND ANXIETY

ANXIETY “…apprehension, tension or uneasiness which stems from the anticipation of danger, the source of which is largely unknown or unrecognized. Primarily of intrapsychic origin, in distinction to fear, which is the emotional response to a consciously recognized and usually external threat or danger. Anxiety and fear are accompanied by similar physiologic changes. May be regarded as pathologic when present to such an extent as to interfere with effectiveness in living, achievement of desired goals or satisfactions or reasonable emotional control.”

FEAR Objective Fears –Direct stimulation of the sense organs; personal experience based Subjective Fears –Based on feeling and attitudes suggested to the child by others, without the child having had an experience personally.

PRINCIPAL FEARS BY AGE THREE YEARS - Visual fears (masks, policeman) FOUR YEARS - Auditory fears (sirens) FIVE YEARS - Bodily harm (falling, dogs, dentist) SIX YEARS - Many fears; especially auditory and spatial SEVEN YEARS - Deeper fears (not being liked/loved) EIGHT YEARS - Fears reduced; continuation of failure, being liked NINE YEARS - Few fears; but ability to compete successfully exists TEN YEARS - School ELEVEN YEARS - Major fears re-emerge; health and animals TWELVE YEARS - Fears dissipate; fear is “silly.”

RELATING EMOTIONAL MATURATION TO THE DENTAL SITUATION Two Year Old Three Year Old Four Year Old Five Year Old Six to Twelve Year Olds

Two Year Old Variable in ability to communicate. Language skills developed at highly variable months in age to children. Solitary play, or if with another child the play is “parallel” play. Fearful; avoid sudden movements, such a moving the dental chair. Children four and under tend to be more cooperative with parent n the operatory with them.

Three Year Old Dentist can communicate with. Frequently talkative; enjoys telling stories. Dentist can engage with questions: pets, brothers/sisters, cartoon characters. Stranger anxiety/fear greatest between 2 and 4.

Four Year Old Good listeners Typically follow instructions. Lively minds and great talkers. Peak of fearful period, with fears declining to age six. Height of “fear of bodily injury.” An issue for dental treatment. Period of intense super-ego development.

Five Year Old Kindergarten age Enjoys group activities; playmates Fears generally reduced. With appropriate parenting is able to accept new experiences. Responsive to comments about appearance.

Six to Twelve Year Olds Elementary school children. Developing independence from parents. Peers becoming increasingly important, and affect behavior. Able to resolve fears. Desires acceptance, therefore more compliant. Adjusts easily Can tolerate unpleasant experiences.

VARIABLES AFFECTING CHILDREN’S BEHAVIORS Parental Behavior –Overprotection (extreme domination or indulgence) –Rejection –Over anxiety –Over-Identification Past Medical History Other Variables: socioeconomic, cultural, sex, ordinal position, sibling relationships, number of children in the family

ASSESSING AND RECORDING CHILDREN’S BEHAVIOR IN THE DENTAL SITUATION Definitely Negative (F1) –Refusal of treatment, crying forcefully, fearful, or any overt evidence of extreme negativism Negative (F2) –Reluctant to accept treatment; uncooperative; some evidence of negative attitude, such as sullen or withdrawn, but not pronounced. Positive (F3) –Acceptance of treatment; at times cautious; willingness to comply, at times with reservation, but follows directions Definitely Positive (F4) –Good rapport with dentist; interested in procedures; enjoys the situation.

DYNAMICS OF BEHAVIOR These codes should be entered in the patient’s record, and will provide a cue for anticipated behavior at a subsequent visit. Children’s behavior will vary through an appointment and the codes should be used to indicate such: “F1 initially and during anesthesia; F4 after rubber dam placement and during treatment.”