Managing behaviour in children

OK. Hello. And now we’re going to talk a little bit about managing behaviour, specifically with some tips for how to manage child patients and their parents as well. OK. So like I say, we’ll think about managing the child. We’re actually going to look at parents, I think, first of all. And really, it’s important to understand that managing children really starts the minute they walk into your practise or your hospital. So it’s not something you just turn on when they come into the clinic. You need to think about this from the minute they arrive. So what do they see when they arrive? And what they see when they arrive is really important.

And it’s really important you have a child friendly environment. Now if you work in a hospital and it’s a child department, then that’s pretty easy. But if you work in a smaller practise environment where maybe you might be seeing adults as well, it’s a little bit more difficult. It’s important you have a space for children to feel where they can relax and where they can play. But it’s also important get the age appropriateness right. So adolescents, in particular, don’t like being stuck in areas that are more designed for under tens. So again, you’re limited by the space you have, but if possible, try and have an area carved out for perhaps older children for adolescents.

What they really want is Wi-Fi and a place to sit with gadgets. And for younger children, with perhaps more obvious things for them to play with like plastic toys and books and writing materials and this sort of thing. Remember that smells and sounds are really, really important. And children really react very strongly to smells in particular. Now there may be nothing you can do about that. Clearly, the dentist has a very particular smell. But do be aware of that. Do be aware that this will be triggering them even as they sit-in the waiting room. Sounds are important.

And clearly, if they can hear somebody else in distress or they can hear a drill whirring away, what have you, that probably isn’t going to be very helpful in terms of getting prepped for when they come in. So it’s important to try and keep, obviously, the waiting area separate from the treatment delivery area as much as you can. Finally, obviously if they’re sat out in the waiting room and the waiting for a long time, that’s probably a great idea. You want to get them in fairly quickly.

Perhaps not as bad as you think though, I think children who have got access to things to play with, who can be distracted actually don’t mind long waiting times so much as parents that tend to really struggle with long waiting times. But clearly, ideally you’ll see them fairly efficiently. All right. So we’ve dealt with them as they walk in. What about managing the parents next? It’s really important you understand the parents. Understand your parents. Not your parents, but understand the parents of the children you are treating. And it’s important you understand what their views and attitudes are to dentistry. Because you’ll be seeing them for, you’ll be seeing the child for, say, half an hour 45 minutes.

But that parent will be the child for the rest of the time. And if they are scared of treatment or if they’ve had a bad experience they will be transmitting that fear, that anxiety to the child. That’s really difficult for you to manage. Because we know that a parent does equal a scared child. So you need to think a little bit about as well, which parent you want to come to the appointment. Because some parents are better, bluntly, at controlling their children than other parents. Some parents may have a more positive experience with dentistry. So it’s really important you pick the right child to come for each visit. Finally, you need to set the rules.

And what I mean by that is you need to make it really clear to the parents to the families what they can say what they can’t say. And if they walk in with a child and go, Oh, don’t worry it’s not going to hurt too much. And you know, I got stabbed last week and all these sorts of very negative types of terms, that’s not going to help. So it’s important the parent understands that they have to support the child equally as much as whatever you’re doing to make sure their child isn’t anxious throughout the appointment. Some people believe that sometimes it’s better to keep a parent out of the room. Personally, I tend to keep them with me.

But there are times when maybe you might feel it’s better to have them outside. And I think that’s something you have to work out, as to whether or not that’s something that you want to do. So they’ve walked in, we’ve dealt with that. Parent, we’ve dealt with them. Finally, we come to the child. Now I think the first thing to remind you, I’m sure you’re all aware of this, is that children aren’t small adults. Biologically, the way they think is really quite fundamentally different the way that adults think. They tend to be very egocentric. And they often can’t understand abstract concepts really around benefits of treatment.

So saying to a child, well if I do this today, which you won’t like, that means in three years time why won’t happen which you also won’t like. So therefore you should have this done today. Often children can’t think like that. What they really think about is what’s happening today. So it’s important to understand that children cannot be treated just in the same way as an adult. Clearly as well, they will have a short attention span. So any treatment you do really, half an hour 45 minutes, that’s your time. If you can’t get it in that time, you have to think to yourself, how am I going to get it done at all?

So your first contact is really critical and it’s really important that you’re non-threatening. So get down to their level. Talk to them. Use their name, don’t just be some imposing figure in a white coat who’s talking to the parents. All that will really help you get a bond with this child and hopefully will help you provide the treatment that you want to do. Make sure you’re talking to them in a way that they can understand. Use their developmental level language. You know, so particularly with very small children don’t use language that they’re not going to understand. That that’s pretty obvious, I would hope. But equally, with older children, perhaps when you’ve got teenagers, don’t talk down to them.

Often they can fully understand what you are trying to communicate and quite a common complaint we find is that adolescents say, well, actually I really hated being talked to like a little child. So it goes both ways using developmentally appropriate language. So now you have to deliver the treatment. And there’s a perception sometimes that some people are good with children and some people aren’t good with children. And actually, we can all be good with children because there are some good simple evidence based behaviour management strategies that we can all use to help us manage children. And the big one, the first one, the most commonly used one is often acclimatisation.

And acclimatisation is really about breaking things down into small blocks, starting off with the easy stuff and then building up to the more complex stuff. So if you have a child who needs work in all quadrants, you might the first visit do some sealants. You know, Etch bond, get them used to the air, the water, the suction. The next visit you might do a fitting, maybe layer in doing a local anaesthetic and you’ll save the extractions to the end. Though it’s possible to do this, sometimes you have to start off with the extraction because that’s what you need to do. But possible in a lot of circumstances.

One of the things that our play specialist does in particular, is if she knows a child is going to have a local anaesthetic the next visit, she will give them the topical to try the previous visit. Because the topical itself it’s quite a big thing for a child to try. As I said before, children are really receptive and really feel quite strongly smells, and that includes tastes as well. And the taste of topical, the feeling of numbness can be quite a lot to take on board. So if they can have that experience before they have a local, it’s one less thing for them to have to deal when they come in for their visit where they’re having a local done.

OK. So after acclimatisation the next big one is tell, show, do. Again, I would hope you’re familiar with that. You tell the child what you’re going to do, you show it to them, maybe in a model or on their arm or something like that, and then you do it. Next is modelling. And by that what I mean is you let the child watch another child have the treatment done. Could be a sibling, clearly it only works if that goes well. So make sure you pick your treatment you’re going to use as an example well, and pick your child well. Because obviously if it doesn’t go right then that’s not going to help with the modelling.

But generally, modelling can be quite useful. And finally, positive reinforcement. We do not do negative reinforcement. We do not tell children off. Everything should be positive. Good behaviour should be rewarded with a sticker or some kind of toy or something like that. So we use stickers a lot. The other thing we use is we have a reward card. A bit like the reward card you get if you go and buy a coffee or something like that. And if a child has been good for say five visits they get five stamps. And they get to go to the treat box and they get to take something out of it.

So something like that is a really powerful way of motivating children to behave. Whatever behaviour management strategy you use, and of course, this also includes things like inhalation, sedation et cetera, which we are not going to talk about today. It’s important you choose the right one. It’s really important to acknowledge that sometimes the right one is general anaesthetic. That’s really hard to work out with some children when you should do that. You often end up in this kind of escalator where we start off with something simple like local. If that doesn’t work we go to inhalation sedation, and if that doesn’t work it goes to GA.

And of course, by the time we get to GA, we really have got a scared, traumatised child. Because we would have had presumably some bad experiences to get to that point. So the other tool to think about when you have children coming in for treatment is really trying to formally assess anxiety. Rather than relying on gut instinct, or on cues that you get from the child, so fully assess anxiety. And then maybe, for the more anxious children, you can have a structured approach to trying to manage that anxiety.