47 minute read
C.E. Credit: The Millennial Family: Adapting Behavior Guidance to Contemporary Parenting
Adi A. Genish, DDS, is a health sciences assistant clinical professor in the section of pediatric dentistry at the University of California, Los Angeles, School of Dentistry. She is actively involved in the predoctoral pediatric dentistry program at UCLA and is board certified by the American Board of Pediatric Dentistry. Conflict of Interest Disclosure: None reported.
Clarice Law, DMD, MS, is a health sciences clinical professor in the sections of pediatric dentistry and orthodontics at the University of California, Los Angeles, School of Dentistry. She is the acting chair of the section of orthodontics and is actively involved in graduate education in pediatric dentistry and orthodontics. She is board certified by the American Board of Pediatric Dentistry and the American Board of Orthodontics. Conflict of Interest Disclosure: None reported.
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ABSTRACT
Understanding the parent/child dynamic is important in the delivery of person-centered dental care to the child. However, the nature of parenting has changed and understanding of child development has continued to develop, affecting the ability of dentists to influence child behavior. The purpose of this paper is to review generational differences, the impact of parenting on child development and changes in approval of behavior guidance techniques to propose new approaches to child behavior.
Keywords: Generational differences, behavior guidance, behavior guidance techniques, parenting, interpersonal neurobiology, affective neuroscience
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The millennial generation is defined by the Pew Research Center as the cohort of individuals who are now between the ages of 25 and 40. [1] It is possibly the most studied generation and has been mostly maligned in popular media, with attention drawn by book titles such as “Not Everyone Gets a Trophy” and “Generation Me” and with memes and videos focusing on perceived shortcomings. The millennial generation has now reached the life stage where parenting and family life become important and is now poised to become the dominant proportion of caregivers for children in the dental setting. Studies indicate that family life is different within the millennial generation in terms of marriage status, living arrangements and a host of other factors. [1] Understanding this changing dynamic is essential to success in the emerging person-centered model of dental care.
The American Academy of Pediatric Dentistry discusses the importance of parental influence: “Positive attitudes toward oral health care may lead to the early establishment of a dental home. Early preventive care leads to less dental disease, decreased treatment needs and fewer opportunities for negative experiences.” [2] The American Academy of Pediatrics emphasizes how patientand family-centered care can improve outcomes by improving the patient’s and family’s experience and increasing satisfaction. Notable side benefits are an increase in professional satisfaction and more effective use of health care resources. [3] The American Dental Education Association has also advocated for a person-centered approach that promotes disease management in the context of social interrelationships. [4]
While there may be regional, genderbased, cultural and socioeconomic factors that influence parenting and child behavior, creating a robust dentistparent-child triad with an eye toward science-based interactions with children and their parents must be a focus when shifting from a surgically oriented, patient-centered model of dental care to a wellness-oriented, person-centered model. Thus, the purpose of this paper is fourfold: 1) to review some of the social shifts that mark the current living generations; 2) to review the influence of parenting on child development; 3) to summarize changes in behavior guidance over the past 20 years; and 4) to propose some new approaches to child behavior as a new generation of parents and children emerge in the dental practice.
Contemporary Generations
While various social factors have always played a role in shaping the parent-child-provider relationship, evolving generational differences can drive how these factors alter the dynamics of this triad. Each new cohort has a perspective on parenting that may change based on societal influence, economics and technology. Understanding varying generational traits in the U.S. allows for a better understanding of contemporary parenting styles and how this may impact child behavior and thus strategies for dentists to treat children.
One of the earliest labels of a parenting style emerged in the early 1990s. Foster Cline and Jim Fay are credited with coining the phrase “helicopter parent” and assigning it to the baby boomer “parents of millennials who sometimes [were] helpful, sometimes annoying, yet always hovering over their children and making noise.” [5,6] These baby boomer parents most likely acquired this reputation of “hovering” over children because of the societal influences at work throughout their own upbringing during the post-World War II time of peace, prosperity and family growth. [7–11] The baby boomers, who are now 57–77 years old, are described as one the wealthiest and best-educated generations of parents in history, obtaining access to financial resources that helped them raise their children. [12] While some boomers may have experienced some economic volatility, the unemployment rate during this time was generally low, allowing for a family structure with two working parents. [12] The ability to shelter their millennial children and overindulge through their parenting was facilitated by increased income as well as small family sizes due to the advent of oral contraceptives and abortion rights. [12,13] These generational experiences promoted a family environment that was often child-centric.
Generation X, now between the ages of 42–56, makes up the majority of the parent population in current practice. Gen Xers were raised in a very different economic time than the baby boomers, experiencing economic recession, a divorce boom and an overall increase in crime and incarceration across the U.S. [10] These “latchkey” kids had a reputation for being resourceful due to being frequently left home alone by a single working parent or two working parents, a characteristic evident in their parenting approach. [10] As a result of growing up during a more tumultuous time in the U.S., individuals of Generation X are thought to be more skeptical of institutions, organizations, government or tradition. [10] As parents, they have earned a new title, the “stealthfighter parent,” coined by public policy consultant Neil Howe. [7,8] While less likely to hover closely, “stealth-fighter parents will choose when and where they attack and strike rapidly, in force with no warning.” The Gen X “security moms” and “committed dads” have also been known to have the ability to be “even more attached, protective and interventionist than boomers ever were.” [7,8] As a whole, Gen Xers are thought to have taken an even more guarded and engaged approach to parenting their children with a targeted focus on preparing them for their future. [10,13]
While positive and nurturing in many ways, the baby boomer “helicopter parents” and Gen X “stealth fighter parents” are thought to have fostered a modern generation of young adults and adolescents who have exhibited a pattern of dependence, needing assistance in decision-making, expecting immediate feedback and holding a sense of entitlement and unrealistic expectations, whether in their own lives or their children’s. [14] The current generation of children, most of whom are children of Gen X, are between the ages of 6 and 26 and have been labeled Generation Z or iGen. They are still being characterized by social psychologists and sociologists, as are the children of the yet-to-be-defined generation “alpha” that will follow them. Anecdotally, the dominant characteristics of Gen Z/iGen have resulted in a strong reaction within the social media communities of individuals who work with children, including educators, physicians and dentists. Thus, it is important for the dental provider to understand the social, societal and parental contexts that influence their development and behavior to ultimately provide a more person-centered approach to care.
Contemporary Childhood
One of the most revealing works on the current status of Generation Z/iGen is “Coddling of the American Mind” by Greg Lukianoff and Jonathan Haidt. [15] Originally published as an article in The Atlantic in 2015, [16] the authors expanded their content and included scholarly references in the hardcover title they released in 2018. Lukianoff, an attorney and free-speech advocate, and Haidt, a social psychologist and professor of ethical leadership at New York University, had noticed an alarming increase in anxiety, depression and suicide rates among the college students entering college around 2013–14. Determined to identify some of the societal trends precipitating these troubling outcomes in young adults, Lukianoff and Haidt presented six possible causes, three of which relate to the generational differences exhibited by contemporary parents. Paranoid parenting, the decline of play, anxiety and depression were hypothesized to have led to this unfortunate trend, particularly among Generation Z/iGen. Within the same time frame as Lukianoff and Haidt’s developments, the fields of affective neuroscience and interpersonal neurobiology were similarly providing a foundation to understand how these three concepts affect contemporary childhood.
Neuroscientists propose that during the early stages of a child’s life, the lower “reptilian” part of the brain dominates function while higher brain functions develop later in childhood. [17] The lower brain structures, namely the limbic system, orchestrate emotions as hormones regulate the seven primary lower brain systems: the “alarm systems” of RAGE, FEAR, PANIC/ GRIEF and the “calm systems” of CARE (attachment), SEEKING and PLAY. [17] The seventh system of LUST generally doesn’t enter into discussions about the effect of parenting on brain development. The more a lower brain system is activated throughout development, the more interwoven it becomes with personality — “emotional states becoming personality traits.” [17] Under the umbrella of these systems, parenting and society influence child personality and behavior. Lukianoff and Haidt’s key findings build on this neurological foundation.
Lukianoff and Haidt’s work highlights the relevance of these neurodevelopmental findings, as they identified a shift in parenting approach near the beginning of the transition into the millennial generation. They suggested that an era of “paranoid parenting” began in the U.S. with a pair of highly publicized child disappearances in 1979 and 1981, triggering the National Child Safety Council’s advocacy for photos of missing children to appear on milk cartons and the initiation of the longstanding “America’s Most Wanted” television series. Meant to draw public awareness and to elicit support in the search for missing children, the attention made parents more concerned about child safety. The culture of paranoid parenting was the subject of a series of scholarly publications by Furedi [18] who noted: “This is a culture that continually incites the public to worry about every dimension of children’s lives. It is a culture that dramatizes every issue facing mothers and fathers and turns everyday problems into scare stories. It is also a culture that denigrates parental competence and insists that mothers and fathers cannot cope without the help of experts. These cultural messages are zealously promoted by a formidable network of professional experts, child rearing gurus, child protection advocates, fear entrepreneurs and politicians.” Many contemporary children are raised in an overprotected environment, with parents preventing them from experiencing both physical danger and “stranger danger.” From a brain development perspective, when young children are taught to perceive the world to be a dangerous place, lower brain structures like the hippocampus and the amygdala trigger the release of stress hormones. This lower brain FEAR system can impair higher brain development, impair emotional regulation and promote negative implicit memory associations with challenging life events. [17,19] Paranoid parenting can extend to the dental setting, with some parents expressing concerns about not wanting their children to have bad experiences or failing to trust their dental providers. This is particularly challenging with the increase in parental presence in the operatory that has occurred over the past two decades.
Another of Lukianoff and Haidt’s reasons for the alarming outcomes for the oldest individuals identified as Generation Z/iGen is the decline of play. Contemporary children appear to be lacking in the kind of free play more commonly associated with the latchkey children of Gen X. Free play is specifically defined as physical activity initiated by and directed by the participants. This is distinct from organized play where an adult supervises the activities. The lower brain PLAY system has an important role in brain development and activates neurotransmitters that promote higher brain development, activate antistress mechanisms, decrease impulsivity and overactivity and develop emotional regulation when a child is engaged in physical play. [17] The contemporary child is thought to be less physically and socially competent, less risk tolerant and more anxious. Under these conditions, the dental setting may seem like a particularly threatening environment. Paired with a caregiver who exercises paranoid parenting, a child with an underactive PLAY system may find routine dental procedures to be difficult because of their invasive or novel nature. This type of child may prove to be a challenge even for providers with high proficiency with basic behavior guidance techniques.
The final of Lukianoff and Haidt’s reasons for the decline in mental health for college-age students is an increase in anxiety and depression. The use of handheld electronic devices and social media are cited as possible reasons. [20,21] Although these studies focus on the high school and college-age population, younger children are also increasing their use of electronic devices. The lower brain SEEKING system provides motivation to explore. [17] When activated, the SEEKING system triggers the release of dopamine, which stimulates cognitive development in the frontal lobe, and opioids, which have antianxiety effects. SEEKING is optimally activated in the context of interpersonal relationships and is thought to be underactivate in the context of excess screen time. Lack of one-on-one connection or parental attunement can also result in an underactive SEEKING system, which could also be related to the increased use of handheld electronic devices by parents. A “connected” child or a child with a “connected” parent might be lacking in the skills to connect with a dentist in a manner that supports basic behavior guidance or they may lack the drive and motivation to successfully fulfill the expectations required for successful completion of a given dental procedure.
As societal changes have shaped parenting, parenting has likewise influenced the nature of interactions professionals have with the individuals of Generation Z/iGen. Both parents and children have influenced the parameters under which the doctor can interact with the child patient. As such, acceptance and use of various behavior guidance techniques have also changed with the generational shifts.
Behavior Management of the Past
The last major wave of publications in the pediatric dentistry literature regarding changes in parenting styles appears to have started in 2002, with the publication of a study that was first presented to the College of Diplomates of the American Board of Pediatric Dentistry annual session in May 2001. The study, by Casamassimo et al., [22] consisted of a questionnaire mailed to 1,129 ABPD diplomates. The key conclusion was that “diplomates report that parenting changes have occurred and they believe these are negative (bad) and have adversely influenced behavior and caused changes in pediatric dentists’ behavior management.”
In November 2003, the second Behavior Management Consensus Conference was held. The proceedings were summarized in the May/April 2004 issue of Pediatric Dentistry. Three of the presentations focused on child behavior and the influence of parenting. Presenters acknowledged that children and families “live and grow in a different social context than 15 years ago” [23] with trends for families “to live increasingly isolated and disconnected lives in our society … with parenting in today’s society … occurring in an increasingly stressful context.” [24] Presenters suggested that changes in family had influenced child behavior. “Behavior of pediatric patients reflects fewer boundaries, less discipline and self-control and lowered behavioral expectations by parents and contemporary culture.” [25] Other studies focused on behavior management. One study presented at the conference specifically asked participants to report if they used each of the 13 behavior guidance techniques with children. Despite the reports of changes in parenting styles and child behavior, the study revealed little actual change over the previous five years of practice. [26] And more significantly, respondents reported no plans to change their use of behavior management techniques going forward.
During the conference, some very specific recommendations were made regarding behavior management techniques, including:
■ Reevaluate the definitions of child behavior in the dental setting, including definitions of appropriate behavior.
■ Develop training in effective communication with parents for pediatric dentists and their staffs.
■ Seek further information on the impact that changing parental attitudes toward behavior management techniques may have on the quality and accessibility of treatment.
■ Conduct research in specific areas of behavior management, particularly in communicative techniques.” [26]
There were also some very thoughtful conclusions about the changing nature of family dynamics and the subsequent effect on child behavior. Presenters advocated for a holistic approach. “Diagnosing the child and family within the immediate local context is central to developing and accomplishing an effective dental treatment plan.” [23] Overall, an empathetic approach was suggested. “It is easy to be critical of parents and their parenting efforts; however, there is much more involved than simply parents who do not care or who are knowingly doing the ‘wrong thing.’ Parenting is difficult under the best of circumstances. For a growing number of parents, the stressors in our society are making it increasingly difficult to parent effectively. It is important to remember that parenting occurs within the context of a society, not in isolation, and parenting problems often reflect society’s problems.” [24] These conclusions continue to be relevant in the current shift toward person-centered care.
In the years following the 2003 Behavior Management Consensus Conference, there was an increase in interest in the association between parenting practices and problem behaviors in general. PubMed summaries of articles addressing “parenting AND problem behavior” numbered less than 100 per year until 2001, after which numbers dramatically increased to a peak of 547 articles in 2018. Specific to dentistry, a number of articles attempted to identify relationships between parenting style and behavior guidance, with a summary of the Baumrind typology described in this journal in 2007. [27] Diana Baumrind’s first description of her eponymous parenting typology was first published in 1966 [28] and has been cited 4,495 times. Baumrind measured parenting according to two dimensions — warmth, which “implies being involved and interested in the child’s activities, listening to the child and being supportive,” and demandingness, which refers to “the amount of control a parent imposes on a child (e.g., expectations for behavior), the implementation of standards and rules and the degree to which a parent enforces the standards and rules.” [29] The typology was modified in 1983 to include four parenting styles: authoritarian (low warmth, high demandingness), authoritative (high warmth, high demandingness), permissive or indulgent (high warmth, low demandingness) and the additional category of neglectful or uninvolved (low warmth, low demandingness). [30]
Studies that focused on the influence of parenting style on approval of behavior guidance techniques suggest that parents characterized by the authoritative typology are likely to partner well with their child’s provider in use of communicative basic behavior guidance techniques, with the majority of parents in one behavioral coding study choosing not to intervene during local anesthesia administration on their children. [31] Subjects scoring high in the permissive category tended to initiate physical contact with the patient by taking the patient’s hand (74%), stopping the treatment (70%) and questioning the pediatric dentist regarding the effectiveness of the anesthesia (50%). [31] An unpublished study of approval ratings of behavior guidance techniques suggested that permissive parents approve of pharmacologic techniques (oral conscious sedation, intravenous general anesthesia and general anesthesia in the operating room setting) more highly than do authoritative or authoritarian parents. [32] Authoritarian parents reacted to local anesthesia administration with use of physical control, firmness and displeasure. [31] Similarly, ratings of authoritarian parents indicate approval of voice control and use of protective stabilization. [32]
A number of other studies focused on the influence of parenting on child fear in the dental setting. The number of articles fulfilling the criteria of “parenting AND dental anxiety” has doubled since 2009, indicating a high degree of interest in the subject. A systematic review relating parenting to dental anxiety and misbehavior summarized the findings of eight articles mostly published between 2008–2015 that met inclusion criteria. “Parenting style was shown to affect dental anxiety in a study of children who visited the dentist for the first time, whereas no effects were seen in children with previous dental experience.” [33] More recent publications demonstrate mixed results, with one failing to find associations between parenting style and child behavior in the dental setting [34] and others suggesting more positive outcomes with authoritative parenting styles in children with no previous dental experience. [35,36] An additional study demonstrated no association between parenting style and dental fear and anxiety. [37]
Studies on the influence of parenting and oral health have also increased, with the search term “parenting AND dental caries” returning three times the number of results in the past decade and “parenting AND oral hygiene” also rising steadily in numbers. Associations are demonstrated between the more desirable authoritative parenting style and oral health. Quek et al. wrote in the conclusions to their study, “Authoritative parenting was associated with positive attitudes regarding both preventive dietary and oral hygiene practices. Actual oral hygiene practices were more optimal in children with authoritative parents, but parenting styles had no impact on actual dietary habits.” [38] Viswanath et al. wrote in their conclusions, “Children of both authoritative and authoritarian parents showed lower caries risk status while the permissive parenting group demonstrated a threefold increase in caries status compared to authoritative parenting.” [39]
In sum, although conclusions presented at the 2003 Behavior Management Consensus Conference suggest that changes in parenting have affected child behavior in the dental setting, subsequent studies on the influence of parenting styles have only been able to demonstrate that positive parenting practices are associated with better oral health, lower caries risk and positive behavior in the dental setting. Studies have not clearly identified the outcomes for the authoritarian, permissive/indulgent or uninvolved/ negligent parenting typology. Whether parenting style turns out to have positive or negative effects on pediatric oral health, the American Academy of Pediatrics policy statement indicates that family should be the child’s primary source of strength and support. [3] In a person-centered care approach, parental approval of care techniques is an essential component of high-quality clinical decision-making. Interestingly, approval of behavior guidance techniques by parents has changed over time, as have changes in use of techniques by providers. Understanding these changes will be important in adapting to the emergence of the millennial parent and their approval of behavioral guidance techniques.
Communicative techniques make up the majority of the techniques used by providers and approved by parents. Adair’s 2004 study of members of the American Academy of Pediatric Dentistry could be considered a baseline study for the 21st century, with a 66% response rate among the 4,180 members who had been sent the research instrument. [26] Results suggested that more than 90% of providers used tell-show-do, nonverbal communication, positive reinforcement and distraction. Tell-show-do has clearly been demonstrated to show extremely high parental approval, with the other techniques likely to have remained high in approval. The same study population expected increases in use of all of these techniques in the years to come. Considering the highly expressive nature of contemporary parents, skills in communicative behavior guidance techniques will continue to be important.
The aversive techniques, however, are more controversial. By 2004, the least frequently used technique was hand-over-mouth exercise (HOME) with 21% of providers reporting use. However, 50% of respondents indicated that they had already decreased use of HOME and another 24% indicated that they expected to decrease use. [26] This controversial aversive technique has since been removed as an approved behavior guidance technique from the American Academy of Pediatric Dentistry’s Reference Manual. Voice control, or use of a firm tone, was being used by 92% of respondents in 2004 [26] with approximately double the percentage of respondents anticipating decrease in the years to come based on changes in parenting. Indeed, parents are not as approving of voice control as they may have been in the past, with its use ranking below general anesthesia and oral conscious sedation. [40] Current data suggest that parents are only mildly approving of the use of voice control. [41] And providers with more than 30 years of experience report higher utilization in the past than currently. [42]
Passive immobilization (sometimes referred to as a “papoose board”) is worth discussing in the context of contemporary parenting because of its decline in acceptability. Based on the 2004 dataset, 66% to 74% of pediatric dentists used passive immobilization with nonsedated children and either 28% or 11% to 17% indicated that they expected to use it less frequently. [26,43] Parental approval was low, [40] with acceptability lower only for the handover-mouth exercise. The American Academy for Pediatric Dentistry began discussing recommendations for use, and by the time the 2013 AAPD Reference Manual was released, the guidelines had changed. The technique is now called protective stabilization and includes both active restraint (physical limitation by an individual) and passive restraint (physical limitation by restrictive equipment such as the papoose board). [44] The guidelines emphasize use of protective stabilization only in specific situations, such as urgent care, limited treatment in a child where sedation or general anesthesia is not an option, children with movement disorders and with the sedated patient. Contraindications include use in a cooperative nonsedated patient or those with nonemergent needs. Use of protective stabilization is not considered appropriate if used for the practitioner’s convenience and certainly not if used punitively. Approximately 25% of a specially selected study cohort of 511 pediatric dentists considered passive protective stabilization “always acceptable” for emergency patients and 23% approved of its use for children with special health care needs. [45] Only 4% considered it “always acceptable” for routine operative care and 51% believed it to be “never acceptable.” Protective stabilization has been reclassified as an advanced behavior guidance technique, recommended for use only by specialists or individuals with advanced training. A series of negative news stories focusing on parents who claimed inappropriate use as well as a negative public perception about the practice was the justification for the policy change by the AAPD, which called for judicious use. Considering the decrease in the use of physical discipline among many contemporary parents and the concern about emotional trauma, protective stabilization is expected to continue its decline in acceptability and use.
Parental presence in the operatory has also demonstrated a shift over the past two decades. Parental absence was the norm in the past. Children were expected to respond positively to an adult authority that was not the parent. With the guideline for first dental visit changing from age 3 to age 1 in the mid-1980s, parents were expected to be present in the dental operatory to provide comfort to their infants and toddlers during oral examination. By the time of the 2004 dataset, more than 60% of dentists appeared to have a practice (greater than 75% of the time) of allowing parents to be in the operatory for emergency visits and for children with special health care needs. Beyond that, 40% would enlist parental assistance in restraining their children. However, only 43% had a routine of allowing parents to be present during routine examination and 33% for restorative procedures. Parental absence was enforced by 45% of pediatric dentists for sedation procedures and by 24% for surgical procedures. A secondary data analysis of the same dataset indicated a 30% to 40% increase in the presence of parents in the operatory over the previous five years [43] while 10% to 20% of the same subject population indicate a decrease in parental presence. Of the eight options given as reasons for the increase in parental presence, two appeared to be for the patients’ benefit — 9% thought that patients behaved better with parents present and 51% appreciated being able to consult with parents about evolving treatment needs during the appointment. Four options were related to parent motivators — 78% indicated that parents preferred to be present, 53% that parents insisted on being present and 21% expressed that parents would not consent to treatment without their presence. Sadly, concern about legal action was the motivator for increasing parental presence for 35% of the respondents. Interestingly, only 7% of participants thought they would further increase parental presence in the years to come. A much smaller follow-up study 10 years later indicated continuing trends toward increased parental involvement, with parental presence for routine examination increasing from 43% in 2004 to approximately 53% 10 years later and from 33% to 43% for routine operative appointments. [42] By this time, 55% of providers included parents to help in “basic communication, reinforcement and occasionally stabilization” and 26% indicated that “parents can observe but not be a part of the doctor-patient interaction.”
Parental attitudes about advanced behavior guidance techniques using pharmacological restraint have shown a substantial change in the past two decades. In 2004, 62% of the pediatric dentists who responded to the study used conscious sedation, of which 27% indicated was lower than in the past. [43] Another 21% indicated use that was higher than the past. Regarding general anesthesia use, 71% of providers used this form of patient management, with 38% indicating that this was an increase over the previous five years and 12% indicating a decrease. Parental approval shows inconsistency in ratings, but parents seem to prefer oral conscious sedation and general anesthesia over passive restraint, [40,46] with increasingly positive parental attitudes and understanding regarding oral conscious sedation. [47] The 2004 expectation among pediatric dentists of increasing use of advanced behavior guidance techniques has proven to be true with more recent studies reporting increased use of oral conscious sedation and general anesthesia, [48] with younger providers more likely to use pharmacologic restraint than more experienced providers. [42] This may be a generational difference in an emerging parent population resistant to inflicting hardship on their children or it may reflect response to a generational difference among the providers themselves.
In sum, trends in parental approval indicate an increased expectation among parents to be allowed in the treatment area. Providers appeared to have responded to these expectations, possibly reluctantly. With higher numbers of parents participating in dental treatment for their children, the increasing approval for positive communicative techniques and decreasing approval for aversive techniques such as voice control and use of protective stabilization requires that the dental provider have a robust armamentarium of basic behavior guidance techniques in their skillset. Although providers with advanced training may be able to take advantage of certification in pharmacologic restraint, this may not guarantee the ability to provide definitive restorative care in all cases. Contemporary parents appear to have very different responses to the concept of treatment under conscious sedation or general anesthesia. Some parents appear to embrace pharmacological options as an alternative to what they believe may otherwise be a difficult experience for their children. Other parents indicate reservations about the use of sedative agents. Thus, the selection of behavior guidance techniques must take an individualized, person-centered approach, considering the child and their parents’ emotional and mental statuses.
Some of the changing trends in use and approval of behavior guidance techniques are supported with shifts in the parenting literature regarding the use of power assertion with children. In later publications, Baumrind concluded that there were significantly different general outcomes for children depending on parenting typology. Children of parents who use the authoritative style have better outcomes in demonstrating interpersonal skills, social responsibility and self-efficacy than those of authoritarian parents. Baumrind concluded that “the kind of power that characterizes authoritarian parents is coercive (arbitrary, peremptory, domineering and concerned with marking status distinctions),” whereas “the kind of power that characterizes authoritative parents is confrontive (reasoned, negotiable, outcomeoriented and concerned with regulating behaviors).” [49] She concluded that “the effects of power assertion are detrimental only when coercive, so that the common presumption that power-assertive disciplinary practices per se are harmful is unjustified.” Applying this conclusion to the changes in use of behavior guidance techniques over the past 10 to 15 years, it might be proposed that the decline in the use of aversive techniques such as hand-over-mouth, voice control and protective stabilization not only meets the changing demands of contemporary parenting, but could be considered beneficial, considering longer-term studies of the influence of power assertion on child well-being. Over the past decade, some criticisms of the Baumrind parenting typology have emerged. One criticism is that it lacks predictive validity. Focused only on warmth and behavioral control, the typology does not address psychological control — control of the emotional state of the child. [50,51] Applied to the concepts of behavior guidance, it might be concluded that the historical focus on selecting and applying behavior guidance techniques can likewise be expected to lack predictive validity. The behavior guidance techniques are techniques — ones developed to elicit cooperation and control behaviors without addressing the emotional state of each patient. Although the psychological control aspect appears to have a negative outcome, the importance of addressing emotions has become an emerging concept in the parenting literature and should play an important role in person-centered care.
Behavior Guidance of the Future
Cline and Fay were among the earliest to explicitly address the mass market audience regarding the typologies described by Baumrind in their book “Parenting With Love and Logic: Teaching Children Responsibility.” Although the book described a number of techniques to achieve behavioral control, the authors were very clear on addressing the importance of empathy. Since then, the fields of interpersonal neurobiology (the study of how relationships affect brain development) and affective neuroscience (the study of the neural mechanisms of emotion) have flourished, giving rise to both scientific and mass-market publications focused on helping parents cultivate the growth of their children’s brains. The dental provider could benefit from applying “brain-based” parenting strategies to the guidance of behavior in the dental setting, again moving toward a more individualized, personcentered care model for each child.
Daniel Siegel and Tina Bryson’s bestselling book “The Whole Brain Child: 12 Revolutionary Strategies To Nurture Your Child’s Development” [52] explains the neurobiology of a child’s brain, which can be divided into the upper and lower brain functions discussed previously (FIGURE 1). The “upstairs” or higher brain is responsible for decision-making and planning, balancing emotions, selfreflection, empathy and morality. [52] The higher brain remains underdeveloped in young children and is proposed to mature in the context of a healthy parent/child relationship. [17,52] The “downstairs” or lower brain is responsible for autonomic function, the fight-or-flight response, sensory memories and emotions. [52] As suggested previously, events perceived to be threatening can activate the lower brain via the FEAR or PANIC/GRIEF system, along with the RAGE system. Parents and caregivers develop emotional regulation in children by helping them make sense of the perceived threat and engaging the higher brain as it matures. Thus, a precooperative child younger than age 3 is not likely to be able to process a threat rationally. An older child can benefit from guidance in engaging the higher brain, but may still lose control over emotions and body. Whether by FEAR- or PANIC/GRIEF-driven fightor-flight response or by RAGE-driven “downstairs tantrum,” stress hormones interfere with higher brain function and the child cannot be reasoned with. [52] Brain-based parenting strategies with mnemonics such as “engage don’t enrage” and “use it or lose it” involve engaging the higher brain in order to regulate the activity of the lower brain (TABLE 1). Giving children choices to involve them in the decision-making process can aid a child during a difficult experience while also facilitating the development of the upstairs brain to engage in the future.
Siegel and Bryson also distinguish between the “left brain,” which is “logical, literal, linguistic (it likes words) and linear (it puts things in a sequence or order),” and the “right brain,” which identifies the “meaning and feel of an experience” and specializes in “images, emotions and personal memories” [52] (FIGURE 1). Young children lack the ability to integrate the functions of the two hemispheres and often overreact to difficult situations with either right brain “chaos” or left brain “rigidity.” Parents and caregivers can promote “horizontal integration” by identifying which hemisphere of the brain is in function during conflict and engaging appropriately, either with logic and solutions or with empathy and emotion. [52] Integration of the emotional and logical brain is proposed to give the child more empowerment and mastery in difficult situations. [52] The brain-based parenting strategies when a child is emotional could be to “name it to tame it” by identifying the emotion to engage the child’s left brain and externalizing the abstract. Parents are also encouraged to “connect and redirect,” which may involve gentle touch, a calm tone of voice, empathetic facial expressions, empathy and pausing (TABLE 1). Once a child’s emotional needs are met, they can then be redirected to use their left brain by giving them solutions, planning, providing logical explanations or setting boundaries. [52]
While the evidence base for behavior guidance techniques grounded in children’s neurobiological development is very limited in the pediatric dentistry literature, there is strong evidence in psychology literature supporting brain-based, parent-driven child behavior therapies such as the well-established Parent- Child Interaction Therapy. [54] Overall, the emerging brain-based parenting concepts could easily be applied to the dental setting. The dental provider must recognize what a child is experiencing in the moment before attempting to control uncooperative behaviors. Diagnosing the “why” of child behavior with the brain in mind becomes the first step in guiding unproductive behaviors in the dental setting. A reasonable next step is understanding the context from which the parent interacts with child and dentist. Finally, the dental provider can choose to employ classic behavior guidance techniques or apply contemporary parenting strategies to address the root of the child’s misbehavior (TABLE 2).
Discussion
The last major wave of scientific publications of the early 2000s that described changes in behavior management could have been related to the transition from one generation of children to the next. And now, dental professionals who provide care to children are on the verge of a fascinating period of transition. Family structure has continued to evolve, the effects of parenting on child development have been more clearly described and use of and approval of classic behavior guidance techniques have changed with the shifts in parental characteristics and values. And finally, the millennial generation is about to overtake Gen X as a representative proportion of parents.
Lukianoff and Haidt’s concept of “paranoid parenting” can provide a framework for understanding both the contemporary child and their parent, particularly parents representing the millennial generation. The “overparenting” that is proposed to take place in the context of increased imagined risk can lead to low self-esteem as adults. [55] Some studies have suggested that mothers use their children to confirm their role as parents and to create a positive self-presentation, which increases their own subjective well-being. [54] Fear of judgement by the dentist or dental staff may trigger a more intrusive parenting style to ensure patient cooperation. Further, parents of children with disruptive behavior are seldom given credit for their children’s strengths, but are often blamed for their children’s shortcomings or misbehavior. [54] This, in turn, may limit a child’s ability to express themselves appropriately or regulate their emotions and could interfere with psychosocial maturation. [55] There is some relationship between parental fear and the level of fear demonstrated by the child, so a fearful parent may predispose their own child to dental fear. Overall, because the dental environment can feel like a very invasive space, both contemporary parent and child are susceptible to overactivation of the lower brain alarm systems (RAGE, FEAR, PANIC/GRIEF). The aversive behavior guidance techniques have been demonstrated to be decreasing in use by pediatric dentists and acceptability by parents. Moreover, techniques such as hand-over-mouth exercise, protective stabilization or passive restraint, parental absence or voice control could actually activate these lower brain alarm systems in both parent and child. [17] Rather than initiating behavioral control, a more productive focus may be to guide emotional regulation with communicative behavior guidance approaches such as tell-show-do, descriptive praise, parental presence (in some cases) and positive reinforcement. Appreciating that delays in emotional regulation may be at the root of what seems to be a difficult child or parent can help guide dentists with a more empathetic approach to both the parent and child experience.
The concerns of Lukianoff and Haidt about the decline of free play and the increase in anxiety and depression seem to be rooted in a shift in contemporary life from the physical to the virtual. This will also have an impact on the relationship between dental provider, child patient and parent. Children with limited physical play opportunities can demonstrate decreased activation of the prosocial PLAY and SEEKING systems in the lower brain, which in turn can lead to heightened impulsive behaviors, decreased risk tolerance, overactivity and decreased stress regulatory mechanisms. [17] Limited free play also comes with limited opportunities to negotiate conflict. The contemporary child may find the highly physical world of the dental setting to be challenging and may not be accustomed to expressing concerns in a productive manner. The increase in use of handheld electronic devices for entertainment exacerbates the effects of less physical play. Virtual play does not activate the PLAY and SEEKING systems as effectively as physical play. Beyond that, the millennial parent has grown with technology and connectivity as a fundamental way of life. Parental distraction by their own handheld devices has implications on the social interactions for their children. As providers, communicative behavior guidance techniques like tellshow-do allow the dentist to model “an energized engagement” with the child [17] that may activate the brain’s SEEKING system and stimulate the activity of the upstairs brain — the rationale, decisionmaking and planning brain. [52] Playful and responsive interactions within the context of communicative behavior management approaches can also activate the brain’s PLAY system. Positive reinforcement and descriptive praise can also be effective in engaging the SEEKING system. Young children will work hard for praise and the feeling of self-mastery that accompanies the successful completion of a challenging task. The behaviors or qualities the adult praises are more likely to be displayed by the child in the future. [54] Appreciating that limited interpersonal interactions may also factor into behavioral response can likewise guide dentists toward a more integrated and positive approach to care.
Conclusions
Person-centered care requires more than a set of skills in behavioral control. In the context of the emerging millennial/ generation alpha parent/child dyads, the dental professional must be aware of the underlying circumstances that manifest as behaviors for both patient and parent. Dentists can use empathy, empowerment and strategies for vertical or horizontal brain integration of the upper and lower brain and the right and left brain respectively to help manage the child experience while also assuring the parent of attention beyond oral health to the whole brain and the whole child. Ultimately, providers must improve their ability to assess the child-parent experience to offer an individualized and efficient child-specific care plan that improves the efficacy of currently accepted behavior guidance techniques.
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C.E. CREDIT QUESTIONS
October 2021 Continuing Education Worksheet
This worksheet provides readers an opportunity to review C.E. questions for the article “The Millennial Family: Adapting Behavior Guidance to Contemporary Parenting” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please visit cdapresents360.com. This activity counts as 1.0 of Core C.E.
1. Drs. Law and Genish discuss which of the following in their article (mark all that apply):
a. The social shifts that have influenced the current living generations.
b. The remarkable consistency in parenting styles from generation to generation.
c. The changes in behavior guidance over the past 20 years.
d. New approaches to child behavior management in the dental practice.
2. The primary lower “reptilian” brain systems that function as “calm systems” and promote higher brain development when activated are which of the following (mark that all that apply):
a. PLAY
b. SEEKING
c. CARE (attachment)
d. REST
3. Which of these is not a function of the lower brain PLAY system (mark all that apply):
a. Activates neurotransmitters that promote higher brain development
b. Increases impulsivity and overactivity
c. Activates antistress mechanisms
d. Develops emotional regulation
4. Which of these are associated with the SEEKING system (mark all that apply):
a. Motivates exploration
b. Releases opioids that have an anti-anxiety effect
c. Is activated by virtual gaming
d. Is activated by interpersonal interaction
5. The shift in contemporary life from the physical to the virtual and an associated decline in free play may result in decreased activation of the prosocial PLAY and SEEKING systems, which in turn can lead to which of the following in children (mark all that apply):
a. Decreased stress regulatory mechanisms
b. Decreased risk tolerance
c. An increase in impulsive behaviors
d. An increase in anxiety and depression
6. The authors suggest that dental professionals who provide care to children are on the verge of a period of transition, where evolving family structure, the effects of parenting on child development and the use of and approval of classic behavior guidance techniques have changed with the shifts in parental characteristics and values.
a. True
b. False
7. According to American Academy of Pediatric Dentistry guidance, which of the following is not applicable to “protective stabilization” for children:
a. Includes both active restraint (physical limitation by an individual) and passive restraint (physical limitation by restrictive equipment such as the papoose board)
b. Has been reclassified as an advanced behavior guidance technique, recommended for use only by specialists or individuals with advanced training
c. Is considered appropriate when used for practitioner’s convenience
d. Is contraindicated in a cooperative nonsedated patient or those with nonemergent needs
8. According to an American Academy of Pediatrics policy statement, families should be a child’s primary source of strength and support. Consequently, in a person-centered care approach to providing dental care, parental approval of care techniques is an essential component of high-quality clinical decision-making.
a. True
b. False
9. Research shows that rather than utilize methods such as passive restraint that may activate the lower brain’s alarm systems, a more productive focus may be to guide a child’s emotional regulation with which of the following communicative behavior techniques(mark all that apply):
a. Descriptive praise
b. Voice control
c. Positive reinforcement
d. Tell-show-do
10. Emerging science on the developing brain suggests that young children lack the ability to integrate the functions of the “left brain,” which is logical, linear and linguistic (likes words), and the “right brain,” which identifies the “meaning and feel of an experience.” Which of the following are suggested by the authors’ discussion on right- and left-brain function in children (mark all that apply):
a. A child may overreact to difficult situations with either right brain “chaos” or left brain “rigidity.”
b. Parents and caregivers can assist the “horizontal integration” of the two hemispheres by identifying which hemisphere of the brain is in function during conflict and engaging appropriately, either with logic and solutions or with empathy and emotion.
c. Regardless of a child’s emotional response, they should be quickly redirected to use their left brain by giving them solutions, providing logical explanations, or setting boundaries.
d. This brain-based parenting concept can be applied to the dental setting.
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THE CORRESPONDING AUTHOR, Clarice Law, DMD, MS, can be reached at claw@dentistry.ucla.edu.
