Behavioral interventions for children's visits to the dentist by Edgar Salgado García

Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Edgar Salgado Garcia Southern Illinois University at Carbondale

Behavior Analysis and Therapy Program Rehabilitation Institute Spring 1998

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Abstract

This paper presents an overview of the major behavioral techniques for managing uncooperative child behavior during dental visits. The first section focuses on interventions that are scheduled prior to visiting the dentist, such as filmed modeling, desensitization, and coping skills training. The second section includes a detailed review of five published reports in which various behavioral procedures were used to manage disruptive child behavior in dental settings. They exemplify the use of reinforced practice, modeling, escape contingencies, and distraction. A brief review is made of some considerations for managing special populations (e.g., the developmentally disabled). The conclusions emphasize the contributions of these studies as well as their importance for pediatric dentistry.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Introduction

A visit to the dentist is often a fearful experience for a child. The dental operatory is a novel environment for the young child. There are strange people who insert metallic instruments into his/her mouth, strange sounds, smells, and even a posture in which the child might feel helpless. Surveys among pediatric dentists in the United States have revealed that one of the major problems that dentists face in clinical practice is the child’s noncompliance (Allen, Stark, Rigney, Nash, & Stokes, 1988). Disruption or noncompliance during dental treatment is detrimental to the child, as it increases the likelihood of his/her own injury and affects the quality of the dentist’s work. Fearful children usually display a number of inappropriate behaviors that interfere with the dental procedure, such as crying, refusal to open the mouth, verbal complaints, kicking, and leaving the chair (Melamed, Weinstein, Hawes, & Katin-Borland, 1975). It has been suggested that a child’s first visit to the dentist may be a cause of dental fears and anxiety in adulthood (Morgan, Wright, Ingersoll, & Seime, 1980). It is estimated that in industrialized countries more than 50% of the population report at least some fear of dental treatments (Poulton, Thomson, Davies, Kruger, Brown, & Silva, 1997). Another reason for using behavior management procedures is the challenge posed by the disruptive behavior of special children (e.g., extremely fearful, developmentally disabled) during dental treatment. Nathan (1989) reviews some of the aversive and more intrusive techniques used by some dentists. These include the use of physical restraint, the “hand-over-mouth” technique, sedation, and even general anesthesia. Some studies have focused on managing developmentally disabled children (Boj & Davila, 1995), and children with attention-deficit hyperactivity disorder (Friedlander & Friedlander, 1992). A number of behavioral interventions for managing disruptive children during dental treatment have been developed over the last 20-25 years. The first studies included the use of modeling (Melamed, Hawes, Heiby, & Glick, 1975), and desensitization (Machen & Johnson, 1974). In the Journal of Applied Behavior Analysis, relatively few studies have been published on this topic. The first was by Stokes and Kennedy (1980), who implemented modeling and reinforcement to reduce uncooperative

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

behavior during dental treatment in a group of children. The most recent is a study by Allen, Loiben, Allen, and Stanley (1992), in which dentist-implemented contingent escape was used for managing disruptive behavior. Most research has been published in dental journals, such as the Journal of Dentistry for Children, the Journal of the American Dental Association, and the Journal of Dental Research. The Journal of Dentistry for Children features a periodic section titled “Behavior”, in which articles on behavioral management are published. This, once again, attests to the importance of this issue in pediatric dentistry. In fact, it has been suggested that effective management of child behavior is the most important responsibility of pediatric dentists (Boj & Davila, 1995). It should be noted that not all interventions to manage child behavior during dental visits are strictly behavioral in orientation. Sometimes other theoretical frameworks are used in combination with behavioral principles. For example, Pinkham (1993) used psychoanalytic theory to explain why children do not comply with the dentist’s requests. He argued that not only fear causes noncompliance, but also power struggles and internal needs for being “in control” of the situation. Also, a study by Klingberg and Hwang (1994) validated a projective test for the assessment of child dental fear. Some studies have also used psychometric approaches for constructing instruments to measure anxiety and fear. One of the most commonly used for children is the Dental Subscale of the Children’s Fear Survey Schedule (CFSSDS), developed by Cuthbert and Melamed (1982). As an example, Table 1 presents a self-report questionnaire used by Parkin (1989) in a study of validation of a scale for rating children’s dental anxiety. One of the major behavioral interventions consists of acquainting the child with the dentist’s instruments, allowing the child to ask questions (Pinkham, 1993). Others use behavioral techniques such as positive and negative reinforcement (Allen & Stokes, 1987). Another approach is the use of distraction (Stark, Allen, Hurst, Nash, Rigney, & Stokes, 1989). Some of these techniques are more difficult to implement than others, in terms of time, effort, and money. For this reason, dentist-implemented procedures are becoming more popular, as they are more cost-efficient (Allen et al., 1992).

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

In the following sections, a review of the major intervention approaches will be presented. First, there will be a consideration of techniques for preparation for dental treatment. These are used in order to reduce fear or anxiety prior to the actual visit to the dentist. Some include reinforced practice, modeling, information, and coping. Then a number of behavior management techniques for disruptive behavior during the dental procedure will be discussed.

Preparation for dental treatment

Several behavioral interventions have been developed for helping children cope with the anxiety associated with medical treatment. Although the focus of the this section is on preparation for dental procedures, a brief discussion will be presented of the major techniques that have been used for managing anxiety in children. Some of these procedures are also used in preparation for dental treatment (Zastowny, Kirschenbaum, & Meng, 1986). Melamed (1988) discusses three important factors that should be considered when preparing children for medical procedures in general. The first one is the mother’s role. This factor has been recognized by some authors (Bush, Melamed, Sheras, & Greenbaum, 1986) as a potential for enhancing the child’s coping with anticipatory anxiety. Based on social learning theory, live modeling has been used to reduce the fear of the child. However, mothers (and also fathers) can be trained through visual modeling so that they can coach their children. In the study by Zastowny et al. (1986), parent relaxation training, information provision, and a videotape which demonstrated active parent-coached relaxation and imagery techniques were compared. Thirty-three parent-child dyads participated in the study. The mean age of the children was 7.2 years. Parent-child pairs were randomly assigned to one of three comparison groups, each of which received the above mentioned procedures. In the relaxation training group, both the parent and the child were taught relaxation procedures. Parents in the coping skills group (active parent-coached relaxation) learned how to use self-talk techniques, along with the relaxation training. In the information provision group, parents and children were provided with information

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

describing hospitalization and surgery experiences with a puppetry film viewed one week prior to the child’s hospitalization. The authors found that the relaxation training and coping skills groups, compared to the information group, reduced the children’s selfreported fearfulness as well as the parents’ reported distress. Children in the two first groups also displayed less maladaptive behaviors as evidenced by direct observation prior to and after the surgical procedure. Another factor that influences a child’s reaction to medical treatment is prior experience or learning. Not only is the number of times that a child has had a medical treatment important, but also the quality of his or her experience (Melamed, 1988). For example, it has been documented that negative experiences with a dentist is a factor in the development of dental anxiety and fears in children and adolescents (Milgrom, Mancl, King, & Weinstein, 1995). The study by Milgrom et al. (1995) examined the prevalence of dental fear in a sample of 895 low-income children in Seattle. Children between the ages of 5 and 11 and their mothers or guardians were interviewed and completed the dental subscale of the Children’s Fear Survey Schedule (CFSS). The results indicated that, controlling for gender, age, mother’s education, and mother’s rating of the availability of dental care, children who were more fearful of the dentist were those who had poor oral health and had treatment for toothache or extraction of a tooth. Also, children with a parent or guardian that has moderate to high dental fear were found to be twice as likely to be fearful of the dentist that children whose parents showed low dental fear. It is also noted by Milgrom et al. (1995) that children who have frequent illnesses are also more likely to have poor oral health. These children are also more likely to have both medical fears in general, and dental fears in particular. Milgrom et al. (1995) also discuss the possibility that dental fears may be acquired through modeling by parents or siblings, and also through “threatening information” (negative verbal reports by parents, siblings or others). The third factor related to medical fears discussed by Melamed (1988) is coping style. Peterson and Toler (1986) conducted a study in which information-seeking about medical treatment was assessed in a group of 59 children (with a mean of 7 years of age) undergoing medical procedures. These authors argued that an important dimension of

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

children’s coping with medical stress was the frequency with which they asked questions to medical staff and parents about what was going to happen (or what was happening) during treatment. Peterson and Toler (1986) argue that children who ask more questions show less anxiety that those who try to ignore what is happening during a medical procedure, such as the induction of anesthesia or a blood test. As can be seen, procedures for preparing children for medical treatment have focused on providing information, training children and their parents in relaxation training or coping skills, and modeling (Melamed, 1988). In the specific case of dental fear and anxiety, similar procedures have been used (Melamed & Siegel, 1980). An early study by Machen and Johnson (1974) explored the use of “modellearning” for reducing children’s anxiety. Thirty-one children, 3 to 5 years of age, were randomly assigned to a control, preventive desensitization, or model-learning group. Children in the desensitization group were gradually exposed to anxiety-inducing stimuli, starting with relatively low-anxiety stimuli such as prophylaxis and radiographs, and then going on to high anxiety inducing stimuli such as the injection of anesthetic and the sound of the drill. Children in the model-learning group viewed an 11-minute videotape of a child showing positive behavior during dental treatment and being verbally reinforced by the dentist. Children in the control group did not receive any training. The results of this study indicated that children in the experimental groups were rated as displaying significantly more positive behaviors than children in the control group. No statistically significant differences were found between the preventive desensitization and the modellearning groups. Another study by Melamed et al. (1975) used filmed modeling to reduce disruptive behavior during dental treatment. Sixteen children, 5 to 11 years of age, participated in the study. Children were matched on age, gender, socioeconomic status, and initial scores on the Children’s Fear Survey Schedule (CFSS), modified with dental items. Then they were randomly assigned either to a modeling group or a control group. The major dependent measure was a behavior profile rating, which included categories of disruptive behavior, such as crying, refusal to open the mouth, white knuckles, rigid posture, verbal complaints, and kicking.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Children in the control group viewed a videotape of a child engaging in behavior unrelated to dental treatment. Children in the filmed-modeling group watched a 31minute videotape showing an initially fearful child treated by a friendly dentist, who reinforced positive behavior and told the child that there was nothing to fear. The dentist also gave the child a toy at the end of the visit (in the videotape). The results showed that children in the modeling group showed significantly fewer disruptive behaviors. They were also rated as showing less anxiety by independent raters and the dentist than children in the control group. A study by Nocella and Kaplan (1982) also addressed preparation for dental treatment. They used stress inoculation and compared it with a no-treatment control condition, and an “attention” control condition. Thirty children, 5 to 13 years, were randomly assigned to three groups prior to receiving dental treatment. Children in the stress inoculation (also called cognitive-behavioral) group were taught to identify stimuli which might induce arousal, to use deep breathing exercises, and to relax specific muscle groups. Also, the experimenters taught the children to imagine the dental procedure and to say positive self-statements, such as “I tell myself, this is a good dentist, I’m doing good, I can handle this”, etc. Children in the “attention” control group were given attention by the experimenters by 15 minutes. They talked about school, summer vacation, pets, hobbies, movies, and other subjects. Children in the no-treatment control group did not receive attention by the experimenters, nor did they participate in the cognitive-behavioral intervention. The dependent measure used categories such as facial grimaces, restlessness, moving arms and/or legs, sitting up, gripping the chair, and verbalizations. A score was obtained by dividing the frequency of responses in each category by the length of the dental procedure. The results of this study indicated that the cognitive-behavioral intervention significantly reduced stress-related behaviors as compared to the control groups. A statistical analysis of contrasts showed that there were no significant differences between the “attention” and the no-treatment control groups. Overall, these studies show how pre-treatment interventions may help to reduce anxiety and disruptive behavior in children undergoing dental treatments. Relaxation,

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

modeling, and stress coping strategies were used in the reviewed studies, all of them showing positive effects on anxiety and negative behaviors as compared to control conditions. Since modeling, and especially filmed modeling, has been commonly used as a preparation technique (Melamed & Siegel, 1980), some considerations about its effectiveness are worth noting. First of all, watching a model behave does not necessarily mean that the child will imitate or learn from it. According to Melamed and Siegel (1980), important variables associated with the effectiveness of modeling include the perceived similarity between the model and the observer, the use of multiple models, and also the time when the modeling is presented in relation to the medical procedure. For example, studies of filmed modeling in preparation for surgery have found that girls imitated both boys and girls similarly, but boys were more likely to imitate other boys than to imitate girls. Also, studies have shown that modeling is most effective when implemented just before the medical procedure (Melamed & Siegel, 1980). Generalizations between medical treatment in general and dental procedures have been made throughout this section. In fact, several aspects of the interventions, as it has been pointed out above, are very similar (i.e., providing information, teaching parents and children to relax). These procedures are implemented prior to the dental treatment. In the next section, interventions that are used mainly during the actual dental treatment will be discussed. Some of them involve a combination of pre and during dental treatment interventions.

Management of disruptive behavior during dental procedures

Behavioral interventions for managing disruptive child behavior during dental treatment basically include the use of reinforced practice, distraction, positive reinforcement, and escape contingencies (Allen et al., 1988). In this section, a review of selected studies will be provided. Each of these studies exemplifies the major approaches to managing disruptive behavior.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Study 1: Reinforced practice In the study by Allen et al. (1988), reinforced practice was the technique of choice for promoting cooperative behavior during restorative dental treatment. Two children (both age 3) participated in the study. These children were observed to be physically aggressive with dental staff, and required physical restraint during most of the sessions. Previous unsuccessful attempts were made to manage their disruptive behavior through prizes and distraction. Four categories of disruptive behavior were recorded within 15-second intervals. They included head movements, body movements, crying and complaining, and body movements requiring physical restraint. The dentist and the dental assistant were also provided with a 6-point rating scale for them to rate the children’s behavior during treatment. They were rated from 1 (extremely cooperative or relaxed) to 6 (extremely uncooperative and anxious). Dental staff were to rate the children 20 seconds after the children entered the room and after each major procedure (e.g., injection, drilling, restoration), and also at the end of the session. A multiple baseline across subjects was used, and the children were observed over 6 sessions of restorative dental treatment. During baseline, dental staff praised the children for compliance and gave them a toy after the session regardless of their behavior. The reinforced practice condition, the children were brought into the operatory individually before the session and were given the opportunity to practice lying still and remaining quiet. The experimenter manipulated the drill and other instruments. Children were required to remain calm for a few seconds, and the time requirement was gradually increased to 30 seconds. They were rewarded with praise and stickers, and also with inexpensive toys that were awarded if they earned five stickers during the practice sessions. The results of this study demonstrated that the reinforced practice sessions were associated with a reduction in inappropriate behaviors. Figure 1 shows the percent of the children’s disruptive behavior in 3 minute blocks during baseline and experimental conditions. The dentist’s ratings of the children were correlated with the observed decrease in disruptive behavior. During treatment, dental staff rated the children as more cooperative and less anxious than during baseline.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Study 2: Modeling and reinforcement Another study, by Stokes and Kennedy (1980) exemplifies the combined use of modeling and reinforcement in reducing child uncooperative behavior during dental treatment. In this study, 8 children, age 7, served as subjects. Four categories of disruptive behavior, similar to the ones scored in the Allen et al. (1988) study, were recorded within 15-second intervals. They included head movements, body movements, crying/complaining/moaning, and any behavior which caused a delay in dental work for a continuous 5 seconds or more. Percent of disruptive behaviors were summarized for 10minute intervals of dental treatment. A multiple baseline across subjects was used as the experimental design. During baseline, the children were instructed by the dental staff to remain quiet. All procedures were explained to the children, as well as the sensations that they could expect. Staff praised the child for compliance, and ignored uncooperative behavior. At the end of the session, the child was given a smile stamp on the hand, regardless of his or her behavior. As it can be seen, this baseline was not a no-treatment condition, but rather an active treatment. During intervention, all the above components described for the baseline condition were included, and others were added. First, if cooperative behavior was displayed by the child, he or she was given the capsule in which the amalgam was mixed (the material to fill decaying teeth). The capsule was painted with different colors each session. Also, the child was allowed to raise the next child in the dental chair, by operating a foot pedal and a hand lever, with the dental nurseâ&#x20AC;&#x2122;s supervision. Second, the children came to the visit approximately 10 to 15 minutes early and were invited to watch the prior child undergo treatment (this was the modeling component). Also, the prior child was invited to watch the next child during treatment. In the results and discussion sections of the article, the authors conclude that tangible reinforcement and observation of and by peers were effective in reducing uncooperative behavior in these children. Their behavior after treatment was considered by the dental staff as acceptable. A strong point about this study is that the authors used continuous and detailed observation procedures, as opposed to rating scales, such as the

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

ones used, for example, in the Nocella and Kaplan (1982) study described earlier. Figure 2 shows the percent of uncooperative behavior for the children during baseline and intervention conditions. It should be noted that in this study, as opposed to the ones described before (Machen & Johnson, 1974; Melamed et al., 1975), used the modeling procedure during restorative treatment. The other studies used modeling before treatment began (i.e., before the first session of restorative treatment).

Study 3: Escape and positive reinforcement The next study to be reviewed was authored by Allen and Stokes (1987), and involved the use of escape and reward in order to promote cooperative behavior during dental treatment in young children. Five children, 3 to 6 years, participated in the study. They were referred by pediatric dentists because of excessive disruptive behaviors, such as kicking, screaming, hitting, and noncompliance. One of the subjects, a 6-year-old girl, exhibited periodic episodes of vomiting. The dependent measures included four categories of behavior (head and body movements, crying/gagging/moaning, and physical restraint). These responses were scored within 15-second intervals. Dental procedures were also scored (exploration, water/suction, injection, placement of the rubber dam, drilling, and restorative procedures) during the intervals. The dentist and the assistant also scored the children on a 6-point rating scale identical to the one described in the Allen et al. (1988) study presented earlier. Physiological measures were also obtained (heart rate and blood pressure) every two minutes using special instruments. A multiple baseline across subjects was used as the experimental design. The baseline condition was similar to the one described in the Stokes and Kennedy (1980) study. The dentist explained the procedures to the child, described what he or she might feel, praised the child for cooperative behavior, and gave him or her a prize at the end of the session if less than 30% disruptive behavior occurred. The treatment condition included a reinforced practice component, similar to the one reported by Allen et al. (1988) and described above. However, an escape component was introduced. As in the Allen et al. (1988) experiment, the experimenters told the child that he or she would have a chance to practice before the visit, but also told him or her

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

that whenever they were cooperative, then the dental procedure would be temporarily stopped. During uncooperative behaviors, the dentist and the assistant turned their faces away from the child and stopped talking, but continued to perform the dental procedure. The criteria for periods of cooperative behavior were gradually increased from 3 to 30 seconds. Then, a mastery test was conducted, in which the child was exposed for one minute to each of six dental procedures (e.g., exploration, injection, drilling). Children were considered to have mastered the procedures when they exhibited less than 30% uncooperative behavior. The authors point out that past research with large samples of children has shown that dentists consider 30% disruptive behavior to be acceptable for performing dental procedures. It is important to note that during reinforced practice the actual dental work is not done. Practice takes place in the same setting (i.e., same room where actual treatment will take place) and using the real instruments. However, needles are removed from the syringes, and the drill bit is not used, in order to ensure the childrenâ&#x20AC;&#x2122;s safety. The intervention also included delivery of stickers contingent on cooperative behavior. The child could earn up to six stickers that were put on a card attached to the dental light where the child could see it. At the end of the practice session, the dentist presented the child with a toy if he or she displayed less disruptive behavior than the set criterion. Then, the dentist told the child that he or she could take the toy home only if he or she was cooperative during the actual dental procedure. The results of this study showed that all five children displayed considerably less disruptive behavior during the intervention condition as compared to the baseline condition. Dental staff ratings of the children also improved from baseline to intervention. During baseline, all children had scores above 3, and at the end of the intervention, all of them had scores below 1.5 for cooperation and 2.0 for anxiety. Small changes were noted in the physiological measures. The authors discuss that the escape contingencies used allowed for a positive behavior (cooperation) to temporarily terminate the aversive stimuli (e.g., drilling), instead of the usual disruptive behavior. The fact that disruptive behavior used to result in termination of the dental procedure is discussed as a source of negative reinforcement

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

for uncooperative behavior. The authors also make a point about the potential use of these behavioral techniques by dentists during regular dental treatment:

...the use of escape and attention contingent on cooperative behavior could be implemented as a regular feature of restorative treatment. The procedure-related interruptions during treatment caused by the escape contingency could gradually be reduced until escape would be a natural product of the rapid completion of each dental procedure. Since children who become compliant and cooperative early in treatment are more likely to earn the positive attention of the dentist and dental assistant, appropriate behavior would likely be strengthened and maintained (Allen & Stokes, 1987, p.389).

Study 4: Distraction Another study by Stark, Allen, Hurst, Nash, Rigney, and Stokes (1989) evaluated distraction as a technique for managing disruptive behavior during dental treatment. Four male children, ages 4 to 7, referred from a pediatric clinic for excessive levels of anxious and disruptive behavior, which included kicking, screaming, and noncompliance. The dependent measures included the Anxious and Disruptive Behavior Code (ADBC), presented in Table 2. This is the same code of four categories used in the Stokes and Kennedy (1980) study and others described above. Occurrence of these behaviors was scored within 15-second intervals. Dental procedures were also scored, using the Dental Procedures Code (DPC). The DPC includes six common dental procedures,: explorer, injection, rubber dam, drilling, water suction, and restorative procedures (e.g., amalgam, filling, and extraction). A 16-item quiz was administered to the children to assess whether or not they were paying attention to the distraction stimuli. The dentists also completed two 6-point rating scales, one for anxiety and the other for cooperative behavior. The experimental design was a multiple baseline across subjects. During baseline, the dentist described the procedure and the sensations that the child was to experience, praised the child for cooperative behavior, and gave him a balloon and a trinket at the end of the session, regardless of his behavior. The distraction condition consisted of placing a poster depicting colorful scenes, animals and children above the

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

child during dental work. A Walkman tape player with earphones was used to play a tape telling a story about the poster while the child was treated by the dentist. During the last day of baseline, a graduate student taught the child to use repetition (saying things to himself) as a means to remember the information presented in the poster and the audiotape. At the end of the session, the child was given a quiz about the poster and story. During intervention, the child was told that he would earn a toy or a chance to play a video game if he answered some questions about the poster and the story. If the child answered 65% of the questions correctly, he received the toy or played the video game. All children showed a reduction in disruptive behavior during the first distraction session. However, disruptive behavior increased over sessions in two children. The results are presented in Figure 3. Dentist’s ratings also showed an improvement, as the children were rated as more cooperative and less anxious during the intervention condition. An interesting finding was that the children who had more than one intervention session actually got worse during subsequent visits. The authors hypothesize that this might be due to escape contingent on disruptive behavior. Also, they argue that it might also be due to the children’s experience with the poster and story, since they learned, over subsequent visits, that they could be disruptive and still answer the questions correctly and earn the prize. The authors conclude that even though distraction was effective at first, it did not sustain behavior change, and thus it was not effective.

Study 5: Dentist-implemented contingent escape The last study to be reviewed in detail was by Allen et al. (1992), and focused on dentist-implemented contingent escape for management of disruptive behavior during dental treatment. Four children, ages 3 to 7, participated in the study. All children were referred for disruptive behavior. The dependent measures included two categories of disruptive behavior from the ADBC (see Table 2), namely: body movements and crying, moaning, and complaining. These behaviors were scored in 15-second recording intervals. The dentists also rated the children using a 6-point Likert-type scale. To ensure the integrity of the independent variable, the dentist’s implementation of the escape contingency was also scored.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

The experimental design used was a multiple baseline across subjects. As in the previous experiment, the dentist described the procedure and sensations, praised the child for cooperative behavior, and gave him or her a toy at the end of the session, regardless of his or her behavior. During training, the dentist was taught to use the escape contingency. The escape condition consisted of the dentistâ&#x20AC;&#x2122;s stopping the procedure when the child was quiet and calm for 3 seconds. The criterion was gradually increased to 20 seconds. Disruptive behavior was ignored, and the dentist reminded the child once that he or she had to remain quiet in order for him to stop for a while. If the child was still uncooperative, the dentist was to simulate continuing work, until the child displayed cooperative behavior. Figure 4 presents the percent of disruptive behavior for all children during baseline and intervention conditions. As can be seen in the graphs, all children showed a decrease in disruptive behavior. However, on some occasions the dentist did not implement the escape contingency as desired, and this was associated with more disruptive behavior. The authors conclude that temporary escape contingent on cooperative behavior was effective for managing difficult children in the dental operatory. A problem in this study was that the dentists did not adhere to the treatment specifications. The authors make the following remarks:

They key to promoting general acceptance of this type of procedure may be in its introduction during graduate and postgraduate training. This is consistent with a recent mandate from the American Association of Pediatric Dentistry, which called for increased attention to nonaversive, nonpharmacological behavior management techniques with an emphasis on demonstrations of competence with these techniques at the predoctoral level (Allen et al., 1992, p.635).

This commentary is important, since management of child behavior is one of the major issues in pediatric dentistry (Melamed, B.G., Bennett, C.G., Jerrell, G., Ross, S.L., Bush, J.P., Hill, C., Courts, F., & Ronk, S., 1983). A study by Nathan (1989) revealed that 85% of the 616 pediatric dentists surveyed in 48 states of the United States use

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

nitrous oxide anesthesia in 35% of their patients. Other “traditional” techniques for managing difficult children include physical restraint (used by 4% of the surveyed dentists), and the “hand-over-mouth” technique (used by 66% of the dentists but only in about 2% of their patients). It seems like dentists are in need of more training in behavioral management techniques. As demonstrated in the reviewed studies, it is possible to manage difficult children, even as young as age 3, with appropriate behavioral strategies. Therefore, more research is needed not only in specific techniques, but also in the way to promote and teach these techniques to dental staff. It may be understandable that some dentists could be discouraged when facing extremely difficult to manage children (e.g., handicapped, ADHD). In the next section, a brief discussion of some of these cases will be made.

Management of special children during dental treatment

The study by Nathan (1989) found that nearly 50% of the pediatric dentists surveyed indicated that they would use some kind of anesthetic for working on a 15-yearold Down syndrome patient with extensive caries. In some cases dentists considered the use of physical restraint (9%) when faced with difficult-to-manage children. Currently, dentists are advised not to use pharmacologic procedures unless it is absolutely necessary. A major concern is the child’s safety during the dental procedure. Some studies have used modeling and desensitization as preparation for dental treatment in developmentally disabled preschool children. A study by Boj and Davila (1995) assessed the effectiveness of a modeling and desensitization tape-slide series (audio tape and slides) shown previous to a dental visit to developmentally disabled children in the United States. They then replicated the procedure with normal children in Spain. The slides showed a professional clown and a 4-year-old girl going through a dental examination. The visit was divided into six segments: Patient positioning, oral examination, prophylaxis, taking x-rays, fluoride application, and the end of the appointment. The tape lasted 33 minutes, and explained what happened during a child’s

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

first visit to the dentist. A Modified Melamed’s Behavioral Rating Scale (see Table 3) was used as one of the dependent measures, along with a dentist’s rating and heart rate. The results suggested that the tape-slide instrument was not useful in reducing uncooperative behavior in developmentally disabled children in the United States (ages 3 to 4 years), but it was effective with normal children in Spain. However, the only measures sensitive to the experimental manipulation were the dentist’s rating and the heart rate measures. Apparently, the results obtained using the Modified Melamed’s Behavioral Rating Scale were not significant between the experimental and control groups with normal children. The authors concluded that: In our opinion the fact that the children had different cultural backgrounds (the studies were performed in different countries, Spain and the United States) does not explain the results. The developmentally disabled children were excited by the technique, but probably could not understand and elaborate the information given, and caused them increased awareness of suspected dental problems. The desensitization and modeling experienced by normal children were extremely helpful. The results of the study showed that anticipation of what will happen in the examination is useful for normal children (Boj & Davila, 1995, p.55-56). According to the authors, more research is needed in devising appropriate interventions with developmentally disabled children. Other techniques that have been used with severely retarded children is to give them drops of fruit juice contingent on cooperative behavior (Stokes & Kennedy, 1980). Behavioral management of ADHD children has also been a concern, as these children often display disruptive behavior during dental visits. Recommendations include scheduling appointments in the morning when the children are least fatigued, and the use of simple and repeated instructions and descriptions of the dental procedures (Friedlander & Friedlander, 1992).

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

A critical analysis of the reviewed literature Dentists’ behavior affects compliance and fear in children during dental visits, as evidenced in a study by Melamed, B.G., Bennett, C.G., Jerrell, G., Ross, S.L., Bush, J.P., Hill, C., Courts, F., & Ronk, S. (1983). They found that aversive techniques, such as criticism, led to uncooperative behavior. Positive reinforcement and escape contingencies were found to be the techniques of choice. Since management of child behavior during dental treatment is a basic issue in pediatric dentistry, the development of an effective behavioral technology is extremely important. The reviewed articles contribute to such a technology in a variety of ways. First of all, coming from a behavior analysis perspective, they provide a systematic method for observing and recording child behavior. Allard and Stokes (1980) consider continuous observation as one of the major contributions of behavior analysis to the management of disruptive children during dental visits. They showed how time-sampling observation systems are useful for obtaining a detailed record of a child’s behavior throughout a dental appointment. While some studies have relied on surveys and questionnaires with hypothetical situations (Weinstein, Milgrom, Hoskuldsson, Golletz, Jeffcott, & Koday, 1996), in which children are asked to rate situations related to a dentist’s visit, behavioral observation methods have focused on the actual behavior, as it takes place, using detailed observation codes. Other studies have used subjective ratings completed by the dentist and other rating scales, but these seem to provide only indirect pictures of the child’s behavior. Another important contribution of the studies is the provision of a basis for a functional analysis of child uncooperative behavior during dental visits. This was attempted in the study by Allen and Stokes (1987). For example, they found that earning a prize was not crucial for reducing uncooperative behavior, but that it was effective only when the reinforced practice was present. They also used an escape contingency that was effective in reducing disruptive behavior. However, they did not conduct a thorough functional analysis, such as systematically introducing and/or eliminating stimuli.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

The Stark et al. (1989) study contributed to assessing maintenance of the cooperative behaviors. They found that distractors did work initially, but were not effective in maintaining cooperative behavior in subsequent dental appointments. It seems like one major limitation of these studies is that they combine several techniques, but they have not addressed the issue of which components are essential for the effectiveness of the intervention. Although it is noted as part of the observations, studies are lacking in a systematic approach to identifying essential components. As behavioral technologies may be costly and/or difficult to teach and implement for dental staff, they should be refined in order to come up with techniques that are as simple as possible, yet effective. Single-subject designs seem to be the research designs of choice for this task. However, group designs, such as mixed (between and withinsubjects) designs, could also be used. For example, groups could be formed on the basis of the type of intervention or component, with repeated measures of cooperative behavior throughout the appointments. Since dental disease is so prevalent among children, behavior analysis could not only contribute in developing behavioral interventions for use during dental treatment, but also to prevent disease. Some studies have focused on encouraging low-income parents to seek dental care for their children (Reiss & Bailey, 1982; Reiss, Piotrowski, & Bailey, 1976). Other studies have attempted to teach tooth-brushing skills to normal and handicapped children (Melamed & Siegel, 1980). Being pediatric dentistry behavior management an area with so much potential for research and application, it is ironic that relatively few studies have been published in the Journal of Applied Behavior Analysis. The literature in Behaviour Research and Therapy seems to be more focused on anxiety models of the acquisition of dental fears, and also on psychometric methods for assessing dental fear. The articles in the Journal of Pediatric Dentistry are somewhat eclectic, but the majority of them have a behavioral orientation. While many of the authors are behavioral psychologists or practitioners, some of them are dentists with an interest in behavior management. However, some of them do not apply behavior observation adequately, and rely more on rating scales or psychometric instruments (for example, Boj & Davila, 1992).

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Conclusions

As concluding remarks, some recommendations for future research in the area of child behavior during dental treatment are:

1. Functional analyses of uncooperative behavior in order to identify the specific contingencies and stimuli that maintain this class of behavior.

2. Identification of essential components of the treatment packages, through systematic single-subject research.

Identification of interventions that work best with certain special populations, such as

developmentally disabled and severely retarded children.

4. Research with different age populations, as some techniques may be suitable for older children, but not with younger ones. Conversely, some techniques that are effective for younger children may be supplemented or modified (or changed altogether) with older children. 5. Research on how to disseminate these techniques among dentists and other dental staff, and on how to teach these techniques to them.

6. Increase the use of social validation, especially the acceptability of these techniques, not only among dentists, but also among parents and the children themselves. In fact, most of the studies reviewed in this paper did not include data on social validity.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

References

Allard, G.B., & Stokes, T.F. (1980). Continuous observation: A detailed record of children’s behavior during dental treatment. Journal of Dentistry for Children, JulyAugust, 246-250. Allen, K.D., Loiben, T., Allen, S.J., & Stanley, R. (1992). Dentist-implemented contingent escape for management of disruptive child behavior. Journal of Applied Behavior Analysis, 25, 629-636. Allen, K.D., Stark, L.J., Rigney, B.A., Nash, D.A., & Stokes, T.F. (1988). Reinforced practice of children’s cooperative behavior during restorative dental treatment. Journal of Dentistry for Children, July-August, 273-277. Allen, K.D., & Stokes, T.F. (1987). Use of escape and reward in the management of young children during dental treatment. Journal of Applied Behavior Analysis, 20, 381-390. Boj, J.R., & Davila, J.M. (1995). Differences between normal and developmentally disabled children in a first dental visit. Journal of Dentistry for Children, January-February,52-56. Bush, J.P., Melamed, B.G., Sheras, P.L., & Greenbaum, P.E. (1986). Motherchild patterns of coping with anticipatory medical stress. Health Psychology, 5,137-157. Cuthbert, M.I., & Melamed, B.G. (1982) A screening device: Children at risk for dental fears and management problems. Journal of Dentistry for Children, NovemberDecember, 432-436. Friedlander, A.H., & Friedlander, I.K. (1992). Dental management considerations in children with attention-deficit hyperactivity disorder. Journal of Dentistry for Children, May-June, 196-201. Klingberg, G., & Hwang, C.P. (1994). Children’s dental fear picture test (CDFP): A projective test for the assessment of child dental fear. Journal of Dentistry for Children, March-April, 89-96. Machen, J.B., & Johnson, R. (1974). Desensitization, model learning, and the dental behavior of children. Journal of Dental Research, 53, 83-87. Melamed, B.G. (1988). Current approaches to hospital preparation. In B.G. Melamed, K.A. Matthews, D.K. Routh, B. Stabler, & N. Schneiderman (Eds.), Child health psychology (pp.173-182). Hillsdale, NJ: Lawrence Erlbaum Associates.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Melamed, B.G., Bennett, C.G., Jerrell, G., Ross, S.L., Bush, J.P., Hill, C., Courts, F., & Ronk, S. (1983). Dentists’ behavior management as it affects compliance and fear in pediatric patients. Journal of the American Dental Association, 106, 324-330. Melamed, B.G., Hawes, R.R., Heiby, E., & Glick, J. (1975). Use of filmed modeling to reduce uncooperative behavior of children during dental treatment. Journal of Dental Research, 54, 797-801. Melamed, B.G., & Siegel, L.J. (1980). Behavioral medicine: Practical applications in health care. New York: Springer. Melamed, B.G., Weinstein, D., Hawes, R., & Katin-Borland, M. (1975). Reduction of fear-related dental management problems using filmed modeling. Journal of the American Dental Association, 90, 822-826. Milgrom, P., Mancl, L., King, B., & Weinstein, P. (1995). Origins of childhood dental fear. Behaviour Research and Therapy, 33, 313-319. Nathan, J.E. (1989). Management of the difficult child: A survey of pediatric dentists’ use of restraints, sedation and general anesthesia. Journal of Dentistry for Children, July-August, 293-301. Nocella, J., & Kaplan, R.M. (1982). Training children to cope with dental treatment. Journal of Pediatric Psychology, 7, 175-178. Parkin, S.F. (1989). Assessment of the clinical validity of a simple scale for rating children’s dental anxiety. Journal of Dentistry for Children, January-February, 40-43. Peterson, L., & Toler, S.M. (1986). An information seeking disposition in child surgery patients. Health Psychology, 5, 343-358. Pinkham, J.R. (1993). The roles of requests and promises in child patient management. Journal of Dentistry for Children, May-June, 169-174. Poulton, R., Thomson, W.M., Davies, S., Kruger, E., Brown, R.H., & Silva, P. (1997). Good teeth, bad teeth and fear of the dentist. Behaviour Research and Therapy, 35, 327-334. Reiss, M.L., & Bailey, J.S. (1982). Visiting the dentist: A behavioral community analysis of participation in a dental health screening and referral program. Journal of Applied Behavior Analysis, 15, 353-362. Reiss, M.L., Piotrowski, W.D., & Bailey, J.S. (1976). Behavioral community psychology: Encouraging low-income parents to seek dental care for their children. Journal of Applied Behavior Analysis, 9, 387-397.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Stark, L.J., Allen, K.D., Hurst, M., Nash, D.A., Rigney, B., & Stokes, T.F. (1989). Distraction: Its utilization and efficacy with children undergoing dental treatment. Journal of Applied Behavior Analysis, 22, 297-307. Stokes, T.F., & Kennedy, S.H. (1980). Reducing child uncooperative behavior during dental treatment through modeling and reinforcement. Journal of Applied Behavior Analysis, 13,41-49. Weinstein, P., Milgrom, P., Hoskuldsson, O., Golletz, D., Jeffcott, E., & Koday, M. (1996). Situation-specific child control: A visit to the dentist. Behaviour Research and Therapy, 34, 11-21. Zastowny, T.R., Kirschenbaum, D.S., & Meng, A.L. (1986). Coping skills training for children: Effects on distress before, during, and after hospitalization for surgery. Health Psychology, 5, 231-247.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Table 1 Self-report questions concerning specific fears

1. When boys and girls of your age come to the dental clinic, quite often they are afraid. This is normal for one reason or another. Please circle the reasons that apply to you: a. I am afraid I will be hurt. b. I am afraid of something said by my parent. c. I am afraid because I do not know anyone here. d. I am afraid but I do not know why. e. I am afraid because of something said by my friends at school f. I am not afraid. In the following questions mark the point on the line that shows how you feel. 2. How did you feel when you woke up this morning and remembered that you were coming to the dentist today? Not worried or afraid-------------------------------------------------------Worried and afraid 3. How did you feel when you were sitting in the waiting room just now? Not worried or afraid-------------------------------------------------------Worried and afraid 4. When you are sitting in the dentist’s chair and the dentist is getting his instruments ready to look at your teeth, how do you feel? Not worried or afraid-------------------------------------------------------Worried and afraid 5. You are in the dentist’s chair to have your tooth filled. While you are waiting and the dentist is getting his drill ready to begin working on your tooth, how do you feel? Not worried or afraid-------------------------------------------------------Worried and afraid

-------------------------------------------------------------------------------------------------------From: Parkin, S.F. (1989). Assessment of the clinical validity of a simple scale for rating children’s dental anxiety. Journal of Dentistry for Children, January-February, 40-43.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Table 2 The Anxious and Disruptive Behavior Code (ADBC)

1. Head movement (H): Any head movement of 15 mm or more, except facial muscles or movements of lower jaw. Movement was scored during interval in which it occurred. Movements in response to dental instructions or questions were not scored.

2. Body movement (B): Movement of any one part of the body 15 cm or more, in either one continuous motion or smaller repetitive (back and forth) motions, that cumulated to 15 cm without interruption of 1 s or more. This was scored during intervals in which it occurred or magnitude criteria were met.

3. Complaints and Crying (C): Any crying, moaning, gagging, or complaining about dental procedures or pain. Complaints in response to questions by the dentist were not scored. 4. Restraints (R): Firm holding of any part of child’s body by dental assistant to restrict movement. Light touches to calm or comfort child were not scored.

-------------------------------------------------------------------------------------------------------From: Stark, L.J., Allen, K.D., Hurst, M., Nash, D.A., Rigney, B., & Stokes, T.F. (1989). Distraction: Its utilization and efficacy with children undergoing dental treatment. Journal of Applied Behavior Analysis, 22, 297-307.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Table 3 Behavior Profile Rating Scale Successive 3-minute observation periods 1 2 3 4 5 6 7 8 9

Separation from mother (3) Cries (4) Clings to mother (4) Refuses to leave mother (5) Bodily carried in Office behavior (1) Inappropriate mouth closing (1) Choking (2) Won’t sit back (2) Attempts to dislodge instruments (2) Verbal complaints (2) Overreaction to pain (2) White knuckles (2) Negativism (2) Eyes closed (3) Cries at injection (3) Verbal message to terminate (3) Refuses to open mouth (3) Rigid posture (3) Crying (3) Dentist uses loud voice (4) Restraints used (4) Kicks (4) Stands up (4) Rolls over (5) Dislodges instruments (5) Refuses to sit in chair (5) Faints (5) Leaves chair

-------------------------------------------------------------------------------------------------------From: Melamed, B.G., Weinstein, D., Hawes, R., & Katin-Borland, M. (1975). Reduction of fear-related dental management problems using filmed modeling. Journal of the American Dental Association, 90, 822-826. Figure 1.

Edgar Salgado Garcia – Behavioral Interventions for Children’s Visits to the Dentist

Percent of children’s disruptive behavior in 3 minute blocks during each restorative dental treatment visit. Shaded areas indicate mean disruptive behavior per visit. Asterisks indicate visits in which the criterion for reward delivery was not met.

-------------------------------------------------------------------------------------------------------From: Allen, K.D., Stark, L.J., Rigney, B.A., Nash, D.A., & Stokes, T.F. (1988). Reinforced practice of children’s cooperative behavior during restorative dental treatment. Journal of Dentistry for Children, July-August, 273-277.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Figure 2. Percentages of uncooperative behavior for each child. Appointment days are separated by the solid and the dotted vertical lines. The shaded bars show the daily mean percentages, and the line graph shows behavior during consecutive 10-min intervals of dental work. The asterisks at the end of some appointments mark the days on which the child was not given the tangible reinforcers.

-------------------------------------------------------------------------------------------------------From: Stokes, T.F., & Kennedy, S.H. (1980). Reducing child uncooperative behavior during dental treatment through modeling and reinforcement. Journal of Applied Behavior Analysis, 13,41-49.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Figure 3. Percentage of disruptive behavior for each child during baseline and distraction. Dental visits are separated by dotted and solid vertical lines. The shaded bars show the daily mean percentages, and the line graph shows behavior during consecutive 3-min intervals of dental work. The ongoing dental procedure is indicated by the symbol of the data point on the line graph.

Edgar Salgado Garcia â&#x20AC;&#x201C; Behavioral Interventions for Childrenâ&#x20AC;&#x2122;s Visits to the Dentist

Figure 4. Percentage of 15-s intervals containing disruptive behavior per 3 min of treatment for each child during each visit. Consecutive dental visits are separated by dashed vertical lines. Shaded regions indicate the mean disruptive behavior per visit.

-------------------------------------------------------------------------------------------------------From: Allen, K.D., Loiben, T., Allen, S.J., & Stanley, R. (1992). Dentist-implemented contingent escape for management of disruptive child behavior. Journal of Applied Behavior Analysis, 25, 629-636.