‘Do you see me?’ Pediatric patients require a unique touch

I remember that episode when new patients come to our pediatric practice. They have the same desire Morgan had, to be seen.

Children need to believe that people in power see them, know them and care about what happens to them. That’s what they’re really asking with those anxious eyes: “Do you see me?”

Bad examples

Starting off right with a new pediatric patient will set the relationship up for success in future dental visits. Pediatric management, it is said, begins in the waiting room. Here are two bad examples I’ve witnessed.

• A speech therapist came into a waiting room, walked up to a 5-year-old girl, looked down and bellowed, “Tiffany! I’m so glad to see you today!” Tiffany cringed behind her mother’s leg, obviously terrified.
• A medical assistant entered a waiting room, eyes on a clipboard, and intoned, “Gavin Smith? Time to go.” Seven-year-old Gavin didn’t budge, just looked at his mother apprehensively.

It’s easy to see what’s wrong with these examples. The therapist assumed a dominant position, used an intimidating voice and didn’t introduce or explain herself. The assistant didn’t make eye contact and didn’t explain what was going to happen. There was no mutual, caring connection in either case.

Good examples include a two-minute warning

Here are two better examples from a typical day in our pediatric practice.

• A dental assistant walks into the playroom and greets a child. “Hi, Anniston, my name’s Beth. I’m going to take care of you today. Hey, those are pretty cool shoes you have on. Do they light up? Wow!” “Anniston, the first thing we’re going to do is pick out a new toothbrush, then the doctor will count your teeth, then you’ll be able to play some more. You and Mommy can come around the corner with me now to look at toothbrushes.”
• A dental hygienist enters the playroom and stoops down to eye level with the child. “Hi, you must be Tyler. I’m Cathy. How do you like that car race game? Are you the red car guy? Looks like you’re winning.” “I’m going to clean your teeth today, Tyler. I’ll show you all my cool stuff, then I’ll polish your teeth with an electric toothbrush and put fluoride vitamins on them, then you can come back and play. I’ll be ready in two minutes, Tyler, so go ahead and race some more. I’ll be back.”

In these examples, a personal connection is established first. Children can be confident that we see them, know them and care about them well before treatment begins. I’ve also discovered that the two-minute warning is a great way to relieve anxiety.

Behavior guidance

Basic behavior guidance in the operatory is easier once a comfortable relationship is established. Tell-show-do, voice control, nonverbal communication, positive reinforcement and distraction can be integrated as part of an ongoing subjective process for each patient.

The American Academy of Pediatric Dentistry (AAPD) offers descriptions for each technique.

• Tell-show-do: Verbal explanations appropriate to the patient’s developmental level; demonstrations of the visual, auditory, olfactory and tactile aspects of each procedure in a nonthreatening setting; and completion of the procedure.
• Voice control: Controlled alteration of voice volume, tone or pace to influence and direct behavior.
• Nonverbal communication: Reinforcement and guidance of behavior through appropriate contact, posture, facial expression and body language.
• Positive reinforcement: Positive voice modulation, facial expression, verbal praise and appropriate physical demonstrations of affection.
• Distraction: Diverting the patient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break can be effective.¹

We can also add live modeling, which a recent study found to be more effective than tell-show-do. Live modeling in which the child’s mother underwent treatment first resulted in lower heart rates for children than either live modeling with the father or tell-show-do.²

Customizing these techniques, along with keeping up a constant stream of information and never letting anything be a surprise, are the best ways I’ve found for dealing successfully with anxious children.

For example: “Tyler, take a look at my special brush. See how it goes around in a circle? Let’s touch your finger. Is it buzzy and tickly? That’s how it’ll feel on your teeth. I’ll start right here on the side, so you’ll know how it works. Is it tickly? Don’t laugh too hard.

“Here’s my water squirter, remember? Here comes the water, and here comes the straw to suck away the extra. Hey, you’re really good at this, Tyler. Look, Mommy’s proud of you. Stay put, we’re going to do the other side next.”

Dealing with parents

As we all know, parents can help or hinder. The AAPD points out that with modern parenting styles, children may be ill-equipped with the coping skills and self-discipline necessary to deal with new experiences such as a dental visit.¹

Sometimes it helps to ask the parent to let you do the talking. “Tyler can only listen to one person at a time, and right now that needs to be me.” This establishes you (with both parent and child) as the person in control.

Another technique is to make the parent’s presence contingent on good behavior. “Tyler, if you can be a good boy and sit quietly, without fussing, Mommy can stay here and watch. If you’re going to fuss, she’ll have to wait for you out front. Which do you want her to do, stay or go?”

Pediatric behavior management can work well if you begin carefully. Establish a comfortable, caring relationship; exhaustively describe everything that will happen before it happens; and be firm, calm and authoritative about the behavior you expect.

References
www.aapd.org/media/policies_guidelines/g_behavguide.pdf; accessed Aug. 25, 2010.
Farhat-McHalyeh N, Harfouche A, Souaid, J. Can Dent Assoc, May 2009, 75(4):283a–f.

About the author

Cathy Hester Seckman is a dental hygienist, speaker, writer and indexer. She is a 1974 graduate of West Liberty State College. As a hygienist, she has been in general and specialty practices for 29 years, including three years as a temporary hygienist. Since 2003, she has worked in a pediatric practice. For the past four years, she has presented continuing education programs for hygienists on pediatric management, nutrition, communication and pre-natal to pre-school care. She has published nearly 100 articles in dental magazines.