Behavioral Interventions for Children's Visits to the Dentist

Behavioral Interventions for Children’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 – Behavioral Interventions for Children’s Visits to the Dentist 1

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.


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


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 (CFSS-

DS), 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).


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


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 self-

reported 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


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 “model-

learning” 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 model-

learning 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.


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 31-

minute 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,


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.


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.


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 10-

minute 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 nurse’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


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


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 children’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


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


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.


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 dentist’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


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-year-

old 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


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).


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.


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 within-

subjects) 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).


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.

3. 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.


References

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children’s behavior during dental treatment. Journal of Dentistry for Children, July-

August, 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.

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in children with attention-deficit hyperactivity disorder. Journal of Dentistry for Children,

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modeling to reduce uncooperative behavior of children during dental treatment. Journal

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Melamed, B.G., & Siegel, L.J. (1980). Behavioral medicine: Practical

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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?


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?


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?


--------------------------------------------------------------------------------------------------------

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.


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).




Table 3

Behavior Profile Rating Scale

Successive 3-minute observation periods

1 2 3 4 5 6 7 8 9 10

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.


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.


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.


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.

--------------------------------------------------------------------------------------------------------

From: Stark, L.J., Allen, K.D., Hurst, M., Nash, D.A., Rigney, B., & Stokes, T.F. (1989).




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.

Documents

Behavioral Interventions for Children's Visits to the Dentist