Draft - Revised EAPD Guidelines on Behaviour Management in Paediatric Dentistry. G Klingberg, R Freeman, M ten Berge, J Veerkamp

Transcription

1 Draft - Revised EAPD Guidelines on Behaviour Management in Paediatric Dentistry G Klingberg, R Freeman, M ten Berge, J Veerkamp INTRODUCTION 2 Why an Evidence-based approach.. 2 Need for guidelines on behaviour management 3 LEGISLATION 3 BEHAVIOUR MANAGEMENT IN PAEDIATRIC DENTISTRY... 5 Definitions 5 Psychological development and aetiology. 6 COMMUNICATION WITH CHILD/ADOLESCENT AND PARENT. 7 Basic communication skills 7 Advanced communication skills 8 Identification of parent-child dyads 8 Recommendations for communication skills training 8 TREATMENT.. 9 Learning and conditioning. 9 Rapport and informed consent. 10 Preventing procedural pain...10 Methods based on cognitive behaviour therapy 11 Exposure 11 Stepwise learning, gradual exposure 11 Systematic desensitisation 12 Modelling 12 Cognitive interventions. 13 Special cases 13 Aversive techniques Restraint, coercion, hand over mouth 13 Sedation and general anesthesia 14 Recommendations for treatment REFERENCES. 15 APPENDICES... 23

2 INTRODUCTION Development of the present guidelines on behaviour management education in paediatric dentistry was initiated during the 4th Interim Seminar of the EAPD in Cologne, Germany held 22nd of April Papers were presented by Dr. Gunilla Klingberg, Sweden, Prof. Dr. Ruth Freeman, U.K., and by Dr. Maaike ten Berge, the Netherlands. The papers were further discussed within the group of councillors, specialists, presenters, and board members of the EAPD attending the Seminar and guidelines were formulated. In the rest of the text they shall be addressed to as the Committee. Why an Evidence-based approach? Evidence-based medicine [EBM] developed as a consequence of clinicians reliance upon their own opinions, past practice and precedent to formulate their treatment plans. EBM was seen as an advance with clinicians integrating evidence-based current best practice with their clinical expertise to provide care for the individual patient taking into account the patients values. Therefore EBM became recognized as a process designed to help clinicians provide the best care for and with their patients. Integral to providing EBM was effective clinician-patient communication which acted as a bridge between evidence-based medicine and patient-centred care. A parallel model was proposed for dentistry where evidence-based dentistry [EBD] had two main goals: [1] the use of the best evidence and/or research, and [2] the transfer of this knowledge into clinical practice. EBD involved 5 phases: 1. Asking evidence-based questions. 2. Searching for the best research evidence. 3. Reviewing and critically appraising the evidence-base. 4. Applying this information inform clinical practice 5. Evaluation of performance of the technique, procedure or material (Richards et al 1997) The importance of adopting an Evidence-based dentistry approach The New Zealand Dental Association has suggested that the importance of adopting an EBD approach is that it encourages dental health professionals to examine the research evidence and hence become better informed in their clinical decision making as well as reducing the variation in patient care. Sackett and Rosenberg (1995) however stated the importance of adopting an EBM approach and, for the purposes here, this has been translated for the importance of adopting an EBD approach: [1] greater efficiency in providing care for patients [2] identification of clinical treatments which will allow for increased quality in the care provided [3] as more care is provided by members of the dental team EBD provides a common language [4] uses similar methods for both undergraduate and postgraduate education as well as continuing professional development Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

3 [5] the use of EBD allows the dentist and her team to keep up-to-date with the research evidence with regard to clinical techniques practice base. The Evidence-based approach in developing clinical guidelines In the formulation of guidelines the research evidence used is not only based upon the most rigorous research designs (randomized controlled trails and systematic reviews) but also case controlled investigations and cross-sectional studies. As the research evidence is evaluated a summary of the salient points is distilled and incorporated into the evidence-based guidelines. In this way, the evidence-based approach provides a set of clinical guidelines which are research grounded; provides dentists in practice with the opportunity to remain up-to-date; provides those in undergraduate and postgraduate education access to clinical research while providing the dental team with a common language in the care of their patients. During the development of the guidelines it became clear, that very few randomised controlled trials have been performed in the area of prevention and treatment of dental fear and anxiety and behaviour management problems in children and adolescents. Based on Cochrane criteria only a limited number of studies would reach the highest level of scientific evidence. Thus, the present guidelines are based on lower levels of evidence, such as cross-sectional studies, cohort studies and also on guidelines developed by other professional organisations, as well as clinical experience. It is the committee s opinion that, If statements are known to be controversial, the level of evidence has to be stronger to include them in guidelines that advise a large group of dental professionals. One of the obvious recommendations therefore is, that there is a need for well-controlled clinical studies in this field of dental care for children and adolescents. Furthermore, there is a need for the revision of clinical guidelines on a regular basis warranted by new research. Evidence based practice is the integration of the best available research with clinical expertise and patient values. Clinical expertise is not a specific type of evidence but merely the skill to combine the available scientific knowledge with clinical practice and integrate the two together with the characteristics and prevailing ideas of the patient. (Adams 2007) Need for guidelines on behaviour management The guidelines have been developed by the EAPD but should serve as guidelines for all dentists treating children and adolescents. The training of dentists and of dental auxiliaries varies through out Europe. It is important that the guidelines are incorporated in a continuous learning process or education for all paediatric dentists. Further, the dental team as a whole, including all auxiliary personnel, should be trained in accordance with the guidelines, to avoid dental anxiety and the need for specialist referral to a paediatric dentist (PD). Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

4 This, however, implies that if the operating dentist does not feel (s)he is competent to meet the needs of the child or feels confident to perform appropriate treatment, (s)he should contact or refer the child and parent for to a colleague or for secondary level dental care to a specialist in paediatric dentistry. Children and adolescents comprise a group of individuals representing a large variation in age, understanding psychological and personality development, temperament and emotions, experience, oral health, family background, culture etc. All these aspects influence the child s ability to cope with dental treatment. Some children are robust and tolerant in stressful situations and are not likely to present problems to the treating dentist, while others are vulnerable and may need more attention and time in order to feel at ease and to cooperate to dental treatment. Paediatric dentists (PDs) need to be furnished with knowledge and feel confident and competent in the management of the child and adolescent patient in order to recognise, prevent and treat dental anxiety and behaviour management problems. The PDs should focus their treatment approach on preventing and treating dental fear and anxiety (DFA) and behaviour management problems (BMP) This may be achieved by supporting and guiding the child when necessary, share and communicate this process with the parent. This guideline will deal with the management of child and parent more extensively. LEGISLATION The UN Convention on the Right of the Child forms the general standpoints in all aspects of children s life, also including when dental health professionals meet and interact with children. The Convention has existed since 1989, and is ratified by all European countries. It is important that all professionals working with children, including dental personnel, are acquainted with the Convention. The overriding point in the Convention is that children have rights. The child has the right to be respected and also to be protected against health hazards, unfair treatment etc.. Therefore the child, taking its level of competence into account, has the right to be involved the decisions about treatment and his or her views should be respected. In this context the child s age and maturity should be taken into consideration, but even a young child should be informed and involved in the planning and treatment process. Another important principle is the best interest of the child, which is found in the third article in the convention. The best interest of the child should always be in focus in all situations and decisions where children are involved, and is an obligation to health care professionals. The Convention has had impact on the way in which children are cared for in hospital for example by the Child Friendly Healthcare Initiative. The rules and regulations governing dental practice differ between European countries. Therefore it is advised that the present guidelines should to be implemented in the context of each country s national regulations. Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

5 The guidelines have been developed to support the clinical paediatric practice. Therefore it has to be stated that every person that works in the clinical setting under the responsibility of the paediatric dentist should act and behave according to the guidelines mentioned here as long as they fit in the legal framework of their country. The Academy advises that personnel should be trained and experienced in behaviour and communication techniques. Controversy The BM guidelines, presented here, are evidenced-based. They are grounded on the highest quality of research (such as randomised controlled trials, meta analysis) as well as systematic reviews on BM strategies. The realiance on the evidence-based results in a number of concerns such as: (a) the guidelines may be misused by managed care companies to disenfranchise practitioners or dental therapists that are not designated, (b) the guidelines may unwittingly make these same practitioners more vulnerable to malpractice suits, (c) the guidelines may be perceived as a means of restricting practice to a limited number of BM treatments, thus precluding flexibility and clinical innovation. While the committee appreciates these concerns they will not be focused upon. Rather the committe will consider the empirical and the evidenced-based research for and against each of the BM strategies discussed. Basic Principles The guideline, presented here, is a document grounded in evidence-based principles. It acts as a benchmark document from which dental health professionals and dentists working with children as well as those specialists in paediatric dentistry can develop their behavioural management skills and treatment manuals. The committee concluded that treatment manuals, in whatever form, are necessary to provide an operational definition of any behavioural intervention, because quite different procedures may fall under the rubric of, for example, exposure or desensitisation. Without clear definitions and benchmarks practitioners maybe unable to determine the nature and similarities of their own practices. Without clear benchmarking statements clinical teachers will be unable to train clinical students to a level determined by robust evidence based research. Therefore the specific details contained within this behavioural guideline document can be adapted in accordance with different attitudes, the clinical experience and opinions of local scientific societies and/legislation of different European countries. BEHAVIOUR MANAGEMENT IN PAEDIATRIC DENTISTRY Definitions Current understanding of paediatric oral health includes absence of dental fear and anxiety as well as healthy oral structures with the aim to form the basis for good oral health throughout life. Besides keeping the oral environment healthy, this implies to keep the patient capable of, and willing to utilize Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

6 the dental service in childhood/adolescence as well as in a lifelong perspective. It is the committee s opinion that the dentist should always aim at preventing pain in all possible ways and prevent distress whenever possible. In order to understand dental anxiety and behaviour management problems the PD should be well acquainted with the following definitions: Dental fear (DF) represents a reaction to a specific external threatening stimulus; this is a normal emotional reaction to threatening stimuli in the dental situation. Dental anxiety (DA) represent a state where the child is evoked and prepared for something to happen; it is not attached to an object, instead a non-specific feeling of apprehension; this is associated with more abnormal conditions. Dental phobia represents a severe type of dental anxiety; is characterized by marked and persistent fear of clearly discernible situations/objects; results in avoidance of necessary dental treatment or enduring treatment only with dread; interferes significantly with daily life. Dental behaviour management problems (BMP) uncooperative and disruptive behaviours resulting in delay of treatment or rendering treatment impossible. Psychological development and aetiology The child s age should be interpreted as equivalent to age-appropriate functioning. The paediatric dentist (PD) should be able to adapt her/his treatment style and program to the psychological and cognitive functioning of the child patient, and not their chronological age, within the treatment situation. In anxiety provoking situations many child patients regress rapidly to previous levels of psychological and cognitive functioning. The PD should have knowledge of the normal psychological development of the child, and its pathology, to recognise age adequate functioning and the stressful treatment situations in which the tired, frightened and frustrated child regresses in their emotional and cognitive functioning. The PD should be competent to react adequately to the treatment situation taking into consideration the aspects mentioned below. Level of cognitive reasoning: The young or regressed child may not be able to understand fully the necessity for dental treatment, the need for local anaesthesia, and/or confuse the pain caused by toothache with the feared pain of the proposed dental treatment. Socio-emotional development: Children differ as much in the rate of their emotional and social growth as they differ in their physical milestones and cognitive functioning. Dentists should have knowledge of developmental schema in order to understand the psychological and cognitive development of the children they care for and to appreciate the role of emotional regression as a factor in the treatment situation. Behaviour can be an effect of personality/temperamental traits. A child who does not protest or show overt negative behaviour is not necessarily non-anxious. Dental anxiety in combination with shyness Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

7 does not necessarily manifests in behaviour management problems. It is generally accepted within behavioural theory that many aspects of behaviour (including abnormal behaviour) are learnt. This proposition is based upon classical conditioning that behaviours are learnt in accordance with a specific stimulus and so when that stimulus is removed or tenuated then behaviour may be unlearnt. This is the underlying theory of the behavioural management of child dental anxiety. Therefore behavioural management is based on and submitted to the same rules and learning procedures as is normal behaviour in its development, continuation and changes. Children with neuropsychiatric disorders may present with BMP. These children should probably be treated differently compared with non-anxious children without such disorders. It should be noted that an unknown number of children may have undiagnosed neuropsychiatric disorders. (NOTE: There is some literature indicating the percentage of children with neuropsychiatric disorders goes up to 25% in referred populations. A great number of them need not a different approach, only a more structured and time-allowing one.) As pain and discomfort before, during, or after dental treatment are major and important risk factors for DFA and BMP, every effort should be made to prevent pain. Further the PD should provide adequate pain control and care during all operative procedures when treating a child or adolescent. This includes both psychological and pharmacological approaches. Apart from all aspects on physical and dental health, the (written) case history should include information on general fears, family background, parental dental fear and child s social and psychological development. Systematic observation of child behaviour prior to- and during treatment should be recorded on the patient record. Behaviour during treatment can be assessed using a behaviour rating scale. DFA could be assessed using a psychometric measure. COMMUNICATION WITH CHILD/ADOLESCENT AND PARENT Communication skills are the most important tools to achieve compliance with dental treatment goals in paediatric dentistry. Communication skills allow the paediatric dentist to empower the child with a positive attitude to dental care, to improve interactions with parents and provide a better dental experience for both child and parent. Furthermore, communication skills provide the paediatric dentist with the appropriate language to negotiate boundaries for parent involvement during dental treatment and by discussing treatment options with parents prevents the potential for conflict. Basic communication skills include knowledge of verbal and non-verbal communication. Verbal communication includes questioning, listening and explaining. Non-verbal cues include body language, eye contact, pitch, tone speed of speech filled pauses (for example, ahs, errs and uhms). Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

8 Advanced communication skills include affective communication, active listening and negotiating skills. These skills will enable paediatric dentists to identify parental and child concerns about health care needs and satisfaction with care. Affective communication and active listening allow the formation of the treatment alliance by improving trust between the parent and paediatric dentist by decreasing misunderstandings and thus providing a positive experience for parent and child. It has been shown that negotiating treatment plans with parents and children builds rapport, instils trust and increases treatment satisfaction. These advanced communication skills have been shown to improve child and parental compliance with negotiated treatment plans. At the centre of the paediatric dentists interactions with parents is their ability to identify various parent-child interactive patterns. The identification of parent-child interactive patterns or parent-child dyads is of central importance as they are predictive of the child and parents ability to cope with anxiety and the degree of intrusive parental behaviours during dental treatment. Competent parent-child dyad: Children who are socially competent are more likely to have parents who are consistent, warm and nurturing in their parenting styles. These parents are able to support their children during dental treatment. No intrusive parental behaviours are noted. Aggressive parent-child dyad: Aggressive children s parents are unable to set limits, have inconsistent parenting styles, lack warmth and caring, may be harsh, rejecting and use coercive interactions and/or physical punishments to control their children. Anxious parent-child dyad: Anxious and socially anxious children more often have controlling and authoritarian parents who are negative and punitive, who set strict controls and inhibit the child s psycho-social development. For parents and children, within the aggressive and/or anxious parent-child dyad categories, there is an increased likelihood for regressive and disruptive behaviours during dental treatment. Appropriate or affective communication strategies can identify the type of child-parent interactive pattern and thus negotiate treatment plans to promote and maintain the treatment alliance with parent and child. Affective communication allows the incorporation of shared control by asking for the child and parent s opinions, clarifying and acknowledging the child and parent s expressed and felt needs and providing reassurance and support. Recommendations for communication skills training All dentists treating and caring for children and adolescents should consider training and becoming competent in basic communication and communication-based interventions and be familiar with the concept of advanced communication skills. They should be efficient at providing verbal and written information for the parent(s) before treatment in order to avoid interference from the parent during the treatment. It may also be advisable to provide extra Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

9 time with parents to allow them to discuss their worries and concerns for their child, preferably without the child being present. PDs should consider training in advanced communication skills. They should be competent and efficient in negotiating and problem-solving interventions to enable parents to prepare their children and themselves for the dental treatment visit. PDs should consider training and becoming competent and efficient in affective communication and active listening skills to enable them to identify parent-child dyads. PDs should consider acquiring knowledge to become competent and efficient in recognising competent, aggressive and anxious parent-child dyads in order to enable the formation of the treatment alliance, decrease misunderstandings and provide a positive experience for parent and child. TREATMENT It is the responsibility of the operating dentist to adapt the treatment (speed, content) to the child s possible dental anxiety, psychological age, and further, take into account possible variation in psychological state or learning capacity. This has to be taken into account when making and performing an individual treatment plan. The child needs to feel safe in the dental clinic before any possibly unpleasant procedures are initiated. General treatment conditions include good rapport, information about treatment, enhancement of patient control, prevention of procedural pain, and avoidance of abusive dentist behaviour. Many children benefit from being accompanied by the parent in the dental operatory provided the parent feels comfortable and is instructed how to act during treatment to support the child. The customs regarding presence of parents or not in the dental operatory varies throughout Europe. This is not tradition in some countries while the parents have the right by law to accompany the child in others. Thus, the presence of parent during treatment has to be decided on legislation as well as on the judgement of the treating PD. See also chapter communication, (p.7) Learning and conditioning LEVEL A Since in general acquisition of dental fear is mainly related to an individual s personal experience it should be the task of the PD s to have full knowledge of the ways conditioned stimuli (CS) develop as well as the mechanisms associated with their inhibition, reduction and inflation. The PD should prevent pairing of conditioned stimuli (CS) with Unconditioned Stimuli (UCS) that can be harmful to the child or enable the development of DFA due to repeated triggering of earlier learned responses (UCS inflation), that are unlike the ones involved in the UCS habituation process (latent inhibition). Research indicates that especially painful events or events associated with negative emotionality might inflate this process. In this process the personality and the mental developmental level of the child play an important role and the PD should be well aware of the child s perception of the dental situation and the treatment. Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

10 The theoretical framework on conditioning is extending rapidly and PDs should be aware of the developments of the research in conditioning. All types of conditioning can be associated with the same basic principles as differentiation, generalisation, inhibition, extinction (see page 7). The following examples are illustrative: [1] Counter conditioning is based on the learning of a new stimulus that is antagonistic with an (earlier) learned stimulus, e.g. relaxation and anxiety induced stress. Stepwise learning (systematic approximation) in general combines graduate exposure with the counter conditioning of the anxious stimulus. Supported with evidence both in the psychological domain as in the dental situation are the pathways of inhibitorial conditioning and differential conditioning. These are related to a gradual exposure to the stimuli of the dental situation prior to an aversive or intrusive dental treatment. Since the level of invasiveness is based on the child s imaginings and perceptions, it may be difficult for the dentist to recognise this level of anxiety experienced by the child patient.. Moreover it should be recognised that the prevalence of psychological problems in children is related to a high level of dental anxiety, therefore paediatric dentists are likely to treat children whose psychological difficulties are expressed as profound dental anxiety. Therefore many of these children will be referred to the secondary dental care. The paediatric dentist may be the first to identify children in need of psychological help and thereby assisting in their diagnosis, the need for appropriate dental treatment planning and possible referral to psychological services.] [2] Aversive Conditioning (AC). Conditioning due to an aversive operant stimulus. Especially in this type of conditioning traumatic events are believed to be the consequence of AC when a neutral or basically positive event is combined with an very negative contingent event (e.g. Little Albert, Skinner 1969). Since many of the aversive conditioning strategies can be thought of a punishments they are less effective than routine conditioning and shaping. Most often reported are the rapid extinction of its positive effect and the frequently occurring negative side effects. Therapists should be extremely cautious in using these. On the other hand also positive effects are mentioned especially shortly after the aversive stimulus. Due to this the conditioning processes of which negative consequences or side effects are reported most often should not be included as first choice behavioural strategies. The negative side effects of aversive conditioning are described extensively (Azrin and Holz 1966, Solomon 1964, Patterson 1969, Eisenberg 1999) Alternative strategies based on guided extinction can be used as a behaviour strategy (eg Time out with positive attention as the response cost).( Dean S.J. and Pitman C.M. 1991) Rapport and informed consent Today, the patient has a strong position in all health care. Still, there are both cultural and legislative differences between countries in Europe, and also between different parts of a population owing to age, religion, ethnicity and so on. Treating children and adolescents is different from treating adults. There is a triangle of people involved in the dental treatment first of all the young patient, then also the parent, and the dentist. A good relationship (rapport) between child patient and dental team is established by communication, allowing an empathic atmosphere, and showing interest in the child. According to the principle of autonomy, the patient should have the right to decide about matters that Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

11 concerns her/him as often as possible. But children are not freestanding agents; they belong to a social unit in which parents usually make the final decisions. All dental treatment should be carried out in collaboration with the child/adolescent patient and her/his caregivers respecting the patient s integrity and relative autonomy and preceded by patients/parents/legal care givers giving informed consent following the legislation of the country. Children should also be informed about treatment options. If the dentist is able to describe also for the child what needs to be done, why, and how, it is also possible for the child to assent from a young age. This information is an important part in enhancing patient control and studies have reported that children want to be more involved in consenting to their dental treatment. Preventing procedural pain Prevention of procedural pain is a cornerstone in successful dental treatment and one of the most important methods to prevent DFA and BMP. This includes psychological like an empathic attitude or enhancing control and communication with child and parent. Further, use of topical anaesthesia as well as local anaesthetics is advised whenever there is a risk for procedural pain. When more extensive treatment is carried out, or when the child presents with DFA, the use of pre- as well as postoperative general analgesics should be considered. Also sedatives like nitrous oxide - oxygen or benzodiazepines are important tools in preventing procedural pain and discomfort. Sedation techniques can also, preferably, be used together with psychological behaviour management techniques. LEVEL A Methods based on cognitive behaviour therapy All dentists who are treating children should have competence in behaviour management techniques, which have proven efficiency in preventing and treating dental fear and anxiety, and behaviour management problems. These are generally based on the properties of CBT (cognitive behaviour therapy), which aim at modifying both behaviour and cognition. Subgroups of techniques can be distinguished within this behavioural approach: stepwise learning, gradual exposure, systematic desensitisation, conditioning, cognitive reappraisal, and modelling. Several techniques are based on important conditioning mechanisms, such as positive- and negative reinforcement, and latent inhibition. Exposure 1. Stepwise learning, gradual exposure LEVEL A The child slowly becomes habituated to dental treatment, by becoming acquainted with the dental setting and personnel, in small steps. Starting a child s dental experience with check-up (i.e. noncurative) visits before any curative intervention will help the child to cope more adequately with potentially invasive (curative) visits in the future (latent inhibition). Furthermore, all treatment being new to a child patient should be informed and introduced in an individually adapted way to the child. Step by step the child is exposed to different potential anxiety provoking procedures or instruments. Each step includes informing the child about what is to be done, showing the treatment/instrument, Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

12 followed by doing the treatment procedure (tell-show-do). Cooperative behaviour is reinforced and then a new step is approached. Each new step creates a moderate increase in stress and possibly fear. The child is kept in the exposure situation until he/she experiences the fear decreases. This creates a feeling of ability to cope within the child. The child s impression of coping ability should be reinforced (operant conditioning). This feedback makes the child aware of its capability. If the child is unable to cope with the new stressful situation, this should be met with empathy and it is advisable to go back to the previous step for more training. Gradual exposure is the BM strategy with the highest level of evidence. The evidence-based research suggests that it is the exposure to frightening stimuli that works (Fox and Newton in 2006). Furthermore the research evidence suggests that gradual exposure is more effective than preparation or relaxation. The proposed mechanism is that the stimulus allows for the anxiety to gradually to be reduced and to become manageable for the child. (Wolpe, 1958, Hermans D, et al. 2006, Fox and Newton 2006) 2. Systematic desensitisation (stepwise exposure) LEVEL A This is a technique, which resembles gradual exposure and tell-show-do but is often specifically focused on a particular treatment aspect (specific phobia), such as receiving an injection, which is now combined with a neutral or positive stimulus or sensation, such as relaxation. It is often a more extensive technique since the entire procedure is lived through in steps, often during multiple sessions. This can take place in vivo or in vitro, and may be combined with other techniques such as relaxation- or breathing training or emotive imagery. Desensitisation follows in principal what has been described for behaviour shaping above, however, with the exception that desensitisation is used when there already are problems related to DFA or BMP. The high level of research evidence suggests that systematic desensitisation is effective in reducing child dental anxiety. Furthermore with continuing use of systematic desensitisation can assist the clinician in controlling relapses in child dental anxiety. (Vansteenwegen et al 2006) For instance often extra time has to be spent on training for injection, as pain-control is even more important in the anxious or non-cooperative child. The child is given theoretical knowledge about both treatment techniques and about possible reactions within the child herself. Desensitisation is often combined with relaxation exercise where the child is taught to focus on special muscles or body parts. This is done by altering contracting and relaxing groups of muscles. Also distraction (cognitive avoidance) can be used as part of desensitisation, and includes exercising forced breathing, imaginary distraction by story telling, listening to music, or playing video games during treatment. It is a subtle but mainly mildly extrinsic strategy with limited effect (van Hout en Emmelkamp 2002). 3. Modelling LEVEL B Modelling is based upon classical conditioning and learning theory. Modelling differs from the techniques discussed above in the sense that it involves indirect learning. Indirect learning refers to learning from others, for example from parents or peers. Children can profit and learn from seeing other non-anxious children, friends or parents undergoing treatment. The child will also observe Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

13 coping strategies and will be able to incorporate these methods of coping into her own repertoire of managing her dental anxiety. Cognitive interventions LEVEL B Depending on a child s age and level of cognitive reasoning, cognitive-oriented strategies may be effective in treatment of fearful children. These cognitive interventions aim at a change in interpretation of perceived threatening stimuli, by for example cognitive reappraisal or restructuring of negative thoughts, through reassessing these stimuli. Fear and anxiety often are acquired and maintained because of negative - or even catastrophic - thoughts and expectations about dental treatment. By exploring the content of these thoughts and by challenging its realistic value, or for example through rewording fearful thoughts and ideas eventually the intensity of the threat may diminish. In order for cognitive interventions to be successful children should have a level of cognitive capacity of an child aged between 8-12 years of age. Special cases Some children are especially vulnerable, for example medically or socially compromised children, and children not speaking or understanding the local language. Also some children, who have a history of much pain resulting in an extremely low pain threshold or children with extreme gag reflex, belong to this group. For these children an initial treatment under general anaesthesia or sedation preferably combined with behaviour therapy to prevent further difficulties during treatment may be the management of choice to avoid negative associations with dentistry. It is essential that the possibilities for dental treatment under general anaesthesia are ensured. LEVEL C Aversive techniques Restraint, coercion, hand over mouth The use of coercive treatment approaches e.g. the use of forcible restraint in dentistry (including such restraining devices as the papoose board) is not practiced in most European countries and in some countries forbidden to use by law (SIGN 2004). In the absence of consistent evidence showing clinical effects to support the use of the treatment approaches mentioned above underlines this opinion. It should be pointed out that a supportive or preventive holding, e.g. holding the child s hand during injection, or using a mouth prop to support it in keeping its mouth open wide, is not regarded as restraint. The Committee, therefore, acknowledges that these aversive techniques exist but the role of behavioural management is not to make the child submissively accept treatment (e.g. coercion) but rather to reduce the child s experience of dental anxiety and to assist them develop their own coping strategies. In case of emergency treatments the dentist needs to focus on the urgency of the treatment and decide what s best given circumstances and after informed parental consent. Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

14 Sedation and general anaesthesia Sedation and general anaesthesia are frequently used to carry out dental treatment in children with DFA and BMP. In 2006 the European Academy of Paediatric Dentistry adopted guidelines on the use of conscious sedation, why this is not covered in the present guidelines. General anaesthesia is also not covered as it an area where the legislation varies throughout Europe and the anaesthesia itself mostly is carried out by medical professionals. Recommendations for treatment All dental treatment for children and adolescents should be preceded by establishing good rapport with child and parents. Informed consent should always be obtained from parents according to the legislation of the country. The PDs should strive for assent also from the child. All dental treatment for children and adolescents should employ strategies to avoid development of dental fear and anxiety and dental behaviour management problems. These include preventing procedural pain and offering children stepwise learning/gradual exposure to all new steps in treatment. PDs should be trained in basic and advanced communication skills. They should be competent and efficient in negotiating and problem-solving interventions to enable children and parents to have a positive experience of dental health care. PDs should take notice of and incorporate some basic conditions into treatment of fearful children: time management, treatment planning, providing guidance, structure, mutual agreement, communication, etc. Building a solid dentist-patient working relation (treatment alliance) should have high priority in paediatric treatment. PDs should have profound knowledge on mental development and its pathology in children. It is an essential part of the PDs work to adapt the treatment to the child s capacities and coping abilities. PDs should acquire knowledge and clinical experience on exposure based behavioural management strategies and be able to apply these strategies during treatment, focusing on prevention of dental fear as well as on fear reduction. PDs should consider consultation or co-operation with a child psychologist, for example in cases of extreme phobic reactions or a need for applying complicated behavioural strategies. Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

15 REFERENCES 1. Aartman IH, van Everdingen T, Hoogstraten J, Schuurs AH. Self-report measurements of dental anxiety and fear in children: a critical assessment. ASDC J Dent Child 1998;65: Adair SM. Behavior management conference panel I report Rationale for behavior management techniques in pediatric dentistry. Pediatr Dent 2004;26: Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS, Kellogg ND, Shapiro RA. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2007;20: Adewumi A, Hector MP, King JM. Children and informed consent: a study of children's perceptions and involvement in consent to dental treatment. Br Dent J 2001;191: Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry 2004;45: Alvesalo I, Murtomaa H, Milgrom P, Honkanen A, Karjalainen M, Tay KM. The Dental Fear Survey Schedule: a study with Finnish children. Int J Paediatr Dent 1993;3: Arnrup K, Berggren U, Broberg AG, Lundin S-Å, Hakeberg M. Attitudes to dental care among parents of uncooperative vs. cooperative child dental patients. Eur J Oral Sci 2002;110: Arnrup K. Paediatric dentistry meets clinical child psychology. Studying groups of uncooperative child dental patients. Thesis. Göteborg: Göteborg University, Arnrup K, Broberg AG, Berggren U, Bodin L. Treatment outcome in subgroups of uncooperative child dental patients: an exploratory study. Int J Paediatr Dent 2003;13: Azrin N.H. and Holz, W.C.: Punishment. In W.K. Honig (ed), Operant behaviour. New York Appleton century Crofts, p Barlow J, Parsons J. Group-based parent-training programmes for improving emotional and behavioural adjustments in 0-3 year old children. Cochrane Database Syst Rev 2003;(2):CD DOI: / CD Barrett PM, Rapee RM, Dadds MM, Ryan SM. Family enhancement of cognitive style in anxious and aggressive children. J Abnorm Child Psychol 1996;24: Barrios BA, O Dell SL. Fears and anxieties. In: Mash EJ, Barkley RA (eds). Treatment of childhood disorders. New York: Guildford Press, 1989, pp Beauchamps TL, Childress JF. Principles of Biomedical Ethics, 4 th ed. New York: Oxford University Press, Beck AT, Emery G. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books, Bedi R, Sutcliffe P, Donnan PT, McConnachie J. The prevalence of dental anxiety in a group of 13- and 14-year-old Scottish children. Int J Paediatr Dent 1992;2: Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

16 17. Bee H & Boyd DR. The developing child, 10 th ed. Needham Heights: Pearson Higher Education, Subject benchmark statements. Academic standards Dentistry. Gloucester. Quality Assurance Agency for Higher Education, Bensing JM, Verhaak PF, van Dulmen AM, Visser AP. Communication: the royal pathway to patient-centered medicine. Patient Educ Couns 2000;39: Black B, Logan A. Links between communication patterns in mother-child, father-child and child-peer interactions and children s social status. Child Dev 1995;66: Blinkhorn AS, Kay EJ, Atkinson JM, Millar K. Advice for the dental team on coping with the nervous child. Dental Update 1990;17: Blomqvist M, Holmberg K, Fernell E, Dahllöf G. A retrospective study of dental behavior management problems in children with attention and learning problems. Eur J Oral Sci 2004;112: Bloomfield L, Kendall S, Applin L, Attarzadeh V, Dearnley K, Edwards L, Hinshelwood L, Lloyd P, Newcombe T. A qualitative study exploring the experiences and views of mothers, health visitors and family support centre workers on the challenges and difficulties of parenting. Health Soc Care Community 2005;13: Burke FJT, Freeman R. Preparing for dental practice. Oxford: Oxford University Press, Buss AH, Plomin R. Temperament in human nature. London: Free Association Books, Carson P, Freeman R. Tell-show-do: reducing anticipatory anxiety in emergency dental patients. Int J Health Educ 1998;36: Casey RJ, Berman JS. The outcome of psychotherapy with children. Psychol Bull1985;98: Caspi A, Henry B, McGee RO, Moffitt TE, Silva PA. Temperamental origins of child and adolescent behavior problems from three to age fifteen. Child Dev 1995;66: Chambless, D.L., Baker, M.J., Baucom D.H., Beutler L.E., Calhoun K.S., Crits-Christoph P., Daiuto A., DeRubeis R., Detweiler J., Haaga D. A. F., Bennett Johnson S., McCurry S., Mueser K. T., Pope K. S., Sanderson W. C., Shoham V., Stickle T., Williams D. A. and Woody S.R.: Update on Empirically Validated Therapies, II. The Clinical Psychologist 51 (1) Chambless D.L., Ollendick T.H.: Empirically supported psychological interventions: Controversies and evidence. Annu. Rev. Psychol. 2001: 52: Child-Friendly Healthcare Initiative Chorpita BF, Albano AM, Barlow DH. Cognitive Processing in children: relation to anxiety and family influences. J Clin Child Psychol 1996;25: Clayman ML, Wissow LS. Pediatric residents responses to ambiguous words about child discipline and behavior. Parent Educ Couns 2004;55: Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

17 34. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95: Corah NL. Dental anxiety. Assessment, reduction and increasing patient satisfaction. Dent Clin North Am 1988;32: Corkey B. Freeman R. Predictors of dental anxiety in 6 year-old children: findings from a pilot study. ASCD Journal of Dentistry 1994;61: Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child 1982;49: Davey GCL. Dental phobias and anxieties: evidence for conditioning processes in the acquisition and modulation of a learned fear. Behav Res Ther 1989;27: Dean, S.J. and Pittman, C.M.: Self-punitive behaviour: a revised analysis. 1991; p Hillsdale, NJ: Lawrence Erlbaum Associates. 40. Do C. Applying the social learning theory to children with dental anxiety. J Contemp Dent Pract 2004;5: Drummond J, Fleming D, McDonald L, Kysela GM. Randomized controlled trial of a family problem-solving intervention. Clin Nurs Res 2005;14: Dumas JE, LaFreniere PJ, Seketich WJ. Balance of power : a transactional analysis of control in mother-child dyads involving socially competent, aggressive and anxious children. J Abnorm Psychol 1995;104: Eisenberg N, Fabes RA, Shepard SA, Guthrie IK, Murphy BC, Reiser M.: Parental reactions to children's negative emotions: longitudinal relations to quality of children's social functioning. Child Dev Mar-Apr;70(2): European Association for Children in Hospital. The EACH Charter Feigal RJ. Guiding and managing the child dental patient: a fresh look at old pedagogy. J Dent Educ 2001;65: Folkes K. Is restraint a form of abuse? Paediatr Nurs 2005;17: Fox C, Newton JT. A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children. Community Dent Oral Epidemiol 2006; 34: Frankel LR, Goldworth A, Rorty MV, Silverman WA. Ethical Dilemmas in Pediatrics. Cases and commentaries. Cambridge: Cambridge University Press, Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? ASDC J Dent Child 1962;29: Freeman R. The case for the mother in the surgery. In: Freeman R. The psychology of dental patient care. London. BDJ Books, Freud A. The role of bodily illness in the mental life of children. Psychoanalytic Study of the Child 1952; 7: Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)

18 52. Gillberg C. Epidemiological overview. In: Gillberg C. Clinical child neuropsychiatry. Cambridge: Cambridge University Press, 1995, pp Gross D, Fogg L, Webster-Stratton C, Garvey C, Julion W, Grady J. Parent training of toddlers in day care in low-income urban communities. J Consult Clin Psychol 2003;71: Hallonsten A-L. Nitrous oxide-oxygen sedation in dentistry. Thesis. Swed Dent J 1982; suppl Hallonsten A-L, Jensen B, Raadal M, Veerkamp J, Hosey MT, Poulsen S. EAPD Guidelines on Sedation in Paediatric Dentistry Hamburg DA, Hamburg BA. Learning to live together. Preventing hatred an violence in child and adolescent development. Oxford, Oxford University Press, Hermans, D. Craske, M.G. Mineka, S and Lovibond, P.F.: Extinction in human fear conditioning. Biological Psychiatry 2006 (60): Holst A, Crossner CG. Direct ratings of acceptance of dental treatment in Swedish children. Community Dent Oral Epidemiol 1987;15: Holst A, Ek L. Effect of systemized behaviour shaping acceptance of dental treatment in children. Community Dent Oral Epidemiol 1988;16: Holst A. Behaviour management problems in child dentistry. Frequency, therapy and prediction. Thesis. Malmö: University of Lund, Swed Dent J 1988; suppl Holst A, Crossner CG. Management of dental behaviour problems. A 5-year follow-up. Swed Dent J 1984;8: Hosey MT. UK National Clinical Guidelines in Paediatric Dentistry. Managing anxious children: the use of conscious sedation in paediatric dentistry. Int J Paediatr Dent 2002;12: Hout, W.J.P.J. van and Emmelkamp P.M.G.: Exposure in vivo treatment in anxiety disturbances: treatment and efficacy. Gedragstherapy 2002 (35): Hummel RM, Gross AM. Socially anxious children: an observational study of parent-child interaction. Child Fam Behav Ther 2001;23: Jensen B. Benzodiazepine sedation in paediatric dentistry. Thesis. Swed Dent J 2002; suppl Johnson G, Kent G, Leather J. Strengthening the parents-child relationship: a review of family interventions and their use in medical settings. Child-Care Health Dev 2005;31: de Jongh A, Muris P, ter Horst G, van Zuuren F, Schoenmakers N, Makkes P. One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions. Behav Res Ther1995;33, de Jong PJ, Muris P, Merckelbach H. UCS inflation and human aversive autonomic conditioning. Biol Psychol 1996;43: King NJ, Ollendick TH. Treatment of childhood phobias. J Child Psychol Psychiatry 1997;38, Draft for the EAPD meeting in Amsterdam June 2006; revised Dec (23)