REVIEW ARTICLE

Expandingchild behavior management technology in pediatric

dentistry: a behavioralscienceperspective
Brett R. Kuhn, PhDKeith D. Allen, PhD
Abstract
Changingattitudes on the part of dentists and parents alike have resulted in increasing interest by dentists to develop
additional child behavior management techniques. Collaborative research betweendentists and behavioral psychologists has
been encouragedby the AmericanAcademyof Pediatric Dentistry (AAPD)to address these concerns, but additional research
is needed.This paperdescribesthree techniquesthat, froma behavioralscience perspective, offer promisefor pediatric dentists
managingdisruptive children. In addition to scientific appeal, these techniques appearto have potential for acceptanceand
incorporationinto the dental operatory. Althoughearly researchsuggests these procedurescan fit easily into routine practice,
are time andcost efficient, and are relatively easy to learn, additional researchis neededto clearly establish their external
validity, cost efficiency, andease of implementation.The discussion focuses on issues relevant to incorporatingnewtechnology
into the dental school curriculumand disseminating it to practicing dentists. (Pediatr Dent 16:13-17, 1994)

Behavior managementis as fundamental to the suc- jection to techniques like HOM,physical restraint, and
cessful treatment of children as are handpiece skills pharmacological intervention; 5-7 and 3) changes in le-
and knowledge of dental materials. 1 Disruptive behav- gal and ethical standards have made many dentists
ior can interfere significantly with providing quality hesitant to use some of the traditional techniques be-
dental care, resulting in increased delivery time and cause of increased concern over liability and risk man-
risk of injury to the child. In fact, surveys of clinicians agement.8. 9
have found that dentists consider the uncooperative As a result, many dentists are interested in addi-
child to be among the most troublesome problems in tional noninvasive, acceptable alternatives. For ex-
clinical practice. 2 Recent findings suggest that nearly ample, more than half of the respondents to a recent
one in four children (22%) seen by pediatric dentists survey believed there was insufficient information avail-
may present marked management problems. 3 These able to them on current anxiety/behavior management
difficulties have lead to the development of a well- techniques. 1° Research between dentists and behav-
established child behavior management arma- ioral psychologists may help address these concerns.
mentarium for dentists. For example, the American To the technical and managementexpertise of dentists,
Academyof Pediatric Dentistry (AAPD)recently en- behavioral psychologists can contribute an understand-
dorsed 10 behavior managementmethods in their 1991- ing of the interface between child development and
1992 Guidelines for Behavior Management. 4 Five consist principles of behavior management, resulting in col-
of communicative management techniques, including: laboration that offers considerable promise. Indeed,
voice control, tell-show-do, positive reinforcement, dis- the AAPD has called for interdisciplinary research with
traction, and nonverbal communication. Also listed behavioral scientists to identify new noninvasive pro-
are the hand-over-mouth (HOM)technique and physi- cedures to help dentists deal with disruptive and unco-
cal restraint. The last three methods comprise pharma- operative children. 1~ Consistent with the AAPDcall,
cological interventions such as conscious sedation, ni- other disciplines are promoting collaboration with be-
trous oxide, and general anesthesia. The focus of this havioral psychologists to enhance education and re-
paper, however, is the nonpharmacological manage- search. For example, accredited pediatric residency
ment of children’s problem behavior. programs now require exposure to behavioral and de-
Two decades ago, the use of these 10 traditional 12
velopmental issues.
behavior management techniques in the dental clinic As behavioral scientists, we offer several observa-
generally was accepted without question. However, tions concerning the research and development of child
societal and professional views on managing child be- behavior managementtechniques in pediatric dentistry.
havior have changed dramatically in the past 20 years. Weacknowledge our limited understanding of dental
Today, there is increased scrutiny by both parents and technology, but believe our considerable experience in
dentists because: 1) the traditional behavioral tech- managingdifficult children in a variety of clinical set-
niques do not always work with all children; 2) changes tings, including the dental clinic, maymake these ob-
in community standards have resulted in parental ob- servations valuable. Consider then, that while devel-

Pediatric Dentistry: January/February1994 - Volume16, Number1 13

oping new techniques is important and has certain audio presentation and did not reinstate it until the
appeal, we believe it may be fruitful also to promote child exhibited cooperative behavior. Three- to 9-year-
exposure to those promising techniques that already old children in the contingent distraction group exhib-
possess an initial research base, but have not received ited decreased levels of disruptive behavior (30-6%),
enough support or attention to be incorporated into while children in the noncontingent distraction group
commondental practice. The purpose of this paper is remained the same (28-28%) and children in the con-
to summarize three of these techniques and to stimu- trol group increased (31-37%).
late renewed interest in further research and, perhaps, Initial research studies suggest that contingent dis-
dissemination to practicing dentists. traction may be an effective, yet practical means of
The three management techniques presented were reducing problem behavior. Start-up costs are modest
chosen based on initial research efficacy with pediatric and the equipment can be operated by means of a foot
populations. All three management procedures are pedal so as not to interrupt ongoing activities. Replica-
relatively nonintrusive and do not require additional tion is needed, and future research should focus on
personnel or significant alterations in the existing den- evaluating the efficacy of contingent distraction with
tal routine. The techniques are not cumbersome to patients selected for more severe levels (> 30%) of dis-
implement and have been (or can be) adapted to fit into ruptive behavior, and with children younger than 4
the existing dental routine. Finally, these particular years old. In addition, while there is no reason to
management techniques have conceptual appeal, as believe that other forms of distraction (i.e., video games)
they are consistent with our current understanding wouldn’t be equally effective, further research is needed
about why children behave the way they do, particu- to identify those distracters that are most salient, yet
larly in situations where escape and avoidance behav- easily accessed by pediatric patients. The ease of imple-
iors are likely. mentation and minimal cost suggests that incorporat-
ing this tool into the standard operatory procedures
Contingent distraction holds considerable promise even as a preventative
Somepediatric dental patients’ disruptive behavior measure.
can be controlled by diverting their attention and en-
Live modeling
gaging them in alternative activities like watching TV,
playing video games, or listening to audiotaped sto- Permitting children to observe other children
ries. Distraction is thought to gain control over an adaptively undergoing dental treatment is an effective
aspect of the patient’s capability to respond (i.e., pay- way of preparing them to accept treatment and to dem-
ing attention) that is incompatible with disruptive be- onstrate what is expected of them. ~2 Numerousstudies
havior.13 Overall, scientific studies looking at the use of have shown the efficacy of filmed modeling in reduc-
various distraction procedures in the dental operatory ing fear-related disruptive behavior. ~’~27 However,prac-
have yielded mixed results. 1~-18 Typical distracting ticing dentists have not incorporated filmed modeling
stimuli do not appear to compete well with the more into their managementregimen, 3,1° possibly due to the
potent reinforcement obtained from disruptive behav- economic and logistical difficulties of making one’s
ior (i.e., temporary escape from an undesirable situa- own video and accessing playback equipment. Re-
tion19). A recent effort to overcome this problem in- search has demonstrated, however, that dentists can
volved enhancing the saliency of the distracting stimuli obtain marked reductions in disruptive behavior by
by providing a requirement that demanded attention simply allowing children to observe one another dur-
to the distracting stimulus. This procedure proved ing dental treatment. In a study by Stokes and
highly effective in decreasing anxious and disruptive Kennedy,28 children first observed 10-15 min of an-
behavior in children. 13 Unfortunately, the distraction other child receiving dental treatment, and then served
technique was complicated and required additional as a model for a peer while receiving their own treat-
time, as well as other nondental personnel to imple- ment. Substantial decreases in disruptive behavior were
ment. observed for children previously identified by the den-
Ingersoll and her colleagues, however, developed a tist as a severe management problem. A followup
distraction procedure that required very few additional investigation 29 studied live modeling during more
resources. Their work suggests that children’s disrup- invasive dental procedures, and determined that sim-
tive behavior can be reduced by making access to a ply being observed by peers during dental procedures
distracter such as an audio tape, dependent (contin- was sufficient to decrease levels of disruptive behav-
gent) upon cooperative behavior, as opposed to pro- ior. The researchers felt that these children were more
viding unlimited access to audiotapes. 2°, 21 Children cooperative because being observed by the next patient
were informed that they could listen to audio taped placed them in the role of a coping model. An impor-
material through headphones, as long as they remained tant advantage of live modeling is that no additional
cooperative. Each time the child became disruptive or equipment, personnel, or alterations in the dental rou-
uncooperative, the dentist immediately terminated the tine are required.

14 Pediatric Dentistry: January/February 1994 - Volume16, Number1

 Future research is needed to assess the efficacy of amount of time. Interestingly, although three of the
live modeling with larger numbers and a wider age children were at an age often considered "pre-
range of pediatric patients. In addition, while the pro- cooperative, "38 during which fears and negative be-
cedure has been shown to reduce uncooperative be- havior peak, 22 the dentist did not have to wait long for
havior for children referred specifically for disruptive cooperative behavior to occur.
behavior, further research might evaluate the efficacy Observations in our clinic suggest that most disrup-
and/or necessity with less problematic children. Un- tive behaviors are the end product of a response chain
like many other nontraditional managementtechniques, that begins early in the dental visit. The provision of
there is someevidence that live modeling is makingits brief opportunities for escape early in the treatment
3way into more dental clinics. visit can interrupt this chain, preventing more frequent
and intense levels of disruptive behavior. While others
Contingentescape have discussed the use of behavioral interventions both
Dentists have long recognized that giving children a in response to problem behavior and in preventing
sense of trust and control is an important strategy in future occurrences, 39 the contingent escape procedure
coping with dental procedures. Using nonverbal com- may present the most potential when initiated early
munication techniques (e.g., raising a hand) to allow and maintained throughout the entire treatment visit
child to stop treatment when they experience discom- to prevent the response chain from escalating toward
fort is one way that dentists have allowed children to increased levels of disruptive behavior.
gain that trust and instill a sense of control. 3° However, Contingent escape is based on well-established learn-
hand raising is not the only response that produces ing principles and is designed to not only diminish
control in the dental operatory. Disruptive behavior undesirable behaviors, but also to increase desirable
also serves this function for a child because it often behaviors. Delayed consequences not tied to specific
results in temporary escape from ongoing dental pro- behaviors fail to teach children how to improve their
cedures. Escape from unpleasant or undesirable events "in-chair" behavioro4° Contingent escape, however, pro-
is one of the most commonand powerful sources of vides immediate feedback to teach children more adap-
motivation, and plays a major role in a wide variety of tive coping behaviors. The procedure is especially
problem behaviors 31 including tantrums 32 and other promising because it requires little training and can be
disruptive behavior.B3 Manyaspects of restorative treat- used continuously with all children with no alteration
ment (e.g., syringe, sounds from a drill, tightness of the in the typical treatment plan. In fact, unlike pharmaco-
rubber dam clamp) may become feared stimuli be- logical interventions, which often increase total treat-
cause they are unfamiliar or are associated with dis- ment time, 4I initial studies have shownthat contingent
comfort. Efforts to escape or avoid (i.e., thrashing, escape requires less time (and produces comparable or
blocking with hands, turning the head, crying) are natu- better results) than some traditional managementpro-
ral responses that are more likely to occur than raising 3s
cedures.
one’s hand. Unfortunately, the dentists’ natural ten- Future research should focus on determining opti-
dency to stop dental treatment in response to disrup- mal training parameters and criterion testing to ensure
tive behavior may, in many cases, serve to encourage adequate skill levels in implementing the contingent
34
that behavior. escape procedure. For example, research is still needed
One recently developed management procedure to ascertain howeasy (or difficult) it is to teach contin-
takes advantage of the powerful motivation to escape, gent escape to dental students and to assess the poten-
and uses it to teach more cooperative behaviors. 3~-37 It tial for preventing behavior problems before they start.
is an adaptation of existing management techniques Finally, as with all three of the procedures described in
(e.g., raising a hand) that allows the child somecontrol this article, the efficacy of contingent escape needs to
over the dental routine. In this procedure, brief peri- be evaluated with larger numbers of children before
ods of escape from ongoing dental treatment are pro- dentists consider placing it in the dental curriculum.
vided contingent upon cooperative behavior. Instead
of raising a hand, the child can receive praise and brief Conclusions
escape (about 5 sec) from dental treatment by simply The need to develop additional behavior manage-
lying very still and quiet. Any disruptive behavior by ment technology has been well established. Collabora-
the child delays escape until cooperation is regained. tion between dental and behavioral scientists has been
The dental instruments remain in or around the child’s encouraged and viable alternatives have begun to be
mouth until the child becomes calmer and more coop- developed. This paper presents three promising cost-
erative. and time-effective techniques that possess an initial
In their most recent research, Allen and his col- research base, but require further study to be fully
leagues 35 found that a dentist whoused this procedure incorporated into the practicing dentist’s arma-
with four extremely disruptive children was able to mentarium. Specifically, research is needed to more
dramatically improvetheir behavior in a relatively short firmly establish treatment parameters, some of which

Pediatric Dentistry: January/February1994- Volume16, Number1 15

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