The Dentist-Child Relationship: Engaging Children’s Cooperation Through Effective Communication

1. The Dentist-Child Relationship:Engaging Children’s Cooperation Through Effective Communication

2. Article in the JournalPediatric Dentistry Nash, D.A. Engaging Children’s Cooperation in the Dental Environment Through Effective CommunicationPediatric Dentistry 2006;28(5):455-459.

3. Communicating with Kids • Effective communication with children is critical to gaining the child’s cooperation to receive dental care. • This presentation will review and discuss four communication skills that can serve as valuable tools in securing and maintaining the cooperation of children. • Tell Show Do; • Reflective listening; • Self-disclosing assertiveness; and • Descriptive praise.

4. Communicating with Children • Effective communication is a primary objective. • Communicate in two basic ways: • verbally: using therapeutic communication skills, as well as talking about school activities, pets, articles of clothing, children’s television programs, books, muppets • non-verbally: holding young child in lap; touching tenderly, smiling approvingly

5. Tell Show Do • Tell-Show-Do is the classical model for communicating with children in the dental environment. • Developed (first documented in the literature) by Harold Addelston, of New York University’s School of Dentistry in the 1950s. • It is essentially a “behavior shaping” strategy.

6. Tell • TELL • before • during • after • TELL… using euphemisms (substitute language) • Understanding critical • Be honest in your TELLing!

7. Show • SHOW (demonstrate) the child what will be happening, how it will happen, and with what equipment. • But, it is not wise to SHOW fear- promoting instruments. • Remember the multi-sensory perspective in SHOWing: children can HEAR, SEE, TOUCH, TASTE, and SMELL.

8. Do • DO what you said you were going to do. • DO it in the manner you said you were going to do it. • As you DO it, continue to TELL the child what you are DOing. • DO NOT DO until the child has a clear awareness and understanding of what you are going to DO. • DO it expeditiously!

10. Haim Ginott, Ph.DClinical Child Psychologist • Between Parent and Child • Between Parent and Teenager • Teacher and Child Ginott Disciples: Faber and Mazlish • How to Talk So Kids Will Listen and Listen So Kids Will Talk • Liberated Parents, Liberated Children

11. Between Parent and Child “When children are in the midst of strong emotions, they cannot listen to anyone…they want us to understand what is going on inside of them—what they are feeling at that particular moment. Only when children feel right can they think clearly and act right. Strong feelings do not vanish by being banished.” Haim Ginott

12. Feelings

13. Reflective Listening • Dentists are in a therapeutic relationship with a child that has strong emotional overtones. • Whereas adults have been socialized to conceal their emotions in receiving oral health care, children express, either verbally or behaviorally, their feelings. • All too often we want to deny their feelings, rather than accept them. • It is critical that we acknowledge and accept children’s feelings in the context of gaining their cooperation in being cared for.

14. Denying Feelings Child: “I’m scared.” Dentist: “There is nothing to be scared about.” A crying child is escorted to the treatment area. Dentist: “What are you crying about? There is no reason to be upset. We are just going to . . .”

15. Denying Feelings • In both instances, and it other comparable situations, the dentist has denied the child’s feelings, rather than acknowledge them in a reflective manner. • The child’s feelings are a fact—a fact we must deal with in a therapeutic manner. • Feelings must be acknowledged by mirroring these feeling back to the children so they may appreciate that their feelings are recognized and understood.

16. Acknowledging Feelings—Limiting Behavior • Accepting, respecting, and empathizing with feelings does not suggest that what children feel can be translated into unacceptable behaviors. • All feelings should be permitted, but certain behaviors are limited. • “I can see you are upset, but remember our rule—hands must stay in the lap.”

17. Acknowledging Feelings • Acceptance of children’s emotions permits them to develop the sense that their feeling are not all that strange. • The fact that the dentist understands, appreciates and respects the internal emotional struggle taking place is truly empathic. • Such acceptance sets the stage for being a powerful helping agent for the child. • Feelings must be addressed before behavior can be improved.

18. Dealing with Feelings Never deny a child’s feelings: • Outright denial:“you can’t possibly feel be scared; there is nothing to scared about.” • Philosophizing: “well it’s too bad you feel that way, but this is necessary.” • Offering advice: “we’ll get along better and things will be easier if you just relax.” • Asking questions:“why do you feel that way?” • Pity:“I feel sorry for you having to go through this.” • Amateur psychoanalysis:“I think the real reason your upset is . . .”

19. “Active Listening” Child:“I’m scared.” Dentist:“I understand. Sometimes new things are scary. It is okay to be scared. Sometimes I am scared of things I do not understand or things I have not done before.” • The dentist might go on to explain the s/he will “tell” and “show” before doing. (Tell.Show.Do)

20. Acknowledging Feelings A crying child is brought to the treatment area. Dentist: “I see one of my little friends who really looks upset. I’ll bet you did not want to come to see me today.” • Reflective or active listening children’s feelings has the positive effect of reassuring children that what they are going through is a normal part of the human experience. It permits children to ‘own’ their feelings, thus respecting their autonomy.

21. Ways to Acknowledge Feelings • Listening quietly and attentively. • Acknowledging the feeling with a word: Oh … mmm … I see. • Giving the feeling a name: “It sounds like you are really nervous about coming to see me today.” • Granting in fantasy what cannot be given in reality: “I really wish I could make those scary feeling go away.” or, “Wouldn’t it be great if we didn’t have to fix this tooth today!” I really wish we could be out on the playground—we could have great fun playing basketball together.”

22. Reflectively Verbalizing Children’s Perceived Feelings • Reflectively verbalizing the feelings a child is experiencing can facilitate a positive relationship with the child. • If a child enters the treatment area smiling and at ease, such non-verbally expressed feeling can be acknowledged by words like: “You look happy to be here today. I am really gad to see you.”

23. Reflectively Verbalizing Children’s Perceived Feelings • If the child enters the treatment are with a negative demeanor the dentist could say: “You look unhappy about coming to see me today. I’ll bet you would rather be home! Today we are going to count your teeth and take some pictures.” • With this approach the dentist not only acknowledges the child’s feelings but also begins to alleviate fears about what will be accomplished.

24. Non-verbal Acknowledgement of Feelings • Taking a young child in one’s lap and holding him/her acknowledges understanding, as does stoking the face of a young child, or tenderly reassuring the pats on the shoulder, arm or hand. • The power of touch is widely acknowledged in the literature. • The tone and modulation of the voice, coupled with appropriate facial expressions, can express understanding, care and empathy.

25. Engaging Cooperation Ineffective/Destructive ways to attempt to gain cooperation—”roadblocks to communication:” • Blaming and accusing: “If we don’t finish this silver filling today it’s going to be your fault!”(“So you think I care!”) • Name calling: “You are being a bad little girl.”(“I hate you.”) • Threats:“If you don’t sit still I’ll have to have someone hold you down.”(“Leave me alone.”) • Commands:“You stop that right now.” (“Try and make me.”) • Lecturing and Moralizing: “It’s not nice to not do what I ask you to!”(“I’m dumb.” “Whose even listening.”)

26. Ineffective/Destructive Ways in an Attempt to Gain Cooperation(continued) • Warnings:“Don’t you touch that!” (Whatever I do, I’m in trouble.”) • Martydom statements: “Will you stop that screaming, you’re driving me crazy!” (“Who even cares.”) • Comparisons:“Why can’t you behave like Johnny over there?” (“I feel like a failure.”) • Sarcasm:“Wow, that sure is helpful.” (when a child holds hands over mouth.) (“He’s mean.”) • Prophecy:“If you don’t behave yourself and let me do this you’ll have ugly teeth.” (“I give up.” “I’m doomed.” )

27. Gaining Cooperation Through Self-Disclosing Assertiveness • Self-disclosing assertiveness permits the dentist to confront a child’s lack of cooperation without employing these so called “roadblocks to communication.” • Note that all of the attempts to gain cooperation by employing the roadblocks cited call attention to the child and all emphasize the word you. • “It’s your fault.” “You are being bad.” “If you don’t …” “You stop that right now.” “Don’t you …” “Why can’t you …?” “You sure are being helpful.” (sarcastically).

28. You Statements • Impugn the child’s character. • Deprecate the child as a person. • Shatter the child’s sense of self-esteem. • Underscores the child’s inadequacies. • Casts judgment on the child’s personality. • They are all ‘put downs’ to which the child can object and take issue.

29. I Messages • The key to gaining cooperation by being assertive is to understand that assertiveness is self-disclosing. • Self-disclosing assertive statements begin with “I.” • Self-disclosure improves a dentist’s personal self-awareness of what is required. • Self-disclosing “I Messages” state explicitly to children what is required to be cooperative. • They enable the dentist to be honest and clear with the child regarding the dentist’s needs and expectations.

30. I Messages • Describe what is seen. • Share what is felt. • Describe a problem being experienced. • Give information of which the dentist is aware but of which the child may not be aware.

31. Examples of “I Messages” • “I see hands that are not in the lap.” • “I cannot see when the teeth when the mouth is closed.” • “I cannot spray sleepy water on the teeth when the mouth is closed.” • “I don’t enjoy working when there is so much noise.” • “I see teeth with lots of plaque on them.” • “I sure become discouraged when I see plaque on the teeth after I have worked so hared to teach how to brush ad floss properly.” • “I’m concerned that this crying will disturb the other boys and girls.” • “I’m afraid this could be uncomfortable with all of the moving around.” • “ I need the hands to stay in the lap.” • “I need the mouth opened really wide to see those back teeth.”

32. I Messages • Sending “I Messages” is more effective at influencing children to modify unacceptable behavior than using “roadblocks to communication” that focus on “You Statements.” • “I Messages” are much less likely to provoke resistance and rebellion. • Communicating to children the effect their behavior is having is far less threatening than to imply there is something bad about them because they are engaged in the behavior. • Consider the difference: • “Ouch! That really hurt me!” • “Ouch! That is being a very bad boy. Don’t you dare ever bite me or anyone else like that again.”

33. I Messages • “I Messages,” because they only describe what is seen, felt, sensed, or wanted, are strong messages because they cannot be argued with—they are the practitioner’s experience. • “I Messages” are more effective because they place the responsibility on the child for modifying behavior. • “I Messages” challenge the child to handle the situation constructively, trusting him/her to respect the clinician’s needs.

34. Engaging Cooperation • Describe: describe what you see, or describe the problem. “I have trouble doing my job when the mouth keeps closing.” • Give information: “When you open you mouth really wide, I can see to put the rubber raincoat ring on the right tooth.” • Say it with a word: “The hands!” • Talk about YOUR feelings: “I am really frustrated because I can’t spray sleepy water on teeth I can’t see.”

35. Praise • All to often in attempting to gain a child’s cooperation, we praise them with evaluative words like “great,” “ good,” “wonderful.“ • However, as humans we are taught to shrink” or “retreat” from direct praise; that is, we don’t quite know how to handle it. • And…when we praise in global evaluative terms like “good,” the child tacitly understands that we are in an evaluative mode relative to our relationship with them, and we could easily also say, “bad.”

36. Praise When wanting to reinforce positive behavior, instead of evaluating…Describe. • Describe what you see. “I see a young man who is holding his mouth open really wide and sitting really still!” • Describe what you feel. “It is really a pleasure to be the dentist of a young lady who opens her mouth so wide.” • Sum up the child’s praiseworthy behavior in a word. “ I see a young man with his hands in his lap. That’s what I call cooperation.”

37. Praise In summary: • DO NOT use global terms of evaluation. Avoid great, good, wonderful, as in “you’re beinggood.”…and certainly negative and pejorative judgments such as “you’re being bad.” • RATHER, think about what is happening with the child that makes you want to say, “Your are being good!” and rather than saying that--describe the conditions present that make you want to say it. In this way, you are defining what good means, a much more meaningful way to “praise.” • ALLOW the child to form their own evaluations of their behavior. • ALWAYS look for opportunities to acknowledge correctness.

38. Additional Ginott Principles • Children are Equal in DignityWith adults, please and thank you and other forms of kindness and courtesy are routine. Children deserve and appreciate the same respect. Use “please” and “thank you” regularly and often. • Children Need to Be Liked Without authenticity and empathy, techniques fail. If you do not enjoy treating children--don’t! If you have enjoyed a child--say so: “I really like you a lot! Thanks for letting me be your dentist.” • Give Children Choices/Options Go out of your way to grant the child some autonomy and control. “Would you like for me to count you top teeth first, or your bottom teeth?”

39. Gordon Model for Communicating with Children ParentEffectivenessTraining by Thomas Gordon

40. Roadblocks to Communication • Ordering, Directing, Commanding • Warning, Admonishing, Threatening • Exhorting, Moralizing, Preaching • Advising, Giving Suggestions/Solutions • Lecturing • Judging, Criticizing, Blaming • Evaluative praising • Name Calling, Ridiculing, Shaming • Interpreting, Analyzing, Diagnosing • Reassuring, Sympathizing, Consoling • Probing, Questioning, Interrogating • Withdrawing, Distracting, Humoring

41. “Owning The Problem” In the dental setting (and in every human relationship) there are times when: • The dentist “owns the problem;” that is, some need the dentist is not being met. • The child “owns the problem;” that is, some need of the child is not being met. • There is “no problem,” as the needs of both the child and the dentist are being met.

42. Three “Problem” Circumstances in the Dental Environment • Child is whining because doesn’t want to be in dental chair; wants to be finished and with parent. But child is being cooperative so the dentist can complete the treatment. THE CHILD OWNS THE PROBLEM. • Child is comfortable, seeming enjoying the experience, and cooperative. THERE IS NO PROBLEM. • Child is satisfying needs, but is being uncooperative, tangibly interfering with dentist having his/her needs met of completing the treatment. THE DENTIST OWNS THE PROBLEM.

43. “Owning the Problem” Area of Acceptable Behavior for Dentist: • Child Owns the Problem • No Problem • Dentist Owns the Problem Area of UnacceptableBehavior for Dentist:

44. Active Listening... is used when: the child “owns the problem.”

45. CHILD TIRED ENCODING PROCESS DECODING PROCESS TIRED WHEN THE CHILD “OWNS THE PROBLEM” “When are you going to be finished?“ Dentist Child

46. CHILD School ENCODING PROCESS DECODING PROCESS TIRED WHEN THE CHILD “OWNS THE PROBLEM” “When are you going to be finished?” Dentist Child “You want to get back to school.” “No, I didn’t mean that. I meant I am really tired of holding my mouth open..”

47. CHILD TIRED ENCODING PROCESS DECODING PROCESS TIRED WHEN THE CHILD “OWNS THE PROBLEM” “When are yougoing to be finished?” Child Dentist “You’re getting tired.”

48. Active Listening ... • In active listening, the receiver tries to understand what the sender’s message means. • S/he then puts his/her understanding of it into own words and feeds it back to the sender for verification. • Does not send a message of own--such as an evaluation, opinion, advice, analysis or question--only understanding of the sender’s message.

49. Active Listening... • Helps children discover exactly what they are feeling. • Helps children become less afraid of negative feelings. When dentist accepts the feelings the child learns that “feelings are friendly.” • Promotes a relationship of warmth between the dentist and the child. Being heard and understood is very satisfying. • Facilitates problem-solving by the child. • Influences the child to be more willing to listen to the dentists’s thoughts and ideas.

50. When the Dentist“Owns the Problem” • When the dentist is prevented from accomplishing what needs to be done, that is, the child’s behavior is effectively preventing such, the Dentist“owns the problem.” • At such times, the dentist must confront the child’s behavior in such a manner as to change it. • This is done most effectively by using “I messages.”