Parental Presence vs Absence - Dr. Julie Maniate

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Parental Presence/Absence During the Treatment of a Pediatric Dental Patient Julie Maniate DMD, FRCD(C), ABPD November 7, 2010

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Parental Presence/Absence During the Treatment of a Pediatric Dental Patient

Transcript of Parental Presence vs Absence - Dr. Julie Maniate

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Parental Presence/Absence

During the Treatment of a

Pediatric Dental Patient

Julie Maniate DMD, FRCD(C), ABPD

November 7, 2010

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Dental Fear

• Handicapping complication, stress

1. Determine prevalence

2. Tools to diagnose presence & severity

3. Tools to measure treatment need &

success of therapy1

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Behavioural Rating Scale

Frankl Scale (1962)1

1. Definitely Negative: Child completely uncooperative,

crying, very difficult to make progress

2. Negative: Child uncooperative, very reluctant to

listen/respond to Qs, some progress possible

3. Positive: Child cooperative, somewhat reluctant/shy

4. Definitely Positive: Child completely cooperative and even

enjoys the experience

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History

Focus: parent presence in operatory

• 18982:

parents be excluded

• 19583:

parent presence/absence did not affect patient‟s response

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History

• 19624:

age 41-49 mths: most negative behaviour

when separated

Age 50-66mths: no significant differences in

behaviour

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History

Focus: relationship b/w level of parental

anxiety and patient behaviour

• 19835: 75% responding dentists restricted

parents from operatory

• Dental schools: taught exclusion of

parents

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For Exclusion

1. Parent distracts

2. Parental anxiety

3. Uncomfortable for practitioner

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For Exclusion

• Psychological journals6-9

Parent-child separation issue

Found: presence of parent has favorable effect on children

child feeling of security and improved coping behaviour

Conclusions contrast sharply with

dental literature.

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For Exclusion

Question:

Could the separation itself have caused the

undesirable behavioural changes?

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For Exclusion

• 197710:

Study of behavioural effect of parental

presence & absence over series of appts

N=98

2 groups: “parent present” or “parent absent”

Group category switched for 2nd appt

Conclusion: no significant differences

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For Exclusion

• 197811:

Study of behavioural effect of parental

presence & absence over series of appts

Allowed parent & child to choose group

Conclusion: parent presence resulted in

children being more relaxed

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For Exclusion

• 198212:

Parent-child separation randomly assigned

Conclusion: no significant difference

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For Exclusion

• 199313:

No significant difference between patients

separated from parents and those who

remained for treatment

Slight increased frequency of negative

behaviour in separated group

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For Inclusion

1. Studies show no significant difference in

patient behaviour

2. Separation can increase stress

3. Parents‟ concerns can be alleviated

4. Opportunity for parent to witness child‟s actual

behaviour14

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For Inclusion

Child

Dentist Parent

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For Inclusion

• Association for the Care of Children‟s

Health (ACCH)15

Advocate/promote parental involvement in

health care setting

• Pediatric medical practice

Parents rarely excluded from observing &

participating in care of child

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For Inclusion

• 198916:

Surveyed pediatric dentists:

60%: parent welcome for initial exam

34%: allow parent during treatment visits

Increasing (slight) trend toward accepting and

inviting parents to be present.

Still no general consensus.

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For Inclusion

Child

Dentist Parent

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Practitioner Attitude/Perception

• Good behavioural management

techniques essential

• Good rapport between dentist and child

shown to influence success of treatment

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Practitioner Attitude/Perception

• 2002 (Crossley & Joshi)17:

Survey: 245 pediatric dentists

Attitudes toward parental accompaniment

Attitudes regarding parental expectations

Attitudes toward use of different child mgmt techniques

Results/Conclusion

80% supported parental accompaniment

Minority felt pressured by parental expectations

87% favoured “tell-show-do” method of beh. mgmt.

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Parents’ Attitude/Perception

• 1998 (Peretz & Zadik)18:

Survey: 104 adults Sociodemographic information

Parent preference re. staying with child

Willingness to assist dentist

Results/Conclusion: No sociodemographic variable

70% expressed wish to be present in operatory

58% willing to assist dentist

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Parental Presence/Absence

(PPA) Technique

• 2009 (Kotsanos et al.)19:

Prospective study: 33 mths 440 children, ages 3 to 10

Frankl 1 or 2 behaviour--offered parental presence only if cooperative/parent stepped out until behaviour improved

Results/Conclusion: 93% responded to PPA technique by displaying

positive behaviour as first visit progressed

All children cooperated in subsequent appts

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Summary

• Parent:

be with children in operatory during dental

treatment, assist when needed

• Dentist:

develop strategies that include parent

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Possible Strategies

1. Est. office policy that invites/encourages parent

2. Train office staff

3. Place an “observation chair”

4. Learn to talk with both child & parent

5. Discuss behaviour mgmt techniques with parents

6. Establish rules of conduct for parent

• “silent observer”

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Conclusion

“Including the parent in the operatory can be

a very rewarding experience for the dentist

who treats children,

and can help build trust and understanding

with the families of our children.”20

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References

1. Folyan MO, Kolawol KA. A critical appraisal of the use of tools for assessing dental fear in children. Afr J Oral H 2004; 1:54-63.

2. Belcher D. Exclusion of parents form the operating room. Brit J Dent Sci 1898; 41:1117.

3. Lewis TN, Law BB. Investigation of certain autonomic responses of children to a specific dental stress. JADA 1958; 57:769-777.

4. Frankl S, Shiere F, Fogels H. Should the parent remain with the child in the dental operatory? J Dent Child, 2nd Quarter 1962;29:150-163.

5. Glasrud PH. Dentists‟ attitudes toward preschool patients. J Dent Res 1983; 62:234.

6. Shirley M, Poyntz L. The influence of separation from the mother on children‟s emotional responses. J Psychol 1941: 12:251-282.

7. Arsenian JM. Young children in an insecure situation. J Abn & Soc Psychol 1943; 38: 225-229.

8. Yarrow LJ. Separation from parents during early childhood. In Hoffmann ML and Hoffmann LW ed.: Review of child development research. Vol1, Russell Sage Foundation, New York 1964.

9. Amorso D, Walters RH. Effects of anxiety and socially mediated anxiety reduction on paired-associate learning. J Personal & Soc Psychol 1969; 11:388-396.

10. Venham LL, Bengston D, Cipes M. Pre-school child‟s response to sequential dental visits. J. Dent Res 1977; 56:454-459.

11. Venham LL Bengston D, Cipes M. Parent‟s presence and the child‟s response to dental stress. J Dent Child 1978; 45:213-217.

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References

12. Pfefferle JC, Machen JB, Fields HW, Posnick Wr. Child behavior in the dental setting relative to

parental presence. Ped Dent 1982; 4:311-316.

13. Fenlon WL, Dobbs AR, Curzon MEJ. Parental presence during treatment of the child patient: A

study with british parents. Brit Dnet J 1993; 174:23-28.

14. Weinstein P, Nathan JE. The challenge of fearful and phobic children. Dent Clin North Amer 1988;

32:667-692.

15. ACCH: Position Statement on Involvement of Parents and Families in Health Care Settings.

Washington, DC, 1978.

16. Nathan JE. Management of the difficult child: A survey of pediatric dentists‟ use of restraints,

sedation and general anesthesia. J Dent Child 1989; 56:293-301.

17. Crossley ML, Joshi G. An investigation of paediatric dentists‟ attitudes toward parental

accompaniment and behavioural management techniques in the UK. Br Dent J 2002; 192:517-

521.

18. Peretz B, Zadik D. Attitudes of parents towards their presence in the operatory during dental

treatments to their children. J Clin Pediatr Dent 1998; 23:27-30.

19. Kotsanos N, Coolidge T, Velonis D, Arapostathis KN. A form of „parental presence/absence‟ (PPA)

technique for the child patient with dental behaviour management problems. Eur Arch Paediatr

Dent 2009; 10:90-2.

20. Certo MA, Bernat JE. Parents in the operatory. NY State Dent J 1995; 61:34-38.